Storm Clouds on the Horizon: The 3 Perils of Unconstrained Academic Growth in Physical Therapist Education

Abstract

The storm clouds we see in physical therapist education portend risks of hardship not dissimilar to hazardous weather conditions that demand preparedness for survival. We propose that the flood of new doctorate of physical therapy (DPT) programs and expansion of established programs over the past decade in the United States warrants action about perils that may challenge the very roots of the academy and seriously affect the practice of physical therapy. These include the potential for the following: (1) supply and demand imbalance: creating an oversupply in the workforce that compromises employment options for practicing physical therapists and new graduates; (2) negative value proposition: worsening economic conditions in physical therapy that could reduce the motivation and feasibility of becoming and remaining a physical therapist; and (3) decreased number and quality of applicants: a declining applicant pool that is insufficient to fill enrollment targets with desired matriculants. On the heels of responding to the volatile world of COVID-19 and pandemic-fueled uncertainty, we must not naively hope that the storm clouds will somehow disappear but must instead direct substantial attention and effort toward solutions that will mitigate the impact of these 3 perils. In this Point of View, we detail the perils, outline their implications, and offer potential responses to reduce the power of the storm clouds, thus preserving the integrity of our profession as it proceeds into the future. Over the past decade, the rapid development of new DPT programs and the expansion of existing programs has helped create conditions wherein supply of physical therapists is now projected to exceed demand. Even though the need for physical therapists is projected by the Bureau of Labor Statistics (BLS) to increase 21% over the next several years,1 the supply has been outpacing the projected growth every year since 2017.2 The Health Resources and Services Administration also reports that in 2022, the supply of physical therapists (267,870) will exceed the demand by 5470 (262,400).2 Data from the American Physical Therapy Association (APTA) also project a surplus of approximately 5000 physical therapists in 2022 that increases to 25,000 by 2031.3 Childs et al have stated that there are 2 major flaws in the methodology of the APTA projections.4 First, setting the supply equal to demand in 2019 inflates the trajectory of projections, suggesting a greater surplus downstream. However, although not ideal, it has been the convention in workforce modeling to set the starting point of supply equal to demand instead of making unsupported assumptions about the degree of surplus or deficit in the absence of empirical evidence.5 APTA did not have reliable “hard data” about a current workforce imbalance at the time of the modeling (R. Watson Ellerbe, personal communication, January 2022). Second, the lack of explicit detail about the attrition rate in the APTA model was cited as a flaw in the methodology. However, although not stated explicitly, the APTA workforce projections did include a 3.7% attrition rate, which was based on the 2019 total occupational separations rate as published by BLS (R. Watson Ellerbe, personal communication, January 2022). We argue that minor differences in the degree of surplus should not be the main point; rather, the existence of 2 independent workforce projections (BLS and APTA) showing surplus conditions should be the primary focus. Regardless of methodological concerns, taken together, these 2 workforce estimates suggest a growing supply and demand imbalance that will likely worsen with the continued proliferation of new and expansion programs. Moreover, the lack of substantial change in our practice models and our reimbursement for care may potentiate this imbalance. New program growth has accelerated since 2013 with 45 newly accredited programs and 70 additional programs in either the candidacy stage (19) or other stages of development (51).6 Importantly, the APTA workforce projections drew data from the Commission on Accreditation of Physical Therapy Education (CAPTE), which included only accredited and candidacy programs and did not include the 51 additional programs in preaccreditation stages of development, most of which can be expected to achieve accreditation.6 Thus, the APTA workforce projections undercount the number of physical therapy graduates expected per year by an estimated 2346 graduates when taking into account the 51 developing programs and average typical class size of 46 students per cohort.6 Even with a 3.7% attrition rate incorporated into the APTA’s workforce projections (R. Watson Ellerbe, personal communication, January 2022), available data demonstrate growth outpacing demand. In light of current evidence, we question the need to continue expanding or developing new programs without assurance of opportunities for graduates to practice in their chosen career. Creating an oversupply in a workforce that promises narrow employment options for graduates is diametrically opposed to sound strategic planning, especially in an environment in which health care cost containment pressures are working to negatively influence practitioner salaries. Ironically, a historical undersupply of physical therapists has allowed competition from other health professions to move into traditional areas of clinical practice and, in several cases, provide duplicate services. This encroachment has blurred our scope of practice, created a false sense of security about our position in health care, and dampened our ability to assure our graduates a secure and sustained position in the health care system. Current efforts to expand our scope of practice into primary and specialized care have not been sufficient (yet) to shift workforce supply into new or underserved areas of practice, especially in the face of significant growth in the education of new physical therapists. The question of optimal supply to meet work force demand is not endemic to physical therapy. For example, pharmacy saw a rampant expansion of programs (2004: 89 programs, 2021:142 programs)7 followed by significant oversupply, decreasing salaries, and a major enrollment crisis in pharmacy schools.8–12 Despite many in the pharmacy community sounding