BACKGROUND AND PURPOSE
In late 2016, the Commission on Accreditation in Physical Therapy Education (CAPTE) introduced its latest standards regarding accreditation of physical therapist education programs. Specifically, CAPTE now mandates that a minimum of 50% of core faculty possess an academic doctoral degree, which is defined as, “A PhD or other doctoral degree that requires advanced work beyond the master's level, including the preparation and defense of a dissertation based on original research, or the planning and execution of an original project demonstrating substantial scholarly achievement.”1 According to the standard, the remaining 50% or less of the core faculty must possess a nonacademic doctorate. Most present programs choose to fill this role with faculty trained with the terminal clinical degree of our profession, the Doctor of Physical Therapy (DPT) degree. Enforcement of these standards is planned to begin on January 1, 2020; however, at present, any program currently undergoing program evaluation by CAPTE must report compliance of the collective core faculty meeting the 50% academic doctoral–degreed faculty, or they must also include a plan and timeline for meeting this expectation.
Members of the physical therapy education community are questioning the necessity of this new standard.1 Leaders within the profession recently solicited feedback from program directors regarding their support in retention or removal of this standard. We believe that the standard, as stated, is important to be retained and that abolishing this standard could jeopardize the advancement of the physical therapy profession and ultimately hinder quality physical therapy care for the public. Therefore, the purpose of this commentary is to support the current standard requiring 50% of core faculty to possess an academic doctoral degree to advance clinical practice by educating students in evidenced-based decision making, contribute to the future of the profession through continued scholarly achievements, and prepare future therapists to operate collaboratively in the ever-changing health care environment. Accomplishing this purpose requires a brief review of how accreditation standards have evolved, a suggested mechanism by which the present standards can most easily be achieved, and a description of a potential path forward for the profession in preparation of qualified faculty to aid in achieving the goals of producing the highest quality, entry-level physical therapist practitioner.
Between 1993 and 2015, all accredited physical therapist education programs in this country ceased awarding bachelor's and master's degrees in Physical Therapy and began awarding a clinical doctoral degree, the DPT. Although this change was mandated, CAPTE did not require core faculty to possess specific academic credentials during this period of transition. Rather, core faculty members were required to demonstrate “contemporary expertise in assigned teaching areas”2 and relied on the regional accreditors to mandate the overarching regulations associated with faculty's academic credentials. In today's CAPTE standards, 100% of all core faculty members must have an “earned doctorate” and, at least, 50% of core faculty members must possess a terminal academic doctoral degree.1,3 This degree is most easily recognized by those faculty with an earned research doctorate, the Doctor of Philosophy (PhD) degree, earned from an institution with established regional accreditation recognized by the US Department of Education. The Doctor of Education and Doctorate of Science may also fulfill this research doctorate requirement1; however, the National Science Foundation suggests that each degree-awarding program be evaluated for the presence of a terminal project of dissertation quality to qualify for the degree to be a terminal academic degree equal to that of the PhD.4 As stated earlier, CAPTE defines an academic doctorate as a PhD or a similar degree requiring substantial scholarship in the earning of the degree.
The recommended make-up of core faculty in physical therapy education is not a new topic of discussion. The concept was addressed by Brueilly et al5 who, in 2007, highlighted the approaching needs for greater numbers of faculty and predicted faculty shortages. Brueilly and colleagues also made recommendations that physical therapist educational programs should be staffed by a core faculty that comprised diversified doctorally prepared teachers and clinicians, notably faculty with terminal professional degrees, as well as individuals with terminal academic degrees in foundational sciences.5 This argument has not changed because the authors recognized more than 11 years ago that a doctorally prepared entry-level clinician would need to be educated by teachers who could engage the learners in developing high-level critical thinking skills, basic foundational scientific information, and soft skills that allow a clinician to be effective in a broad range of clientele.
