What’s in a Title?

Confused

Since adopting a doctoral educational standard, there has been much controversy over how we, as physical therapists, should refer to ourselves. Over the past week, there have been several lively debates taking place during the #DPTstudent chat and on the ‘Doctor of Physical Therapy Students’ Facebook Group. In all honesty, I think the APTA’s Vision Sentence says it best…

By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, activity limitations, participation restrictions, and environmental barriers related to movement, function, and health.

As the profession continued to grow and mature, additional educational standards had to be in place in order to meet our growing scope of practice. This led to the gradual progression from a certificate program to bachelor’s degree to master’s degree and finally culminating in a doctoral degree. Today’s physical therapists treat patients in a multitude of settings from orthopedic to neurological (and everything in between) utilizing evaluative skills to implement the most appropriate and safe interventions to alleviate pain and restore function. Knowing the breadth of knowledge necessary to become a successful therapist and the recent implementation of direct access, this level of education is a necessity. So, with this added educational requirement and professional responsibility comes the right to be designated a ‘Doctor’, right?

Some within the healthcare community and even some of our own colleagues don’t seem to believe we should use this distinction… Is it because it’s undeserved? After I complete a 4 year undergraduate degree and a 3 year doctoral degree, I’m not sure how it couldn’t be deserved. After the hours upon hours of studying, 12 hour days of lecture, countless written and practical examinations, over 90 weeks of clinical affiliations, and far too many student loans; using the distinction ‘Doctor’ seems appropriate to me. Using this term is an honor allowed to those who dedicate themselves to the highest level of education within their particular field. It does not matter whether it is in the field of audiology, optometry, chiropractic, podiatry, dentistry, pharmacy, veterinary medicine, medicine (MD/DO), or physical therapy. Doctor is not an isolated term for physicians and it was never meant to be.

Many believe referring to ourselves as ‘Doctors of Physical Therapy’ will confuse our patients, but isn’t it our job to educate them? How many patients know that a physical therapist now needs to complete a clinical doctoral degree? How many know that they have direct access to our services? How many know that we are musculoskeletal experts? Few and far between. This needs to change. We need to change the culture around our profession and what the public perceives our profession to offer. This starts with our introduction.

“Hi, my name is John Snyder. I am a Doctor of Physical Therapy specializing in the rehabilitation of orthopedic and sports conditions. What brings you in to see me today?”

Upon graduation, this will serve as my introduction and clears up many questions and/or misconceptions my patient may have. It not only educates my patient as to my level of education, but also serves to explain my profession and area of expertise. We should not and cannot hide our education, it is a disservice to ourselves and to our patients. Our patients want piece of mind in knowing that they are being treated by a qualified healthcare practitioner, so why hide your qualifications? I am not proposing that we walk around in white lab coats, slinging our stethoscopes around our neck requesting that everyone refers to us as Dr. So-and-So. I simply think we need to advocate for our profession and this starts by educating the general public. This simple introduction gets our point across without the pomposity that could easily follow when explaining your advanced education.

All of this being said, I do not want to infer that those receiving a DPT are superior clinicians compared to those who are practicing with a BSPT or MSPT. Believe me, this is not the case. There are so many phenomenal clinicians that I either observed during my undergraduate education or worked under during my clinical rotations that are unbelievably intelligent, personable, and dedicated to their work… Only one of which had completed his DPT. I know many therapists who did not have the opportunity to pursue a DPT early in their careers have mixed emotions about the progression of our profession, but I do believe eventually the increased educational requirements will improve clinical outcomes and increase the use of evidence-informed practice. In my opinion, the purpose of the DPT was to allow our profession and subsequent education to evolve and only time will tell if this education translates into improved clinical practice.

So, do you introduce yourself as a Doctor of Physical Therapy? Why or why not?

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16 thoughts on “What’s in a Title?

  1. John –

    Thanks for the post. I appreciate your contribution to what is a difficult conversation within the profession and outside of it as well.

