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CASE REPORT

Implementation of a Hospital-Based Orthopaedic Physical Therapy Residency Program

A Case Report Describing Clinical Outcomes, Productivity, and Perceived Benefits

Winslow, John PT, DPT, OCS, MTC, ATC; Costello, Michael PT, DSc, OCS, MTC

Author Information
Journal of Physical Therapy Education: December 2019 - Volume 33 - Issue 4 - p 307-314
doi: 10.1097/JTE.0000000000000100
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Abstract

INTRODUCTION

Physical therapy residencies are postprofessional programs intended to train licensed physical therapists in a specialty area. They provide ongoing mentorship and clinical supervision by experienced physical therapists. Similar to the medical model, physical therapy residency programs combine didactic coursework with integrated clinical experiences. The residency program is typically 12 months long with a minimum of 1,500 hours of supervised clinical practice and didactic coursework. The capstone for most residency programs is to sit for the American Board of Physical Therapy Specialties (ABPTS) examination and become board certified. Residents have historically been onsite; however, more recently, hybrid distance learning models have been developed to increase opportunity for residency training. The first physical therapy residency program was founded in 1979 at Kaiser Permanente in Hayward, California. The American Board of Physical Therapy Residency and Fellowship Education (ABPTRFE) is the accrediting body for the American Physical Therapy Association (APTA) for postprofessional residency and fellowship programs in physical therapy. The first residency and fellowship programs were credentialed by the ABPTRFE in 2000.1 Currently, there are 264 credentialed physical therapy residencies across the country representing 10 specialties: acute care (4), cardiopulmonary (8), clinical electrophysiology (1), faculty (1), geriatrics (18), neurology (49), orthopaedics (105), pediatrics (21), sports (46), woman's health (10), and wound management (1).2 In 2017, there were 1,209 residency positions available across all accredited programs; thus the opportunity for the projected 10,599 physical therapy students graduating in 2018 is relatively small.3

One of the challenges to developing a new residency is convincing the host institution that it will be beneficial in the long-term. Institutions do not receive federal funding like they do for medical residency programs and must bear the cost of the entire program.1 The number of physical therapy residency programs would likely be higher if federal funding was available. Although the actual cost of running a physical therapy residency program has not been published, it is reasonable to assume that the overhead to the host institution will be substantial. Costs may include release time for the residency coordinator and faculty, additional continuing education for faculty, course resources and materials, marketing, and a decrease in productivity expectation. Furze et al1 recently proposed that until the physical therapy profession adopts residency training as the expected route to advance from entry-level physical therapist to highly competent, specialized clinician, host institutions will incur the costs of the programs.

Institutions may be more willing to invest in physical therapy residency training if there was evidence of benefits to the institution that would offset costs. These benefits could include improvement in physical therapy clinical outcomes and patient satisfaction scores leading to increase referrals. It is also possible that residency programs could contribute to improved employee job satisfaction and retention, therefore reducing the costs related to recruitment of qualified staff and training of new staff. Residents often accept positions at the host institution after completing the program.

The purpose of this case report was to describe the effect of implementing a hospital-based orthopaedic physical therapy residency program on clinical outcomes and the perceived benefits of the residency program by physical therapy staff and hospital administrators. We hypothesized that implementation of a residency program would improve clinical outcomes. We also hypothesized that physical therapy staff and hospital administrators would report positive perceived benefits to the institution of staff clinical skills, staff retention and recruitment, job satisfaction, and the image of the institution in the community.

REVIEW OF LITERATURE

There is very little literature published on the benefit of residency training in physical therapy. The only outcome study was conducted by Rodeghero et al,4 where clinical outcomes of physical therapists who had completed residency (n = 45) or fellowship (n = 12) programs were compared with those who had not (n = 306). In this study, the fellowship trained group of physical therapists achieved better clinical outcomes than the other 2 groups. No difference in outcomes was observed between the residency group and the therapists without residency training. The results of this study challenge the clinical benefit of residency programs: however, the lack of differences may be attributed to residents most often being new graduates having less clinical experience than their fellowship-trained or nonresident counterparts.5 Cleland et al6 demonstrated that physical therapists who attended a 2-day continuing education course on cervicothoracic disorders in conjunction with ongoing mentoring sessions achieved significantly greater outcomes compared with a continuing education group without ongoing mentorship. This study supports educational programs that include structured clinician oversight.

