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“A True Profession”

Jerome L Martin

I commend Threlkeld et al for providing a framework for the clinical doctorate (DPT) as the first professional degree in physical therapist education. There are additional reasons why the DPT should be the only degree for the profession. Notice that I used the word “profession.” Traditionally, those occupations recognized as “true professions” have been medicine, law, and the clergy.

The professionalization of any field is an evolutionary process along a continuum from nonprofessional (technician) to professional (expert). According to Blau and Scott,1 there are 6 major characteristics of all professions:

  1. Professional decisions are based on a distinct body of knowledge possessed only by those representing that profession. Can anybody else do what a physician does?

  2. Professionals possess a level of expertise in a specific, limited area. This expertise allows them to exert authority in only their specialized area.

  3. Professionals' interaction with their clients is characterized by “affective neutrality.”1 This entails adherence to a specific code of ethics that directs behavior.

  4. Professional stature is predicated on the individual's performance in relation to standards determined by his or her colleague group.

  5. Professional decisions are not based on self-interest or personal gain, but on the altruistic goal of helping others.

  6. Professionals are members of an organization that requires self-control of their professional behavior, training, and practice.

In reviewing those characteristics, we should ask the following questions:

  • Do physical therapists have complete autonomy of practice? (Not, by law, in all cases.)

  • Do we have a level of expertise that only we possess? (DPT?)

  • Do we have a professional association? (Yes.)

  • Do we have licensure or a credentialing process that certifies the role and scope of practice of physical therapy? (Yes.)

  • Do we have a code of ethics? (Yes.)

  • Do we have rigorous training requirements before entry into practice that only we possess? (DPT?)

So, what don't we have to be recognized as a true profession like medicine, law, and the clergy? In my opinion, we cannot make independent decisions or have complete autonomy in our practice. I contend that direct access is the vehicle for us to gain that autonomy. Would it be easier to achieve direct access if we could argue from the perspective of the DPT? The Pennsylvania Physical Therapy Association just won a lawsuit brought by chiropractors who argued that “physical therapy” is a generic term and that anyone can do physical therapy. Would the DPT enable us to better refute those kinds of claims and make the case that only physical therapists can practice physical therapy?

The profession needs to move forward expeditiously in considering the DPT, eliminate the multiple levels of entry into the profession, and make a clear statement to the health care industry and society in general that we are capable of independent decision making! Physical therapy has all of the key characteristics traditionally viewed as hallmarks of true professions except the highest level of education and the ability to make autonomous decisions. The DPT will help to satisfy these two characteristics.

As DPT programs develop, they should provide avenues for physical therapists with bachelor's or master's degrees to return to earn the DPT. The DPT programs, in environments where appropriate, should consider offering PhD programs so that those people who desire to pursue academic careers will be able to obtain the DPT/PhD. Professional degrees or clinical doctorates will not meet the criteria for promotion and tenure in the academic setting. Curiously, why aren't we calling it the “PTD” instead of DPT?

The profession, at this stage in its history, needs to take the next step in meeting all of the elements of a true profession. The DPT is simply the next logical step in the evolution of our profession.

References

“No Difference in Substance”

Throughout most of the article, by Threlkeld et al, the reader could substitute “MS” or “entry-level [professional] MS” in place of “DPT” with little or no difference in substance. The authors do not differentiate the DPT from the master's degree well.

Student Outcomes

Yes, the physical therapy environment is vastly different today from what it was only 1 year ago, and I feel we should use these tumultuous times to our advantage. In his June Editor's Note on the DPT (“The Future We Want; the Future We Get”), Dr Rothstein states that “in the face of shortage, expectations are diminished.” Does this mean that in the face of excess, expectations must be elevated? To answer this question I give a resounding “yes.” The DPT may, provide a partial solution to the multifaceted and complex dilemma in which we are currently immersed.

Dr Rothstein also notes that some in the profession may wonder whether this is an opportune time to pursue the DPT. I would answer in the affirmative only if the pursuit of the DPT is based on sound reasoning. But what is our rationale? The answer must lie in what we want our graduates to be and in how the DPT graduate differs from the graduate of non-DPT programs. Threlkeld et al frame the DPT with an emphasis on conceptual and integrative competence. How does the curriculum specifically address these competencies? How are these competencies assessed? And are we saying that the non-DPT graduate does not and cannot possess these attributes? Even more importantly, how do we assess these differences between modes of academic preparation? The answer must lie in student outcomes.

Threlkeld et al provide an insightful analysis of the external factors that influence professional education, and I share their opinion that the public image of a physical therapist should not be transparently biased by academic preparation. Hopefully, the public's image of all physical therapists is that they are informed professionals who serve as a competent entry point into the health care system. This perception should transcend educational preparation or academic degree. In fact, the numerous questions posed by the authors and framed by Stark et al's1 conceptual basis could and should easily be applied to all physical therapists, not just those prepared at the clinical doctorate level.

The authors state that image should not be a factor; however, I take issue with the fact that the authors use the DPT graduate's self-perceptions (image) as a basis for the DPT. It is almost amusing that these DPT graduates feel they “have increased respect from physicians” and note that doors have been opened “that would not have ever been opened otherwise.” These perceptions are made neither with a comparison to non-DPT graduates nor with an experiential base to draw on. The same holds true for responses attributing “rapid advancement into management positions, assignments in the marketing arena, and assuming primary responsibilities for the development of new clinical service programs” to the DPT. Again, what about using the other non-DPT graduates for a comparison? If the move to the DPT becomes mandatory, the rationale for adopting the DPT must not be based on unfounded testimonials. The answer must lie in student outcomes.