an early alarm,8,11 the expansion continued and market forces are now forcing a new equilibrium in pharmacy with precipitous declines in salaries, employment, and student applicants.9,10,12 We believe that physical therapy may be heading in the same direction as pharmacy. If we fail to heed those warnings, the market will impose its own corrections on our profession. Are we willing to “face into the storm” that is beginning to affect physical therapy education as Alan Jette asked us to do for practice?13 Have we been overconfident about our ability to expand the scope of practice and create new jobs to avoid an oversupply of physical therapists? We believe the most logical and immediate solution to the impending oversupply of physical therapists is to slow or halt the development of new and expansion programs until we can achieve an upward trajectory of demand supported by full demonstration of evidence-based practice, equitable health care reimbursement, and expansion of job opportunities that match the aspirations of practitioners across the span of their careers. Careful and collaborative planning is critical to achieve and maintain a balance of workforce supply and demand. A value proposition is a promise of benefit or outcome, in this case of entering a profession that is robust and meaningful in health care service and has opportunities that can sustain a long-term career. In the face of oversupply, the proposition of becoming and remaining a physical therapist may be at risk. We believe the value proposition for physical therapists is also being challenged by encroachment, lack of regard for the efficacy of our services, and reimbursement challenges. Decreasing reimbursement will likely have a negative effect on practitioner salaries, which could diminish interest in entering or remaining in the profession. Salaries, for example, may not keep pace with inflation rates. We also are moving precariously close to an unsustainable student debt limit without evidence of substantial institutional or governmental investment in scholarship funding, leaving practitioners with a student debt burden that challenges the economic value of a career in physical therapy.14 Accrued debt load is associated with numerous factors, one of which is the type of program attended. Data from the CAPTE indicates that students graduating from programs developed since 2006 (67 of 85 programs housed in private institutions)6 enter the profession with total debt closer to the $150,000 threshold at which the net present value (lifetime economic power) of the DPT degree falls below most other health professions.14 Moreover, APTA reported that the majority of new graduates (9 in 10) have already passed this threshold, with an average debt of nearly $153,000 ($116,000 from their physical therapy education).15 The impact of this debt is affecting career choices, work settings, and quality of life, including important life events such as purchasing homes or contributing to retirement. Furthermore, all of this is compounded for underrepresented populations.15,16 If the issues related to debt in physical therapy are not addressed, it will contribute to the negative value proposition in physical therapy and have other potential downstream consequences such as delaying or forgoing post-professional education, which could, in turn, affect the professoriate. The fact that a majority of developing programs (38 out of 47 or 78.7%) and newly accredited programs since 2006 (67 of 85 or 78.8%)6 are in private institutions with total tuitions over $100,000 highlights the growing problem of student debt in physical therapy. Berry reports that student loan debt is approximately $35,000 higher at private institutions than at public institutions ($138,361 to $103,482, respectively).17 Indeed, the growing problem of student debt may be more of a reflection of the costs of attending new programs (which are housed mostly in private institutions) that have recently started graduating students rather than increases in tuition at already accredited institutions. We believe this complex picture of student debt in physical therapy warrants serious and collective attention by all stakeholders. The dueling forces of oversupply in some areas and maldistribution in others, decreased reimbursement, and increasing student debt move the value proposition of physical therapy as a career option closer to unsustainable for many who may be interested. Moreover, the value proposition will touch the lives of practicing physical therapists who are or may experience negative salary pressures if available positions are filled with less expensive new graduates, graduates who specialize early and demand a narrower scope of practice, or with physical therapist assistants or non–physical therapist personnel trained on the job. We believe that rectifying these conditions will require a long-term, concerted, profession-wide effort to accelerate activities in (1) research that further clarifies the value proposition of physical therapy, (2) advocacy to the public about the importance of physical therapy to health across the lifespan, and (3) policy changes that improve reimbursement and support for professional education. Re-defining the value proposition requires a realistic assessment of the pressures facing our current practitioners and the potential that DPT education expansion will exacerbate these pressures. Application rates for health professions education programs are a proxy for survival in the competitive environment of career preparation. These rates are monitored by all professions as a signal of continued interest in the work and impact of each group and a barometer of health of the individual education programs. Enrollment targets are set first through institutional planning processes and pursued to ensure the financial health of the institution. Although accreditation dictates that workforce need must be shown for class size to expand, it may not be the primary motivation when planning institutional expansion.18 Enrollment targets are controlled by accreditation rules to avoid exceeding approved cohort size. Growth in DPT programs occurs by (1) increasing the size of existing cohorts, (2) adding additional cohorts to an existing program, (3) creating expansion programs affiliated with existing programs, and (4) developing an entirely new program at an institution not yet hosting