Doctorate in Physical Therapy: Is It Time for a Conversation?

The practice of physical therapy is quickly advancing and moving into new realms. This is an exciting period of growth and development in our profession, and the changes in health care delivery, social demographics, and globalization of health care are perfect opportunities for physical therapists to take on new and emerging roles in our health care system and to provide leadership in the field. As the profession forges ahead, a question arises: Is it time to discuss the idea of a “clinical doctorate” as the requirement for entry level to practice?

A clinical doctorate (or “practice doctorate”) programme is an entry-level degree that prepares students with the competencies required to enter clinical practice and become eligible for licensure.¹ In physical therapy, this is often called the Doctor of Physical Therapy (DPT) degree; it differs from a PhD, where the focus is on research and the production of original scholarly work, and from a “post-professional doctorate” or “advanced practice doctorate,” which offers study in advanced or specialized clinical competencies to professionals who have graduated with another entry-level qualification, such as a bachelor's or master's degree.

The title “doctor” is used across many health care professions in Canada. Physicians and surgeons, chiropractors, dentists and dental surgeons, podiatrists, optometrists, naturopaths, and veterinarians all require a doctoral degree for entry to practice. Common themes that have been identified across these professions include autonomy in practice, knowledge of research, a specific number of credit hours required for the programme, and a specific number of clinical hours required. Some professional programmes also require that the student complete a residency prior to full licensure.¹

What is Happening in other Countries?

In the United States, the American Physical Therapy Association has mandated that all programmes for physical therapy be at the doctoral level by 2020, and 213 of 232 physical therapy programs have already transitioned to the DPT.² The first doctorate-trained physical therapists in the United States graduated in 1996 from Creighton University in Nebraska, and models of the programme were being built as early as the 1980s.³ Bond University, which offers the only clinical doctorate programme in physiotherapy (D Phyt) in Australia, graduated its first class in 2009.⁴ This programme offers a 2-year problem-based curriculum to train students at the doctoral level. In Europe, there are currently no clinical doctorate programs in physiotherapy.

Justifying the Need for a Higher Credential

Although there are some who argue that a doctoral degree would acknowledge the rigorous academic training and advanced clinical skills already possessed by our current graduates, others question whether the issues facing the physical therapy profession today and in the future can be solved by entry-level doctoral programmes.^3,5–7

Threlkeld et al.⁶ developed a theoretical framework describing three major forces that would influence the movement from a master's degree to a doctorate at entry level: external forces, intra-organizational forces, and internal forces. Although these were primarily discussed with reference to the US system of health care and education, much of the framework is readily applicable in Canada. Threlkeld et al. defined external forces as those that lie outside the immediate educational programme⁸ and broadly categorized these forces into society and professional community. Societal needs include the changing demographics of our population, such as ageing and increased immigration; delivery of culturally sensitive health care; and the explosion of research in genomics and its influence on health. Professional community issues are those such as the influence of a doctoral degree on salaries, workforce demand issues, market niches for new graduates, and views on the title “doctor” on the part of other health care professionals and the general public.⁶ Intra-organizational forces were defined as influences of the universities and academic settings in which the doctoral programme would be delivered;⁶ each physical therapy department would need to evaluate its ability to deliver this programme, whether the programme matches the mission of its institution, and whether the departmental structure exists to allow the delivery of an entry-level doctoral degree programme. Finally, internal issues were defined as those within the professional programme itself, for example, whether programme faculty support a transition to a higher-level degree, whether the outcomes for the degree match the curricular goals, and whether the students have expectations and meet outcomes consistent with those of a doctoral degree.⁶

Perhaps the most important conclusion to be drawn from examining this framework is that a broad range of stakeholders needs to be involved in the discussion of entry-level doctoral programmes. These stakeholders include, but are not limited to, physical therapy clinicians, health professional colleagues, members of the public, health care policy makers, hospital administrators, academic leaders within the university, members of regulatory boards, physical therapy educators, and researchers. The unique views of each of these stakeholder groups on the impact of the DPT will deepen our understanding of critical issues and provide the foundation for discussion.

The Debate

Many of the arguments for and against moving toward the DPT credential have been well described in the physical therapy literature, as well as in the literature on other health professions.^5,9–11 Table 1 summarizes the major points that cross disciplines.

Table1.

