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July 2005

To Degree or Not to Degree?
By Lynn Grieger. RD, CDE
Today’s Dietitian
Vol. 7 No. 7 P. 31

Will future RD students need a graduate degree to sit for the exam? Find out what’s behind the recommendation and what some influential RDs are saying about it.

“Can we guarantee there will be a future for the dietetics profession at all?”

This statement is from the Dietetics Education Task Force Report and Recommendations released earlier this year. The American Dietetic Association’s (ADA) House of Delegates (HOD) appointed the task force in 2004 to use a “clean-slate approach” to create a new plan to educate and credential nutrition professionals. After reviewing current dietetics education standards and practices, the task force concluded that fundamental changes are required to answer “yes” to the above question. They note two major areas of concern: sufficient time to meet competencies and disconnect between education and supervised practice.

The first two of seven total recommendations are:

1. The Commission on Dietetic Registration (CDR) require a graduate degree for eligibility for the CDR registration examination for RDs and professional entry into dietetics practice.

2. The Commission for Accreditation for Dietetics Education (CADE) require accredited programs preparing students for RD credentialing to have a seamless educational system providing both the academic preparation and supervised practice necessary for credentialing in one graduate degree-granting program.

If these recommendations are approved, not only will a graduate degree become a requirement to take the registration exam, but no longer will students first complete an undergraduate degree, then apply for and complete an internship program. Instead, potential RDs will begin and end their education and supervised practice in one institution, providing for “seamless education.”

I’m one of the 50% of RDs without a graduate degree, and I blame it directly on fear of chemistry. The first recommendation, one of seven, really caught my eye. I followed a nontraditional route to becoming an RD—a BA in European history followed by four years of active military duty before I decided to change directions from military intelligence to healthcare. My original undergraduate program let me opt out of math and science, and the thought of graduate-level chemistry courses left me in cold sweats. Instead of working toward a graduate degree in nutrition, I completed the courses then required by the CDR without earning a second undergraduate degree and was accepted by an internship program. That was 16 years ago, and while the thought of a graduate degree periodically crosses my mind, it’s never been something I’ve truly considered.

Why a Grad Degree?
The task force bases its recommendation for a graduate degree for all entry-level practitioners on analysis of actual dietetics practice, feedback from employers and educators, and environmental trends. Because of the explosion of science and technology, it’s become impossible to adequately train new RDs in four years of undergraduate education and approximately 900 hours of internship experience. Jane Ross, PhD, RD, CD, professor in the department of nutrition and food sciences at the University of Vermont, agrees with the findings. In her 29 years of experience educating future dietitians, she knows there simply isn’t enough time to cover all the necessary competencies in our current education system. Requiring a graduate degree before beginning practice in theory allows enough time for greater depth of learning and more focus on research.

The task force also points to the trend of requiring increased amounts of education in other healthcare fields as a major reason nutrition professionals need more training. We need to develop a sound scientific knowledge base before we ever venture into practice on our own. Several professions are considering requiring an entry-level practice-based clinical doctorate degree: pharmacy, physical therapy, occupational therapy, and audiology. If we expect to work with other healthcare professionals as respected and knowledgeable peers and be regarded as true nutrition experts, then the reasoning follows that comparable levels of education are crucial.

What Is “Seamless Education?”
Currently 43% of dietetics undergraduates either are not accepted for, or do not apply to, supervised practice programs. Structuring education so students flow seamlessly from undergraduate to graduate to supervised practice in one institution is potentially more cost-effective, fair, and responsible, according to the task force. Yolanda Ortega-Gammill, RD, is the new practitioner representative to the education task force. She notes that she has a friend who completed a combined master’s degree/internship program that included a graduate assistant stipend. Ortega-Gammill not only had to pay tuition to attend her internship, she also had to relocate, start paying student loans, and cope with other financial pressures at the same time. She believes that if she had the opportunity to complete a graduate degree and supervised practice at the same time, she would have ended up better both professionally and financially.

There are three possible scenarios under the proposed new system:

• graduate degree — earn an undergraduate degree in any area of study; apply for a graduate program that includes both didactic and supervised practice; eligible for the RD exam;

• 3 + 3 program — spend three undergraduate years in any area of study; in the third year, apply for a three-year graduate program that includes both didactic and supervised practice; eligible for the RD exam; and

• practice doctorate program — complete an undergraduate degree in any area of study; apply for a 3.5-year practice doctorate program that includes greater emphasis on the skills necessary for autonomous practice including differential diagnosis, clinical reasoning, ethics, clinical concepts, and clinical practice; eligible for the RD exam.