DPT education. Since 2013, 52 programs have increased their approved class size, 6 programs have added additional cohorts, 17 expansion programs have been created, and 45 programs have been granted candidacy to deliver a new DPT program.6 The success of these actions relies on having sufficient applications from qualified candidates to realize enrollment targets. However, the slowly declining trend in application rates for physical therapy is not occurring in allopathic medicine and osteopathic medicine, both of which are experiencing record level growth in applicants.19,20 Data from APTA’s Physical Therapy Application Service represent reports from 95% of developing, candidacy, and accredited DPT programs. A distinction in the data is made between the number of applicants (individual people) and the number of applications because prospective students often apply to more than 1 of the 275 recognized DPT programs in the United States (includes programs granted candidacy). A peak number of applicants and applications to DPT programs occurred in 2016, with a slow decline occurring each year since that time. The most recent data from APTA’s Physical Therapy Application Service show a 6.7% decline in completed applications during the period 2019 to 2020 (R. Bannister, personal communication, January 2022). Although environmental conditions (eg, the pandemic) could be responsible for any decline, it is important to recognize that, of 13 health care professions (ie, allopathic medicine, communication disorders, dentistry, occupational therapy, optometry, osteopathic medicine, pharmacy, physical therapy, physician assistant, podiatry, psychology, public health, veterinary medicine), physical therapy had the third largest decrease in applicants in 2019–2020 and the second largest decline in applications over the last 4 years (R. Bannister, personal communication, January 2022). Perhaps more importantly, a deepening trend of decreasing enrollment is beginning in DPT programs, with 92 programs of 275 (33.5%) reporting the inability to matriculate a full cohort in 2021 (2015 = 35, 2016 = 50, 2017 = 48, 2018 = 53, 2019 = 64, 2020 = 71).6 An increasing number of programs and enrollment positions across programs, paired with a flat or decreasing number of applicants, does not bode well for the collective health of our DPT programs. Importantly, we seem to be heading in the same direction as pharmacy, which has experienced decreased total applicants every year since 2009, with many programs having to decrease the size of their cohorts.7 Despite downsizing cohorts and closure of some schools, pharmacy still had fewer matriculants than available seats (15,419 seats and only 13,324 applicants) in 2020 to 2021,21 which meant that approximately 20% of programs did not fill their already downsized cohorts. An additional concern is the qualification of applicants, and pharmacy has shown a consistent year-to-year decrease of matriculant overall and science grade point averages (GPAs) since 2006–2007 (overall: 3.49, science: 3.40) to a low in 2019 to 2020 (overall: 3.28, science: 3.12).7 In the early years after the warning of a potential surplus in pharmacy,11 the GPAs decreased marginally from year to year. However, over the years, these marginal decreases accumulated until it became evident that there had been an undeniable shift in applicant qualifications. Thus, the GPA decline acted as a trailing indicator, thereby confirming negative trends in applicant pool competitiveness and perhaps decreasing interest in becoming a pharmacist. If physical therapy mirrors these trends, it does not portend well for both the quantity and qualifications of applicants. Based on available data, it is still too early to determine if there has been a change in quality of applicants in physical therapy. Using GPA as a trailing indicator of decreased competitiveness, we believe this trend may emerge in the near future. Closure of existing physical therapy programs is rare and has only occurred a few times in the history of physical therapist education. Practically speaking, halting the development of new programs already in process may not be feasible unless leadership at these institutions chooses to redirect resources to other ventures while the workforce dilemmas in physical therapy are addressed. In Table 1, we offer what we believe are practical strategies for survival in academic physical therapy. Although some of these strategies address seemingly competing dynamics in the control of supply and the expansion of demand in the health care system, they demonstrate the complex interplay of solutions required to mitigate the consequences of these 3 perils. We appeal to the education community to unite in the effort to keep our profession strong in these uncertain times. Proactive Survival Strategies for Academic Physical Therapya aACAPT = American Council of Academic Physical Therapy; APTA = American Physical Therapy Association; CAPTE = Commission on Accreditation of Physical Therapy Education; DPT = doctorate of physical therapy; PT = physical therapy. This Point of View issues an alert for the DPT education community that application, enrollment, and workforce data are not in alignment with the trend of program expansion, whether that occurs by developing new schools, adding cohorts, creating expansion programs, or increasing class size. The profession of pharmacy began its call for response to “uncontrolled academic growth”8 in 2005 and continues this call to date. We believe the creativity and commitment of physical therapy can be harnessed for effective action to avoid negative consequences of our growth patterns and extend the impact of our work in health care. Above all, we are calling for a clear-sighted view of the storm clouds on the horizons of education, research, and practice in physical therapy. Although not a simple solution,22 a profession-wide strategic approach focused on how the workforce meets the needs of patients and population health is critical for physical therapy to survive.23,24 Concept/idea/research design: S.S. Deusinger, M.R. Landers Writing: S.S. Deusinger, M.R. Landers Data collection: M.R. Landers Data analysis: M.R. Landers Project management: S.S. Deusinger, M.R. Landers There are no funders to report for this work. The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.

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