Traditionally, rehabilitation professions have evolved to encompass a deepening understanding of a relatively finite number of conditions they are trained to rehabilitate. As a result, newer and more effective clinical methods develop. The master's degree became the entry-level requirement in the 1960s for speech-language pathology because the knowledge and experience required for competence in these methods was considered too extensive for a four-year undergraduate degree.
In the 1980s it was recognized that the mechanism used for communication—the aerodigestive tract—was a source of morbidity and mortality in patients with a variety of acute medical conditions. Because the education and training of the speech-language pathologist addresses the management of communication disorders in patients with aerodigestive tract abnormalities, speech-language pathology became the default profession for the management of a new range of conditions arising from increased survival rates from disease and the growth in surgical and medical technology.
Since then, the knowledge and skills necessary to prepare SLPs equally in all areas of practice have grown not only deeper, but also exponentially broader, without a parallel growth in required educational preparation. At the University of Pittsburgh, we believe that the two-year master's degree could no longer absorb more breadth without dramatically reducing the depth of knowledge necessary to prepare experts and leaders in evidence-based practice.
In 1996 we made a dramatic change in our master's-level clinical practicum program and replaced the in-house speech and language clinic with the "clinical network" in which our faculty practice. First-year speech-language pathology students are educated in this service, supporting acute- and tertiary-care hospitals, rehabilitation centers, outpatient clinics, and community rehabilitation and educational centers.
This change began an eye-opening phase in our department's perception of the future of the profession. The doctor of clinical science (CScD) program represents a unique option for advanced scientific education in the practice and pedagogy of speech-language pathology. The standards of excellence set and achieved by the graduates of this program are mandated by ethics and deserved by our consumers.
Speech-language pathology, as expected to be practiced in medical and some other settings, requires a higher standard of preparation than is now mandated. A profession-wide drive toward an entry-level doctorate is not and probably never will be universally sought by SLPs. The doctoral level of preparation may be essential in some settings. Doctoral-trained clinicians can provide the leadership the profession needs to ensure that the growing scientific knowledge base is translated expertly to the clinical setting. The CScD is the clinical correlate to the research-oriented doctor of science (ScD) degree and was developed to prepare a cohort of clinical leaders.
Reimbursement may require that service providers hold an advanced degree and/or expertise level (see Johnson et al., 2010). Direct access for clinical practice and billing privileges are influenced by provider status and perceived independence. These factors may become the minimal standards for independence, leadership positions, and billing privileges.
The degree designator for a clinical doctorate in speech-language pathology has importance for the profession. The ScD and PhD degrees are universally recognized and awarded as research qualifications in the United States. The ScD prepares individuals primarily for clinical leadership roles with a secondary emphasis on research preparedness. A "clinical" PhD must incorporate complete research and clinical curricula, at the risk of sacrificing one for the other, or diminishing both.
Gaining the complex knowledge and skills required for doctoral-level performance in both research and clinic requires more time than that available for the completion of a single degree. Given the inherent complexity and scope of practice of speech-language pathology, it would be unwise to suggest that the PhD be used to "house" a clinical doctorate. There is a strong potential for diluting the research preparation required for the PhD if we also want to address advanced clinical issues. Borrowing the degree designator will not miraculously award the recognition, respect, integrity, and status to the clinical doctorate that was advocated by Aronson (1987).
We strongly support the doctor of clinical science (CScD) designator for the clinical doctorate in speech-language pathology. This designator makes clear the scientific basis of the clinical professional and the advanced level of education required. If the speech-language pathology profession adopts a sole degree designator, it will signify a unified national approach to advanced clinical education. This practice would be in line with long-standing professional doctorates such as the juris doctor (JD) and medical doctor (MD), degrees with which the speech-language pathology degree designator should align (see The Higher Learning Commission, 2006).
CScD Program Goals
The aim of the University of Pittsburgh program is to provide in-depth knowledge and skills in:
- advanced clinical practice
- evidence-based decision-making
- clinical team leadership skills
- multi- and interdisciplinary work
- professional dissemination of information
The depth of study and preparation of speech-language pathology students may have been diluted by the expansion of the profession into new areas. It may no longer be realistic to think that we can produce advanced, expert clinical leaders in two years for all clinical settings. Master's degree preparation is designed to produce competent clinicians. The CScD program is designed to graduate leaders with expert skills and knowledge, the ability to work in partnership with leaders in other areas of specialization, and the tools to collaborate with and disseminate knowledge from researchers.
Graduates of the University of Pittsburgh's clinical doctoral program are prepared for independence, leadership, and excellence in clinical practice. Professional avenues of work include clinical service and administrative and clinical faculty positions. This program involves continual, extensive reading and critical evaluation of existing literature to develop the skills to evaluate efficiently the theoretical and scientific evidence base to support good clinical practice.
The master's degree coursework provides a tremendous amount of content in a relatively short period. The PhD program produces independent researchers capable of investigating important questions regarding the nature of disorders and their treatment. With the CScD program, we aim to prepare clinical fellows (first-year post-master's) and then residents (post-master's years 2 and 3). After three years of advanced clinical and academic education, the graduates will be able to analyze clinical problems expertly and produce an evidence-supported, strategic approach to intervention within the constraints of the medical setting. Our teaching and mentoring methods develop independence in decision-making, critical self-evaluation, and focused development of expertise in areas of specific clinical interest.
