Was The DPT The Right Direction For Physical Therapy? 10 Points To Ponder

By 2015, all physical therapist educational programs will be clinical doctorate degrees.  Along with this transition, it has been proposed that all physical therapist assistant educational programs become Bachelor’s degrees by 2030. A similar trend exists in the worlds of pharmacy and nursing.

But is this the right direction to take? Or did the profession of physical therapy in the United States develop a faulty plan built on faulty assumptions, and then sell that to the profession? Is it degree bloat? Or value-added benefit?

Here are 10 points to ponder.

1. This is the only country in the world to do so. The United States is the only country in the world that has the doctorate degree as the entry-level degree for physical therapy practice. Most of the clinicians that have had the greatest impact on our profession (i.e. McKenzie, Maitland, and Kaltenborn) have a Bachelor’s degree as their entry level to practice.

From a purely logic-driven perspective, either the United States has it all right – and all the other countries of the world don’t – or something is amiss here from the get-go.

2. The perceived benefits of being a “doctoring profession”. Many in the physical therapy profession have proclaimed that being a “doctoring profession” would allow physical therapists to have greater “equality” with other clinicians and to provide better care.

But as noted by Erin Fraher, an assistant professor of surgery and family medicine at the University of North Carolina School of Medicine,

“Everyone’s talking about improving patients’ access to care, bending the cost curve and creating team-based care … Where’s the evidence that moving to doctorates in pharmacy, physical therapy and nursing achieves any of these?”

What it has done is put the physical therapy profession directly in the cross hairs of the American Medical Association. Physicians focus on the use of the term “doctor” and defend their scope of practice fervently. The goal of the physical therapy profession has never amounted to “wanting to be a doctor” in the traditional sense of the word. But perceptions count, especially when it is the AMA.

3. The perceived patient expectations. The APTA has proposed that societal expectations would demand the move towards a clinical doctorate degree. This cultural change has simply not occurred or even become a relevant point of discussion. In my own 24 years of clinical practice, I have never once heard or had expressed to me the importance of this in the consumer's eyes. I guess that means that either I am oblivious to it or this simply is not the expectation in the community.

4. A critical element in attaining consumer direct access – or is it? The APTA has proposed that the profession needs the doctorate level of education to help our efforts in professional autonomy. The hard data would indicate the opposite. Over the past 12 years, the number of DPT programs has exploded, but the number of states with true consumer direct access has stayed stable at 17 states. I believe this to be one of the greatest fallacies of the DPT debate. Again, I would refer to #1.

5. It focuses on the needs of a changing landscape of health care. I have heard the phrase that “entry level graduates need to know more in the current health care system”. Fair enough. But are they learning the things they need, such as refined clinical reasoning skills, education in business models, and greater clinical instruction?

If the level of education was so critically important, then those with Bachelor’s degrees as the entry level of practice would simply not survive in today’s system. We know that to be a falsehood. It doesn’t require a doctorate to provide excellent patient-centered clinical care in today’s changing landscape.

6. It is a more extensive degree than the [insert here] degree. This follows closely with #5. Doctorate students get the same (if not fewer) clinical hours in their education now as compared to Bachelor’s degree programs 25 years ago. Although didactic classroom education is important, clinicians are made in the clinic. Having greater research skills doesn’t matter if you don’t know what questions to ask in the clinic. It puts the cart before the horse.

Who’s providing that necessary clinical instruction for the vast majority of these students? Bachelors- and Masters-educated physical therapists, of course.

7. Licensure defines autonomy – education doesn’t. With or without a clinical doctorate, the bottom line is to attain licensure and pass the board exam. With or without a clinical doctorate, a physical therapist has to be responsible for his or her clinical actions and must make appropriate referral to other clinicians when the patient’s condition falls out of their scope of practice. This isn’t something new attached to the clinical doctorate – we have always done this.

If licensure requires the clinical doctorate level of training, then anyone that doesn’t have it would be unable to pass the exam. Foreign-trained physical therapists are quite capable of passing the licensure exam, especially if they receive the same exam preparation that US students receive.

8. A degree that has a very poor return on investment. As it stands right now, most physical therapy students are going to come out of school with $100,000 or more in debt. Over the past 20 years, salaries have not matched this rise in educational cost. Reimbursements are dropping in the meantime. But expectations of the new graduate are rising and they expect this to equate to dollars and cents.

9. It has fostered an “us versus them” mentality within the profession. Back when the concept of the clinical doctorate was first proposed, there was a “we are all in this together” mentality. Not so much now. There is an attitude that exists within the profession that screams a ”my degree is better than yours” mentality. This has been counterproductive to say the least. I would suggest that once a new graduate has 10,000 patient visits, regardless of entry level degree, they can then pass judgment on education and clinical skills.

10. It was an attempt to change our self image. In most other countries in the world, a physical therapist is a highly-regarded, independent, autonomous professional and an equal in the world of health care. That is the self image of the profession. It is not quite the same in the United States. While the profession is moving along at glacial pace, the DPT provided something new and exciting, a shiny new object on the horizon. But did the DPT just give the profession a new coat of paint and an inflated sense of self without accomplishing the social and cultural dynamic that is so critical to its success?

Who benefited from this change? Does the consumer benefit? I would suggest “no” as consumer access to care has not changed. Does the PT benefit? Salaries are not going up, reimbursements are going down, and the cost of education is skyrocketing.

But if you assess the situation from the perspective of the world of academia, you see the value. Why? Consider the economics from the educational perspective. How many hours of instructional time does a student receive, and what would the cost of that time be? I read an example that suggested that if you consider $43,000 a year for tuition, and about 500 hours of instructional time, it would come down to $86 for every one hour class period that you attend or don’t attend. For a class of 25 students, the school is compensated over $2,000 for one hour of time. No wonder there are more and more PT programs springing up!

Consumer access to physical therapists – regardless of degree. The consumer will choose the provider that can help them to get better - regardless of name, degree, or letters after your name. They will also do so based on the ability to access the provider directly without a referral requirement and without limitations.

The patient will choose a chiropractor, massage therapist, or perhaps even their personal trainer for guidance and care. Why? The patient perception is that it will help, it is readily accessible, and there are fewer roadblocks to care. There is rarely mention of degree program completed – or lack thereof.

If the consumer can’t access you directly, the degree won’t matter. It is apparent that the entry level degree requirements for licensure have not changed the level of patient access to physical therapy.

Physical therapists can stand together – with or without a clinical doctorate. We can build a profession that has the basic tenets of consumer direct access as its foundation – regardless of entry-level degree – much like the rest of the world. It just requires a “Vision Now” mentality – the sooner, the better.

Photo credits: garlandcannon