There have been a number of studies that looked at the benefit of advanced degrees and specialty certifications.7–9 Hart and Dobryzykowski7 reported outcome data for 14 physical therapists (7 orthopaedic certified specialists [OCS] and 7 non-OCS) and 258 patients that suggested OCS credentialed physical therapists require fewer visits to achieve rehabilitation goals compared with non-OCS certified therapists. Renzick and Hart8 found similar results when they compared the differences in outcomes for patients with low back pain managed by physical therapists with or without specialty certification (OCS), manual therapy certified (MTC), and Fellowship of the American Academy of Orthopaedic Manual Physical Therapists (FAAOMPT). The physical therapists with MTC credentials achieved better outcomes than physical therapists without specialty training, which supports postprofessional training. In a study comparing nonpatient care skills, graduates of residency programs demonstrated advanced leadership and other professional skills compared with nonresident trained graduates.10 Graduates of residency programs have been shown to have a perceived benefit from their training. In a survey conducted by Smith et al,11 orthopaedic physical therapy residents had a high rating for their ability to logically reason, perform examination skills, treat effectively and efficiently, and diagnosis properly.

CASE DESCRIPTION

The development of the residency program began in early 2007, when the physical therapy department director and senior clinicians met to discuss the feasibility of such an endeavour, including desire within the department, and available resources. A senior clinician assumed the role of Program Coordinator. The Physical Therapy Department Director and Program Coordinator acquired institutional approval from the senior hospital administration and then began to develop and recruit staff to serve as didactic and clinical faculty, as well as to work on the materials required for APTA/ABPTRFE accreditation. The planning phase (2007 and 2008) included developing the curriculum, training existing staff to be faculty and mentors, hiring one new staff physical therapist to teach a specific content area, recruiting physicians to be involved with the program, obtaining classroom space, and preparing the ABPTRFE accreditation application. Staff physical therapists who were selected to be didactic faculty (N = 12) and mentors (N = 13) attended additional continuing education courses to deepen their knowledge in certain content areas. The didactic faculty spent significant time reviewing current literature and developing course materials. Residency didactic faculty updated the coursework each year based on participant feedback, a review of new literature, or changes in curricular requirements described by ABPTRFE. Outside institutions provided no coursework.

The Residency Curriculum initially consisted of 15 didactic courses totalling 122 hours of instruction and 150 mentoring hours. Residents treated patients independently for 30 hours and received 3–4 hours of mentoring each week. Residents also observed local physician specialists, served as teaching assistants in a local entry-level physical therapy education program, and completed a case report. The first resident began training in January 2009, and the program received Accreditation from APTA/ABPTRFE in 2010. The program accepted one resident each year until 2013, when the program expanded to accept 2 residents. All PT staff were encouraged to attend didactic courses, which were offered free of charge. Didactic coursework was offered to clinicians outside of the hospital system for a fee, thus providing an additional revenue stream to support the residency program.

OUTCOME MEASURES

The Patient-Specific Functional Scale (PSFS), a self-reported, patient-specific measure, was used to assess functional change with treatment.12 This measure was adopted by the hospital outpatient department because it is applicable to a wide variety of orthopaedic conditions, simple to administer, and has been shown to be responsive to clinically relevant change over time.12 During the initial evaluation, patients were asked to identify 3 important activities they were unable to perform or were having difficulty with as a result of their orthopaedic condition. In addition to identifying the activities, the patients were asked to rate, on an 11-point scale (0 = unable to perform and 10 = able to perform at the same level before injury), the current level of difficulty associated with each activity. The PSFS is a reliable and valid instrument frequently used in clinical research with a minimal clinically important difference between 2.0 and 3.0.12 Considering that the PSFS relies on patient specific parameters as opposed to fixed content, it has been recommended that the scale be used as a measure to asses change over time rather than comparing absolute scores.12

The 3 scores were entered into an electronic medical record (EMR) that automatically averaged the scores. The average score represented baseline function. On discharge, patients completed the PSFS again, and those values were entered into the EMR. Final outcome scores were calculated as the difference between the discharge score and the baseline score and transferred into a secure database with no identifying patient or therapist information. Only complete data sets with initial and discharge scores were included in the analysis. Data were collected for 2 years before the start of the residency program (2007–2008) and 4 years after the inauguration of the first resident (2009–2012).

