The Future of Physical Therapy Education

This recent opinion piece in the NYTimes and blog post in the Harvard Business Review has many parallels to the transformation that has to (and I believe will) happen within the PT profession over the next 10 years, primarily a reduction in the number of years that students are on the “tuition dole” from a typical 3 years to closer to 2. As it currently stands, PT students already pay tuition during their final year, with the vast majority of that time being spent in a clinical affiliation setting where the university is actually providing very little in direct services in exchange for those final year tuition $s. I can already hear DCEs around the country shudder in reaction given the amount of administrative time they invest in matching students to clinical affiliations, visiting clinical affiliation sites and students, etc. However, even this is a highly inefficient process that itself needs reform (and one we’ve discussed here previously), primarily through the adoption of longer term internships with a standardized curricula that leverages peer learning and collaboration similar to a medical residency model (which btw is in stark contrast to our current disjointed 1:1 instructor:student model in which experiences are highly variable between clinical affiliation sites that are, at best, only loosely connected to the academic program). Some of these models are beginning to pop up (examples here, here, and here), but far more progress needs to be made in reforming clinical education to catch up with the reforms that happened years ago in the didactic curricula with the the transition to the DPT. These longer term internships would eventually morph into a post professional residency model in which PT students graduate and sit for licensure after 2 years, with the 3rd year internship/residency in an employed setting not unlike medical residency. This would be a huge boon to clinical education providers who no longer have to dance around complicated billing regulations (especially federal) regarding the provision of care by unlicensed personnel. On a related note, why virtually any of us provide clinical education in the current model speaks to the enormous benevolence and altruism among the PT community (because it makes absolutely no rational sense), and certainly one of our major strengths as profession.

Although the applicant pool to PT academic programs currently remains strong, we will undoubtedly see a tightening in the jobs market for PTs as the implications of increased federal regulations (discussed recently here) with respect to Medicare (ie, MPPR, G-codes, etc.) fully kick in over the next several years. There is little doubt, for example, that MPPR is a huge boon to PTAs, for example, who will soon be the provider of choice for virtually all Medicare patients (sorry Medicare patients…you won’t have much access to skilled PT). The collective implications of these reforms will cause prospective PT applicants to be faced with an increasingly difficult choice…take on an ever growing debt burden in a tightening job market and the resultant difficulty in paying back student loans versus  simply choosing another profession. The good news is that crises bring out the best in entrepreneurs so the profession will adapt and overcome. The real question though is whether we will do so at a rapid enough pace to be on point (ie, patient access without referral, wellness, etc.) in a post health care reform environment or if we will stay relegated to hospital basements for the next 50 years as we have the last 50. What say you?

John

14 responses to “The Future of Physical Therapy Education

  1. That is a very eye-opening assessment of the field. I agree there will be some real soul searching amongst both current PTs and teenagers in high school considering a career in PT. I’m certain that most in PT, and for that matter most in healthcare, are uncertain of the future of the healthcare system and the implications of reform and increased regulation. I think beyond entrepreneurship there will be a necessitated need for the real cream of the crop to rise up and take the profession by the horns. The means to which we all have the ability to join the conversation or at the least stay updated are easier than ever with access to social media/blogs/and news feeder options. Let’s all put our head together!

  2. Burton Ford says:

    I see it as a major problem in the future if we as a country do not get this student loan mess remedied in some way, let alone physical therapy education. Too expensive, not enough return on investment. I definitely agree it doesn’t have to be that way, perhaps the third year of PT school being free or a lot cheaper would be one of the ways. We really need to bind together, especially for the sake of new grads considering the tuition hikes, and quickly. I suppose allowing a 3rd year PT student bill, get paid a small amount, and have a clinic pay the school tuition? Is it just me or do PT students pay about 360 million dollars in tuition each year? 18000 students x ~ $20,000/yr.

  3. Steve says:

    OK an op ed and a blog post—-interesting. Now get some factual information in this post.
    This seems like the same argument that Universities just charge tuition for nothing during con-ed…and private companies will do it for FREE? I doubt it!
    If it were such a bad system how do explain the large number of applicants to PT schools?

