Three years and zero education
To be perfectly honest, I didn’t learn anything from my three years of coursework to earn my Doctor of Physical Therapy — at a cost of $130,000 at the cheapest state school I could possibly attend.
That’s not to say I didn’t learn anything during those three years — I learned a lot from studying for my Certified Strength & Conditioning Specialist (CSCS) certification, reading articles at T-Nation, studying health protocols by Life Extension, and treating 3–5 massage clients for sports injuries each week.
When I asked my professors when we would be learning actual clinical skills, they would tell me I could learn whatever I wanted in continuing education, after I graduated. At one point, I got so frustrated with the system that I took 200 hours of massage continuing education in one semester on top of my coursework, earning my board-certification as a massage therapist.
Follow my journey and look behind the curtain of healthcare education in the US. You may just realize that American healthcare is designed to keep you sick. After all, if your physical therapist gets you better, you’re not a patient anymore — and paying customers are what keep businesses open.
At least I got some work experience, right?
I got a lot more out of being around the strength & conditioning and athletic training professionals from Virginia Commonwealth University Men’s Basketball as their team massage therapist than I did from my physical therapy coursework or my 40+ weeks of full-time internship work.
(The best thing about PT school for me was that it landed me my dream job while I was a PT student, because I could demonstrate that I was a competent manual therapist through my interest in moving my career forward from massage therapy to physical therapy.)
I actually lucked out in my internships and had consistently good physical therapists as clinical instructors. But I learned about one fact each week — MRIs for lumbar impingement probably won’t change treatment; cardio is great for depression in Army soldiers; mobilization with movement (MWM) of the hip can help improve the squat pattern in elderly patients; etc.
Honestly, I got more out of 2 days of Active Release Techniques (ART) training when I was six months out of massage school than I did out of a year of PT internships, just because I came into those internships with a decade of personal strength training experience and knowledge from reading T-Nation.
I didn’t think I was on the cutting edge of science when I treated a teenage girl with hypermobility syndrome by using farmer’s carries, kettlebell swings, and pull-up progressions. Honestly, it’s how I would treat anyone with terrible posture and severely deficient strength levels resulting in generalized pain. But when her pain resolved, it impressed my clinical instructor enough to nominate me for a scholarship. At graduation, I won that scholarship, recognizing me as the student with the best clinical skills in the class.
What’s wrong with the system
My personal belief is that physical therapists moved from a bachelor’s degree (30 years ago) to a master’s degree (20 years ago) to a doctorate (10 years ago) in order to compete with chiropractors, who are also “doctors” — though they are not medical doctors with prescribing privileges.
Chiropractors receive a doctorate of chiropractic (DC) degree usually after 8 years: 4 years of undergraduate and 4 years of medical school— similar to medical doctors (MDs). Chiropractors who want the fast track can attend a combined program to receive both the BS and the DC degrees after 6 years.
We were never told this explicitly, but it seems that physical therapists were having trouble getting laws passed for “direct access” because physical therapy was traditionally considered an allied health profession. Direct access means patients can see a chiropractor or physical therapist directly, without seeing a medical doctor (MD) or osteopathic doctor (DO) first to get a prescription — though direct access laws vary greatly from state-to-state.
Do I think physical therapists should have direct access? Given that usual prescriptions from physicians for physical therapists don’t actually include diagnoses, and instead read something like “shoulder pain” — absolutely, skip the doctor. It’s rare that a doctor will know enough to actually get a correct orthopedic diagnosis, and the PT is going to confirm it anyway.
Does that mean all doctors are useless for musculoskeletal injuries? Not at all. I’ve often worked in PT clinics with physicians in-house who really want to nail an accurate orthopedic or musculoskeletal diagnosis, even if they know very little about how to actually treat said injury. I think that’s great.
But what’s happened is you’re now asking physical therapists to get a ton more training in order to receive the doctorate, without actually teaching them more about how to treat patients. Instead the doctor of physical therapy (DPT) degree focuses on multiple-choice questions about basic science and patient safety, not critical thinking and clinical reasoning about treatment.
Was my experience unusual?
I was an advanced student who graduated high school at 15 and was already a massage therapist before PT school, so I probably didn’t get as much out of physical therapy school as someone who got a kinesiology degree in undergrad, right? You might think so, but my background actually gave me the perspective necessary to be identify the deficiencies in the program.
Anyone who has worked out at a commercial gym is going to actually have a pretty good sense of some basic exercises at about the same level of competency as a new graduate physical therapist. Really, a physical therapist treating you could just tell you to do all the machine exercises you’re not currently doing instead of those you are, and your injury may treat itself.
Taking a weekend course to become a personal trainer so you feel comfortable setting the weights on the machines would make you about as good as your typical physical therapist, at least when we’re talking about new grads.
Personally, I went to PT school directly to improve my clinical care skills, not in strength training, but in manual therapy. I thought I would learn spinal manipulations (I learned 4, total, in the entire curriculum). Our entire manual therapy curriculum was a total of 4 hours of hands-on lab work, just 2 hours for massage and 2 hours for mobilizations and manipulations.
That means no new grad physical therapist is going to know much about exercise manipulation or manual therapy, at least until they get the chance to attend some continuing education courses on their own. That’s not just my experience — it’s how the curriculum for physical therapists is designed.
What about PT school rankings?
You might think going to a better physical therapy school would mean you learn more. I went to the #20 PT school in the nation (VCU), which is also ranked as the #5th cheapest. Theoretically I received an education in the top 8% of all PT schools in the US, at least according to VCU’s marketing copy.
The problem with PT school rankings (from US News & World Reports) is that they base ranking on a survey sent to the directors of all the PT schools. So it’s a popularity contest that invariably sees little change from year-to-year. They actually call it a “peer assessment score” — it’s hardly a ranking system.
