Costs associated with higher education and utilization of student loans have increased significantly over recent decades, with Americans now holding more than $1.5 trillion in educational debt.1 Between 1980 and 2010, the cost of attending a public 4-year institution increased by a multiple of 3 when accounting for inflation without a corresponding increase in household income.2 Between 2004 and 2014, student loan debt increased by 327%, with educational loans now constituting the second largest debt category in the United States, trailing only household mortgages.3
High levels of student loan debt may delay the ability of college graduates to make major purchases such as a home or car4; delay life decisions such as marriage and having children5-7; and may delay retirement plan contributions.4 Concerns have also been raised about the mental health impacts of educational debt on young adults because high student loan balances have been associated with decreased psychological functioning.8 Intensifying this issue for graduate students is the loss of lower-interest, federal, subsidized Stafford loans, with student borrowers now forced to replace this funding with more expensive unsubsidized or private loans.9
Increasing student loan debt is a concern within many health care professions, including physical therapy. Tuition and fees required for completing an entry-level physical therapist educational program during the 1999–2000 academic year were, on average, $18,013 for public institutions and $50,556 for private institutions.10 Since then, educational costs have more than doubled, with the average tuition and fee required in 2018–2019 to complete a public physical therapist educational program to be $64,993 and $112,714 for a private educational program.11
There are many reasons for increased costs within higher education. State appropriations for public colleges and universities have been steadily decreasing, leading institutions to increase tuition and fees to make up for lost state funding.12 Other contributing factors include an increase in administrative positions,13 facility improvements to enhance student recruitment,14 and increased costs for employee salary and benefits.15 Entry-level physical therapist educational costs have also increased due to the degree having transitioned to the Doctor of Physical Therapy (DPT), resulting in additional academic credits and tuition.16
For physical therapists, educational costs have increased without a proportional increase in income. Between 2007 and 2016, entry-level physical therapist salaries had an annual growth rate of 2.02%, lower than salary growth for occupational therapists, pharmacists, and physician assistants.17 Estimating entry-level salary is important when analyzing student loan debt, as one definition of manageable debt is having less debt at graduation than one's annual starting salary.18 Utilizing the 25th percentile of the Bureau of Labor Statistics Occupational Employment median annual wage for physical therapists has been previously found to be a valid measure for estimating entry-level salaries.17 In 2018, this average entry-level salary was $71,670,19 an increase of $13,790 over 2007 levels.17
In addition to the recommendation of accruing less educational debt than one's starting salary, debt-to-income ratios are also used to determine loan affordability. Frequently cited guidelines suggest that for educational debt to remain manageable, repayments should not exceed 8–10% of gross monthly income.20,21 Baum and Schwartz22 proposed an income-based repayment model asserting that higher earners can assume a higher income-to-debt ratio than traditional guidelines. Utilizing this model, entry-level physical therapists can afford educational loan repayments up to 15% of gross monthly income, a guideline applied in prior physical therapist student loan debt research.23 Applying this framework, this study employs a 15% maximum debt-to-income ratio as the definition of manageable student loan debt, utilizing gross monthly income and student loan payment amounts.
In 2018, Pabian et al23 evaluated entry-level physical therapist salaries to determine student loan balances that are considered acceptable, defined as repayments of less than 15% of monthly gross income; greater than acceptable, defined as repayments between 15% and 20% of monthly gross income; and as a hardship, defined as repayments over 20% of monthly gross income. The authors determined that $80,000 in student loan debt would be at the high end of the acceptable income-to-debt category, and a loan balance over $120,000 would be within the hardship category.
Although concerns have been raised about increased educational debt for physical therapists, there has been minimal related research. Previous studies have primarily focused on graduates from one institution or from a small number of institutions, and no previous study has compared DPT student loan debt between public and private institutions. Thompson et al16 surveyed 92 physical therapists who graduated from one public program between 2005 and 2007. Eighty-six percent of participants had student loans, and 68% reported a loan repayment period longer than 10 years. Only 3% of participants had loan payments greater than the 15% gross monthly income guideline, and no participants reported loan repayments over 20% of gross monthly income. This study found no significant relationship between monthly loan repayment amounts and decisions regarding buying a house or having children. Participants with higher repayment amounts reported more difficulty with financial savings, travel, and discretionary spending.
