Clinical Dietitians/Nutritionists Have Complex Training Needs
I think most nutritionists would agree with Drs Skipper and Lewis that now is a good time to examine the educational needs of clinical dietitians and nutritionists. Both the opportunities and threats facing the field of clinical nutrition are greater than they were 30 years ago.
However, the problems facing clinical dietitians and nutritionists are not unique. Most healthcare workers (physicians, dietitians/nutritionists, pharmacists, physical therapists, occupational therapists, registered nurses, clinical psychologists, audiologist, etc) are facing similar increased demands for basic training and continuing education.1-7
* The potential of medical therapies and preventive measures is expanding rapidly with new scientific advances. However, these advances are of little value if healthcare professionals are not provided with more training in evidence-based medicine so that they can apply this new knowledge. This generally means that all health professionals need more training in molecular biology/genetics, biostatistics/epidemiology, and pharmacology/toxicology.
* Clinical trials are an essential part of translating basic research into practice and often give patients quicker access to new therapies. Many new clinical therapies for chronic diseases involve multiple modalities of diet, pharmaceuticals, and physical therapies (such as exercise). Thus, healthcare providers need a more interdisciplinary training and more updates on scientific ethics and federal regulations on clinical research.
* Our healthcare system is extremely complex and is approaching an economic crisis. Our growing population of elderly, especially those with chronic diseases, fuels this problem. Furthermore, the differential in healthcare available to low- and high-income Americans is increasing. Thus, all healthcare workers need a broader understanding of economics, law, and ethics with constant updates on the rules and regulations enforced by Medicare and other third-party payers.
* We live in a consumer-oriented society that expects high-quality and rapid updates on their health issues, often from a distance. Moreover, unfortunate incidents about healthcare delivery, public health, and prior clinical trials have reduced the confidence of many consumers in healthcare systems. Thus, healthcare professionals require more training in all types of communication technologies and consistent updates on federal regulations and current events.
National Institutes of Health Is Suggesting One Potential Solution
The National Institutes of Health (NIH) is addressing these issues through its Roadmap. A major initiative in NIH's Roadmap is to award the Institutional Clinical and Translational Science Awards (CSTAs).8 These new CSTAs are expected not only to replace the old General Clinical Research Centers in medical schools but also to provide more interdisciplinary training to healthcare professionals, to provide more outreach to patients, and to do more translational research. As part of these CSTAs, institutions are expected to provide "career paths in clinical and translational science[horizontal ellipsis]leading to advanced degrees (MS and PhD)."8 Those trained are expected to become the leaders in modernizing American healthcare systems.
One common interpretation of this mandate by the 12 universities receiving these CSTA grants and the 52 universities receiving CSTA planning grants is that institutions must establish interdisciplinary master's and, ultimately, doctor of philosophy (PhD) degree programs in "clinical sciences." It is assumed that those entering these programs will already have a basic degree in a healthcare profession.
These new graduate programs in clinical sciences could meet the needs of some dietitians/nutritionists seeking to gain increased depth and breadth of knowledge so that they can more effectively treat their patents' medical dietetics needs. They also will be empowered to direct clinical trials to improve medical/nutritional therapies. Moreover, because of the NIH mandate, universities are apt to preferentially invest their (often limited) resources for graduate education in these new graduate programs in "clinical sciences."
What Are Clinical Doctorates?
The doctorate suggested by Drs Skipper and Lewis would be considered a clinical doctorate. Clinical doctorates (sometimes called first professional degrees) are not new. Consider doctor of medicine and doctor of veterinary medicine degrees.
On many campuses, the creation of clinical doctoral programs and then approval by all-campus review committees have been controversial and difficult processes. Those proposing clinical doctorates usually state that entry-level practitioners in their field need more training than currently provided to meet the bulleted points listed above.2-7 Thus, training periods were too long to be just baccalaureate or perhaps master's degree programs.
However, many critics claim that the motivation for these degrees is really the desire of healthcare professionals to work independently of physicians and be able to bill Medicare for their service directly and accordingly raise their salaries (personal communications from other graduate deans and faculty to J. L. Greger, 1990-2006).1 Some academics think that clinical doctorates are really master's-level programs with internships. Critics also question the ability of individuals without doctorates to train those seeking doctorates. They note that it is already difficult for busy healthcare professionals in hospitals (who are paid totally through clinical revenues) to spend time on training.
What Can We Learn From Other Clinical Professions?
The development of clinical doctorates has varied among fields. The following short overviews of clinical doctorates in various fields may offer potential models for those considering new training options in clinical dietetics/nutrition.
Clinical Psychology
Clinical psychology is perhaps the field with the most "mature" clinical doctoral program options.9 In 1949, clinical psychologists recommended that the training of scientist-practitioners be accomplished through PhD programs (which included a yearlong internships) in clinical psychology. In 1973, a national training conference on clinical psychology reported that practitioners needed less research experience and recommended the creation of doctor of psychology (PsyD) programs.
These 2 options have functioned long enough to provide useful statistics.9 PhD programs in clinical psychology are under the aegis of graduate schools at universities; the PsyD degrees are often located in freestanding psychology schools or in professional schools. As of 2002, the acceptance rate of students into PsyD programs was higher than into PhD programs in clinical psychology (40%-41% vs 11%-15% of applicants, respectively). However, nationally, PsyD programs were less apt to provide financial support to students than PhD programs (ie, 18% vs 70%-80%, respectively, of students were offered tuition and assistantships). Generally, students in PhD programs took 1 to 1.5 years longer to complete their doctorate than did students in PsyD programs. However, PsyD students were more apt than PhD students to enter the doctoral program with a master's degree already completed. Graduates of PsyD programs, on average, did not perform as well as graduates of PhD programs on the national licensing examination for psychologists.
