The employers’ perspective on how PhD training affects physicians’ performance in the clinic

In 2006, a political agreement coined “Globaliseringsaftalen” (The Globalisation Agreement) resolved to increase investment in science and research in order to strengthen economic growth and innovation in Denmark. Some of the resources were earmarked for increasing the intake of PhD students, and today the Danish universities enroll approximately 60% more PhD students than in 2006 [1]. As requested by the government, approximately 30% of the PhDs originate from the Health Sciences [1].

This development has sparked a heated debate in the field of medicine that has played out in the professional as well as the daily press. In particular, the discussion has revolved around whether the PhDs are worth the investment or if we are engaging in (costly) over-

education [2-4].

However, the PhD investment is still relatively new, and scientific evidence regarding its social and scientific impact is lacking, also within the field of health. The present study is part of a larger study on the impact of a PhD degree in connection with physicians’ and nurses’ clinical work, and it is a first step towards obtaining a more nuanced understanding of how the competencies of MD-PhDs (i.e. physicians holding a PhD degree) unfold in clinical practice as seen from different perspectives. In the present study, we explore the employers’ perspective.

METHOD

This descriptive study is based on a mixed methods approach using quantitative data as well as qualitative data.

Quantitative data collection

This part of the study was conducted as desk research (January-June 2016) based on pre-existing statistical data, figures and reports from Aarhus University (AU). We collected and analysed three sets of data as described in Table 1.

Quantitative data analysis

We conducted simple descriptive analyses of the quantitative data; i.e. we did not conduct comparative analysis of the data across the data sets as we did not have access to the raw data on which they are based.

Qualitative data collection

The qualitative data collection was conducted in March-June 2016, primarily in the Central Denmark Region, but also to a lesser extent in the North Denmark Region. Two interview studies were carried out: One with six executive consultants and one with four appointment committees (see Table 2 for details).

Purposive sampling was used to select participants, and recruitment was carried out in two different manners: 1) Six executive consultants from selected wards were contacted via e-mail and then by phone. They all agreed to participate in interviews, which then took place at their office. 2) The coordinators of five selected appointment committees were contacted via e-mail and passed on our interview request to the committees. One coordinator never responded despite e-mails and phone calls, but the remaining coordinators arranged for the first author to meet with the four appointment committees for half an hour either before or after they held job interviews for residency training.

Interviews

Semi-structured interviews were carried out with 42 physicians – six individual interviews and four group interviews. All interviews were conducted by the first author. Individual interviews lasted between 45 minutes and one hour, whereas the group interviews lasted 30-40 minutes. All interviews were audio-recorded. The interview guide addressed the informant’s expectations of MD-PhDs and experiences with MD-PhD in the clinic.

Qualitative data analysis

Interview data were analysed following the qualitative contents analysis approach described by Emerson, Fretz & Shaw [8]. The excerpts used (in Table 3) are meant as illustrative examples of the overall analytical themes. Excerpts were translated from Danish into English by

the first author and reviewed by the second and last

authors.

Ethical approval

The study was approved by the Danish Data Protection Agency (R. no. 2015-57-0002, Sequential no. 211). Approval by The Central Denmark Regional Committees on Biomedical Research was not required. All hospitals, wards, medical specialities and physicians remain unnamed in order to maintain their anonymity and confidentiality.

Trial registration: not relevant.

RESULTS

Results from the quantitative study

As for the AU in general, the number of MD-PhD graduates from the Faculty of Health at the AU rose during the period from 2010 to 2014. The increase in the number of MD-PhDs was 44%, whereas the increase recorded for the rest of AU was 33%.