    There is an intriguing yet increasingly uncomfortable contradiction that is being taken and maintained within the profession. On one hand, you have this statement: “I do not want to infer that those receiving a DPT are superior clinicians compared to those who are practicing with a BSPT or MSPT”. On the other hand, you stated: “It not only educates my patient as to my level of education, but also serves to explain my profession and area of expertise.”

    Perhaps one thing needs to be sorted out first – why is the US the only country in the world that has a doctorate as the entry level professional degree? While we’re discussing it, if the issue was the degree, then how come there are many countries that have a BSPT as the entry level, and also have “unrestricted” direct access and better relationships as “equals” in the health care environment?

    I think we would agree that the profession is, first and foremost, one built around expertise in movement. That is the brand, something that we all aspire to build, refine, and promote. You are at an exciting time in the development of the brand. Bravo! But – the degree is not the brand, nor does it specifically have a relationship to the quality of the brand – and that has been shown globally. Sadly, our profession (in this country) has made them one and the same in the eyes of the consumer.

    Allan

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  2. I agree with Allan.

    John, I applaud you for wanting to use that introduction with your patients in the clinic, but I am willing to bet you don’t use it past lunch on your first day.

    I have struggled with this idea of titles and our “deserving” to use Doctor when introducing ourselves to patients. On one hand, you are 100% correct that you have the right to address yourself as such. You completed an intense curriculum which provided enough credits for a Doctoral degree. On the other hand, just as Allan pointed out, there is such a significant expectation when using that term that I doubt over 50% of PT’s actually meet or surpass. This is exactly why MSPT’s and BPT’s have no difference in wages, and are actually preferred by some employers over new DPT’s.

    This leads to my next point. The biggest problem I see with moving to the DPT is that we have one lingering issue within our field. Have we changed the way we assess ROM in the past 20 years? Have we changed the way we administer MMT? How about our understanding of muscle insertion/origin or innervations? Are MSPT’s unable to analyze gait? Further, has the gait cycle changed recently? Taking these questions into account, do we have any new techniques that actually REQUIRE an advancement in our education? My point is, while our techniques have been honed and our understanding of some conditions and treatments have slightly changed, the bulk of our knowledge and training has undergone little change in the past few decades.

    So tell me, besides wanting to elevate the profession from a respect and acknowledgement standpoint, what does your DPT provide that your colleague’s MSPT doesn’t? An ability to use PubMed? A 1-2 credit radiology course that you likely took little away from? A pharmacology course that taught you how to look up drug interactions?

    I am not trying to belittle your argument, as not long ago I sat right where you do on this discussion… and I, too, told everyone I would be introducing myself as Doctor. It hasn’t happened yet, and I don’t see it happening in the near future, either. I am very proud of the DPT degree I earned, as well as the ability to use the title “Doctor”, I’m just not sure it was ever necessary. We will see what the next 20 years bring.

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    1. Excellent reply Allan and Preston. I am from South Africa and we have a BSc PT, MSc PT and the PhD for physiotherapist. We have direct access for the last 20 + years. I believe that it is how you brand yourself that will make the difference and not your title that will change attitudes of patients and other health care professionals. I have contemplated doing my PhD but as a physiotherapists and owner of a private physiotherapy practice, I would gain nothing except the ability to have the title DR. I will be able to charge exactly the same as my colleagues with only a BSc or MSc and my clinical skills will not be different.

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  3. Embrace the DPT! public perception is so important. How many people in our country know the difference in education between a PT and a massage therapist? How many people have an accurate understanding of the skill set, education and value of the PT? Does the DPT help or hurt these issues?

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  4. Excellent post John! As a PT with a Masters and 15 yrs experience who is just about to finish a tDPT, this is something I’ve thought about. You make some excellent points & I agree that it is our job to educate the consumer/pt to our skill & education level. Not to do that would be a disservice to our profession.