Stepp et al24 administered surveys to student physical therapists at one public institution just prior to graduation between 2010 and 2016. The average student loan balance for the 464 participants was $83,516, with the average balance increasing 15% over the 6-year study period. The authors concluded that if an entry-level physical therapist had the study's average loan balance and estimated starting salary, they would be unable to meet recommended 10-year repayment guidelines due to monthly payments being too high compared with income. The authors also recommended the addition of curricular content on financial literacy within DPT educational programs due to participants ranking loan repayment as unimportant relative to other job incentives.
The American Physical Therapy Association25 conducted a survey of 2,839 physical therapists who graduated from educational programs between 2013 and 2015, with 88% of participants graduating with student loan debt. For participants with student loans, the average loan balance at the time of graduation was $124,000, with a median reported salary of $70,000. For participants with student loan, 33% stated educational debt had influenced the geographical location of their primary clinical position, and 35% stated educational debt had influenced their choice of practice setting. The presence of an employer-based student loan reimbursement program was reported by 6% of participants, with the median reimbursement being $10,000.
In 2015, a report determined that 75% of DPT program graduates from the California State University (CSU) had student loans, with the average amount borrowed for attending the program to be around $74,000.26 This amount was in addition to any student loans borrowed for prior undergraduate or graduate study. The report also concluded that the average educational debt of CSU DPT graduates to be at the higher limit of what is considered manageable based on starting physical therapist salaries.
Shields and Dudley-Javoroski17 performed net present value (NPV) modeling to determine the cost–benefit analysis of attending a physical therapist educational program. Net present value determines the economic value of a career by comparing factors including education costs and future wages, as well as determining what level of debt would be considered manageable or unmanageable for graduates. Their results found NPV for physical therapist education to be higher than occupational therapy, optometry, and veterinary medicine and lower than dentistry, pharmacy, and physician assistant education. The authors concluded that if PT students accrue $150,000 or more in student loans, they would only be able to meet the recommended debt-to-income ratio over an extended 300-month graduated repayment plan, which lowers initial payments but increases the amount of accrued interest. This modeling also found that PT students who accrue $200,000 or more in student loans would be unable to meet recommended debt to income guidelines under any repayment plan.
Previous research has also shown that college students generally have a low level of personal financial knowledge.27 Chui28 described the design and implementation of a 15-hour elective personal finance course for pharmacy students on personal finance, including content on financial goals, loan management, and budgeting. Student course satisfaction was consistently high, and course enrollment increased significantly over a 4-year period. Besides educational debt, credit card debt is another component to consider in the college population because it has been reported that college students with high student loan balances more likely to have twice as many credit cards than those with less student loan debt.29 In addition, college students with more than $1,000 in credit card debt are more likely to be stressed, binge drink, and engage in tobacco and drug use.30
The high costs of attending a physical therapist educational program may also decrease diversity within the physical therapy profession. Studies have shown that prospective students from lower socioeconomic backgrounds,31,32 and older students33 are more likely to report being discouraged by the costs of higher education. The increasing costs of physical therapist educational programs may dissuade less advantaged students, as well as prospective students seeking a midlife career change from pursuing a career as a physical therapist.
This purpose of this study was to determine the levels and potential repayment of student loan debt for graduates of public and private physical therapist educational programs and to determine the relationship between debt management education, student loan debt, and credit card debt in DPT students just prior to graduation. Having a greater understanding of these issues may be helpful for the design of debt reduction strategies within physical therapist education.
Seven hundred thirty-three DPT students scheduled to graduate in the spring or summer of 2019 completed the study survey, with 45.8% of participants attending a public institution and 54.2% attending a private institution. As Commission on Accreditation in Physical Therapy Education (CAPTE)'s projected number of DPT graduates for 2019 was 10,721,34 participants composed approximately 6.8% of 2019 physical therapist program graduates. During the 2018–2019 academic year, 52.2% of physical therapist educational programs were housed within private institutions and 47.8% were housed within public institutions,11 which is similar to the institutional enrollment of study participants.
Average participant age was 25.95 years. As participants were scheduled to graduate from their DPT educational programs in spring or summer of 2019, they would have applied to their program 3 years earlier during the 2015–2016 Physical Therapist Centralized Application Service (PTCAS) admissions cycle. The average age of accepted PTCAS applicants during that academic year was 22.91 years,35 suggesting that the average age of study participants is comparable to the national average.
This research study consisted of a cross-sectional survey design and was approved by the Institutional Review Board at the Northland Community and Technical College in East Grand Forks, MN. Participants were DPT students scheduled to graduate in 2019 from CAPTE accredited physical therapist educational programs. In the spring of 2019, program directors for all accredited DPT programs were identified through a CAPTE online directory, then emailed a link to an online survey with directions to forward the link onto students who would be graduating in the spring or summer of 2019. The linked survey contained an invitation to participate in the survey, the purpose of the study, and survey instructions.