The time from completion of qualifying education to enrollment in a PhD programme was reduced from six years in 2003 to three and a half years in 2014. The age of PhD graduates decreased from 38.07 years in 2003 to 36.71 years in 2014, but we have not been able to detect a significant difference. However, the decreased age of the PhD graduates may be related to the reduced time between completion of their qualifying education and their enrollment in a PhD programme. The enrollment time, i.e. the period from enrollment at Health, AU, to the handing in of the PhD thesis, remained relatively constant across the three cohorts: four years including any delay or leave of absence. Based on the employment report [5], we found that 100% of the 2010 cohort and 99% of the 2014 cohort are currently employed either in Denmark (89%) or abroad (11%). 87% of the PhD graduates who stay in Denmark are employed in the public sector, whereas 10% are employed in the private sector and 3% in other businesses. In the public sector, 64% of these PhD graduates are affiliated with one of the regions, 32% with the Danish state and 3% with other parts of the public sector. However, the majority (75%) of the PhD graduates who stay in Denmark are employed in Aarhus or the eastern part of Central Region Denmark. Only 16% are employed in others parts of Jutland, 6% in Greater Copenhagen and 3% on Funen. In comparison, 53-64% of PhD graduates from the rest of AU are employed in Aarhus or the eastern part of Central Denmark Region and between 25-27% in Greater Copenhagen. The employment report also stated that PhD graduates are much less mobile in terms of geography and workplace than graduated students who do not hold a PhD degree.

Finally, the employment report concluded that most of the requirements that PhD graduates meet in their jobs are matched by the skills they have attained in their PhD degree programme – in particular, the ability to find relevant information, acquire new knowledge, manage complex problems and work independently [5].

Findings from the qualitative study

Based on the interview data, three predominant themes were identified: Science and the critical gaze, “The cult of the PhD”, and PhDs in demand at regional hospitals.

Science and the critical gaze

The majority of informants conveyed that they expected the MD-PhDs to have achieved basic scientific research skills and did not regard having a PhD as important in connection with clinical skills (see Table 4, quote no. 1).

Being able to critically assess new medical knowledge – or having a “critical gaze”, as some informants called it – and being able to employ it in the clinic was, in many of the informants’ opinion, one of the primary skills that the MD-PhDs brought to the table. This skill was counter-posed with basing clinical decisions solely on previous experiences or even convention.

Several informants pointed out that a “critical gaze” was essential in terms of conducting evidence-based medicine. The ultimate aim of evidence-based medicine, many informants stressed, was for patients to be offered the newest and very best treatment. Furthermore, many informants found the “critical gaze” exceedingly relevant in a clinical setting where complex new treatment methods are presented continuously (see Table 4, quote no. 2).

Some of the informants found that the process of doing a PhD also influenced positively some of the other seven roles of physicians, especially the roles of communicator, collaborator and manager [9]. They related this influence to the circumstance that the PhDs had been in charge of their own project, which included being responsible for collecting data, working independently, meeting deadlines, collaborating with different groups of people (e.g. colleagues, patients, scientists) and managing their own time (see Table 4, quote no. 3).

Some of the informants found that MD-PhDs raised the standards and ensured constant progress in the wards by continually wondering about and questioning clinical practice (see Table 4, quote no. 4).

Similarly, some of the informants proclaimed that by focusing on and bringing attention to scientific research, the MD-PhDs acted as ”role models” or “locomotives” for the rest of the ward in terms of being critical, reflective and educational (see Table 4, quote no. 5).

”The cult of the PhD”

While most of the informants felt that the MD-PhDs were committed, highly skilled and made great contributions in the clinic, some found that too much emphasis was put on the PhD degree. One executive consultant talked of “the cult of the PhD” to illustrate the way the PhD degree had by some been elevated into the only currency that mattered in medicine. He and other informants believed that while a PhD degree prompted certain skills, these skills could also be achieved in other – and less expensive – ways, e.g. by following seminars, doing administrative jobs or doing research with experienced colleagues.

In line with this argument, some argued that clinical experience should also be taken into account and that the importance of diversity in the clinic should not be underestimated; i.e. that different kinds of physicians are a considerable asset in the clinic (see Table 4, quotes no. 6 and 7).