Productivity, measured in “patient visits” and zip code data, representing the service area, was available for 6 years before the planning and development of the residency program and for 6 years after. The zip code data were specific to physical therapy services only. These data were included as a means to assess growth of the department.

After the completion of the outcome study, physical therapists working in the outpatient department at the hospital were given a survey, developed by the authors, to determine their perception of the residency program. Physical therapists surveyed included all outpatient physical therapists employed at the institution (department director, didactic and mentoring faculty, and staff physical therapists not involved in residency training). The survey contained 19 questions related to job satisfaction, professional development, staff retention, and success of the department. Hospital administrators were given a similar survey of 15 questions to determine their perception of the residency program. Administrators included hospital senior leadership (chief operating officer, chief financial officer, vice presidents, and medical director). The authors were not aware of previously validated surveys assessing the value of Physical Therapy residency education, so they developed a survey based on conversations with directors, faculty, and program participants from other residency programs. The authors asked what items they thought important when evaluating the quality and impact of their own programs. The authors included questions for administrators because of the consensus from these conversations that institutional administrative support is important for program viability. The survey was reviewed by 2 independent physical therapists for clarity of questions before distribution. Each survey comprised a series of questions with responses on a 7-point Likert scale: strongly agree (SA), agree (A), somewhat agree (SWA), neither agree nor disagree (NAD), somewhat disagree (SWD), disagree (D), and strongly disagree (SD). Staff physical therapists and administrators were sent an initial email containing a link to the survey and received a follow up email 2 weeks later.

RESULTS

A total of 3,717 patient outcome scores were entered in the database. There was a steady improvement in clinical outcomes measured on the PSFS from 2007 to 2012 (Figure 1). Each year, the mean score on the PSFS exceeded the minimal detectable change for significance (2 points).12 In 2007, the mean score on the PSFS was 3.81 and in 2012, 4 years after the start of the residency program in 2009, the mean score on the PSFS increased 37% to 5.21 (Table 1). The median also rose from 3.81 to 5.30. The mode had the greatest change from 2.0 in 2007 to 10.0 in 2011 and 2012. A paired t test comparing outcome measures in 2007 (preresidency) with outcome measures in 2012 (4 years postresidency) showed a statistical difference P < .0001 with a 95% confidence interval of 1.65–1.06.

Average PSFS 2 Years Before the Start of the Residency Program and 3 Years After the Inauguration of the First Resident. PSFS = Patient-Specific Functional Scale
Table 1
Table 1:
Descriptive Statistics for the PSFS Outcome Scores

The physical therapy department experienced a significant increase in referrals and subsequent financial growth after the introduction of the residency program. In 2000, the department performed 42,093 total patient visits and in 2006, the number s slightly higher at 43,912 (+1,819). In 2012, after planning and implementing the residency program, the number of patient visits increased to 60,983 (+17,071) (Figure 2). Zip code data showed that patients were travelling from outside the service area to receive treatment at the hospital from staff physical therapists with specialized training. In 2006, there were patients from 151 different zip codes and in 2012, the number increased to 192 (+41).

Number of Physical Therapy Visits 6 Years Before the Planning and Development of the Residency Program and 6 Years After

Response rate for the surveys was 100% (19/19) for physical therapists (Table 2) and 100% (6/6) for administrators (Table 3). Twelve of the 19 physical therapists were didactic instructors and mentors and one additional staff physical therapist was a mentor only, the remaining 6 staff physical therapists were not involved in residency instruction (Females = 9, Males = 10). The average years of experience was 13.6 years. Over the course of the study period, 4 staff therapists became ABPTS board certified. Administrators worked at the institution for an average of 15.3 years.