Creighton University is truly a pioneer in the DPT. The authors, who are faculty at Creighton, note that their students opt for the DPT versus other degrees offered in physical therapy. I fear that institutional competition and enrollment management have resulted in “degree escalation.” It appears that there is a good deal of “keeping up with the Joneses” to remain competitive in the higher education market. Many institutions are making the transition to the DPT. I would venture to say that many of these transitions have occurred on the basis of testimony and competition and not on the basis of a serious re-evaluation of the institutional and departmental mission—that is, they have occurred without significant alterations to the current curriculum or without assessments of student outcomes and overall program effectiveness.

The current dilemma concerning the DPT should spur serious self-reflection as we are all affected by this issue. Though it was a slight drop, the first decline in overall APTA membership in this decade occurred this past year. In light of the current environment, membership in APTA may take a dramatic plunge. This is the time, however, that physical therapists not belonging to APTA should join their professional organization. Physical therapists need to be informed, involved, and pro-active. Physical therapists should work for a solution and not let complacency contribute to disjointed efforts, knee-jerk reactions, and poor dissemination of information. Physical therapists should look to their leadership to be proactive and to provide valid data from which to make informed opinions and facilitate meaningful dialogue.

Now is the time for members to band together and demand more from our parent organization. The DPT needs to be thoroughly studied. Focus groups and “town meetings” to provide qualitative data are a good start. We need to push APTA to create a national database in conjunction with existing physical therapist education programs. Among other things, these data should be used to provide information on the academic environment, program and graduate geographical saturation, and, most importantly, short-term and long-term cognitive and affective student outcomes.

References

“Buying Respect”

I read both the article and the Editor's Note with an open mind, looking to be convinced. After reading both, I am even less convinced than I was!

Several of my concerns with the DPT revolve around Dr Rothstein's own words in his editorial. I agree with the statement that physical therapists did not obtain the data to support our clinical activities while we had the luxury of time. Yet, to my knowledge, there have been no data to support the move from the bachelor's degree to the professional master's degree in terms of superior outcomes of graduating therapists at the higher educational level. Even Threlkeld et al admit that there are “limited data to answer questions about the interaction of the [DPT] degree with the marketplace.”p570 In addition, the employment surveys of graduates of DPT programs discussed in the article indicated that “we cannot contend that [the employment] diversity was a function of the degree over other factors”p570 and “the influence of the professional degree on salary cannot be stated with certainty.”p570 How can anyone even begin to justify progressing to the DPT without these data?

Although Dr Rothstein mentions that “many of our academic faculty were poorly equipped” in regard to teaching and scholarly activity and that these faculty members would never have been hired by any other department, the article specifically addresses the DPT as a method of preparing therapists for the academic setting. How can this be? Most academic institutions donot recognize the DPT as a terminal degree. In addition, we are selling our current academicians short if we think we can educate physical therapists in the profession of physical therapy and in educational psychology and instructional methods simultaneously and with the level of quality that we have come to expect.

My impression of the move to the DPT is that as a profession, we are trying to “buy” the respect of the public, physicians, and third-party payers through a credential. You can't buy respect—you have to earn it! We have made great strides as a profession in earning the respect of physicians and the public and in educating and influencing third-party payers. Let's continue our efforts in that direction rather than chasing a rainbow.

In summary, my position on the DPT is “Just say NO!”

Management, Leadership, and Business

The authors adopt a conceptual framework that, at best, hints at the management, leadership, and business factors necessary to be included in professional doctoral physical therapist education program. The authors state that “DPT program graduates who are employed in…standard settings have reported rapid advancement into management positions, assignments in the marketing arena, and assuming primary responsibilities for the development of new clinical programs.”p570

There is no direct message addressing the opportunity to develop a high level of skill in the areas of management, leadership, and business in any DPT program that might exist. Let's be sure we design programs to enhance our skills in these areas.

“The Future Standard”

I am writing to express my strong support of the DPT as the standard professional degree for physical therapists. I feel this way for the following reasons:

  1. Meeting the demands of today's physical therapy clinical setting requires highly educated and highly skilled health care professionals. Exceptional diagnostic and treatment skills are a must. I believe that most patients are not referred to a physical therapist with an appropriate diagnosis, and it is up to us to make one and then treat effectively. Insurance does not give us much time to do this. If we are going to be valuable assets to health care today, we must be competent and efficient. We can't afford to waste time, because ultimately the patient loses. It is not fair to the patient—who often doesn't get to choose his or her physical therapist—to be in the hands of someone with less-than-adequate education and training. Not only do these therapists give all of us a bad “rap,” they waste the patient's allotted insurance dollars and visits.

  2. The amount of education required to become the professionals that we need to be to best serve our patients is worthy of a doctoral degree. Already, therapists are going to school for 3 additional years following a 4-year college degree, only to earn a master's degree.

  3. Image is so important in this day and age. If the title “Doctor of Physical Therapy” gives us better bargaining power with third-party payers and legislators, then it has added value. Additionally, the public is still naive regarding our education level. For instance, I was once asked by a patient if I had to get an associate's degree to be a physical therapist.

  4. The proposed curriculum for the DPT that I am familiar with includes additional coursework that would be most helpful in preparing competent entry-level physical therapists (eg, in pharmacology, histology, basic radiology).

  5. Doctoral requirements to enter the profession would help “weed out” those who are not willing to go the extra mile. I realize this is not a guarantee against apathy and unprofessionalism within the profession, but I know of mediocre physical therapists who would not have entered the field if it required a graduate degree, let alone a doctoral degree.

  6. A doctoral degree would help distinguish us from massage therapists, certified athletic trainers, kinesiologists, and others. I realize that our education already does this, but those who are not familiar with our education (ie, legislators, the public, physicians, insurance companies) don't see that distinction as clearly as they should. A doctoral degree draws that line.

I see the DPT as the future standard for our profession. I graduated with my master's degree one-and-a-half years ago and just recently started the advanced clinical doctorate program to become a better clinician and keep up with the demands of physical therapy. I think we are doing ourselves a disservice if we do not go this direction.