CURRENT CORE FACULTY PROFILE AND DECLINING SCHOLARSHIP
The most recent data available from CAPTE which provide insights into how many entry-level physical therapist programs are meeting the 50% terminal academic degree standard come from the 2015 aggregate data, which reports that nearly three-fourths (73.8%) of programs met the standard as reported in the Annual Accreditation Report.6 The potential for meeting this standard is currently being addressed in most of the existing entry-level programs that are meeting the standard ahead of enforcement deadlines. CAPTE also requires that all core faculty provide evidence of an active and ongoing scholarly agenda.1 Arguably, the research doctorate best prepares the faculty member for a productive scholarship career. This evidence of productivity is seen in physical therapy education as well. Scholarship productivity profiles from current faculty make-up show those with an academic doctorate and senior rank with scholarship release time at Doctoral/Research institutions almost two times more productive than junior faculty with clinical doctorates at Master-level instiutions.6,7 Questions concerning core faculty make-up are the same today as they were when Brueilly et al. suggested a strategy to address shortages through a blend of doctorally prepared faculty in 2007, though the replacement of terminally academic degreed faculty is a higher priority to address today because of several factors including continued faculty shortages, an ever-growing number of entry-level programs, and the expected retirement of many senior faculty.5,8
The ability of faculty to uphold scholarly agendas to comply with CAPTE's standards is declining, questionably from lack of preparation to fulfill the role, as well as retirement of senior faculty members.9 Increased teaching loads caused by faculty shortages and the growing number of new programs have the potential to negatively affect scholarly activity because burgeoning workloads may exceed normal percentages in programs where vacancies exist.10 Likely also because of increasing workloads, a decline in full-text publishing by core faculty may also result. The number of peer-reviewed articles published by core faculty members has declined by 20% over the past decade, whereas the number of presentations has increased by approximately 40%.11 In 2016–2017 alone, the ratio of full-text publications to abstracts has decreased from 83% in 2007–2008 to approximately 46% (Table 1).10,12,13 Numbers suggest that there may be increased reliance on presentation abstracts to meet scholarly agenda requirements set forth by CAPTE. Lower levels of scholarly products are not likely to meet productivity standards at many institutions where full-text publications carry more weight than presentation abstracts. It has been recently noted that 40% of full publications contain at least 1 major change from initial abstract, indicating that such works are frequently preliminary or incomplete and require substantive changes before publication.14 Relaxing the requirement of core faculty credentials would likely result in a decreased number of terminal academic degreed faculty because universities are likely to opt for the less restrictive options of faculty mix. Physical therapist education programs have, over the past 15 years, hired increasing numbers of clinical specialists to both meet increased faculty demand and improve clinical education.2,10 At least 578 clinical specialists were hired between 2006 and 2017, a number 3.5 times greater than the number of faculty possessing a PhD hired during the same period (Table 1).3,10 These hiring trends are discouraging for the advancement of scholarship in the profession. High levels of scholarly activity have been positively associated with holding senior rank, possessing a terminal academic degree, having greater academic experience, and lacking a clinical specialty credential.6 The collective effect of decreased publication of full-length articles and increased reliance on physical therapist education faculty who lack terminal academic preparation suggests that the generation of scholarly products in the field of physical therapy is at risk.
ADVANCEMENT OF THE PROFESSION
Scientific knowledge forms a fundamental pillar of any medical specialty, generating the evidence required to support and expand that practice. Failure to understand the causes of pathologies, determine efficacy of treatment, and expand scope of practice leaves any medical specialty essentially fixed in time and place. Evidence-based practice (EBP) is dependent, in part, on access to and the integration of the best available ;research evidence in the clinical decision-making process. The American Physical Therapy Association has made strides in clinician's availability to make use of EBP in a number of ways. The advancement could be credited to the association making EBP an essential component of its Vision 2020.15 Regardless of the reason, advancing the profession has allowed facilitation of the development and implementation of a comprehensive list of outcome measures that can be administered to a specific patient population via the Evaluation Database to Guide Effectiveness, underwriting the training and research costs required by members to develop clinical practice guidelines and most recently launching the Physical Therapy Outcomes Registry in an effort to improve patient care by benchmarking and informing future research.16 At the center of this association's wide efforts are data collected in studies that utilize optimal experimental design, appropriate analysis, and reasoned conclusions. Current changes in scholarly output within the profession would suggest that as a profession, we are increasingly unable to provide the data recognized as essential to advance our practice and our ability to deliver optimal care to our patients.