    I use the Dentist or Eye doctor parallel. “I have a dentist appt with Dr. …” or “I’m going to get my eyes check at Dr. …” and when I’m in their office I address them as “Dr. …” I think the same should occur for a person going to outpt PT. “I have a physical therapy appt with Dr. Snyder.” There is no mistaking doctor to mean MD or DO in those situations.

    The slippery slope is in a hospital/rehab setting. Misrepresenting ourselves is also a disservice to our profession & would be confusing to a patient. Your greeting example is good, but in the hospital/rehab setting where MD & DO’s are common as well, I would probably add, “Please call me John” so there would be little doubt that you are NOT a MD/DO.

    Mike

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  5. Excellent post John. This has been an issue for many years, and I still struggle with some aspects on both sides of the argument. While Allan makes a valid point that many other countries still have the BS as the entry-level degree. Those countries also matriculate physicians, dentists, etc with BS degrees. A high school graduate enters directly into medical school, physiotherapy, or dentistry in countries like Australia, New Zealand, & South Africa. Interstingly, Australian universities are slowly starting to offer the DPT degree.
    I agree with some of the other comments as well, and generally refer to myself as Dr. Marich in the clinic, but once I introduce myself I have the patient refer to me as Andrej. Professionalism is not something you get with a degree, it is something you earn by your actions and interactions with patients, staff, and other medical professionals.

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  6. As I previously stated, I do not believe there is a huge education gap between the DPT and MSPT curriculum (or BSPT for that matter). What makes a great therapist? Passion, knowledge, personality, and devotion. Your degree is the starting point and your willingness to continually improve your hands-on skills, knowledge, and clinical reasoning make you an expert or, conversely, incompetent. This blog post is less about the clinical abilities between the degrees and more about supporting the progression of our profession.

    In order to grow as a profession and enter into a broader direct access role, the implementation of a doctoral degree was necessary. This better places our profession at the same level as related fields (DC, DPM, ect.). We constantly refer to ourselves as ‘musculoskeletal experts’, but in the public’s eyes, the letters behind the name are needed to back up this claim. Once they are seen and treated, our proficiency and skill-set are apparent, but we need to get them into our clinics first. Where do patients go when the hurt their back? Not to their PT, that’s for sure.

    Without outwardly educating patients and other healthcare providers as to our status as a doctoring profession, the DPT will not serve its purpose. I can’t even remember how many times I have been asked, “wow, do you really need a doctoral degree to be a therapist?” The more we educate our patients, the fewer times this question will arise and the more cognizant the general population will be of our educational standing. Why is it that a podiatrist or dentist is instantaneously greeted with ‘Dr.’? Why can’t the same be done for physical therapists? Simple answer, they don’t know. We need to educate. We need to advocate.

    I am sure other professions have gone through similar growing pains, but by hiding the evolution of our educational standards, we are extending these growing pains.

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  7. John: There is one key assumption that you (and many in the profession) have perpetuated – “In order to grow as a profession and enter into a broader direct access role, the implementation of a doctoral degree was necessary”. There is no data to support this belief – in this country, or any other for that matter.

    In 2000, the number of direct access states was 16; in 2012, it had grown to 17. There has yet to be a state that had restrictions that became unrestricted. But we continue to be told that “the doctoral degree was necessary to enter into a broader direct access role”. At this rate, we will both be old and gray (me far more than you, of course!) when we get to 50 states.

    While we’re at it, let’s look at the global experience. Most have BSPT degrees as the entry level degree. I can speak to this as I was trained in Canada. Ontario has had direct access since 1993 – with a BSPT degree. When I was practicing in Canada (prior to DA), there was a good understanding of the role of PT in the general population (something lacking in the US), and I was certainly considered an equal peer (and respected as such) by other members of the health care profession (again, oftentimes lacking in the US). A discussion with PTs from Denmark, Australia, New Zealand, UK, and many other nations would probably yield similar results.