“Fatal Assumption”

The case put forth by the authors proceeds under the fatal assumption that the DPT embodies the compensations for our current deficiencies in professional education. I suggest that (1) the DPT does less to ensure the competence of a student's training than does a full realization of the educational potential of a master's degree, and (2) the absence of such a realization is equally possible at the MPT and DPT levels.

The Commission on Accreditation in Physical Therapy Education (CAPTE) cannot mandate the degree at which institutions offer professional education. However, CAPTE can certainly ensure that the adequate training of a physical therapist requires, by nature, a genuine “graduate-level experience.” CAPTE will be much less effective in ensuring that programs fully realize the shades of distinction between a (genuine) MPT and a DPT (assuming these shades exist). I find it impossible to accept the assumptions of the authors that DPT graduates will be on a clinical “fast-track” or that they will teach or garner external funding better than those in non-DPT professional education. This is because no enforceable, tangible criteria define DPT education. As such, the only credible issue for debate is that our graduates “deserve” the title “doctor.”

Many of the arguments made by Threlkeld and colleagues are anecdotal: that the DPT best fulfills the goal of integrating science into practice, that the profession's obligation to society will expand in the future, that public image and respect demand the title “doctor,” and that their DPT graduates feel more respected. The authors emphasized the importance of societal image. I suggest that the DPT represents the now common practice of “degree inflation”; that our professional training has not met or exceeded the rigors and endurance characteristic of medicine, dentistry, and veterinary professional education (and that it does not need to do so, given our scope of practice); and that we are accepting the more recent, less stringent standards of professions such as chiropractic, pharmacy, and podiatry. Is this the image we want to portray to an increasingly more sophisticated health care consumer? And what of the chaotic, confusing image we now portray to the public and other health care professionals by our multitude of awarded degrees or titles? Creating such confusion within a single profession is socially irresponsible.

I propose that the DPT agenda exemplifies a common observational mistake: When we examine an ailing client, we sometimes look for the most obvious problematic finding and then attribute the ailment to that finding. In this case, the ailment is a dissatisfaction with the end-product of professional education; the finding is that we're not conferring the title “doctor” on recipients of that education. I suggest that ailments within our professional educational process are better addressed by understanding how current model programs achieve their high-quality “outcomes” and then tightening accreditation standards to encompass such findings. I also suggest that our ailment exists not in professional education, but in addressing the educational needs of our professionals after graduation—and it is here, away from the distraction of “doctor envy,” that our time, energy, and journal space should be occupied.

Where Is the Evidence?

As an academic administrator of a long-standing accredited program at a doctoral level I university, I endorse many elements of the authors' vision for education of the professional physical therapist. However, I remain unconvinced that the professional doctoral degree is itself necessary or indeed sufficient to accomplish the goals set forth by its advocates. My comments are designed to follow the model of Stark et al1 used by the authors of the original article.

Professional Education

External Influences From Society and the Professional Community

Several years ago, in preparation for implementation of a new professional master's degree curriculum, the faculty at our institution revisited the program mission, philosophy, and goals as they related to the new curriculum. We set ourselves the task of making specific commitments in terms of graduate attributes and competencies that we felt should differentiate between graduates from the master's curriculum and those from the prior baccalaureate curriculum.

This task was not as simple as it might seem intuitively. Rudimentary elements of competency are clearly identified in the evaluative criteria for accreditation2 and must be met by all education programs. Therefore, competencies regarding the ability to evaluate and treat patients, review and apply scientific evidence, participate in management and education functions of physical therapy practice, and demonstrate safe and ethical practice are assumed. Any accredited program has to document effectiveness in these domains, regardless of the professional degree. Bank et al3 reported on a survey of employers' perceptions of new graduate physical therapists from baccalaureate versus postbaccalaureate education programs. Their analyses showed no difference between graduates with baccalaureate, master's, and doctoral degrees in any of the following areas: preparedness for work in the areas of evaluation skills, interpersonal skills, treatment skills, and exhibition of professional behavior.

The possibility exists that other attributes might reflect the outcomes of new postbaccalaureate curricula, especially doctoral curricula, which are presumably designed to require greater critical thinking and inquiry-based learning. Rothstein4 has stated that educational institutions should turn their attention to developing more thoughtful practitioners who can critically evaluate evidence and use outcomes data in all aspects of practice. The new curriculum implemented at our institution certainly has the language of critical thinking and inquiry throughout. Therefore, we have proposed that professional master's degree graduates will not only meet the accreditation standards for these attributes, but somehow go beyond previous graduates in demonstrating those behaviors.

There is a danger in assuming that—because we, the faculty, attempted to facilitate these attributes throughout the curriculum—they will appear. Measuring whether doctoral graduates actually perform better than their counterparts who graduated with other credentials will be difficult. For example, surveys of employers of graduates often encompass questions about graduates' ability to function in the employment setting, such as safe and ethical practice and effective documentation, evaluation, and treatment. Most supervisors would come to some agreement on at least a nominal level of measurement of whether a graduate practices safely and effectively. But asking an employer about graduates' critical thinking and ability to use evidence in practice is more elusive and requires interpretation by the employer. Obtaining outcome data in this area will require an operational definition of the application of these attributes.

Failure to obtain such evidence puts physical therapist educators dangerously close to the “faith” attitude of practitioners whom Rothstein decries5 (ie, they believe that what they do is good and worthwhile, and they will continue to practice in accordance with this belief until evidence to the contrary is produced). I submit that this is no different than believing that, because physical therapist educators work so hard to stimulate attributes of critical thinking and scientific inquiry in the curriculum, these attitudes must of necessity be reflected in the graduates. The belief that, because of the change of a professional degree designation, such attributes will of necessity follow is an even more grievous presumption.

