Clinical Specialties

Preparing for the future of physical therapy.

By J. Anthony Sinacore, PT, DPT

Have you ever stopped to wonder where our profession is going and what it will look like in 10 years? For most of us, that speculation probably changes often and is influenced by what is going on in politics and research, which is completely logical. Due to political activity, our practices have changed significantly, and rightfully so, as we move away from the need for physician referrals and embrace the power of direct access. Thanks to research, we have also moved away from passive modalities and treatments that have proven to have minimal effect on patient outcomes.

Politics and research have been the determining factors of where the physical therapy profession decides to stake its claim in a society mired in uncertainty and doubt about whether, or even if, any health care provider or system has patients’ best interests at heart. Looking back several decades, we have improved by leaps and bounds regarding our point of contact and how we market our profession. But as of right now, it’s obvious our consumers still don’t understand the breadth of what we can offer them, and who can blame them? It’s no secret that both politics and research move at a glacier-like pace. From a bird’s-eye view, physical therapists are generalists among a sea of specialists. What do I mean by that? Let’s break it down.

Historically, when someone had a health-related issue, they saw their primary care physician (PCP) to treat the ailment. The PCP would diagnose and treat the condition and that was that. Now a trip to the PCP often leads to a referral to a specialist for advanced care, a confirmation of the PCP’s diagnosis or a search for a second opinion from another specialist, and/or a collaborative approach to managing the issue. Because of how vast our knowledge of medicine has become, the generalist now needs the aid of a specialist. And thanks to the internet and sites like WebMD, some nervous individuals might even bypass their PCP altogether to see a specialist for their specific (and often self-diagnosed) problems. Hypochondriacs or not, they may not be going through the appropriate channels in the eyes of health care professionals, but for them the choice is obvious and effortless: It’s one less copay to worry about and a great deal of time saved to see someone who can “treat them better.” With improved technology and access to information, people are instinctively preferring to see the specialist over the generalist.

While politics or research has yet to demonstrate whether specialty practice has faster and improved patient outcomes, it is important to understand our profession is and needs to be moving in this direction as well. With nine accepted clinical specializations, we have the ability to embrace this opportunity for change and make this yet another large stepping stone in our profession’s future.¹ Clinical specializations are a chance for the public to understand that we, too, offer the opportunity for a patient to see someone who has advanced knowledge about their current impairment. Whether or not there has been reported evidence of superiority, “specialist” is becoming synonymous with “optimal outcomes.” With our current successes with direct access, we are facing a critical time when marketing specialized care and advocating for our colleagues to earn these certifications can change the way our patients perceive our entire profession.

How can we do this, you might ask? Residencies are becoming a quick way (12 months on average) for clinicians to earn the title of clinical specialist. Unfortunately, most believe the large pay decrease and limited programs in each region do not provide realistic opportunities for everyone. For clinicians with several years of experience who do not want to spend a year in a residency program, there is a simpler way to achieve the requirements. Most specialty certifications require at least 2,000 hours of direct patient care (25 percent of those within 3 years) to be eligible to sit for the daunting specialty exam.1 These two requirements often deter experienced therapists from achieving the board-accredited certifications; they feel that they already treat as a specialist and that the time and money spent to gain the extra letters on their curriculum vitae are not worth it.

But this might not be the case in the near future. Despite the current resistance from the large majority of physical therapists, year after year at the American Physical Therapy Association (APTA) Combined Sections Meeting, hundreds of individuals are recognized for taking the next step in their professional career by being awarded the title of clinical specialist. Whether the physical therapist’s decision to earn certification is patient driven, personally driven, or business driven, there is increased attention as to what this change may represent. The annual number of physical therapists earning specialty certifications may have remained consistent up to now, but I imagine it will begin to skyrocket exponentially in the next 5 to 10 years. Why should that matter to you? Because hiring young professionals, even new graduates, with a specialty certification will create a ripple effect in the physical therapy profession for both new and experienced clinicians.

Let’s take a look at how the landscape of the Doctorate of Physical Therapy (DPT) curriculum has been shifting. The cost of tuition is at an all-time high while the salary for therapists within their first 5 years is currently unable to justify the loans associated with the DPT degree. We are facing a massive boiling point with this current system. Students are beginning to question whether a mountain of debt is truly worth a three-year doctoral degree with such low monetary incentives. To confront this issue, leaders in the academic realm are beginning to propose newer models to entice students to continue signing up. One new model suggests a student can earn their doctoral degree within 2 years and work (yes, with pay) as a clinician under the supervision of a licensed therapist for their third year before sitting for the National Boards exam. Similarly, another model proposes that the student can finish the general DPT curriculum within 2 years, and the third year would place them in a specialized program much like a residency.² By the time they graduate, they will not only be able to sit for the National Physical Therapy Exam (NPTE) but will also be able to take the American Board of Physical Therapy Residency and Fellowship Education (ABPTRFE) specialty certification exam earlier than expected.