    Not surprisingly, these “growing pains” that you mention appear to be a US phenomenon.

    If we are going to be a profession founded in “evidence”, then let us also consider the “evidence” when we discuss how to advance the profession and what is required to do so. Thus far, the US experience is not consistent with the initial selling points of the DPT.

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    1. You make very good points, especially in terms of restricted DA… What do you believe the greatest restrictions are at this point? Lack of advocacy/understanding of our role by general public and other healthcare providers?

      I still believe the DPT is an integral piece in getting the profession to the level it deserves, but I would love to hear your thoughts with regards to other (potentially more important) factors.

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      1. Just to clarify – I am an advocate of education! With that said, I think that the educational process could have been mapped out in a far better way. As an example, we could have maintained the BSPT as the entry level of practice – the generalist. Then, we could have developed Masters programs that allowed the clinician to refine their skills in a particular area of study (i.e orthopedics). Having a Masters degree would then indicate further training – much like the OCS has attempted to do, but in a standardized educational model. After some clinical practice with those advanced skills, a clinician would then have established the questions that need answers – and a Doctorate would then make perfect sense.

        You have asked the age-old question, for sure! What is the mechanism that is underlying all of this? Though I am sure this is multi-faceted, I can say that part of the problem is the self image and self perception of those in the profession. Professional autonomy continues to be debated in 2013! How is that possible in the evolution of the profession? It should be a part of your very being, your “DNA”, as a PT.

        I would also go back to the issue of “branding”. The degree has become more important than the brand. But as Preston noted, “the bulk of our knowledge and training has undergone little change in the past few decades.” We need to be bringing PTs together as PTs, as the “practitioner of choice” – not as DPT or MSPT or BSPT.

        If you had to pick out one limiter to the profession – only one – what would it be?

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      2. The one factor that continues to hold our profession back is the lack of unrestricted direct access and I think most therapists would agree with this. How can the general public view us as musculoskeletal experts when they can’t see us directly for their LBP or ankle sprain? For our profession to advance, direct access is a necessity. Patients who receive treatment early in the acute phase typically respond more favorably than those that do not… But we don’t see them until they see their PCP, orthopedic surgeon, neurologist, and/or chiropractor.

        Through advocacy and patient education, a larger percentage of the general population will understand that physical therapy is more than hot packs, ultrasound, and massage. The more individuals that understand our growing educational requirements, scope of practice, and effectiveness, the quicker this process will progress. The transition to an entry-level doctoral degree and the increasing prevalence of residency/fellowship programs will also increase the public’s perception of our expertise.

        I agree that we have to look past the variation in education amongst clinicians. The DPT is here to stay and other clinicians must accept this. Additionally, new graduates/students need to understand that the DPT does not equal a superior clinician. Experts in the field seek continuing education; they don’t do the bare minimum. Constant honing of clinical reasoning, manual skills, and knowledge are what make a superior clinician, not the letters behind the name.

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  8. How do we increase DA? Work with a group of surgeons and physicians? Market directly to the public, sort of like US Chiros? Market directly to insurance companies with the evidence that we save them money? All good strategies.
    One thing we can not do is dilute the “brand.” So after 16 years of practice, a doctorate, an OCS, and a specialty manual therapy certification, I have no way of making more money or seeing specific ICD-9 codes or impairments than a new grad. My skills are better, but we both can bill for an upper cervical manipulation. Hmmm. I can also bill for rehabilitation of a patient following a head injury. Not my expertise, but I can do it. This is where we need to change, in my opinion. That coupled with less technicians and assistants will provide better care, better outcomes, cost savings, and more results than any degree changes. Throwing our patients to the techs and assistants is not in our best interest.

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    1. Steve, I 100% agree with you, especially in terms of our over-reliance in supportive staff. I had the unfortunate experience of observing a physical therapy facility that was very much run like a factory. The PTs would evaluate the patient and come up with a general plan of care… After that point the PTAs took over and carried out the majority of the patient’s care. The discrepancy in staffing was absurd (something like 4 PTAs to each PT). This is something that needs to change. On a related note, the current joint mobilization and PTA debate is especially concerning.