Furthermore, in addressing the questions proposed in the Appendix of the Threlkeld et al article, the salient question seems to be not whether the doctoral degree is sufficient to answer the questions, but whether it is necessary. In other words, we should determine whether graduates of professional master's degree programs are already meeting the professional outcomes and whether the professional doctorate would result in a documented ability to meet these outcomes at a higher level. Before the profession makes a move to change the education of the physical therapist once again, data must be presented documenting the value of the professional doctorate as compared to the master's degree. Only in that manner will the profession be able to justify a move that has the potential to change the nature of physical therapy practice, affect the demographics of the profession, increase societal cost for physical therapy services, and most certainly increase the higher education debt incurred in the course of becoming a physical therapist.

Societal needs.

Threlkeld et al discussed anticipated changes in the coming wave of health care consumers, calling for physical therapists to be educated to provide high-quality service in a culturally sensitive model. However, it is well known that one of the most effective strategies to promote equal access to health care services for a culturally and economically diverse group of consumers is to make sure that representatives of these groups are trained as health care professionals. Cornely et al5 concluded that one of the most effective ways to increase minority representation in the profession is to increase minority enrollment in education programs.

Hageman and Meyer6 discussed the mission-based focus of physical therapy programs located in state higher education institutions. They identified several factors that influenced physical therapists' choice to practice in a rural area, which included growing up in a rural area. The clinical doctorate, by increasing the length, cost, and accessibility of physical therapist education, has the potential to negatively affect the distribution of physical therapy practitioners who are willing to meet the needs of subgroups of the population, including minorities, the economically disadvantaged, and the geographically isolated who have difficulty with access to care.

I have serious concerns about this impact because, like Hageman and Meyer,6 I represent a physical therapy program with a strong mission to educate therapists to practice with a rural, often economically and educationally disadvantaged population. The physical therapist education program at my institution has participated in many state and federally funded initiatives to address this issue. It would be very disconcerting if a standard set by the profession reversed the trends and progress made to date.

Workforce issues.

Threlkeld et al acknowledged that workforce issues provide insufficient data to support a change to the doctorate. However, I was extremely concerned about one statement regarding the preparedness of professional doctoral graduates to work in academic faculty positions. This is another issue that will arise during the transition to a profesional doctoral degree and that must be discussed.

Since the early 1980s, there has been a major push in the profession to develop sufficient faculty trained at the doctoral level to serve as academic faculty. Through most of that period, it was well understood that the doctoral credential represented postprofessional qualification, in many cases progressing first through the advanced master's degree. I do not think any professional program can or ought to encourage graduates to pursue academic faculty appointments, other than as clinical adjuncts or laboratory instructors. Professional experience and development of basic and clinical knowledge are absolutely essential to serving as a qualified faculty member.

Individuals with advanced master's degrees in fields such as anatomy, exercise physiology, psychology, neurobiology, and public health who have a professional degree plus clinical experience make a very valuable contribution to our academic faculty. If individuals with professional doctoral credentials are able to compete with them for academic faculty appointments, I am very concerned about the effect on the quality of our academic faculty. One could argue that all academic faculty should be encouraged to obtain a traditional advanced doctoral degree (ie, PhD, DPH, EdD). However, representing these credentials to our consumers—including, in this case, students—will be a challenge. The qualifications of the faculty with advanced training as described above far supersede those of any graduate of a professional doctoral program; however, the potential for misrepresentation or misinterpretation of the credentials is great.

Salary.

As a consumer of physical therapy research, the data on salary presented in the article alarmed me. The representation of these data would not be permissible in any other article submitted for publication in Physical Therapy, and I do not believe it should have been presented here. The authors present data indicating that doctoral therapists receive an average salary that is slightly higher than baccalaureate graduates receive and that graduates with master's degrees receive the least. The authors acknowledged that these data were not adjusted for years of practice, which, in my opinion, makes them totally uninterpretable.

But, going a step further, the sample size on which these mean salary data are presented is difficult to credit: baccalaureate-educated (n=1,175), master's-educated (n=530), and doctoral level (n=4). It is difficult to believe that, in a journal of the caliber of Physical Therapy, these numbers were even permitted to be presented as data. There is a difference in the sample sizes of 4, 530, and 1,175 among doctoral-, master's-, and baccalaureate-level practitioners, respectively. This, at best, is dismissable data; at worst, it might be inferred that the authors preyed on a naive readership that would not catch this fallacy. Perhaps the professional doctoral graduates are capable of catching this error, whereas other graduates are not. However, such elementary components of analysis of data and literature have been part of every physical therapy curriculum with which I have been affiliated, including the 2-year baccalaureate.

Public image.

The authors cite anecdotal reports from an alumni survey that indicate graduates report several advantages to their doctoral credential. However, many of these advantages are based on a public perception of what is meant by doctoral credentials, not on a documented outcome of measurable characteristics that distinguished DPT graduates from other professional graduates.

There is no doubt that the public will associate the doctoral credential with a higher competency level than either the master's or baccalaureate credential. However, our professional mandate is to provide substantive evidence that in the case of the professional doctoral degree this perception is valid. Bank et al3 reported that most employers recommended that the profession adopt a standard professional degree, and they endorsed the professional master's as their degree of choice. Only 11% of the 137 respondents preferred a professional or advanced doctoral degree. The proponents of the professional doctoral credential are obligated to address such published findings in building their case for the degree.

Governmental influence.

Insufficient data are presented to support the notion that society would support the higher education debt incurred by students in graduate physical therapist education programs. It is true that new sources of financial aid become available to students in postbaccalaureate degree programs; however, these are also traditionally based on the concept that the population of students who progress beyond 4 years of college education becomes smaller and smaller. With the increasing numbers of programs requiring graduate-level education for entry level, more and more stress may be placed on this system. The profession may risk self-aggrandizement in assuming that the funding sources that support graduate health professional education, ultimately the public, would put the same priority on education of physical therapists as on physicians or dentists. Furthermore, with declining salaries and job availability, the market forces that encourage students to incur such amounts of higher-education debt are certainly changing. This deserves further study.