As with many fields in medicine, the scope of rehabilitation science is rapidly expanding. For example, a special series recently published by the Physical Therapy Journal in April, 2016 focused on regenerative rehabilitation, discussing concepts such as “the integration of principles and approaches from the fields of rehabilitation science and regenerative medicine.”17 These authors described a very important synergy between and advances in medical devices, surgical techniques, and biomarkers.17 The National Institutes of Health has long recognized the need for rehabilitation strategies and recently offered a comprehensive Research Plan on Rehabilitation that identified research priorities to guide the field.18 Translational Science was identified as a major agenda item and called for assessing biological and physiological adaptations associated with rehabilitation strategies and identifying biomarkers that are prognostic or capable of guiding prescription of rehabilitation interventions.18 Furthermore, Stout et al19 clearly identified the need for participation by a physical therapist in advancing the rehabilitation care of cancer survivors. Active participation in the expanding field of rehabilitation medicine clearly requires an expansion of research-focused physical therapy faculty, and preservation of the 50% mandate seems to be the best counter measure to disturbing trends in scholarly productivity and advancement of the profession. Failure to have an appropriate blend of faculty members could be detrimental to future elevation of physical therapy in advances in rehabilitative medicine.
SUCCESSFUL PROMOTION AND TENURE
Sustainability of accomplished educators and researchers within physical therapist education programs relies on the ability to secure promotion and tenure which, in turn, provides faculty with academic longevity and academic success. This process within higher education is defined by institutional culture and organizational-specific requirements.9 Evaluation of faculty has historically been driven by three criteria: teaching, scholarship, and service. Barriers to meeting even minimal criteria may exist for many faculty who have not been trained at the academic doctoral level because of a lack of foundational knowledge conducting research, thus placing them at increased risk of not sustaining an academic career. Advancement of the physical therapy degree to the doctoral level accompanied by increased focus on scholarly productivity by CAPTE increased the rigor and requirements for successful promotion and tenure.14 Junior faculty's needs related to professional development and career advancement before adoption of the clinical doctorate have been identified as requiring assistance in scholarship to include a shift in workload and direct mentorship from senior faculty members.20,21 These needs still exist and may even be more pronounced with an ever-elevating accreditation standards of a progressive scholarly agenda. Faculty who have earned an academic degree through significant scholarly work are more prepared for success in navigating the avenues of tenure and promotion than their less-experienced colleagues. Because of the identified dependence between nonexperienced faculty and others more experienced in scholarship, decreasing the number of academic degreed faculty is likely to have a direct negative impact on rates of promotion and tenure in core faculty.
Historically, successful rates of achievement of promotion and tenure are lowest for allied health faculty, especially at level I Carnegie institutions and perceptions of barriers include difficulty in participation and achievement of scholarship, as well as the lack of understanding of the tenure process.21,22 Formalized mentorship programs, possession of academic doctorate, and previous publications have all been associated with higher achievement in promotion and/or tenure among allied health faculty.23 Success of these candidates could potentially be related to acquired skills and knowledge specific to scholarship and teaching, as well as support and assistance from mentors.23 Student involvement in faculty-developed research projects is also associated with successful promotion and/or tenure, which could assist in overcoming barriers to release time for scholarship.23 Collaboration between those with earned academic doctorates and faculty with clinical doctorates has been identified as a theme among programs from the National Study of Excellence and Innovation (NSEI), a Carnegie-type study that recently investigated themes associated with excellent entry-level DPT Programs across the United States.8 Upholding a minimum of 50% core faculty with earned academic degrees decreases the burden on senior faculty's scholarly productivity and potential of “burnout” from institutional service commitments associated with senior rank and tenure.24 The team approach in scholarship paired with mentorship could assist programs in achieving elements of accreditation along with fostering a collaborative culture for junior faculty and students. Ultimately to sustain longevity of the core faculty in physical therapist education, there must be a blend of academic and clinical doctorally prepared faculty who can work collaboratively toward a common goal of scholarship and educational innovation.