Table 2
Table 2:
Results of the Survey for Perceived Benefits of the Orthopaedic Physical Therapy Residency Program Reported by Staff Physical Therapists
Table 3
Table 3:
Results of the Survey for Perceived Benefits of the Orthopaedic Physical Therapy Residency Program Reported by Hospital Administrators

CONCLUSION

Clinical outcomes improved 37% from the start of the planning process (2007) to the graduation of the fourth resident (2012). Considering baseline outcome data (2007–2008) were collected during the planning phase, improvement in the PSFS during this time period may have been because of faculty and mentors attending additional continuing education courses and spending significant time reviewing current literature and developing course materials. It is possible that the gradual improvement in clinical outcomes from 2007 to 2012 was a result of gained experience over time and not from implementation of the residency program. However, during this time period, productivity increased 39% compared with the previous 6-year baseline improvement (2000–2006) of only 4%. The service area also expanded with patients coming from an additional 41 zip codes, demonstrating that patients began travelling from outside the service area to receive treatment at the hospital from staff physical therapists with specialized training. Before 2007, patient volume was constant and therefore did not justify additional staff. The residency program became a focal point of a strategic vision to expand physical therapy services. This vision also included additional clinic space and marketing efforts. As patient volume grew, additional staff therapist positions were added and filled with resident graduates. Marketing efforts promoted the residency program to the public and referring physicians as a means to differentiate the department from its regional competitors.

The change in mode on the PSFS from 2.0 to 10.0 represents a greater frequency of large improvement within the patient population. This change could be attributed to staff physical therapists developing a higher level of skill in treating musculoskeletal conditions as a result of being involved with the residency program. In addition to teaching and mentoring, staff physical therapists, including those not directly involved in the residency, regularly attended residency courses. This hypothesis is supported in part by the results of the therapist survey. Most of the physical therapists surveyed responded that the residency program made them a better clinician (SA = 11, A = 7), improved their examination skills (SA = 8, A = 8), and their treatment skills, contributing to the professional development of the department as a whole. Overall, the steady increase in PSFS scores suggests a positive effect of the residency program.

The results of the surveys indicate that both physical therapy staff and hospital administrators had a very positive view of the impact of the residency program and reflect anecdotal reports that the residency program fostered a “culture of excellence.” Several therapists reported that the residency program motivated them to become more involved in the profession (SA = 6, A = 8) and to seek advanced training and board certification (SA = 7, A = 3). Most responded that the program contributed to improving clinical outcomes and patient satisfaction. Most of the administrators and therapists agreed that the residency program contributed positivity to the image of the hospital and of the physical therapy department within the community in general, and specifically with referral sources. This sentiment was reflected in the increased productivity of the department and widening geographical area from which the department attracted patients.

All the administrators strongly agreed that the residency program was a good investment for the hospital and that the residency program helped to recruit and retain highly qualified physical therapists. Everyone agreed that resident graduates who stayed on as employees consistently exceeded expectations. Since the start of the program in 2009, there have been 14 graduates of the orthopaedic physical therapy residency program, and 100% passed the OCS exam on their first attempt. In 2017, national board certification passing rates for residents was 90% versus nonresidents 77%.3 Previous research has shown that advanced training and specialization for physical therapists improves clinical outcomes.6–8 Since the start of the residency program in 2009, 4 of the 11 residents accepted full-time positions within the hospital system after graduation, a clear benefit of hosting a residency program. All surveyed therapists responded that they valued working at an institution that had a residency program, and most responded that the program has improved employee satisfaction. Most of the therapists and administrators responded that the program contributed to staff retention. Administrators unanimously recommended other hospital systems to invest in physical therapy residency programs.

When the physical therapy profession decided to advance from the bachelor and master degrees to the entry-level doctorate, clinical education was not advanced with it.13 Academic programs added additional coursework in medical screening, diagnostic imaging, pharmacology, and clinical reasoning; however, clinical education remained the same. In her 18th John H. P. Maley Lecture, Kornelia Kulig,13 PT, PhD, FAPTA, explained the importance of residency training and why it is essential for the future of physical therapy. Kulig stated that there is a high expectation for doctoral trained clinicians and a need for clinical specialization. She went on to recommend that we embrace physical therapy residencies as an expected path in physical therapists training and to pursue the development of a suitable infrastructure capable of providing residency training for all new graduates. Finally, Kulig13 stated, “Residency education is a necessary step to clinical mastery. Clinical mastery does not happen through self-study, through academic course work, or by reading books.”

Clinical education placement has become a challenge for academic institutions. The growing number of new physical therapy education programs, 284 accredited as of January 2019, and expanding class sizes is placing a strain on the current clinical education system. Directors of clinical education are managing hundreds of affiliation contracts and are constantly scrambling to place students. Many clinical sites refuse to take students, stating their therapists are too busy because of increased productivity demands. Some clinical sites have begun charging academic institutions and others are considering doing the same.14 This shortage of clinical education sites is expected to grow and will impact the future of the physical therapy profession.