Let’s break this down by the numbers. With roughly 236 accredited physical therapy programs, upwards of 10,000 students graduated in 2016.³ With a 99.4 percent employment rate, roughly 9,994 individuals enter the workforce every year (and that number is rising). Let that number sink in. Almost 10,000 physical therapists enter the workforce every single year. I think it’s safe to say that without a doubt our profession is still growing.

Unfortunately, there aren’t as many clinics or job openings popping up as there are new graduates, which then creates a highly competitive market—and not just for the inexperienced clinicians but even for those changing jobs with 5 to 10 years of experience. Competition will heat up even more when these new education models come into effect.

Individuals looking to start a career in physical therapy aren’t naive. When choosing which schools to apply to, they will factor in the experience they will receive with the cost of tuition to find out which program is going to give them the most bang for their buck and set them up to be the best clinician possible in three years. While these hybrid models haven’t yet hit the mainstream, it seems to me that students will like the idea of spending $25,000 to $40,000 less in tuition, getting paid during clinical affiliations, and fast tracking their way to becoming a clinical specialist. Remember that these are the physical therapists the patients will be wanting to see. It’s a no-brainer.

So back to how this can impact you. I’m sure if you’re a practice owner, you’ve already had to make a tough decision when needing to hire a new employee. Do you take the new graduate with minimal experience but lower salary requirements, or do you welcome the experienced clinician but forgo the higher pay grade they are requesting? The new grad will require a little more formal training but is more likely to adapt to your practice style and company culture compared to the clinician with their “own bag of tricks” who can jump right in and get comfortable. I would imagine if the experienced clinician was also a clinical specialist, that leaves little room for argument as to what they can bring to your clinic compared to the younger counterpart. The decision is obviously multifactorial and requires an extensive cost-benefit analysis; depending on your private practice’s situation, either could be a suitable choice.

But what if I told you the new graduate was also a clinical specialist and is comfortable working with a slightly better salary than a typical new grad but one that is less than what was requested by the clinician with 5 to 10 years of experience. The new grad would not only be able to help you market your clinic as having a “specialist” but would also bring a lot more experience in their specialty area than the other candidate. In salary expenses alone, the positives begin to start outweighing the negatives, especially if the new grad will be charging the same number of units per patient visit. Keep in mind that for third-party payers, physical therapy is already considered a specialty service, so in-network copays have increased accordingly. When a patient is paying $45, $50, or $60 plus per visit, they are going to want to know their care is coming from a bona fide “specialist.” By hiring a new grad with their “X” clinical specialty or a #freshPT straight out of a residency with a specialty certification, you could be saving your clinic a lot in employee wages while still receiving an enormous return on investment in passive referrals or organic referrals from your marketing campaigns.

If you hire a clinical specialist, you will be able to:

1. Market your clinic as a “specialty clinic” knowing that your patients are searching for these buzzwords when seeking out a health care professional.
2. Accept and treat patients who have complex needs from a new and unique viewpoint.
3. Educate clinic staff about the latest evidence and new treatment strategies.
4. Begin to decrease the number of visits per episode of care, ultimately leading to increased patient satisfaction (think less reimbursement in the now but subsequent episodes of care in the future as well as more word-of-mouth referrals).

If you are an experienced clinician without an “X” clinical specialty who is looking for a new place to work, understand that the clinical landscape is changing, and the ability to secure employment in the near future may not be as easy as you think. Maybe it’s worth showing your value to your community and future company by sitting for a board-certified clinical specialty. Why not have a discussion with your current and future employers about the benefits of earning a specialty certification and propose that they pay for or contribute toward the cost of your certification exam? Your demonstrated work ethic, determination, and loyalty may be all it takes for them to see this as a win-win situation.

If you are a current student or resident, these points of discussion may help during your interviews and salary negotiation. Demonstrate the potential and commitment you can bring to their clinic: You’ve worked hard and now you intend to prove your value. Then watch your hard work pay off!

References:

¹ American Board of Physical Therapy Specialties. Updated April 4, 2017. www.abpts.org/Certification/. Accessed July 29, 2017.

² Childs J. The Future of Physical Therapy Education. Evidence In Motion blog. Published January 19, 2013. www.evidenceinmotion.com/blog/2013/01/19/the-future-of-physical-therapy-education/. Accessed July 29, 2017.

³ Commission on Accreditation in Physical Therapy Education. Aggregate Program Data 2016–2017. Published March 10, 2017. www.capteonline.org/uploadedFiles/CAPTEorg/About_CAPTE/Resources/Aggregate_Program_Data/AggregateProgramData_PTPrograms.pdf. Accessed July 29, 2017.

J. Anthony Sinacore, PT, DPT is a licensed physical therapist and certified athletic trainer in the state of Delaware. He earned his BS in athletic training from Indiana University in 2012 and his DPT from the University of Pittsburgh in 2016. He is currently an orthopedic resident at the University of Delaware. He has been an editorial board member for Impact magazine since 2016 and his interests include PT private practice startups and entrepreneurship in the outpatient orthopedic/sports settings.