Intraorganizational Influences

Threlkeld et al make a clear statement of influences that contribute to the professional culture, including the mission of the institution of higher education.

Institutional mission.

The authors suggest, at a minimum, that DPT programs should be housed in higher education institutions with a rating of doctoral university II or higher. A review of Table 2 in their article indicates that, as of 1 year ago, 62 of 168 institutions sponsoring accredited physical therapist education programs would meet this criterion. As the policy adopted by the APTA House of Delegates at APTA's 1999 annual conference suggests, there is a critical need to assess the number of physical therapy education programs.7

However, the emotion of the current health care environment should not lead the profession into rash decision making. First and foremost, the distribution of qualifying institutions must be carefully assessed. Are the institutions representative of the geographic diversity of the country? With a total of 62 doctoral university II institutions, there would be approximately 1 institution for physical therapist education per state, with perhaps 2 programs located in the 12 larger states. But large states with immense population needs for physical therapy services may not be able to provide enough graduates out of 1 or 2 education programs.

The needs of smaller states must also be considered; they could possibly be left without an education program for physical therapists. Many years ago, our colleagues in occupational therapy published a manpower document that stated that the presence of an education program for specific health care practitioners is directly related to the distribution of practitioners for that region.8 Smaller states representing largely rural populations could be at extreme disadvantage in recruitment of physical therapists. A thoughtful analysis of distribution of qualifying physical therapist education programs is necessary to ensure that we do not unintentionally bias societal access to physical therapy and qualified service providers.

Program mission and staffing.

Threlkeld et al discussed the role the DPT degree may play in helping to bridge the gap between academic and clinical faculty. However, the insertion of a clinical doctoral degree may affect other professional trends associated with preparing to work in an academic environment. First, there is the concept of clinical specialization that the profession has endorsed. How the professional doctorate affects the motivation to pursue clinical specialization should be assessed. It seems imprudent for the profession to walk away from a credentialing process that was many years in the making and only recently seems to have realized its potential. Furthermore, the concept of advanced master's degree training needs to be taken into account. Our profession has been enriched by physical therapists availing themselves of numerous opportunities to study at a graduate level in disciplines related to the field of physical therapy such as those outlined previously. The long-term effects of the professional doctorate could mean the profession might become increasingly reclusive, no longer availing itself of the rich knowledge base of other related disciplines.

Continuing education.

The professional doctoral credential will presumably result in the need for current practitioners to use professional development opportunities to upgrade their credentials. I would like to restate my challenge to define the difference between the graduate with a professional doctorate and the physical therapist clinician. However, in the case of upgrade, the clinician likely has years of experience, has participated in mandatory continuing education, and has perhaps become a clinical specialist or received an advanced degree. The nature of transition programs that target the range of current level of professional training and development has yet to be determined. In fact, in order to justify the participation of a large professional workforce in a credential upgrade program, the question of what such a movement has to offer the individual and the profession must be clearly articulated.

If there is a struggle to define and measure the difference between professional graduates of different degree programs, which has yet to be supported by data, we can only imagine the difficulty inherent in the design of transition programs that have real value both to the individual and to the profession. In the absence of this documented real value, such programs could arguably be a means for universities that have the capability to offer upgrade programs to reap huge financial benefit. This is particularly true because electronic instructional media have made geographic accessibility to such institutions largely an irrelevant issue.

Professional Outcomes

Threlkeld et al have outlined areas of professional competence and professional attitudes that must be addressed in the course of moving to a professional doctoral degree. They have also articulated in their Appendix a number of questions that need to be answered about the doctoral degree. However, I have argued that what the authors have proposed is analogous to a simple posttest-only research design (ie, attempting to define and measure outcomes of professional doctoral education programs for the physical therapist).

This design is nonexperimental. I suggest that science demands more sophisticated analyses. By comparing follow-up data obtained through surveying graduates and employers of the same physical therapist education programs prior to offering the doctoral degree and after, a simple pretest-posttest design is used. But scientific rigor would be enhanced to an even greater extent by introducing a control group, preferably matched. Such a study would be as follows: I propose to match education programs for size, type of institution, and other variables and compare graduates of those programs offering the professional doctorate with graduates of those programs offering the professional master's degree. Rigorous assessment and comparison of outcomes can then be developed, and results obtained and analyzed. Such studies could be begun retrospectively with programs currently offering the doctoral degree. Prospective studies would be even more compelling, although they would take a longer time to complete.

Summary

Scientific rigor is being demanded to assess our clinical effectiveness.4 The rationale for failing to hold our education programs to such outcomes data prior to making a sweeping change eludes me. If data can be presented that the professional doctoral degree is necessary and sufficient for achieving the professional outcomes espoused by Threlkeld et al and other leaders in the profession who endorse the professional doctorate, I will not hesitate to support this professional initiative. Until such evidence presents itself, however, I will remain skeptical, and I encourage others in the profession to require data-based evidence before endorsing such a move. The change of professional degree credential is likely to have an enormous impact on the profession in the 21st century. Such a change surely demands that we ascribe to our own standards of evidence.

References

Author Response:

One of our goals in publishing our Professional Perspective was to provide a framework for discussion about the role of the professional doctorate as an entry-level (professional) degree in physical therapy. We are pleased that several of our colleagues have chosen to contribute to that discussion. In our response, we will reply to the common themes that have been raised. But first, we would like to address the issue of what constitutes a profession.

We agree with Dr Martin's comments that the discussion of the doctorate in physical therapy (DPT) is closely tied to a collective vision of physical therapy as a profession. We appreciate this opportunity to extend the discussion to include the professional status of physical therapy. Dr Martin refers to Blau and Scott's sociological text entitled Formal Organizations,1 published in 1962. The sociological theory on professions at that time was the well-known structural-functional perspective, wherein professions were seen to possess certain characteristics or attributes such as those listed by Dr Martin (eg, a theoretical body of knowledge, autonomy of practice).14

The word “profession” comes from the Latin, profiteri, which means to declare aloud, to accept publicly a special way of life in which one promises that the profession can be trusted to act other than in its own interest.5 Historically, law, medicine, and the clergy have been used as principal examples of professions. More recent theoretical work and discussion among sociologists have focused on the social and political process that is involved when occupations seek to professionalize.610 These authors characterize the dynamics of a profession as a fundamental social process embedded in the relationship between society and those who practice the profession.