Hospital/health systems in collaboration with other local and regional physical therapy facilities (outpatient clinics, extended care facilities, home health organizations, school systems, occupational health groups, and wellness and prevention programs) along with academic institutions, have the ability to provide high-quality clinical experiences and year-long residency training for all physical therapists. Creating a clinical education network15 that includes all ABPTS specialty areas (cardiopulmonary, geriatrics, neurology, orthopaedics, pediatrics, sports, women's health, acute care, oncology, and wound management) would provide a breadth of settings and populations for students and residents to gain clinical experience. Physical therapy residents would play a vital role in mentoring physical therapy students. Joint appointments between the academic institution and network facilities would provide continuity between academic coursework and clinical education. Smaller networks could combine with larger networks to ensure all areas of specialization are covered. To provide opportunity for diversity, students and residents could apply to have experiences outside their own network. The partnership between academic institutions and network facilities would need to be mutually beneficial, including financial subsidy, to ensure quality and sustainability. Benefits of being a network member include residents potentially staying on as full-time employees, improved clinical outcomes, continuing education for staff, increased job satisfaction, and the potential to negotiate reimbursement with regional payers by networks demonstrating improved clinical outcomes with fewer patient visits. This model would address multiple issues facing the physical therapy profession including the growing challenge of clinical education placement, advancing clinical education from the masters to the doctorate level through residency training, and fair reimbursement for physical therapy services. This model is also in line with the APTA's current vision statement for the physical therapy profession that emphasizes collaboration with community organizations and other healthcare providers and fosters adoption of best practice standards to ensure high-quality cost-effective health care.

There were several limitations to this study. We did not have consistent capture of PSFS scores every year, this was because of changes in computer software and hardware systems. It is possible that this inconsistency skewed the data. Although it was not consistent, the sample size each year was large (N = 657–1,369). Only patients with complete initial and discharge data were included in the analysis. This may have contributed to selection bias as patients with incomplete data may have discontinued care because of a lack of progress. However, patients may also have discontinued care because of significant improvement and the perception that no further care was necessary. It would have been advantageous to have more years of outcome data before the planning and implementation of the residency to better establish a baseline trend. It is possible that the trend of improving outcomes was because of factors not related to the implementation of the residency, but instead to other factors such as increasing experience of the staff. However, Resnik and Hart8 did not find that therapists with greater clinical experience were more likely to achieve the best patient outcomes, but rather therapists with advanced training such as OCS, FAAOMPT, or MTC. During the study period, 4 staff therapists became OCS, and 2 resident graduates who also became OCS were retained as staff therapists after graduation. In addition, the productivity and zip code data available for 6 years before the start of the residency demonstrate a marked change that correlates to improved clinical outcomes. The survey of department staff and hospital administrators has not been validated, but instead was based on the authors experience. Finally, the generalizability of the results is limited because the data were collected from a single hospital-based orthopaedic residency program. Institutions who choose to “farm out” the didactic or mentoring duties may not see the same improvements in clinical outcomes. We believe the benefit to the entire department comes from the “culture of excellence” fostered by the residency program.

CONCLUSION

The results of this case report suggest that hospital-based orthopaedic physical therapy residency programs have the potential to improve clinical outcomes, job satisfaction, professional development, staff retention, and productivity. It provides some justification for hospitals and other facilities that offer physical therapy services to invest in residency training. Although financial data were not published, the hospital-based physical therapy department in this study experienced a significant increase in referrals and subsequent financial growth after the introduction of the residency program. A zip code analysis showed that patients were travelling from outside the service area to receive treatment at the hospital from staff physical therapists with specialized training. Published data on the comprehensive financial costs associated with hosting a residency program would assist institutions when considering starting a residency program. Further research should continue to investigate the impact of residency training comparing clinical outcomes of graduates with nongraduates of similar years of experience. A commitment to residency training for all physical therapists by hospitals, rehabilitation facilities, academic institutions, and the APTA will elevate the profession and ultimately improve patient outcomes.

REFERENCES

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Keywords:

Physical therapy; Residency; Clinical outcomes; Benefits

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