Participants were required to complete an electronic consent form prior to completing the survey. Demographic questions were on participant age and if the DPT program they attended was housed within a public or private institution. The survey included questions asking participants to state their total student loan debt (DPT + undergraduate debt) at the time of graduation; their student loan debt borrowed solely for attending a DPT program at the time of graduation; and total credit card debt, all rounded to the nearest $1,000 increment. Additional survey questions asked participants their estimated starting salary as a full-time physical therapist after graduation; their concerns regarding student loans debt; their estimated student loan payback duration in years; and the presence or absence of debt management education within their DPT educational program.
Descriptive statistics were calculated for all variables. Independent t tests were calculated to determine if the dependent variables (total student loan debt, student loan debt borrowed for attending a DPT program, and estimated repayment duration) were different for students who attended public versus private DPT programs. Independent t-tests were also calculated to determine if the dependent variables (total student loan debt, student loan debt borrowed for attending a DPT program, estimated repayment duration, and current credit card debt) were different between participant who did and did not have educational debt education within their DPT program. Pearson correlations were calculated to determine relationships between total student loan debt, student loan debt borrowed for attending a DPT program, estimated annual starting salary, expected years for loan repayment, and credit card debt. Alpha for each probability test was set at .01 to guard against an excessively large Type 1 error rate.
Six hundred sixty-seven participants (91%) reported some amount of student loan debt at the time of graduation, and 35.2% reported the presence of debt management education within their DPT programs. 39.4% of participants from public institutions reported the presence of debt management education compared with 29.8% of participants from private institutions. Participants' average expected starting salary for their first full-time physical therapist position was $67,559 (±$9,371). Also, 23.8% of participants reported having credit card debt, with the average balance for those with credit card debt being $1,993 (±$3,329) (Table 1).
Table 1. -
||Overall Sample, N = 733 (%)
|Did your PT program provide debt management education?
|Will you graduate with student loan debt
|Current credit card balance
For participants with student loan debt, 81% were concerned about loan repayment after graduation; 91% were concerned about the ability to make future major purchases, such as a house or car; and 53.5% estimated a student loan repayment period of 10 years or less (Table 2). For participants with student loans (n = 667), the average loan balance at the time of graduation was $122,726 (±$59,873) and the average estimated repayment period was 15.03 years (±9.1 years).
Table 2. -
Debt Information for Subjects With Student Loan Debt
||Overall Sample, N = 667 (%)
|Total student loan balance
|Concerned about ability to repay student loans
|Concerned about making future major purchases
|Estimated years to repay student loans
| 0–5 y
| 6–10 y
| 11–15 y
| 16–20 y
| 21 or more y
Table 3 includes the comparisons for participants with student loan debt from public and private institutions. At the time of graduation, the average total student loan debt (DPT plus undergraduate) for participants graduating from a public institution ($103,481 ± $52,246) was significantly (P < .01) lower than the average debt for participants graduating from a private institution ($138,361 ± $61,173). The average student loan debt borrowed just for DPT program attendance was significantly (P < .01) lower for participants graduating from a public institution ($83,087 ± $42,296) than that for participants graduating from a private institution ($112,207 ± $50,885).
Table 3. -
Comparison Between Subjects With Student Loan Debt From Private and Public DPT Programs (N
||Public Institution, M (SD)
||Private Institution, M (SD)
|Total amount of student loan debt (prior education + DPT)
|Student loan debt for DPT program
|Expected years to pay off student loan debt
||13.6 y (±8.78)
||16.2 y (±9.20)
Abbreviation: DPT, Doctor of Physical Therapy.
aP < .01.
Participants graduating from a public institution had a significantly (P < .01) shorter average estimated loan repayment period (13.6 years ± 8.8) than those graduating from a public institution (16.2 years ± 9.2). There was a significantly higher average student loan balance at the time of graduation between participants graduating from public ($103,481 ± $52,246) and private programs and a significant difference (P < .01) in estimated loan repayment duration between subjects attending public and private programs (Table 3).
Participants who received debt management education estimated a significantly (P < .01) shorter time for loan repayment (13.2 years ± 7.9) than those who did not receive this education (16.0 years ± 9.5). There were no significant differences between participants who did or did not receive debt management education regarding the amount of student loan debt, student loan debt borrowed for DPT program attendance, or for amount of credit card debt (Table 4).