      As far as billing for specific ICD-9 codes, I understand your reasoning, but I believe this is an area that should not be touched. As a profession, we have enough trouble advocating the usage of manual and manipulative therapy… Requiring a certain level of experience or credentialing to perform a cervical manipulation, for example, would be counteractive to the growth of our profession and the patient outcomes that should follow.

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  9. This was posted under “The U Word.” (http://orthopedicmanualpt.com/2013/02/07/the-u-word/) by accident…

    Jim Van Dyke:

    I apologize for my brevity. I am a PP owner and one of the “Old” PTs w/o a Masters or Doctorate, but I had over 260 credit hours of College work, 7 years total, graduated with Honors and scored in the 90% of the State PT Lic exam. I’ve worked hard to develop my practice skills and my practice and business. I attend over 30-40 hrs of Cont educ each year to stay abreast with up to date science and clinical “best tx” approaches only to have to compete with many POPTs that are staffed by “DPTs” that often times don’t give the quality care and time the patient deserves in order to keep the “revenue up” for the Dr’s “deep pockets” and that only hurts the chance of themselves to ever have/own their own clinic. I’ve followed your blog but recently noticed what I perceive as a bit of a “Confidence” level as though we all need to be DPTs. I don’t agree. It has not achieved what it was supposed to; help us become more independent and free us from having to be dependent on the Dr’s for our referral base etc.. I see more and more DPTs working for POPTS and it is killing our independence. I see both sides, kids graduating with Huge Student loan debt and needing a job vs understanding that working for the Dr’s is just killing and competing directly with PT owned PT PP clinics. I don’t mind a good for “fight”/competition, but I don’t get to “control” the patient flow, what they know, that they can “choose their own PT and not have to go to the POPTs, so the Dr offices “Kindly” refer them around the corner, or is some instances, “the very next door office” (how convenient) to be seen by “their PT” that just happens to be a DPT. Isn’t that convenient also. And in order for the DPT to keep their job “Value” the tell the patient “their clinic is the best” and don’t go down to the other place (the one that just happens to be owned and run by the PP PT) and the patients listen because how could they know any better?? Now, until we somehow get some laws that prevent Dr’s from referring to themselves us “OLD Non DPTs” have to compete against that??? We have and we do because we are the ones that paved the way for the DPTs and now they are “shooting our” profession in the foot and deeply hurting their chances of ever owning their own clinics………… Wasn’t that one of the reasons for all the extra “education”? I could write more, but I have to get back to work, my days are long and hard,…….and I love it, just give me a level playing field and I like my chances. I suggest you go and shadow and “OLD PT” someday and see just how much they know, then ask yourself if you would rather have their experience and savvy or you knew DPT. I for one am tired of hearing how much better the new PTs are vs the OLD. Its not very accurate to say the least and won’t matter much longer if the majority of the neW DPT grads just go work for the POPTs. Enough said. Good luck to you. JVD PT