EXCELLENCE IN PHYSICAL THERAPIST EDUCATION
The professional identity of physical therapists has been called into question, and there is a consensus among leadership regarding concerns with the current model of physical therapist education.25 The ever-changing health care system has become more environmentally complex, and standards of restructuring with the Affordable Care Act and Triple Aim moves emphasis toward cost, quality, and access.26 The recent NSEI Carnegie modeled study in physical therapist education was conducted with the intent of identifying components of excellence and modernization present in current entry-level physical therapist educational and residency programs to address proposed concerns in the changing world of health care.27 Results suggest that learning environments of excellence are a nexus of student-centered and patient-centered learning. Leaders in the field have also proposed the use of entrustable professional activities to ensure cognitive, psychomotor, as well as affective domains of learning are solidified before graduation to prepare students for independence in clinical practice.28 In the 2016 Pauline Cerasoli Lecture, Jette identified large variability in curriculums across accredited programs and proposed that content may possibly reflect outdated knowledge and skills, thus not preparing students for current best practice.25 CAPTE's revised standards in 2016 reflected additions in curricular content to include topics in genetics, nutrition, and molecular biology.1 In addition to these updated standards, the Federation of State Boards of Physical Therapy (FSBPT) also has revised the National Physical Therapy Examination content outline effective in 2018 to reflect these changes in standards.29
New content and emphasis areas include increasing the foundational knowledge and implications of physical therapy treatment and interventions for all body systems and structures. These changes have necessitated an increase in the depth and breadth of foundational sciences in physical therapy education as needed in preparing students for a more complex health care environment. The ability to provide such a significant change in instruction content is best achieved by faculty who are more academically prepared in the areas of their teaching content through an earned terminal academic degree.8 Clincially trained faculty without some form of advanced training, such as a residency or fellowship, are not able to teach beyond the entry-level curriculum they received and thus would not meet CAPTE standards for instruction in the foundational sciences without substantial training.1,30
Preparation of entry-level students to meet the changing and challenging health care needs in the ever-increasing complex health care environments is essential. The NSEI identified a conceptual framework of excellence, which involves the fostering of adaptive learners in practice-based learning environments to improve clinical reasoning and performance in complex clinical settings.27 Changing demographics of patients that include increased incidence of chronic conditions and comorbidities along with the ever-changing health care environment stresses the importance of flexible, adaptive, evidenced-based practicitioners.31 Educators who possess earned academic degrees in the science of teaching and learning are best equipped to advance the profession through innovative instructional methodologies to accommodate for a more complex health care system.8,32
The NSEI identified a common theme of excellence in entry-level education specific to the “praxis of learning”33 a specific pedagogy, focused on cultivating movement scientists and deploying practiced-based learning. This methodology in DPT education is aimed at enhancing clinical reasoning skills and cultivating professionals within the field. Innovative teaching methodologies aimed at meeting contemporary health care expectations have been proposed as a solution to advance physical therapist educational programs, specifically integration of interprofessional collaboration and simulation.34 Cultivating learner-centeredness through problem-based application parallels today's health care environment of patient-centeredness and arguably prepares future practitioners to advance the profession. Recommendations set forth by the NSEI study include faculty who are trained in the science of teaching and learning, working alongside clinical specialists' current in today's practices to meet this need.33 Arguably, those who possess terminal academic degrees in the field of physical therapy and foundational sciences are best prepared to take on this challenge paired with individuals with clinical expertise. The end goal is to bring excellence and innovation into physical therapist education to advance the profession and shift the paradigm to ultimately meet the changing needs of the society. This blend of faculty was proposed in 2007 with the same end goal in mind by blending individuals from complementary fields to enhance the depth and breadth of both academic and clinical frameworks while upholding academic and accreditation standards.5
The practice of physical therapy is changing in response to a rapidly evolving health care environment. The profession is proactively attempting to keep up with these changes by updating practice definitions and concomitant accreditation requirements. The current CAPTE standards requiring at least 50% of core faculty to be trained in an academic doctorate area is necessary and imperative to protect the future of the profession of physical therapy. Members of core faculty who possess terminal academic degrees are best suited to produce scholarship that advances the profession, are most likely to achieve sustainability in the academic environment, and when paired with clinical faculty are capable of cultivating graduates who can adapt in the ever-changing health care environment. A minimum threshold of 50% faculty with earned academic doctorates is key to moving our profession forward, allowing advancement of the profession through scientific and educational research, providing stability in their role, and establishing excellence for the educational programs of tomorrow. Only with this group of core faculty who are uniquely equipped with these skills can our academic preparation of tomorrow's clinicians succeed, much less survive. We, as academic leaders in the profession, must insist on retaining, and possibly even strengthening, the requirement of a minimum 50% mix of terminally academic degreed faculty within our cadres.
