Running As Fast As I Can

I was recently told my bio for the company website wasn’t long enough. “Not a big deal,” she said. “Just tell me why you’re passionate about physical therapy. Why did you become a physical therapist?”

“Because I didn’t want to spend 8 years in med school” said my mouth. My brain silently added “Well hell you might as well have, you might actually have money.” Let’s just say it wasn’t my best day.

I went home in a panic. If the only answer I could think of was “Because I didn’t want to spend 8 years in med school,” then was I in the right profession? I had assumed I was, because dammit, I’ve devoted a lot to this profession. I attended state association board meetings as a student. I was president of the student special interest group, I helped start a movement around student debt, I started a podcast on physical therapy news, I’ve been to most conferences every year, I completed a residency and I recently passed the orthopedic specialty exam. Oh, and I have $195,000 in debt. Get your shit together Rach, now is not the time to second-guess your life choices.

When I sat down to apply to physical therapy school, I thought I had considered all my options. I looked into medical school (too long), nursing (no autonomy), and physician’s assistant (why did I say no?). Unlike many others who enter this profession, my only contact with a physical therapist was not for my own health. I was talked into volunteering for a therapeutic riding program that had a physical therapist on staff, and hey, it seemed like a cool job. Physical therapists had autonomy and there was a chance a horse could be involved, so why not.

I completed my observation hours — I even took a month to go to Costa Rica and volunteer with a physiotherapist in a nursing home. I loved it. PT, definitely for me! …right? At this point in my life, I had completed my undergrad degree in biology and, despite assurances that I would find a job because I had a college degree, I worked 60 hours a week for minimum wage in the glamorous business of hardware and food service (not together). It was time for a change. $15,000 in student loans from my useful undergraduate degree in biology seemed like a lot of money at the time, and it was only growing. I wanted to “do something with my degree.”

Looking back at my pre-DPT days, they weren’t that bad. I lived in Chicago; no car required. Food service is never boring, hardware sales always raised my feminist ire (actually, sir, you can’t use that anchor to mount your Dresden wall sconces, but I’m a female, what would I know, so go right ahead), my roommates were fabulous, and the cash bar around the corner was a prime hang out. But I wanted more than the drudgery of the 60 hour work week to barely make rent. So, I chose PT.

As I sit here now, 2 years out of school, I keep thinking back to something that was said to me several times at conferences and other PT events. “We eat our young.” Unfortunately, it’s true. Don’t get me wrong — I have wonderful mentors and there are so many good human beings who have decided to become PTs. But the high debt to income ratio, the false promises and high workload in many settings, and the changing healthcare world is not a conducive environment for the new graduate. And the response when we complain? “You chose this.”

Now I tell people not to choose this profession. I tell students to look at physician’s assistant or athletic training or nursing. Sometimes I tell people to not even try to go into healthcare. But PT? Unless you can get into a school that won’t leave you six figures in debt, don’t bother. Run the other way.

At this point, you might be thinking that I’m just whining. I did, in fact, choose PT knowing I’d end up in significant debt. But the debt is just one reason I tell people to run. The other reasons are more complex and not well understood by someone who hasn’t been enmeshed in the profession. But I’ll enumerate them here.

1. It’s not just the fact that we have student loans. It’s the attitude of academia and the profession as a whole towards the growing debt. “You chose this, you figure it out.” “Also, you should consider residency.” “Hey, what about mandatory residency?” To give credit where credit is due, the American Physical Therapy Association has recently committed to working with other student professional groups and organizations to find solutions. In the trenches, there is very little employers can do — reimbursement rates are sinking and private practices are struggling to keep head above water; to put it bluntly, your six figure loan debt isn’t their problem. Since this piece was written, APTA’s President Sharon Dunn has commented on student debt in her address to the House of Delegates. Watch it and read the transcript here.
2. Advanced practice is not well defined and does not come with an increase in pay. Residency changed the way I practiced. The mentorship was invaluable. I am so much more confident in my practice — I even perversely recommend residency to new graduates who reach out to me. I took the OCS (which takes months to grade, just like all computerized multiple choice exams). I am a better clinician, two years out of school. But that doesn’t mean I make more money, or that anyone outside my profession actually knows what the designation “OCS” means.
3. A large percentage of the profession does not practice at the top of their license. If I had to hazard a guess, I would say greater than 50% — and that’s probably on the low side. Modalities abound. You need to bill 4 units per patient to turn a profit, even if you can accomplish meaningful change in 15 minutes or less. If you don’t want this to bother you [as much], don’t even think about doing a residency. New graduates have evidence-based or evidence-informed practice pounded into them until the day they graduate. And then in mid-May, they are released into the often inhospitable waters of the Real World, where they watch clinicians use ultrasound and e-stim and laser until the cows come home. And it. Is. So. Hard. To be that person who consistently raises the bar. “BUT WAIT,” scream the PTs who are practicing at the top — ”You just have to find a clinic that practices at the top of their game!” The world is full of “just gottas.” Relying on your new graduates to change the tenor of the profession while simultaneously swimming under the combined burdens of student debt and stagnant pay is unrealistic and an impossible burden. *cue the discussion on burnout*
4. Direct access does not mean we are primary care providers. Despite the #ChoosePT and #GetPT1st campaigns, we are not primary care providers. Direct access increases patient access to care, but not does offer the benefits of being a “primary care provider.” Therefore, despite holding a doctorate and being an entry point into the healthcare system for patients, we are not eligible for many programs that give assistance (student loan repayment, mortgage assistance) to PCPs. The APTA is currently pursuing legislation that would add PTs to the National Health Services Corp, making us eligible for loan forgiveness in underserved areas. Check out the legislation and contact your legislators here.
5. The House of Delegates does not represent the population it claims to serve. For those who don’t know, the House of Delegates is the policy-making body of the American Physical Therapy Association. Each state sends a delegation. The delegates vote on policies and guide the actions of the APTA. For example, that pesky doctorate degree? The House of Delegates voted for that. The opposition to physician owned physical therapy services? House of Delegates. However, the House of Delegates is primarily composed of academia. Delegates are also not required to reach out to constituents to gather opinions to inform their own decisions (some try, but are often not successful, and there seems to be little support for this at state and national levels). The end result is 402 people casting votes for what they think is best.
6. We’re condescending assholes to each other on social media. Check out any PT-themed Facebook group.

The final result of these 6 complaints is a profession that doesn’t know what to do with their latest generation of recruits. The transition from school to practice is incongruous. The high expectations of the profession and call to altruism jar with the low reimbursement rates and high debt to income ratio. And if you choose to bring this up, *gasp*, you run the risk of becoming a social leper.

Two months ago, I chose to put my physical therapy news podcast, Talus Media, on hold indefinitely. I had a wonderful team, but collectively we were sinking under the pressures of being new grads looking for a place in the world. I was growing to resent the profession, slowly turning sour under self-imposed responsibilities instead of choosing the projects that sparked my passion.

I have chosen to try to remember why I got into this profession. I didn’t become a PT to get embroiled in the strange politics of the House of Delegates or the APTA. I became a PT because I wanted to help humans. I also became a PT because I believed that I would be able to live a happy, fulfilling life and have flexibility. So that’s where I’m going to focus my energy. Instead of sprinting to the front of the pack, I’m going to enjoy a more leisurely pace, and remember why I chose PT.