Several of the questions regarding autonomy, direct access, and degree status raised by Dr Martin relate to important theoretical concepts about the professionalization process.6 For example, the client-serving occupation has to demonstrate to the public that the service that the profession provides is essential or of importance to the client, that the service task is exclusive, and that the task is complex. The extent to which the public recognizes the profession as providing that kind of service depends, in part, on image-building activity. Successful public recognition permits autonomy from the client and from employer organizations and results in status as a full profession. Despite the fact that they provide an essential, exclusive, and complex service to patients or clients, emerging professions or semi-professions are those professions for which the public remains unconvinced of their professional status. We believe that Dr Martin's claims about consensus for degree status are important and have everything to do with successful image building for the emerging profession of physical therapy.

We must also remember that the public's perception of a profession is not static—it is constantly reassessed. Professional status is not an indelible mark that once achieved will remain forever; rather, it is a position of trust given by the public that must be continually renewed through dedicated service to the good of clients and the needs of society. McGaghie says it well. “Professions are creatures of their Zeitgeist, the general intellectual and ethical climate and needs of a time.”11(p3) We will categorize the remainder of our responses within the model provided by Stark et al.12

Professional Education

External Influences From Society and the Professional Community

Messaros, Quarrier, and Tippett have expressed concern that the professional characteristics presented within the Stark framework could be applied broadly to physical therapist education, not merely to DPT education. We sincerely hope that this is true as we have tried to capture many of the facets of professional education that are based on societal need and the needs of patients. We contend that, when these facets are considered in aggregate, our description of physical therapist practice and education includes a level of societal expectation and professional training that is characterized by a professional doctoral degree.

It is heartening to read expressions of professional pride, but we question why these writers expressed aversion to the doctoral nomenclature as applied to physical therapy. The education system we have outlined is clearly comparable to existing professional doctoral degrees. We do not accept the contention of Messaros that only medicine, dentistry, and veterinary medicine have achieved some unique level of educational rigor that provides these professions with the sole right to confer professional doctorates upon their graduates. Messaros has even excluded the classically accepted professions of law and the clergy.

A review of the evolution of professional doctoral degrees as well as contemporary sociologic theory of professions supports our view that the professional doctorate is not the sole domain of a preselected few; rather, it is an indicator of a unique type of trust placed by society in a profession and the willingness of the members of that profession to accept and fulfill that trust.6,8,13 Professions evolve and can also regress. If physical therapists are to establish themselves within the public's view as autonomous professionals, then the only label that signifies that level of practice is the professional doctorate.

Societal needs.

Mandich proposes that the increased time and expense related to education at a doctoral level present barriers to rural and minority populations. This challenge exists for all professional doctoral programs and can be addressed in many ways. However, the solution should not compromise the educational purpose or professional outcome. Targeted recruitment policies accompanied by support groups, scholarships, and loans have been successfully used to attract and sustain students from rural and minority populations. Another strategy has been to allow students to engage in early study at an institution located near the targeted population and then have students transfer to a site that offers professional immersion and “enculturation” to complete the remainder of the program. We view the DPT as an opportunity to educate professionals who can provide primary physical therapy for rural and minority communities. Providing professionals who meet this need for increased access to physical therapy services clearly justifies the increase in time and expense for the doctoral degree.

Salary.

The available statistical data comparing salary ranges according to degree are limited, a fact reinforced by the misgivings of Mandich. The number of respondents from which our data were drawn was clearly stated, and we have confidence that practitioners can interpret these data adequately. A re-examination of the 1998 salary data collected by the Division of Practice and Research of the American Physical Therapy Association (APTA) still provides insufficient numbers to estimate salary trends of the small DPT population; thus, the data we published from the pool of 51 Creighton University graduates continue to be the best available. If APTA data are broken down by highest academic degree, the salary for the first year of physical therapy practice averages $39,134 (SD=$21,234) for graduates with a bachelor's degree (n=169) and $37,615 (SD=$18,570) for graduates with a master's degree (n=313) (unpublished data; APTA Division of Practice and Research; personal communication). The data for Creighton DPT graduates still compares quite favorably, with 66% of the sample (34 of 51 respondents) reporting salaries between $40,000 and $60,000.

Public image.

Another concern conveyed by Mandich, Messaros, Tasso, and Tippett was uneasiness about the subjective impressions of DPT graduates concerning the relationship of their degree to their professional status and advancement. Brennan provides a supportive view of the utility of the doctoral title in establishing relationships with third-party payers, lobbying in the political arena, and distinguishing physical therapists' practice from a range of other providers.

The positive qualitative information provided by some of the DPT graduates should not be dismissed or trivialized. The statements of the graduates provide clear evidence of successful professional socialization and a strong message of self-efficacy linked to the graduate's desire to advance and become integrated into the larger community of professionals. We believe that those who would dismiss these comments due to the lack of comparative data from recent graduates with other degrees are asking the wrong question. The comments are not comparative data; they are initial data that are indicative of positive education outcomes. Similar outcomes might be achieved by other education strategies, but we contend that the professional doctoral framework has the highest likelihood of achieving these outcomes and of evoking the societal reinforcement to maintain the therapists' self-view as the unique provider of physical therapy care.

