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October 2001


The Future of PT

By Rich Smith


The profession of physical therapy will find itself in a world of hurt before long unless it soon abandons "edict- and guru-based" practice in favor of treatments and techniques backed by hard evidence of efficacy, according to Jules M. Rothstein, PhD, PT, FAPTA, a professor at and former head of the Department of Physical Therapy, University of Illinois, Chicago (UIC), and winner of the 2001 McMillan Lecture given at the 2001 annual conference of the American Physical Therapy Association (APTA).

One solution, as Rothstein sees it, is to fill the ranks of physical therapy with better-educated practitioners-men and women who know how to access and assess available research on efficacy. The place to produce these better-educated individuals, he contends, is in the physical therapy school.

Rothstein-editor of Physical Therapy, the journal of the APTA since 1989, and previously chief of clinical services at the University of Illinois Medical Center-recently was interviewed by Rehab Management on his views concerning physical therapy education and, in particular, the merits and potential problems with the relatively new doctor of physical therapy degree (DPT).

REHAB MANAGEMENT (RM): You contend that practitioners of physical therapy often do not know whether there is evidence to support the approaches they have embraced. How is this detrimental?
ROTHSTEIN: Having no evidence of efficacy puts you on uncertain terrain. It is not fair to the patient unless we are honest about what we know and don't know and admit what is based on evidence and what is not. It is certainly not fair to the payor. What would be revolutionary for our profession is for us to make it a routine matter of course to look for that evidence of efficacy. It may turn out that there really is no evidence to support this or that technique. But at least we would have engaged in good science by having conducted the search for evidence. Like all health care professionals, we will have to function in many areas without the benefit of evidence, but that is something we should hope to change as we gather more evidence. We cannot suspend patient care until all the evidence is in, but we can be candid to ourselves and others about the certainty we bring to our interventions.

RM: Why is evidence-seeking not a common practice among PTs already?
ROTHSTEIN: In part, the reason is that most physical therapy schools do not teach from an evidentiary basis. Instead, we depend on an authoritarian model in what I have called guru-based therapy. The problem is that, while we have a lot of wonderful people in our profession, we do not have a tradition of checking what they say, of validating and verifying what they say, or demanding they check through research. An irony in this is that some of the gurus don't even know they're gurus. They just say things and, because of their personal and professional charisma, people fall at their feet. You can tell when you're dealing with guru-based therapy because the therapy always has someone's name in front of it-the So-and-So Approach, the So-and-So Taping Technique. But is anyone asking, "Where's the evidence that this actually does anyone any good?" How long will people keep speaking about these same techniques without ever attempting to do research on them? My point is that if guru-based therapy does not stop, it will destroy our profession.

RM: How so?
ROTHSTEIN: As the Baby Boomer generation ages and begins to heavily tax the health care system to the point that resources severely shrink, the profession of physical therapy will be vulnerable to massive cutbacks. The cutbacks will be experienced if we are still practicing based on edict and guruism. The payors are going to have to allocate their money very judiciously, and so are individuals. They are less likely to pay for anything that is not based on evidence.

RM: What is the solution?
ROTHSTEIN: The starting point is to fill the ranks of physical therapy with better-educated practitioners. If you go through the average curriculum of physical therapy programs, you discover that a great many treatments are discussed without addressing the extent to which evidence exists in support of these treatments. Because of that, we're going to have to change the educational structure and have a revolution in terms of faculty, in terms of teaching differently, and in terms of working with clinicians who will appreciate this difference.

RM: You have been quoted as saying that the better-educated therapist is the one who possesses the title of doctor of physical therapy-DPT. True?
ROTHSTEIN: Yes, the DPT degree should be seen as clear evidence to employers that the PT they are hiring is a better-prepared practitioner. As far as I am concerned, the holder of the DPT should be the best equipped to be an effective practitioner because the DPT should be a recognition that the holder has been educated in physical therapy to the fullest extent possible within the context of a postbaccalaureate program. More important, these individuals should be in the best position of any physical therapist to continue growing professionally, by virtue of the rigorous and thorough education they have just completed.