  4. Igor says:

    Please clarify the statement below. Do you really think PTAs do not know what they are doing and don’t provide skilled PT?

    There is little doubt, for example, that MPPR is a huge boon to PTAs, for example, who will soon be the provider of choice for virtually all Medicare patients (sorry Medicare patients…you won’t have much access to skilled PT).

  5. Barbara Sanders says:

    The Academic Council of the APTA is working to develop a Clinical Education Summit in 2014 specifically to discuss some of the topics John presented. Obviously, this is a very complicated issue with many concerns and many interested parties. The goal for us all is quality education of physical therapy and physical therapy students. There will never be one perfect model but we would like to address the quality options that can be incorporated into existing educational models. Evidence based infromation is critical to helping make informed decisions. Information about the proposed summit is available to the broader practice communities on the APTA web site.for communities.

  6. Physical therapy has wide scope in future.People are moving towards these alternate medicines which is giving them much benefit.Therefore people undoubtedly going towards these kind of medicines.

  7. Dr. Duane A. Williams says:

    Interesting dialogue. There are many decisions to be made. I think, as a profession, we jumped into the deep end of the pool before learning how to swim in the health care system.. What is the evidnence-based body of knowledge of physical therapy we want to practice and offer to the public? We have PTA and DPT programs, but nothing in between. Maybe the MPT should be the the entry-level into PT practice and the DPT could be earned in specialty areas (including generalists) as part of a paid clinical residency program. Also, is our profession adequately addressing prevention/wellness activities since a majority of health care problems are lifestyle related? We are paying for our hasty decisions.

  8. Shawn Valentine PT, DPT says:

    Being one year removed from graduating with my DPT the biggest complaint I had back to the school right before graduation was our last year of the program. The first four months were all elective type of classes and then the final six months were spent out on a clinical affiliation…I told them I felt it would have been much more productive to complete class work for two years and then the final year be completely clinical based…of course I feel that should be a residency year but the school does not want to hear that all simply because they would have lost out on 36x$31,000 = $1,116,000…colleges and universities have as much impact on us new grads as does the evolving nature of the healthcare reimbursement system.

  9. Barbara Van Gorp, PT, DPT, OCS says:

    This is a very interesting discussion. I think we as PT’s need to step it up in hospital settings and get involved in mgmt and development so that we do work on being an important part of the healthcare team. It takes time, it takes committment, but the skills we have in PT are needed. We just need to show in all areas that our skills are not the same as a personal trainer, ATC, PTA etc. We have to educate students coming thru programs and give them clinical that challenge them. John is correct – we are too variable across the nation with accountability on clinicals. We have to step up as a profession and show leadership.

  10. Kyle Anderson SDPT says:

    Interesting discussion that needs to be addressed, and as a current 3rd year PT student I hope something changes soon. I worry for the profession if something isn’t done.

  11. K. Faust, PTA says:

    Government regulation will dictate how the profession is paid because the majority rely on Medicare. As a PTA who is not sure she wants to spend the money on PT school, it is disappointing for me to not further my education because of the tuition cost. I agree with a 2 year program with a residency for the 3rd year. I have worked with many PTs who have a BS to the DPT and what really matters is that the PT wants to be a good PT and cares about progressing his or her patients. The degree doesn’t necessarily make a good PT. And, please appreciate a good PTA, just as I appreciate and respect any good PT. We spend 2 years of education on PT after our pre-reqs are met, so we can assist the PT with treatments and meet patient goals. And, we are considered “skilled” treatment.

  12. DPT student says:

    Reflecting on my own clinical experience: Strengths and weaknesses, as well as my rationale as to what an academic institution’s affiliations for clinical education should ethically and legally hold true.