Mandich cites a 1997 survey by Bank et al14 that reports an employer preference for a professional master's degree. It is understandable for employers to prefer a familiar degree. The pool of employers surveyed by Bank et al had little experience with DPT students, and only 8 employers had any experience with DPT employees. Given the 421 master's-level therapists engaged by these employers, the possibilities for a broad comparison of the attributes of 8 DPT graduates would have been exceedingly small. At the time of the survey, there were fewer than 50 therapists in the United States practicing with a professional DPT credential. As more employers are exposed to practitioners with DPT credentials, we anticipate that the preference will swing to the doctorate just as the employers in the survey by Bank et al strongly preferred the professional master's degree over the bachelor's degree.

Governmental influence.

Mandich raises a concern about public endorsement for federal or state funding to assist physical therapists in obtaining graduate professional degrees. We view public support as dependent on the public's view of physical therapists as independent professionals who provide preventive and rehabilitative services. Our society clearly views these services as valuable. The linkage in question is the binding of these services to physical therapist providers. The doctoral credential exemplifies an independent provider of care, and the professional who bears a doctoral credential is under scrutiny to live up to that expectation.

It is somewhat instructive to review the current programs from the Health Resources and Services Administration, Bureau of Health Professions, Division of Student Assistance.15 This is one of the primary federal sources of funding for students in health care. Twelve categories or “disciplines” are listed: allied health, behavioral and mental health, chiropractic, dentistry, medicine, nursing, optometry, pharmacy, physician assistant, podiatry, public health, and veterinary medicine. Of those 12 disciplines, only 5 are eligible for both Health Professions Student Loans and Health Education Assistance Loan Refinancing: dentistry, optometry, pharmacy, podiatry, and veterinary medicine. Medicine is eligible for Primary Care Loans and Health Education Assistance Loan Refinancing. All of these disciplines award the doctorate as the first professional degree. Clearly, the professional doctorate is more strongly tied to available federal student loan programs than any other credential.

Intraorganizational Influences

Institutional mission.

We have advocated the development of professional doctorates at educational institutions with professional cultures that support and provide multiple professional doctoral degrees. This description would include those “institutions with a doctoral university II or higher (Carnegie) rating, within a medical center, or at institutions that provide a spectrum of professional education at the doctoral level.”16(p574) Because the Carnegie rating system does not consider the professional doctorate when ranking education programs, a number of master's degree colleges that offer professional doctoral degrees would be overlooked by the Carnegie rating but would still be part of the pool of institutions that could provide an appropriate doctoral culture. Mandich expresses concern that this approach would result in a marked reduction in the number of schools offering a physical therapy degree, which, in turn, would reduce the availability of physical therapists. Rather, we speculate that a reduction in the number of physical therapist education programs in conjunction with an expansion in the size of the remaining programs (increased students, faculty, and resources) would improve the overall efficiency of physical therapist education, provide an appropriate number of graduates, and concentrate experienced faculty to improve scholarly interaction and productivity within these institutions.

Internal Influences

Program mission and staffing.

Mandich and Tasso take issue with the usefulness of the DPT as a faculty credential. The recognition of a clinical doctorate as an academic credential is certainly within the purview of each institution. We again state that, as in other health care professions, the clinical doctorate combined with demonstrated clinical expertise can yield a valuable faculty member for professional education. The evidence for this pattern in health care professional education is readily available in the literature.

The 1997–1998 survey of US medical schools showed that 74.6% of full-time faculty in clinical departments held the MD degree and only 14.5% held the PhD degree.17 The clinical departments employed 82% of all faculty within the medical school. The distribution of faculty credentials in US dental schools is even more striking.18 From a data set of 10,434 dental faculty who provided degree information, 84.3% (n=8,793) reported the DDS or DMD as their highest degree, and most of these respondents (n=8,095) considered their primary responsibilities to be clinical. Only 8.5% (n=888) of dental faculty reported the PhD as their highest degree. It should be noted that neither medicine nor dentistry excludes clinical faculty from their ranks. The profession of pharmacy is just completing its conversion to the PharmD as the sole professional credential, yet 40.8% of pharmacy faculty already report the PharmD as their highest degree.19

Although fewer objective data are available, the doctoral education programs of clergy and law rely heavily on faculty whose primary credential is the terminal professional degree of their respective professions. The viability of terminal professional doctorates within any given promotion and tenure process is specific to the academic institution. We expect that physical therapist education will demonstrate similar trends as professional doctoral education becomes the norm. In contrast to the concerns of Mandich, we do not perceive that a professional doctorate inhibits practitioners from pursuing clinical specialization, causes professional reclusiveness, or prohibits the pursuit of appropriate academic graduate degrees.

We restate that the DPT degree represents a broad preparation for practice but cannot replace clinical experience. When strong foundational preparation is combined with adequate experience, these individuals are well qualified to teach in the applied sciences and clinical phases of a professional program. The formal association of DPT-credentialed faculty with an academic institution produces distinct incentives for clinical research initiatives and provides an excellent foundation for clinical residency training.

Program structure.

An issue raised by Mandich, Messaros, Quarrier, Tasso, and Tippet was the demand for marked differences between physical therapist education that awards a master's degree and physical therapist education that awards a doctoral degree. In our article, we outlined several characteristics that we consider to be integral to professional doctoral education, including intensive study in the foundation sciences, strong grounding in theory and ethics, accentuation of the importance of the psychosocial domain, and extended clinical rotations. The desirability of this range of course work to support clinical practice is echoed in the letter by Brennan. Herrick's letter advocates increased curricular content in “management, leadership, and business,” an appeal that is consistent with current realities across all the medical professions. Even more important than the explicit curricular content is the infusion of the cultural expectations associated with the professional doctorate, such as a strong sense of obligation to society and the imperative to become a health policy advocate.

Do physical therapist education programs that award a master's degree strive for the same goals as those of a DPT program? We believe that they do. All physical therapist education programs must meet the CAPTE requirements, and physical therapy faculty are devoted to ensuring that physical therapy curricula are comprehensive. Mandich describes how the physical therapy faculty at West Virginia University underwent a process of defining differences in competencies in order to justify their movement from a bachelor's to a master's degree curriculum and wonders what new competencies would be added to justify the doctoral designation. A jargon term applicable to this competency-added approach is “ratcheting.” This is fundamentally an internal approach that does not compare professional competencies or curricular demands with an external framework.