RM: Does the DPT have practical application for the recipient, or is it just an embellishment?
ROTHSTEIN: It qualifies, in my estimation, as an entry-level degree. In fact, I believe it should be the only entry-level degree for a PT. The way it works is this: you are a physical therapy student pursuing your bachelor of science degree. You do this in order to fulfill your PT curricular prerequisites. At the end of that, you then enter a postbaccalaureate program, which culminates with the conferring of a DPT degree. Here at UIC, you complete the DPT program in 3 years. The significance of the DPT to the profession, to the health care industry, and ultimately to the patient is that the care being provided is coming from an individual who has learned more about application and will need less time in initial clinical practice after graduation to function at a high level. Graduates of a DPT program (where the program is done correctly) should be ready to practice at a much, much higher level as soon as they enter initial clinical practice.

RM: Now that the DPT degree is finding acceptance in a growing number of schools, do you see a downside in any of this?
ROTHSTEIN: I am concerned that physical therapy students will be lulled into thinking that the postbaccalaureate programs offered around the country are all more or less the same in terms of instructional content and, more important, in terms of quality. The reality is that, at present, there are the accreditation requirements of CAPTE (Commission on Accreditation in Physical Therapy Education), but content and quality can vary greatly. That means a school calling the diploma issued at the end of its postbaccalaureate program a master's degree could conceivably have provided instruction and training of a higher quality than that which was provided by another school awarding a DPT.

More than that, I would argue that the school offering the master's degree is cheating its students because the students are doing what by any fair measure should be recognized as doctoral-level work. But, on the other hand, that same school is not cheating its students at all because it is providing the superior education-and that is what matters most.

RM: This disparity among schools-is that strictly a reflection of the breadth and depth of the course work?
ROTHSTEIN: No, it is also a reflection of the quality of the faculty. I am sorry to say this, but there is a dearth of qualified faculty to provide the level of instruction that a good DPT program requires and deserves. On many campuses, the physical therapy faculty's credentials are often inadequate for academic purposes and for making contributions to scholarship and research efforts.

RM: A criticism leveled against the DPT degree is that it will raise costs. First, the cost an aspiring PT must pay to be made employable; second, the cost employers must pay in the form of salaries and benefits commensurate with the higher level of expertise possessed by the holder of a DPT degree. Your response?
ROTHSTEIN: Any increases in costs will be easily offset by the fact that DPTs from a quality program are prepared to function with minimal or even no supervision right out of the box. Properly trained DPTs are going to be a cost-effective asset to the enterprise that hires them, and will actually keep other costs in check because their expertise will contribute to shortening the length of time patients need services, to reducing the volume of services patients need, or to both. I also see no additional costs that need be borne by employers. I see no reason why persons with a DPT should receive salaries any higher than any other competent newly graduated therapist. When master's degree programs grew in number, it was not the degree that made salaries go up but rather it was supply and demand; therapists with both entry-level master's and bachelor's degrees got higher and essentially equal salaries.

RM: At PT 2001, you had the honor of giving the annual McMillan Lecture. In that presentation, you took to task those practitioners who pine for a return to the past, to the glory days of physical therapy. What is your objection to that?
ROTHSTEIN: The physical therapy department used to be the profit center for many hospitals 30 years ago. The inside joke was that, while the PT department may have been relegated to the basement, it paid for the hospital's first two floors. And there was a lot of truth to that-there wasn't a physical therapy department around that did not bring money into the hospital to support other services that could not pay for themselves. When we were in that position, hospital administrators treated physical therapy practitioners with courtesy and esteem and they offered financial rewards and did not demand the highest levels of productivity. There was even a shortage of therapists, so hospitals were offering great opportunities, sign-on bonuses, you name it. This changed in the mid 1980s when DRGs (diagnosis-related groups) for billing purposes began. From then on, inpatient PT billings were no longer counted separately from the hospital's. We lost our star status as a result. With the advent of cost containment a few years later, many PTs and PT supervisors were laid off. In part, they were laid off because the money was no longer there to continue paying for them. But the other part of that was that some of them were laid off because they were not very effective at delivering good outcomes.

RM: Closing thoughts?
ROTHSTEIN: PTs should be valued not merely because they possess a clinical doctoral degree, but because of what they do. Believe me, you can seldom be more cost effective as when you are only giving treatments that make sense because they have been proven to work.

Rich Smith is a contributing writer for Rehab Management.

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