Does a Grad Degree Equal a Better Practitioner?
A majority of participants in focus groups that were part of the task force work process disagreed that changing the dietetics education system is necessary. Instead, they were more concerned with recognition of the RD as the nutrition professional, competition with other practitioners, and consumer perception of the RD. The task force, in Appendix E, states, “defining the profession through education and credentialing standards is one of the few true levers available for change.” The task force question-and-answer document notes that the $1.5 million national print advertising campaign conducted by the ADA in 1998-1999 failed to meet the goals of increasing public awareness or credibility of RDs. The task force believes that increasing the education and competence of RDs will result in enhanced image more effectively than any marketing campaign.

If each RD is responsible for marketing himself or herself and our profession, then does a graduate degree really make a difference? Sandra Parker, RD, CDE, is the chair of the Diabetes Care and Education dietetic practice group (DPG). Although she considered working toward a graduate degree early in her career, family obligations and financial concerns got in the way. She’s a recognized expert in her field, currently enjoys a wide range of professional opportunities, and does not believe a graduate degree would enhance her career. However, she sees the value in maintaining similar education requirements with other healthcare professionals, and believes advanced degrees will be essential for RDs in the future.

Pat Kelly, RD, chair of the Medical Nutrition DPG, believes each RD makes his or her own reputation, with or without a graduate degree. She was an oncology dietitian prior to specialization and became a certified nutrition support dietitian when it was offered by the American Society for Parenteral and Enteral Nutrition. Both advanced certifications enhanced her knowledge and credibility. Since they were directly related to her practice responsibilities, they carried more weight than a general graduate degree. She notes that continuing education standards should be tightened and a peer-reviewed component added to ultimately improve the reputation and practice of all RDs; and if more entry-level education is required, how can we justify earning continuing education via reading journal articles that have the answers included in the publication?

Ortega-Gammill wishes she had started a graduate degree program as soon as she passed the RD registration exam. Now she is married, has children, works part-time, and volunteers for various leadership positions with the ADA. She would love to begin work on an MPH degree but notes that she struggles to balance her professional aspirations with the reality of her family life—a position reiterated by everyone with whom I spoke.

Undergrad vs. Graduate Training
Ross says that many undergraduates never intend to become RDs but instead use their undergraduate training for careers in research, food management, or entry into other healthcare fields such as physical therapy. Yet they are counted as part of the 43% who don’t apply for, or aren’t accepted into, internship programs. Instead of requiring a graduate degree, Ross believes that including more emphasis on research in undergraduate programs and restructuring the RD exam to move from pure knowledge and skill assessment to include actual competency will result in greater benefits to the profession.

Ortega-Gammill believes there is too much uncertainty in the current internship application process. Often dietetics students become disillusioned if they do not secure an internship and may go on to other careers. She likes the proposed changes that eliminate this uncertainty and ultimately allow for more in-depth mentoring and broader opportunities to become an RD.

Nineteen percent of current dietetics internship programs include a graduate degree. If graduate degrees are truly important for entry-level practice, why aren’t there currently more of them? Frances Largeman, RD, food and nutrition editor at Health magazine, chose an internship where she could earn a graduate degree but only took two required courses. She found graduate school expensive, was ready to begin working, and wanted to move to a different area of the country. Her lack of a graduate degree has not prevented her from pursuing her desired career path in journalism. If many current RDs cite time and expense as barriers to earning graduate degrees, why would people choose a career that from the beginning mandates this additional education? Are we running the risk of decreasing the number of RDs with these new education requirements?

The task force notes that employers say entry-level RDs are not meeting their expectations. Yet all the clinical managers I spoke with indicated that they do not preferentially hire new practitioners with graduate degrees. D. Milton Stokes, RD, is chief clinical dietitian at St. Barnabas Hospital and Nursing Home in the Bronx, N.Y., and is currently pursuing a graduate degree in public health. Stokes prefers a system where entry-level RDs work for a few years to obtain experience and decide what area they want to specialize in before they begin a graduate program. He values education and agrees that our current system needs revision, but cautions against becoming so highly specialized that practitioners are locked into one area from the beginning of their career. Also, his employer helps pay for his graduate degree, which is an important consideration for many RDs.