Table 4. -
Comparison Between Subjects With Student Loans Who Received and Did Not Receive Debt Education (N
||Debt Education, M (SD)
||No Debt Education, M (SD)
|Debt taken out for DPT program
|Participant's estimated years for student loan repayment
|Credit card debt
Abbreviation: DPT, Doctor of Physical Therapy.
aP < .01.
Table 5 contains correlations of student loan debt levels, expected annual salary, and expected repayment duration for participants with student loan debt. Significant positive correlations (P < .01) were found between student loan debt balances and expected annual salary; between student loan debt balances and credit card debt; and between student loan balances and expected years for loan repayment. There was no significant correlation between expected annual salary and estimated student loan repayment duration.
Table 5. -
Correlations for Participants With at Least Some Student Loan Debt (N
|Measure (n = 667)
|1. Total student loan debt
|2. DPT program debt
|3. Expected annual salary
|4. Expected years to pay off student loans
|5. Credit card debt
Abbreviation: DPT, Doctor of Physical Therapy.
aP < .01.
Table 6 contains estimated monthly repayments for standard 120-month, extended fixed 300-month, and extended graduated 300-month repayment plans for the average student loan balances of participants by institution type. All monthly repayments within this study were calculated utilizing an interest rate of 6.08%, which is the unsubsidized professional/graduate student loans interest rate for July 2019 to July 2020, the start of the repayment period for DPT students who graduated in the spring or summer of 2019.36 As graduated loans have their monthly repayment increase over the repayment period, the first and last month payments are included within the table.
Table 6. -
Monthly Payments for Average Loan Balances for Participants With Student Loan Debt (N
||Public PT Program, $103,488
||Private DPT Program, $138,361
||First payment: $526
||First payment: $703
|Last payment: $1,006
||Last payment: $1,345
Abbreviation: DPT, Doctor of Physical Therapy.
DISCUSSION AND CONCLUSION
For participants with student loan debt, the average total loan balance was $122,716 with an average of $99,153 borrowed for DPT program attendance. The difference between these averages and the average balances of participants attending public (total debt: $103,482; DPT program debt: $83,087) and private (total debt: $138,361; DPT program debt: $112,207) DPT programs demonstrates the importance of determining institution type when conducting educational debt research. Participants' average estimated starting salary was $67,599 (±$9,371), which is similar to a recently reported entry-level salary for physical therapists.37 Also, 70.9% of participants with student loans reported a student loan balance exceeding this estimated average starting salary.
The maximum student loan balance maintaining monthly repayments within a manageable debt guideline, defined in this study as less than 15% of participants' average estimated starting income, was $75,700 for a standard 10-year repayment period. 75.1% of participants with student loans reported a balance exceeding this amount. This result, along with the high percentage of participants with a student loan balance greater than participants' average estimated starting salary, reveals that a majority of surveyed DPT students would have difficulty meeting 10-year student loan repayment guidelines. These participants would require a longer repayment period to ensure monthly payments stay within a manageable debt-to-income ratio.
Beyond 10-year repayment periods, 25-year repayment periods with fixed or graduated monthly payments are also available for student loan borrowers. The maximum student loan balance maintaining monthly payments below 15% of participants' average estimated starting salary for a 300-month fixed repayment plan is $129,800. However, 38.7% of participants with student loans reported a loan balance exceeding this amount. The maximum student loan balance maintaining the first monthly payment under 15% of participants' average estimated starting salary for a 300-month graduated repayment plan is $166,000. However, 21.4% of participants with student loans reported a loan balance exceeding this amount.
Due to monthly payments rising throughout the repayment period for graduated loans, maintaining payments under the 15% manageable guideline may not be possible for a $166,000 loan due to the growth rate of physical therapist salaries. This may result in a lower maximum manageable student loan balance for this type of loan. Assuming a 2.02% annual growth rate, participants' average estimated annual salary would increase to $111,448 after 25 years. The last monthly payment on a $166,000 300-month graduated student loan would be $1,614 or 17.4% of estimated monthly income. Significantly more interest is also paid under a graduated plan, with interest paid over a 300-month repayment period for a $166,000 student loan being $186,222.