As in PhD training, advanced clinical students specialize in a specific area in which to develop expertise and leadership. Unlike the master's level of preparation, CScD students develop high-level skills in all areas from the outset. They learn methods of writing and presenting suitable for publication and public speaking in competitive environments. Novel teaching methods include clinical debates and hands-on, one-to-one clinical mentorship by faculty. Students participate in medical grand rounds and case presentations to multidisciplinary teams. Each student undertakes three five-week medical rotations with clinical disciplines, not to contribute as an SLP but to be immersed in the culture and practice of other professions, such as neurology, dietetics, palliative care, and neonatology. This experience gives students a deeper understanding of patients' conditions and the perspectives of other clinical experts in dealing with illness.
The CScD program was developed with flexible entry points to accommodate students across a range of life experiences: immediately post-bachelor's or post-master's degrees, experienced practicing clinicians, and/or PhD researchers.
Practicing clinicians might be specialists in their fields and, as such, represent a rich learning resource for the student body. Assignments are clinically focused and individually tailored. Students and faculty can access the most up-to-date body of evidence in speech-language pathology.
The CScD program includes several key factors:
- Each student's education is customized to his or her needs.
- During all three years, students work 50% of the week in a clinical position external to the university (i.e., not a "placement") and they are continually mentored by expert faculty members in an academic process that bridges clinic and classroom issues.
- Students develop critical thinking skills and research-design knowledge that enable them to implement evidence-based practice in their clinical experiences and to withstand cross-examination by multidisciplinary clinical colleagues. Development of clear, concise, convincing oral presentation skills allows students to share a significant body of experience with a variety of listeners, from patient to physician, and to maintain a consistent position during contentious conference proceedings.
The program has experienced a number of successful outcomes.
- Current enrollment: Eight students are enrolled in the post-master's program, with three more to enter in the next six months.
- Graduates: Our first four program graduates completed all requirements by April 2011. One continued work as the coordinator for clinical education at the Veterans Administration Pittsburgh Healthcare System (VAPHS), one enrolled in a PhD program, one returned to the West Coast to develop specialty clinics in dementia assessment and treatment, and one is undecided.
- External papers and presentations by clinical doctoral students beyond program requirements: Although students are not required to publish work they are required to produce two pieces of work for submission to an external body. Our students are strongly encouraged to publish and present and have produced two chapters; nine refereed papers; 10 refereed seminars at ASHA conventions, the International Association of Logopedics and Phoniatrics, and the National Black Association for Speech-Language and Hearing; five refereed posters at ASHA and the American Cleft Palate Association conventions; 15 invited presentations; 12 presentations, including in-service trainings, to the VAPHS, Pittsburgh Children's Institute, Children's Hospital of Pittsburgh, and local acute hospitals; and six articles in an 18-month series in a United Kingdom publication.
- Research: Research is not required, but projects are underway in areas including the use of Q methodology (combining the best of qualitative and quantitative methodologies to reveal subjective perspectives that are internally valid and externally reliable) in evaluating clinicians' perspectives of the speech-language pathology profession, and a comparison of parent and child perspectives in voice.
Developing a Program
Institutions considering the development of a clinical doctoral program may want to consider a number of factors that may affect the success of the effort.
- Existing expertise in the department: Is there an adequate proportion of faculty members with PhDs? Is there a strong and active program of research? What is the balance of active research to teaching/service? Does faculty expertise cover a range of clinical areas?
- Expertise outside of the department: SLPs routinely work in multidisciplinary teams and should be educated with other professionals to understand the range and depth of perspectives of clinical care without professional parochialism.
- Local support: Interest and support should be established among local/regional employers for clinical doctoral education.
- Curriculum goals and objectives: A broad curriculum should be considered, with possible optional areas of focus such as administrative, medical, and school-based tracks. The curriculum should not simply be more master's-level work: there must be increased depth and breadth of study. Research education is relevant in terms of supporting clinical education.
- Specific courses, program needs, and requirements: Available courses should include, for example, core credits in administration policy, law, head and neck anatomy, and scientific writing; advanced disorder areas such as neuroscience and autism spectrum disorders; a research evaluation requirement including research methods and statistics; and internships involving mentored supervision.
- Clinical practice: Students should either remain in a paid clinical position (but with hours reduced to perhaps half-time) or be placed in a carefully selected post with local employers. This experience provides the bridge between classroom learning and clinical applications. Academic credits should be awarded for structured activities linking clinic and classroom.
- Coursework: A balance of courses within and outside of a typical communication science disorders department is recommended. This diversity increases the breadth and perspective of studies and fosters the integration of academic ideas into clinical multidisciplinary teamwork.
Launching a new professional academic entity as opposed to expanding a current one requires careful deliberations and some degree of risk. The University of Pittsburgh was able to benefit from a range of faculty with experience in education, research, and continuing professional development and from the international expertise of the program's director, who brought ideas and lessons learned from a similar venture in the United Kingdom.
We remain firmly dedicated to simultaneous academic learning and clinical experience, and recognize that this pairing may present challenges in the employment market. We are fortunate to work with excellent clinical facilities in the greater Pittsburgh area.
Applications to the program continue to increase despite the academic and financial demands of three further years of study—no easy decision for the students, half of whom are international. Our clinical "residents" are bridging the chasm between advanced learning and clinical life in presentations ranging from national/international meetings to contributions to in-service training. Information flows both ways between the two sides of our professional world.
We expect that the clinical doctorate in speech-language pathology will help the profession meet the challenges of a rapidly changing health care environment. Ultimately, the success of a program is judged by its graduates, not by its eminent faculty or robust program structures. We have reflected on, adapted, and continue to scrutinize the program. Dialogue continues between faculty inside and outside communication science and disorders and the university, students, and clinicians. We are proud of our first graduates and students and consider that, so far, we have achieved our aims.