    I mentioned a 50+ week clinical internship as a “strength” however it also presents as a major weakness in the ethical and legal realm of providing clinical education. For almost a year, in my cohort there have been 44 students who have been working anywhere from 36-40 hours per week (some of us on 12 hr. days) for absolutely free, and at the same time we have been paying for it generously, approximately 7-8k per semester to paint the picture. When I tell patients or friends that I see 20-30 patients per day as a student and do not get paid they literally cannot believe it, as they shouldn’t. I understand the traditional model of clinical education where some people may just say, “That’s how it is” when the correct response should be, “That’s how it was, now what are we going to do about it.” I also understand that not only is the profession changing, but so is the realm of clinical education in what we hope to build a bright future for young clinicians. I am not going to go in depth when I say that physical therapy clinical education should not provide the opportunity for business, or a specific private practice to thrive or make monetary profit directly from the volume of patients that an individual intern bills 3rd party payers for on a daily basis.

    In the United States, an “internship or trainee” is defined by the The U.S. Department of Labor’s Wage and Hour Division which allows an employer not to pay a trainee or intern if all of the following are true:

    1. The training, even though it includes actual operation of the facilities of the employer, is similar to what would be given in a vocational school or academic educational instruction.

    2. The training is for the benefit of the trainees.

    3. The trainees do not displace regular employees, but work under their close observation.

    4. The employer that provides the training derives no immediate advantage from the activities of the trainees, and on occasion the employer’s operations may actually be impeded.

    5. The trainees are not necessarily entitled to a job at the conclusion of the training period.

    6. The employer and the trainees understand that the trainees are not entitled to wages for the time spent in training.

    Similar To An Education Environment And The Primary Beneficiary Of The Activity:
    “In general, the more an internship program is structured around a classroom or academic experience as opposed to the employer’s actual operations, the more likely the internship will be viewed as an extension of the individual’s educational experience (this often occurs where a college or university exercises oversight over the internship program and provides educational credit). The more the internship provides the individual with skills that can be used in multiple employment settings, as opposed to skills particular to one employer’s operation, the more likely the intern would be viewed as receiving training. Under these circumstances the intern does not perform the routine work of the business on a regular and recurring basis, and the business is not dependent upon the work of the intern. On the other hand, if the interns are engaged in the operations of the employer or are performing productive work (for example, filing, performing other clerical work, or assisting customers), then the fact that they may be receiving some benefits in the form of a new skill or improved work habits will not exclude them from the FLSA’s minimum wage and overtime requirements because the employer benefits from the interns’ work.”

    Displacement: “If an employer uses interns as substitutes for regular workers or to augment its existing workforce during specific time periods, these interns should be paid at least the minimum wage and overtime compensation for hours worked over forty in a workweek. If the employer would have hired additional employees or required existing staff to work additional hours had the interns not performed the work, then the interns will be viewed as employees and entitled compensation under the FLSA.”

    Job Entitlement: “The internship should be of a fixed duration, established prior to the outset of the internship. Further, unpaid internships generally should not be used by the employer as a trial period for individuals seeking employment at the conclusion of the internship period. If an intern is placed with the employer for a trial period with the expectation that he or she will then be hired on a permanent basis, that individual generally would be considered an employee under the FLSA.”

    If some of my fellow students are scratching their heads on marking any of the above criteria as “false”, please, keep reading. Now that the law has been reviewed and understood, I am constantly debating on whether the facilities where I received my own clinical education “followed the rules” set forth by the above entity to ensure work-related benefits and rights (yes, students still have rights in the workplace). Over the course of this last year, as a student I have displaced “regular” employees as a working physical therapist. I have billed thousands of dollars (1300 treatment visits and counting) based on a revenue-by-volume model where the business I worked for derived an “immediate advantage” and where there were no “operations impeded” by my presence as a student physical therapist. Did I gain adequate clinical experience/exposure during my clinical rotation? Sure. Did the employer/business gain monetary benefit directly from my “productive work” as an intern? Absolutely.

    As an accredited academic institution that provides evidence-based learning for future physical therapists, I would recommend a few things.

    1. Ensure proper screening of your clinical affiliates. DPT programs screen the students thoroughly upon academic enrollment with interviews and documentation review. The same attention needs to transgress when sending students for year-long clinical experiences to ensure their rights under the Fair Labor Standards Act (FLSA).

