No new therapist will graduate as a fully-finished product, ready to tackle the most challenging and complex cases that rehab therapy can throw their way. For us less-recent grads, the post-graduate education happened on the job—the School of Hard Knocks for treating others’ hard knocks, if you’ll forgive the pun. Through mentorship and continuing education, skills were honed, but specialization was more about where you worked: acute, skilled nursing, or outpatient rehabilitation. It wasn’t until recently that this journey began to shift. In 2020, the transition from a master’s degree to a clinical doctorate became mandatory for all new grad PTs—and with that, the path to a more traditional medical model was set in motion with a push toward specialization.

In recent years, we’ve seen a remarkable increase in residency programs for physical therapists—but they’re certainly not a new phenomenon. The earliest residency program began in California in the late 1970s for orthopaedic physical therapy, with the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) establishing early guidelines. It wasn’t until 2000 that these initiatives became accredited by the APTA as the first residency and fellowship programs. Since then, the expansion has been exponential, with 362 accredited residency programs and 46 accredited fellowship programs as of June 2022, according to the American Board of Physical Therapy Residency and Fellowship Education (ABPTRFE).

Students today now have the benefit of residency and fellowship opportunities to help bridge the gap from DPT programs to specialized clinical work. And while I do agree that leveling up the profession is extremely important, the question remains as to whether the growing trend toward specialization and residency is actually benefiting the profession—and more importantly, patient care and outcomes.

Are residency programs the right choice?

The benefits of residency programs as a supplement to DPT training are somewhat obvious, as laid out in this blog post: residencies offer practical clinical experience and mentorship that new grads are craving and weren’t otherwise receiving in the classroom. There’s also some evidence that many graduating students feel unprepared to start treating patients on their own, and are seeking residencies to close that perceived competency gap. As we found in WebPT’s 2022 State of Rehab Therapy report, 54% of surveyed students said that they only felt “decently prepared” to treat patients upon graduation, but needed to learn more. Elsewhere in the report, students cited clinical training and residency programs as the top choice for desired curriculum additions.

Some students, on the other hand, may see residency programs as a necessary next step in their professional development. Former residents have expressed their belief that residency programs are a way to jumpstart their career and further their education and training with the aim of becoming the best clinician they can be. Others are eager for the mentorship that comes with a residency, or are looking for the chance to further their proficiency within their chosen specialty.

Plus, residencies look mighty good on a resume, as shown in this study. But despite those positives, there are some drawbacks to residency programs that need to be addressed, each of which begs the questions:

• Is the cost of PT education becoming untenable as we compare the earning potential of a physical therapist?
• Is the looming student debt crisis diminishing our ability to recruit and retain the best and brightest in our field?

Residency programs aren’t yet catering to all who want them—or to all specialties.

With the heightened interest and push toward residency, it’s become a very competitive landscape—to the tune of a 45% rejection rate among residency applicants. There are more than 10,000 new DPT graduates a year, and only 1,263 residency and 271 fellowship positions as of 2021. And, prospective residents may be at a disadvantage based upon where they live. As of 2021, the South Atlantic region (defined as the Eastern Seaboard states south of Pennsylvania as well as Puerto Rico) contains 95 of the 347 residency programs—compare that to the New England region, which only has 12. So, if you’re lucky enough to get accepted into a residency program, there’s a decent chance that you’re going to have to pick up and move—just another expense for a new grad PT.

As specialization in the profession has grown, residencies have expanded; however, there’s still work to do if academics want to keep up with mainstreet. A look at ABPTRFE’s data from 2021 shows that 4,645 of the 6,998 total residency program graduates since 1998 have been in orthopaedics, and 2,144 of the 2,587 total fellowship graduates during that same period were in the Orthopaedic Manual Physical Therapy practice area.

The other 10 board-certified specialties are far less represented in those numbers: sports residencies, the next most popular program, have had 826 graduates in total, with neurology coming in third with 774 graduates. And more nascent residency programs for the remaining specialties—pediatrics, geriatrics, women’s health, clinical electrophysiology, cardiovascular and pulmonary, acute care, and wound management—have had 260 or fewer graduates since their inception. These specialities, however, have a much steeper growth curve now that the specialization momentum has caught fire.

As this study notes, “If residency programs are an important component of advancing practice for physical therapists and meeting societal needs, a broader distribution of residency programs in all specialty areas is critical.”

Residents may not be getting a great return on their investment.

I have previously written about how urgent the student debt crisis is, and adding more costs to a newly graduated PT’s education certainly won’t help the issue. According to ABPTRFE data from 2021, the 32% of residency programs that charge tuition cost $7,000 on average, including fees.