Relevance to nutrition. At many universities, a graduate program in clinical nutrition (as has been done in psychology) could be created as just another option under the already approved PhD program in nutrition. A number of universities already have done this. Internships could become a required part of PhD programs in clinical nutrition (as they do in psychology).
Pharmacy
In 1992, the American Association of Colleges of Pharmacy recommended that the clinical doctorate in pharmacy (PharmD) replace the bachelor in pharmacy as the entry-level professional degree in pharmacy.3 PharmD is a 4-year professional degree preceded by at least 2 years of preprofessional education. All pharmacy schools in the United States have discontinued their baccalaureate degrees as a first professional degree.
Miller and Webb3 believe that the pharmacists with doctorates "are better prepared to address the complexity of patient-medication management" and have hence earned "increased respect from professional colleagues." The average national base salary of all pharmacists is $87,000, but of PharmD graduates, it is $110,000.10
Relevance to nutrition. PharmD has been cited as a success story for clinical doctorates. However, pharmacists operated more independently than other healthcare professionals and earned higher salaries before the creation of PharmD programs. Hence, the benefits attributed to this clinical doctorate are not apt to accrue (at least as much) to other health professionals with clinical doctorates.
Physical Therapy
The American Physical Therapy Association actively campaigned for the creation of a clinical doctorate, that is, a doctorate in physical therapy (DPT).4,6 This degree has become the main route by which current students can become professionals in physical therapy. The net result is that in 2000, there were 9 baccalaureate, 184 master's degree, and 19 doctoral (accredited and developing) programs in physical therapy. In 2006, there were no baccalaureate, 43 master's degree, and 167 doctoral (accredited or developing) programs in physical therapy.
Ward4 noted that "there have been many challenges associated with transitioning to a clinical doctorate" but that patients are better served by physical therapists who have a strong background in evidence-based care. He notes that the American Physical Therapy Association found that practitioners with a clinical doctorate earned only slightly more than those with a master's degree after limited work experience (1-3 years) but reported greater job satisfaction.
Relevance to nutrition. More information is needed before the usefulness of doctorate in physical therapy programs as models for clinical dietetics/nutrition can be judged. Questions need to be answered: Do differences exist in salary and job satisfaction among clinical (not academic) physical therapists with doctorates in physical therapy and those with master's degrees in physical therapy after 5 or more years of experience? How were university structures altered to accomplish these transitions (ie, did physical therapy programs leave departments of kinesiology, and were the physical therapy programs moved to medical schools)? Accordingly, did these programs become less interdisciplinary and more isolated (ie, instruction after the first 2 years of college training was accomplished by primarily physical therapists)? If so, this type of training model would be counter to NIH's suggestions in the CSTAs8 and probably would not prepare clinical dietitians/nutritionists for long-term careers.
Audiology and Occupational Therapy
The American Academy of Audiology recommended that the doctor of audiology degree become the entry-level degree for clinical audiologists by 2007.7 At least 30 universities are offering doctor of audiology degrees in 2007.
As of 2007, a master's degree or higher is the minimum educational requirement for entry into the field of occupational therapy.11 In December 2006, an accreditation council of the American Occupational Therapy Association, Inc, adopted the standards for doctoral degree-level education programs in occupational therapy.12
In general, assessments of the advantages and costs of these clinical doctorate programs to universities, students, and ultimately patients, remain debatable.
It Is Time for Nutritionists to Consider Options?
Those proposing a clinical doctorate in dietetics and/or nutrition should carefully analyze data from other clinical fields and try to answer the following questions: Will the creation of a doctorate lead to this degree becoming the minimum educational requirements in clinical nutrition within 10 years? Will students graduate with larger debt loads? Will the additional training have long-term effects on clinical dietitians/nutritionists' salaries and job satisfaction or will the effect last only for about 3 years? Will the number and quality of students seeking PhDs in nutrition be affected by the creation of clinical doctorate in dietetics/nutrition?
Faculty members in nutrition departments should reevaluate their current graduate programs in nutrition. Can master's programs, courses, and thesis topics be made more relevant to clinical dietitians/nutritionists? Should every advisory (MS and PhD) committee for clinical dietitians/nutritionists include at least 1 faculty member from pharmacy, medicine, physical therapy, biostatistics, or some other clinical field? Are there other ways to encourage students to gain more interdisciplinary skills? Should more faculty members in nutrition departments be actively involved in the CSTA training programs?
Are Salaries the Real Issue?
This is an undiplomatic question, but it was asked in several reviews of clinical doctorate programs in which I participated. This question is particularly relevant to clinical dietetics/nutrition. Generally, dietitians are paid lower than other healthcare workers (Table 1).
I think it behooves all nutritionists in academia to be interested in improving the salaries of clinical dietitians/nutritionists because this is a very good way to show that we care about our students, which is a good way to recruit more and better students at all degree levels. In the long run, this is also a way to improve patient care by providing well-trained, satisfied clinical dietitians/nutritionists. I am not sure that a clinical doctorate in dietetics/nutrition will accomplish this goal.
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