For participants with student loans, 53.5% estimated a repayment period of 10 years or less, which is inconsistent with the 75.1% of participants with a loan balance exceeding manageable debt to income guidelines for a 10-year repayment period. This discrepancy, as well as the significant positive correlation between student loan balance and expected salary, demonstrates a potential incongruency between participants' expectations and reality regarding future income and loan repayment ability. Previous research has also shown that college students tend to underestimate the time required to repay their student loans.38
Applying a 6.08% interest rate to participants' average loan balances by institution type, repayments for a standard 120-month repayment period would be 20.4% of estimated gross income for participants at public institutions, and 27.4% of estimated gross income for participants at private institutions. These debt-to-income ratios place the average student loan balance for participants from both public and private programs well above the 15% manageable debt-to-income ratio and above the 20% hardship category as defined by Pabian et al.23
Applying an extended, fixed-payment 300-month repayment plan to participants' average loan balances, repayments would be 11.9% of estimated income for participants at public DPT programs and 16% of estimated income for participants at private DPT programs. A 300-month fixed repayment plan would maintain payments within manageable guidelines for the average participant at public DPT programs but not for the average participant at private DPT programs. Applying an extended, graduated, 300-month repayment plan to participants' average loan balances, the first repayment would be 9.3% of estimated income for participants at public DPT programs and 12.5% of estimated income for participants at private DPT programs. A 300-month graduated repayment plan would maintain the first monthly repayments within manageable debt-to-income ratio guidelines for the average public and private DPT student.
Of the total participants, 35.2% received debt management education within their DPT program. Participants who received debt management education had, on average, $3,520 less student loan debt taken out solely for their DPT Program and $570 less credit card debt, with these results not statistically significant. A majority of participants expressed concern regarding their ability to repay student loan debt and make future major purchases.
Jette39 proposed several approaches to decrease costs for attending physical therapist educational programs, including increasing program cohort sizes to enhance program efficiencies; awarding credit based on prior learning; developing a 2-stage licensing system, where students would graduate in 2 years, then complete a paid internship instead of paying tuition for clinical education courses; and educational programs collaborating regionally for clinical education administration. Beyond these ideas, lobbying for additional government loan repayment programs could also be successful, as 76% of surveyed PT graduates in one study stated potential interest in a student loan forgiveness program of up to $50,000 for a 2-year commitment to practice in an underserved area or community.25
Ensuring the availability of information regarding potential student loan debt for prospective students is also important. Prospective students weigh the time and costs of an educational investment against anticipated salary to help determine a potential career.40 Accreditation standards require physical therapist educational programs to publicly post information regarding program costs and employment rates.41 It may also be beneficial for programs to make graduate salary and student loan data publicly available to assist prospective students in making educational and career decisions.
Limitations of this study include a relatively small sample size relative to the total number of 2019 DPT graduates; not inquiring about the specific types of student loans taken out by borrowers; not inquiring about all sources of debt, such as a mortgage or car loans; and utilizing estimated salary. Regarding debt management education, limitations included not inquiring about student satisfaction levels with current debt management education within DPT programs, the types of debt management education within DPT programs, and not asking where the debt management education occurred within the DPT curriculum. Additional limitations included only analyzing certain student loan repayment plans, not utilizing additional definitions of manageable student loan debt, and not including gender or ethnicity questions within the survey.
As the cost of higher education is anticipated to continually increase, further research within this population is warranted to determine the impacts of student loan debt and strategies to decrease debt levels. Additional research with recent PT graduates should assess stress levels as well as how career and other life decisions have been impacted by educational debt. Future research with PT students should include local cost of living measures; reasons for choosing a specific DPT program; total household educational debt; and satisfaction with salary, program costs, and educational debt information obtained prior to program enrollment. Research with PT students should also start in the first year of their educational programs to determine how best to prepare students for managing debt postgraduation. It may also be beneficial to determine how debt management education prior to DPT program enrollment, such as within high school or undergraduate education, may impact student loan debt levels. Research on educational and efficiency strategies within PT programs would also be beneficial, as would research on how DPT student loan debt levels may impact diversity, equity, and inclusion within the physical therapy profession.
This study is the first to compare student loan debt and estimated repayment periods between DPT students at public and private institutions and is the first study to research the relationship between debt management education and DPT student debt. The average participant with student loan debt who attended a public DPT program would require a 25-year nongraduated repayment period to maintain manageable monthly payments, and the average participant with student loan debt who attended a private DPT program would require a 300-month graduated repayment period to maintain manageable monthly payments. As a majority of participants will require longer than 10 years to repay their student loan debt after graduation, it is imperative for the profession to implement educational debt reduction strategies in the near future.
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