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  10. Is there any longitudinal data to support that DPT’s are somehow better trained to evaluate and treat those conditons that BS and MS PTs have been treating very well for years? Are state board exam scores edging upward? Is GPA higher?
    What about an outcomes based study that shows care delivered bya DPT shows greater outcomes in a quicker amount of time?
    Direct Access has not been fully implemented in the US and even in areas where it has been implemented there are caveats and restricitons applied to it. I have had many DPT students in their final clinical who still had trouble with Fryette’s laws, did not reconginize how to properly rehab a post op ACL knee, did not know how to properly prescribe exercises or how to eccentrically train a patient in fucntional planes and functional movements.
    I have over 750 hours of continueing education and have served as a proctor to Medical Students who were doing their PM and R rotations. I have written articles, reviews, and continueing education courses. I review 3-5 articles in professional journals across a variety of specialities a week. I also have 17 years clinical experience in orhtopedic settings all with a simple BS. I can review and read x-rays, MRIs, and CTs.
    The DPT is another entry level degree, and when you graduate you will still be a PT. You will not be able to order diagnostic studies and I doubt your state practice act will allow you to review them and make conclusions based on those films.
    The point in the case is, you still will be treating impairments like the rest of us based on a thorough clinical evaluation.
    Furthermore, in the modern age of litigation, it will only take one malpractice suit to set a precedent of DPT’s and PTs becoming targets of lawyers and their clients. Are you ready for that extra responsibility? The increased liability? It may take a few years but it will happen.
    So I have completed more hours in post graduate work in education, have advanced certifications in manual therapy, have 17 years clinical experience, which is more than a DPT will have when they exit their program . . .seems to me I have the right to claim the same DPT status.
    So tell me how you would functionally train a post operative ACL to best facilitate the biomechanical and kinematic function in a middle third patella tendon graft and how you would alter that rehabilitaton if it were a cadaver graft versus and hamstring allograft. Do you prefer single bundel or double bundle repairs? How to you adjust you program in the presence of anterior knee pain? What are the red flags in the first six weeks of rehab you would look for? How long does it take the graf o mature and be a a level of strength that supports open chain activities? How do you incorporate eccentric loading of the hamstrings in functional activities? What is the role of the hamstrings during the landing phase of a jump?
    Put a DPT fresh out of school in a sports medicine clinic and see if they can answer these questions.
    With that title of DPT comes an increased responsibility and if you want that tilte you better be ready to accept that responsibility. Because the minute you hit the clinic floor and you accpet that first patient, you wil be making those clinical decisions. If you are in my clinic and you make the wrong decision it will cost me a potential patient and might anger the referral source. I assure you that mistake would only happen once. If you are in your own private practice, that wrong decision will cost you revenue and without revenue you cannot operate a clinic.
    I respectfully disagree that the title of DPT will somehow impart a level of confidence in patients as you have suggested. That level of trust and confidence is usually based on outcomes and results, a working relationship with physicians and referral sources, and building your reputation in a community.
    Ask any first year medical doctor at a new clinic and see if their patients are impressed by name and nomenlature alone . . .probably not . . .you have to build and earn that.

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  11. Well this is very straight forward. Generally speaking most of the physios who are against the DPT are the old folks. they will always argue that it was not neccessary mentioning all example and telling you that theres no difference to BS and DPT. Well old folks theres a difference, the experience you requered through your continous education after gratuating as a BS Physio, those who qualify as a DPT are being toaught those and DPT is necessary we dont have to sit on the table and discuss this cuz your excuses are plain and simble, you dont want to spend more money cuz already you have the experience we get that but we the new generation and those old folks who support the move we are going forward. Im also a Physio in south africa with DPT and belief me it helped in changing people perception and we all know in south south africa the move is blocked by old folks cuz the energy and the money is not the but we are going forwars. Wilma Erasmus you better take it as well the sooner the better. we all know that in south africa most Physios in private pratices dont wanna spoil the relationships between them and medics who reffer patients to them, we understand its a business decision but it does not benefit the profession as a whole cuz we know medics dont like physios with the title Dr. in south africa its coming soon with a new society and/ new council. we dont wanna a situation of bending your knees to a medic in order for you to get patients being reffered to you as the physios of tomorrow. the bus has to stop now. like it or not the youth are gonna change sooner than later in south africa and the world will follow. before i forget big up to the Indian physiotherapists i support the move BS with te drs courtesy title. why not if others can? where is equality. no confusion even in south africa, patients are still calling physio the physio doctor without urself misleading. they show they understand the difference. we work with dentist in the hospitals and patients are not confused they know the doctor is a dentist so they will know the doctor is a physio as much as they know the doctor is a medic. good bye people take it or retire!!!

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