Arguments For or Against Moving to a Doctorate in Physical Therapy (DPT)

Arguments to Support Moving to a DPT	Arguments Against Moving to a DPT
Physical therapy would be recognized by our colleagues and by the public as a truly autonomous profession. Because new graduates are often required to work in autonomous positions, where there is little opportunity for mentoring, we need to prepare our graduates for autonomous, direct-access practice at the entry level.	A change in “title” will cause confusion for the public as well as among our health professional colleagues. The presence of multiple degrees for the same profession can also lead to confusion, especially among our colleagues and administrators, who may not be aware of the difference between an entry-level doctorate and an advanced degree, such as a PhD (research based) or a post-professional doctoral degree. The public may confuse a doctor of physical therapy with a medical doctor. Furthermore, we may not be able to use the title “doctor” in hospital or community health settings, depending on regulatory issues around the use of the title “doctor.”
The changing clinical environment requires a higher level of knowledge and skills upon entry to the profession (e.g., knowledge of pharmacology, genomics, diagnostic imaging, differential diagnosis, reimbursement, legal and ethical issues). Many of these areas are already included in curricula, but this is not recognized in the form of a terminal degree, as is the case in other health professions with entry-level doctoral degrees.	We may be viewed as trying to “buy” legitimacy for our profession by awarding graduates a higher credential for fulfilling the same entry-level requirements.
A doctoral programme would offer a greater number of clinical internship hours, either within the programme or as a residency, thereby improving patient care and the interaction skills of new graduates.	There is some evidence to suggest that PTs with advanced degrees are less likely to move into rural health care positions.13 An entry-level doctorate requirement could limit the delivery of physical therapy services in many regions of Canada.
Doctoral-level graduates would be more likely to continue to develop our own science and evidence base. It has been shown that students to whom a doctoral title is important are also more likely to be interested in taking on academic positions in the future.14 Appointments for clinical teaching faculty in academic institutions may also be easier for holders of a doctoral degree.	Changing the entry-level credential may have an impact on employment. A doctoral level of education may be associated with an increase in salary and result in fewer jobs' being available for physical therapists. Health care administrators may be more likely to hire rehabilitation assistants or clinical kinesiologists to provide services traditionally offered by physical therapists. This may also relegate the physical therapist to a primarily evaluative or administrative role, leaving hands-on therapy to assistants.
The current physical therapy curriculum already has the academic rigour of a clinical doctorate degree. We are not recognizing the current degree requirements at the proper level.	A higher degree credential may represent a further obstacle to foreign-trained physical therapists seeking to enter the Canadian workforce, as most countries do not currently provide doctoral-level degree programmes in physical therapy.
The doctoral-level degree would be more attractive to prospective students, and thus would continue to attract strong candidates to physical therapy degree programmes.	Institutions may be limited in their ability to offer a DPT programme. A department's level of independence within an institution can affect its ability to deliver a programme at the doctoral level. Departments may also be expected to offer transitional programmes for holders of bachelor's or master's degrees, which will put increased strain on academic departments.

Evaluating Our Current Position

In Canada, we have only recently (in the past 10 years) moved from a bachelor's degree to an entry-level master's degree. As we think about entry-level education, it may be the right time to critically evaluate the impact that the entry-level master's programme has had on our profession. A unique opportunity for such evaluation was available in the United States in the late 1980s and early 1990s, when both bachelor's- and master's-trained physical therapists were graduating at the same time. Several surveys explored the differences in practice patterns, use of research, and other professional issues between bachelor's- and master's-trained students. Although results varied among surveys, physical therapists with master's entry-level education indicated more appreciation for research and a greater likelihood of conducting research, anticipated greater involvement in both research and teaching, and anticipated greater level of preparedness to enter the profession where there was direct access to patients.¹²

Evaluation of the Canadian experience with master's entry-level education may be used to explore a number of questions, including the following:

• Has the master's degree improved patient care?

• Has the master's degree affected employment patterns, workforce issues, or salaries for physical therapists?

• Are more master's-level graduates taking on leadership, administrative, or advocacy positions in the health care system?

• What has been the impact on involvement in professional organizations, research, clinical teaching, or academic appointments of entry-level physical therapists?

• Has there been a change in the degree of hands-on therapy being provided by physical therapists?

• Is there a change in demographics or aptitudes in the pool of students applying for physical therapy programs?

• Is there a difference in the public perception of physical therapists who are trained at the master's level?

Although these are just a few of the questions we need to explore, this type of critical inquiry would put us in a better position to truly discuss how a change in the entry-level degree can affect our profession.

Summary

Whether the conversation takes the form of debate or discussion, this may be the right time for physical therapists across the country to start talking about the DPT. It is our responsibility to determine the educational needs of our own profession, and it is essential that we start these conversations early, with a broad range of stakeholders.