Are Graduate Degrees the Only Way?
Ross agrees that our current education system needs to be revamped, but worries that these recommendations don’t go far enough in meeting the stated objective of increasing time spent ensuring competency. The new education options don’t substantially increase the amount of time students currently spend in preparing for a career in dietetics. Many students take five years to complete their undergraduate degrees and then follow with another year of supervised practice. Unless competency is specifically addressed, the change in education will not result in improved entry-level practice. Ross’s department just completed a proposal for a graduate degree/internship program at the University of Vermont that is basically the same as the first option in the task force recommendations. She believes this is a viable option for many, but certainly not the only route to become an RD.

One benefit of including a graduate program with supervised practice is the availability of student loans. While the task force acknowledges the greater expense incurred with a graduate program, most internships now charge tuition yet interns are not always eligible for financial aid. It may be easier in the long run for students to obtain a graduate degree immediately, rather than waiting until later when typically family and work responsibilities often make spending the time and money on a graduate degree prohibitive. Web-based graduate degree programs may decrease the travel time involved, but the expense continues to be a major barrier for many current RDs. Recent discussion on the ADA electronic mail list concluded that RDs shouldn’t start a graduate program believing they will recoup the expense in higher salary levels.

Change Is Necessary
Everyone I spoke with agrees that change in the way we educate RDs is necessary to compete in today’s healthcare market and to ensure a respected role for RDs in the future. Increased time spent developing competency in the wide range of areas required for RDs—community nutrition, foodservice, clinical nutrition, and management—is crucial to train truly competent practitioners. Fostering sound research skills and educating practitioners to develop and follow evidence-based guidelines is a necessary part of training RDs.

The task force includes only two members who do not have graduate degrees: one is a student and the other a new practitioner representative. Ten of the 14 other members are educators. While it may seem intuitive that educators are best-positioned to recommend changes to our current education system, there is also value in asking many RD practitioners and employers in a wide variety of settings for their input. A medical model for educating RDs may work for those who are clinically oriented, but not every RD pursues—or ends up working in—clinical care.

It’s discouraging that many RDs I spoke with were not even aware that the task force existed, or that recommendations in the manner we educate and train RDs have been proposed. A straw poll at the Dietetic Educators of Practitioners DPG Northeast area meeting held in the beginning of April resulted in all 58 members voting against the recommendations as they currently stand. They agreed that change is necessary but are unsure that the proposals will create significant improvement in the skill and competency of entry-level RDs.

Next Steps
The HOD discussed the task force recommendations at their spring meeting held April 30 to May 1. Due to the enormous amount of e-mails and phone conversations from ADA members about the recommendations, the HOD opted to vote on the following motion:

1. The task force should continue working.

2. A review of the task force’s composition will be conducted to ensure that appropriate balance is present and, if necessary, adjustments will be made.

3. The RD and DTR recommendations need further consideration by the task force.

4. The results of the dialogue will be communicated to members to keep them informed and when appropriate, member input will be solicited before further action should be taken.

5. The task force will be asked to collaborate with the CADE to outline what the implementation steps may look like and will include a timeline and focus.

6. Given the discussion during the HOD meeting, the HOD Leadership Team crafted a motion that was posted May 6:

Therefore, be it resolved that the Dietetics Education Task Force, using the above guiding principles and member input, continue their investigation of education for RDs and DTRs to meet future needs and, at a minimum, provide a progress report in October and a final report no later than May 2006.

During electronic voting the end of May, the HOD accepted the motion. The new charge to the task force will be to explore alternatives to address the future education needs of all entry-level dietetics professionals (DTRs, RDs), as well as advanced-level practitioners. In addition, the HOD Leadership Team has been asked to review the task force composition and make adjustments to ensure inclusion of nonclinical practitioners (food and culinary professionals, community, foodservice management, and/or school nutrition services). Members can watch for a report this fall on progress being made by the task force to continue the discussions.

If the recommendations are approved, current RDs will be “grandfathered” in and it will likely take five to 10 years from that point to make changes in the educational process.

— Lynn Grieger, RD, CDE, is in private practice in southwestern Vermont and the Healthy Eating Expert at www.ivillage.com.