Furthermore, many of the informants distinguished between MD-PhDs who continued to be active researchers after they had finished their PhD versus MD-PhDs, which an executive consultant termed ”diploma PhDs”, i.e. physicians who used their PhD as a shortcut to being admitted to the clinical specialisation of their choice and then stopped doing research altogether.

PhDs in demand at regional hospitals

Whereas informants from the university hospital generally felt that they had enough PhDs in their wards, many informants from what they themselves termed “the periphery” of the region called for more MD-PhDs. Basically, they believed that PhDs would raise the standards at their respective wards by bringing into focus evidence-based treatment and by making research a part of their clinical practice. The demand included not only research-active PhDs, but also the so-called ”diploma PhDs” (see Table 4, quote no. 8).

However, some of the informants were skeptical as to whether more PhDs at the regional hospitals was a realistic way of doing research, especially in terms of establishing good, sustainable research environments, attracting sufficient funding and of doing without physicians in the clinic in favour for research.

DISCUSSION

This study is based on a combination of original and existing quantitative data and original qualitative data in order to gain insight into the impact of the PhD degree in connection with physicians’ clinical work as seen from the employers’ perspective. There are, however, limitations to the study. In terms of the quantitative data, the employment report had a quite low response rate (46% for the 2010 cohort and 50% for the 2014 cohort). The empirical data that the study is based on stems mainly from the Central Denmark Region and from selected medical and surgical specialities. Attitudes and experiences might be different in other Danish regions and within other specialities.

Overall, our quantitative study shows that an increase has been observed in the number of MD-PhDs from AU that surpasses the increase of PhDs in the rest of AU, that MD-PhDs are, to a great extent, employed in the public sector, and that, overall, the skills of the MD-PhDs match the demands of the employers. Our qualitative study largely confirmed the latter finding, as most of our informants were satisfied with the skills that the MD-PhDs brought to the clinic, especially in terms of their ability to critically assess and make use of new medical knowledge. Some informants found that the process of doing a PhD influenced several of the physician roles in a positive manner, and that MD-PhDs may affect a ward towards a more evidence based and motivated practice, demonstrating that MD-PhDs contribute in the clinic in ways that are not directly measurable.

However, our data do not indicate whether the current number of MD-PhDs is appropriate or too high or low. Our quantitative study shows that all of the MD-PhDs are employed, but does not indicate to which degree they were employed owing to their PhD, and our qualitative study shows disagreement among the informants as to the appropriate number of PhDs. Some (especially in the regional hospitals) expressed a demand for more MD-PhDs, while others were concerned about what they considered the too high status of the PhD degree and stressed the need for diverse skills in the clinic. While our study suggests that the regional wards make great use of MD-PhDs, international studies imply that recruiting physicians (with or without a PhD-degree) to remote areas is a general challenge [10, 11]. Furthermore, it is not only a question of attracting the MD-PhDs, but also a question of whether to centralise medical research in large, specialised units or rather spread it out regionally. Based on this small study, it seems regional hospitals could make good use of more MD-PhDs.

Some of our informants found that some MD-PhDs ceased doing medical research in the clinic after completing their PhD, turning into what one informant dubbed “diploma-PhDs”. Their experience is confirmed in a recent Danish study [12], which shows that two thirds of the MD-PhD graduates become research inactive within two years after graduation. This prompts the question of what causes some MD-PhDs to stop doing research. Further research is needed in this area.

Finally, it is worth noting that international studies, especially from the US, have long expressed concern over a looming shortage of physician-scientists, predicting an impending crisis in clinical research [13], suggesting that the continuing quality and progress in medical treatment calls for an ongoing, future-proofing focus on academic medicine.

Correspondence: Pernille Andreassen.

E-mail: pernille.andreassen@cesu.au.dk

Accepted: 8 December 2016

Conflicts of interest: none. Disclosure forms provided by the authors are available with the full text of this article at www.danmedj.dk.

Acknowledgements: The authors would like to thank the participating physicians as well as the HR departments at the participating hospitals.