Rather than “degree inflation” as assessed by Messaros, we propose that our current master's level educational structure is the victim of “curricular inflation.” A review of master's degree curricula will show that most have greatly exceeded the requirements and scope of other professional or graduate master's degree models.20 If an existing physical therapist education program is providing the scope and intensity of education as outlined in the model of the professional doctorate, the master's degree designation is certainly a misnomer and fails to recognize the efforts of the faculty and the skills of the graduate.

The doctoral education model does not segregate the profession by ascribing certain professional attributes solely to those awarded the DPT. There is no mystical didactic course or spectacular clinical experience that only a doctoral program can provide and that will forever separate the 2 degrees. It is a futile attempt to make black-and-white contrasts in a spectrum of educational experiences possessing all shades of gray. Rather, we have outlined attributes consistent with a professional doctorate, and the graduates of such programs have earned the right to be recognized by the doctoral title.

Continuing education.

Like Martin, we have advocated the provision of opportunities for practicing therapists with certificates, bachelor's degrees, and master's degrees to convert their credential to the DPT. Several education programs are already in place that allow physical therapists to undertake this transition to the DPT.21 Some physical therapists will choose to extend their education to include a PhD, but the example provided by medicine implies that most physical therapists will not select the traditional graduate education route.

Mandich expresses concern about mandated participation in a transitional DPT program. No other profession that has converted its degree structure to a doctorate has made such a requirement. The APTA document addressing the transitional DPT does not recommend such a mandate.22 An individual practitioner would make a decision about the utility of obtaining a transitional DPT and choose a specific educational institution just as he or she would for any other degree. Some data are available about the knowledge and skills that practitioners would perceive as valuable in a transitional DPT degree, including information about managed care or insurance regulations, business management and administration, a research component, an opportunity to address a specific clinical specialty area, and improved teaching skills.23 We view these goals as complementary to practice and consistent with professional doctoral education.

Professional Outcomes

Certainly, more extensive study of graduate outcomes is essential, and efforts are under way to collect these data from physical therapists with a DPT degree. Arguments that we cannot move forward until these data are available are problematic. We cannot acquire adequate outcome data if there are few (or no) doctoral graduates. We would certainly encourage comparable data to be gathered and published concerning graduates who were awarded certificates, bachelor's degrees, and master's degrees.

Mandich cites a 1997 survey reported by Bank et al15 in which employers perceived the skills of newly hired physical therapy graduates in the areas of patient evaluation skills, interpersonal skills, patient treatment skills, and professional behaviors to be equal, regardless of degree level. However, Mandich overlooked Bank and colleagues' report that newly hired DPT graduates were perceived as stronger in patient education, supervising assistive personnel, application of research findings, and professional advancement potential. These are precisely the areas in which we would hope a doctoral-level graduate would demonstrate strengths. Even the encouraging results of Bank et al must be considered with caution as there were only 8 DPT graduates represented in the pool of 293 new graduates.

Mandich proposes a design for a comparative outcome study but does not account for the variability within an education program such as changes in faculty, revisions of master's or doctoral curricula over time, and the extraordinary diversity in clinical education experiences. Even so, we can predict that a well-designed outcome analysis will not yield clear, unambiguous answers. No educational process can override the variation between individual students or graduates, the vast regional differences in marketplace opportunities, and the powerful effects of early employment experiences and mentorship. The academic degree is only one of many factors that influence outcome.

Summary

The adoption of the DPT as the sole degree for entry-level practice is but one step in the evolution of physical therapy as a profession; it is a signpost along our path. The foundational education signified by the DPT degree cannot, by itself, overcome the roadblocks to our professional autonomy. We must be prepared to couple our educational efforts at the entry level with an intensive, supervised postprofessional clinical mentorship. Working models for clinical mentorship experiences include the internships and residencies undertaken by medicine, dentistry, pharmacy, and other disciplines. The task of developing internships and residencies will demand years of development, but the fundamental framework is in place through the clinical residency certification process.24

The legal challenges to the autonomy and expertise of physical therapists, similar to the incidents leading to the Pennsylvania lawsuit recounted by Dr Martin, are often based on the premise that physical therapy is composed only of modalities or techniques that can be mastered by many other individuals. We must state clearly to our colleagues and to the public that physical therapists provide physical therapy care that results from the acquisition of distinctive academic knowledge and the judgment gained from unique clinical experiences. Modalities and procedures are to physical therapy care as venipuncture and medications are to medical care: tools that are in widespread use by many personnel but that can be applied in a distinctive, effective manner only by a professional with a specific type of knowledge and expertise. This high level of skill is signaled by the doctoral degree.

A central question that underlies much of the discussion about the clinical doctorate seems to be philosophical and has to do with our identity: Do we believe that physical therapists are professionals? We conclude that physical therapy has reached that developmental milestone. Certainly, professional maturation will continue, but it is time to assign a title that adequately describes the practitioner's abilities. Professions exist to serve society and meet the needs of individual patients. We believe we can best ensure and signify our role as the unique providers of physical therapy care to society and to patients by instilling in physical therapists the knowledge, skills, culture, and title of the professional doctorate. The words of Catherine Worthingham speak as strongly today as when they were published in 1970: If physical therapists are to assume a professional role in relation to other health professions, including medicine, a closer approach to peer equivalence, mutual respect, and recognition of responsibility is essential. When the majority of practitioners are at the baccalaureate level, such an accomplishment is unlikely.25(p1321)

We hope that this exchange of ideas will encourage the array of stakeholders both within and outside of the profession to join the discussion of the DPT as the sole degree for physical therapy practice.

References

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