    2. Due to the fact that the 6 criteria above are not met in many situations during clinical residency, as physical therapy students it is our right to be informed that we may HOLD AN “EMPLOYMENT RELATIONSHIP” AND THAT THE FAIR LABOR AND STANDARDS ACT’S MINIMUM WAGE AND OVERTIME PROVISIONS MAY APPLY TO US.

    3. There needs to be strict guidelines set forth with clinical affiliates where there is a solid understanding for the difference between a “trainee” and “employee” as evaluated by the The U.S. Department of Labor’s Wage and Hour Division (WHD).

    With all this true I have had a great experience during my year-long rotation. I feel that I have grown as a professional and that I will achieve success as a physical therapist moving forward. I hope the current landscape of clinical education changes in the future so that students and cohorts alike are able to achieve a sound clinical experience under the laws set forth, and if deemed appropriate for their given position, are compensated for their efforts which is well-within their rights.

    http://www.dol.gov/whd/regs/compliance/whdfs71.pdf
    http://wdr.doleta.gov/directives/attach/TEGL/TEGL12-09acc.pdf

  13. sarah says:

    I am finishing my bachelors degree in May and I have been accepted into PT and OT school. (I applied to both not sure which one to pick) What should I do! I am completely lost with what to choose. I keep hearing PT is so secure and it is so easy to get a job, then on the other hand I hear there are not jobs etc. With OT I hear it is a up and coming field or I hear it is impossible to get jobs. WHATS THE TRUTH! I would love to hear a PT and OT’s response to my situation. Thanks for the help.

  14. Fed Up says:

    Been in the Physical Therapy profession for almost 20 years; Management, Senior Tech, Exercise Specialist, etc. As far as I have witnessed, alongside with other P.T.’s, the profession really screwed itself by adopting the DPT level of education for a profession that doesn’t need that kind of education. Physical Therapy is simply a branch from nursing and doesn’t require the kind or amount of education that it has self-proclaimed itself into. If physical therapy actually stuck to its scope of practice/discipline, then none of this would even be an issue. The education physical therapy is great, but not really needed since most of what actually works on patients, exercise, massage, etc isn’t physical therapy, its fitness training and massages, which isn’t physical therapy. Physical Therapy profession has become an embarrassment to the medical community if anything. If you want this profession to be respected in the medical community, then you need to humble yourselves, realize what your profession really is, and stick to your scope of practice instead of stealing other disciplines and trying to take credit for it. Also, you’re the only profession who chooses to take apart their own people. I hear so many P.T.’s cutting down P.T.A’s and for what? Whether you like it or not, P.T.A’s have the same training as P.T.’s do; the only thing P.T.A’s don’t have training in, is “Evaluations”. You P.T.’s need to get your “&%$!” together, before it’s too late. I have a deep respect for the profession, but only the ones who actually perform Physical Therapy and there are very few of them. There is a reason why Physical Therapy is used in Long Term Skilled nursing facilities; because that’s where Physical Therapy can actually be used. Opening up outpatient facilities was a bad business decision, since 90% of patient in those clinics didn’t need it and now that insurance companies are cleaning house of certain professions, a lot clinics have closed down or are using other “Disciplines” to market themselves and bring in revenue. You guys need to scale back down to what your discipline really is, or you will find yourself in HUGE student debt and no job. Just imagine if Personal Trainers expanded their education and learned Neurology or Surgery; it would be a good education, but for what? They aren’t Neurologists or surgeons. Well…. Physical Therapy is the same thing, they have a great education on the body, but that’s it; they aren’t Neurologists and you don’t need that kind of education to do gait training, joint mobilization, or neural re-education, etc; which is based on theory and if it’s still based on theory after 50 years or more, the it’s obviously doesn’t really work. Get your &^^% together before it’s too late. Physical Therapy can still be a good profession, but you need to stick your scope of practice and STOP taking apart your own people/PTA’s; you’re all in this together.

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