4. NSF. National Science Foundation: Where discoveries begin. 2018. https://www.nsf.gov/
. Accessed February 10, 2018.
5. Brueilly K, Williamson E, Morris S. Defining core faculty for physical therapist education. J Phys Ther Educ. 2007;21:10–14.
6. Hinman M, Brown T. The changing profile of the physical therapy professoriate- are we meeting CAPTE's expectations? J Phys Ther Educ. 2017;32:95–104.
8. Jensen GM, Hack LM, Nordstrom T, Gwyer J, Mostrom E. National study of excellence and innovation in physical therapist education: Part 2—a call to reform. Phys Ther. 2017;97:875–888.
9. Kaufman RA. Reflection on disciplinary nature and the status of physical therapy scholarship. J Phys Ther Educ. 2005;19:3.
14. Smith HD, Bogenschutz ED, Bayliss AJ, Altenburger PA, Warden SJ. Full-text publication of abstract-presented work in physical therapy: Do therapists publish what they preach? Phys Ther. 2011;91:234–245.
17. Ambrosio F, Kleim JA. Regenerative rehabilitation and Genomics: Frontiers in clinical practice. Phys Ther. 2016;96:430–432.
19. Stout NL, Silver JK, Raj VS, et al. Toward a national initiative in cancer rehabilitation: Recommendations from a subject matter expert group. Arch Phys Med Rehabil. 2016;97:2006–2015.
20. Pagliarulo MA, Lynn A. Needs assessment of faculty in professional-level physical therapist education Programs: Implications for development. J Phys Ther Educ. 2002;16:16.
21. O'pt Holt TB. A study of tenure among allied health faculty. J Allied Health. 1991;20:245–254.
22. Epple Calvert ML, Vaughn CA, Sullivan CA, Garn G. Knowledge and perceptions of tenure guidelines and criteria among allied health faculty: Case study. J Allied Health. 2007;36:e142–e159.
23. Peterson C, Stuare D, Hargis J, Patel R. Promotion and Tenure: Institution, program, and faculty-candidate characteristics—ProQuest. J Phys Ther Educ. 2009;23:64–70.
24. Padilla M, Thompson J. Burning out faculty at doctoral research universities: EBSCOhost. Stress Heal. 2015;32:551–558.
25. Jette D. Unflattening. J Phys Ther Educ. 2016;30:4.
27. Jensen GM, Nordstrom T, Mostrom E, Hack LM, Gwyer J. National study of excellence and innovation in physical therapist education: Part 1—design, method, and results. Phys Ther. 2017;97:857–874.
30. Jensen GM, Gwyer J, Shepard KF, Hack LM. Expert practice in physical therapy. Phys Ther. 2000;72:42–62.
31. Ward BW, Schiller JS. Prevalence of multiple chronic conditions among US adults: Estimates from the national health interview survey, 2010. Prev Chronic Dis. 2013;10:E65.
32. Jensen GM, Nordstrom T, Segal RL, et al. Education research in physical therapy: Visions of the possible. Phys Ther. 2016;96:1874–1884.
33. Jensen GM, Hack LM, Nordstrom T, Gwyer J, Mostrom E. National study of excellence and innovation in physical therapist education: Part 2—a call to reform. Phys Ther. 2017;97:875–888.
34. Deusinger SS, Crowner B, Burlis TL, Stith JS, Crowner BE, Burlis TL. Meeting contemporary expectations for physical therapists: Imperatives, challenges, and proposed solutions for professional education. Phys Ther Fac Publ Progr Phys Ther. 2014. http://digitalcommons.wustl.edu/pt_facpubs
. Accessed February 12, 2018.