So, are residency programs worth the cost graduates are paying as it relates to professional development and patient outcomes? Well, the results are mixed based on the limited evidence available. According to one study published in February 2015 in the Journal of Orthopaedic & Sports Physical Therapy (JOSPT), “fellowship training may contribute to statistically greater patient outcomes,” whereas “(r)esidency training did not appear to contribute to improved patient functional status change or efficiency.” The study’s authors did note that there are limitations to their study, and what can be derived from it.

The ABPTRFE’s findings have noted that, according to their data, residency graduates posted higher first-time passing rates in board certification examinations than non-residency graduates by 17% (94% to 77% respectively). But the elephant in the room is that neither certifications nor residencies necessarily equate to higher pay for therapists, despite the added cost. And no definitive data has been shown that residents or fellows produce better patient outcomes translating into the potential for increased reimbursement.

Part of the problem, as noted in this study, is that “physical therapy residency and fellowship education is still in its toddler stage of development.” As such, there’s not yet a body of qualitative research that has fully measured the effects of residency training—and without that definitive data, it’s difficult to substantiate the cost of the extended education and the medical model being followed in PT.

PT pay remains low, with or without residencies.

Let’s break down the cost of current educational requirements against the student debt-to-income ratio. The median salary for PTs in residency programs is $51,490 which is roughly 80% to 95% of what other PTs are making out in the job market.

That number isn’t that far out of line with the 58.7% of students 27 years old or younger in our survey who were making less than $60,000, but woeful when you consider that over half of the students we surveyed in our State of Rehab Therapy report were leaving school with more than $70,000 in debt, and a third with more than $100,000.

How can we improve PT education?

Rather than the disparate pathways we use today to make piecemeal changes to PT education, perhaps it’s time for us to apply some Kaizen methodology and review the PT educational experience in aggregate to eliminate waste, improve satisfaction, and decrease costs. Reducing the cost and length of DPT education or connecting residency specialization as a requirement for the DPT are interesting ideas that are being tested in real time today.

Expand hybridized, two-year DPT programs.

Hybrid DPT programs, which mix online coursework with in-person instruction and skills training, may prove to be a better option for reducing the cost of earning your DPT allowing for the opportunity to move to a residency program with reduced financial burden. Another obvious benefit of the two-year, hybridized model—which is being proven with improving student diversity numbers in the EIM partner programs—is that it expands access across populations and geography to these programs.

As BGSU’s DPT program website notes, “Our two-year DPT model means our graduates can enter the workforce and earn an income sooner than students in a traditional three-year DPT program.” Most importantly, these models prioritize students’ time in hands-on experiences both on campus and in clinics. And the results thus far have been very positive—if we’re using the metric of students passing state licensing exams as a measure of success, so far two-year programs are hitting the mark.

Create more mentorship programs.

While it’s true that residency programs are required to focus on mentorship as part of the standards set by ABPTRFE, there’s no reason that mentorship has to fall entirely under the residency umbrella—especially when so many new therapists don’t have the benefit of joining a residency program. Creating independent mentorship programs in private practices and in other industry specialties would provide support to new PTs with advice and guidance as they navigate the early months and years of their careers, without the cost to graduates associated with residency. (If you’re considering your own mentorship program, the APTA offers best practices for mentoring in physical therapy.)

Mike Markee, PT, DPT, PhD, COMT, ATC puts it best in our report, “Even if not through something as structured as a residency or fellowship, clinicians could benefit from some form of mentorship, one could argue, throughout their career.”

Other working models focus on organizations offering residency at no cost to the therapist, but instead require employment agreements for a set period in exchange for covering the costs. Fortunately, there are already some examples out there for how these models can work in practice. The VA system offers a number of free residency programs in different locations around the country, which you can find from the ABPTRFE directory. For those in the private sector, there are ways to reduce the cost to students without eating the expense entirely; Dignity Health, for example, waives the cost for their orthopaedic residency programs in exchange for a commitment for two years of employment. There’s also a number of scholarship opportunities available to help defray the cost for students and make residency a more financially palatable option for those who choose it.

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In working with a number of DPT students and PT residents through Rizing Tide, I know the future of rehab therapy is very bright. However, I do hope we can continue to scrutinize and improve the DPT journey—and throw the sacred cows to the wayside in order to do what’s best for our profession. With the growing number of two-year, hybridized DPT, sophisticated residency, and coveted fellowship programs, I believe we are moving in the right direction to streamline the DPT education process and align the cost of education with the earning potential for physical therapists. As a start, monitoring metrics like graduation rates, licensure pass rates, student debt ratios and student diversity will help validate this specialization path. More importantly, it will ensure that residencies and specialization will ultimately lead to success in the future for the PT profession as a whole, and will improve patient care and outcomes.