They don’t track student outcomes to evaluate starting salary (like they do for MBA programs) or return on investment (like Forbes does for MBAs). Why not? Because PT school is simply a terrible return on investment for students: $130,000 and three years of school in order to earn $60,000 a year. But that’s a different point — what about new graduates’ clinical care and skill?
If what we care about is whether patients are receiving good care from physical therapists, then ranking programs should actually track patient outcomes. Such a study is impossible because of our fractured healthcare system, let alone the privacy issues it would bring up.
So instead PT schools focus on their popularity and reputation among peers through things they can control like the Miami-Marquette fundraiser and survey statistics like graduation rate (92.6% at VCU), one-year employment rate (100%), and licensure examination first-time pass rate (97%).
That last point is critical to understanding why physical therapists don’t actually learn any clinical skills in PT school.
Teaching to the exam
If the entire goal of your PT program is to get your students to graduate, get them employed, and get them to pass the licensure exam, then you’re not going to be able to focus on clinical rehabilitation. Instead, you’re going to simply teach whatever is on the test, and the licensure exam is over 80% focused on basic science and memorization. That model of testing fits well with the test’s multiple-choice question format.
The most common thing any outpatient physical therapist is going to do is treat musculoskeletal injuries, but that makes up only about 30% of the exam, and only 10% of the exam is focused on musculoskeletal interventions.
This was best encapsulated by my professor who said, “Don’t do that with your patients, you’ll leave them sore” when I was discussing squat progressions with another high-aptitude student, who worked out at a local CrossFit gym. Like me, that classmate was able to get through the program, but then has never found a full-time PT job that was a good fit.
I’ve treated many patients with dementia, COPD, stroke, brain injuries, and other “non-musculoskeletal injuries.” I actually treat them the same way (using musculoskeletal interventions) to help them regain independent functioning. I still focus on strength, endurance, and balance, but with a little more time spent on walking and assistive device usage.
But for some reason, on our licensure examination, it was necessary for me to know which collagen fiber type makes up a certain type of epithelium, or which spinal tract could be affected in a hypothetical patient. Guess what — those things don’t actually determine treatment; the patients’ deficits do.
To put it another way, the difference between the CSCS certification test (which covers Olympic lifting and sprinting technique) and the PT licensure examination was the difference between your freshman English class in college and what you learned in middle school. Neither is particularly advanced, but at least the CSCS gave me a few new ideas for prescribing strength training, instead of just giving out the same 5–10 exercises.
If you’ve ever been to physical therapy and been given a photocopied handout with 6 exercises illustrated by black-and-white drawings, then your physical therapist is not actually customizing your treatment plan to your condition, particularly if they told you to do 3 sets of 10 repetitions of each exercise. They’re just doing what they were taught to do in school.
Are healthcare incentives backwards?
Do I think physical therapists are bad people or malicious? No, of course not. The American Physical Therapy Association has a whole “physical therapist for life” campaign where they want individual PTs to establish brand loyalty in their communities, and I don’t think you can do that if you’re actually a bad player. But I do think physical therapists enable a lot of people to stay sick or play the victim role a lot more than necessary.
The entire American healthcare system is now dominated by patient satisfaction surveys, which on their face seem like a good thing. After all, the customer is always right, and happy patients are going to spread your name in the community. For PT clinics, this is mostly seen in reviews, like any other brick-and-mortar professional in today’s day and age.
The problem is that physical therapists are asking people to do something they’ve probably never done consistently (exercise) — something that is mildly difficult, takes time, and causes discomfort in the form of muscle soreness. Exercise is not even particularly effective for muscle-building if you’re not eating enough calories and protein (about 1g per pound of bodyweight).
Think about it: when you come in for a PT session, you and your insurance pay the PT. When you get better, you stop paying. The incentive for your PT is to take as longer to get you better, especially if it keeps you happier.
That’s not even to mention when physical therapists working in the home ask patients to take accountability for their own safety by removing trip hazards like throw rugs — homebound patients hate change. One time I asked a patient not to use her walker to shove her small dog out of the way, because she might fall, so she asked my company for a different physical therapist.
A better model of healthcare would allow your physical therapists to get paid the same whether or not you are actually going in for services right now. (This is called capitation and can also be abused, since bad actors could enroll more patients and provide less treatment to each one). But flipping the incentives from what they are now would mean that PTs would have a financial motivation to help you get better quickly and prevent future injuries.
Since your new grad physical therapist only knows the smallest amount about effective strength training, they’re going to just be super friendly with you instead. They’ll put you on a bike or some other equipment so you can feel like you got a good workout. You’ll do a lot of band work with resistance bands, because they cause less soreness, even though bands are extremely difficult to progress accurately.
You’ll like how your physical therapist asks about sports, your kids, and what you do for work, and you won’t know the difference. But after 20 or 30 physical therapy sessions, you’re going to be wondering when your injury is actually going to heal up, when your physical therapist is going to mention that you’re running out of insurance authorization.
I would rather work you harder and help you get better in half as many sessions, but that’s bad for business. You’ll be complaining about soreness while I try to educate you about functional anatomy and posture to prevent your next injury. You’ll probably be a less satisfied patient than if I had done less with you.
And, if I do my job and actually get you better in 10–15 sessions instead of 20–30 visits, we actually made half as much money, and my clinic is going out of business. So, I don’t think physical therapy education is going to be changing any time soon, at least until our healthcare system starts paying your PT to keep you healthy — instead of paying your PT to keep you sick.
And if you’re seeking PT care, I’d seek out someone with an advanced certification, like Active Release Techniques (ART), Postural Restoration Institute (PRI), or preferably Dynamic Neuromuscular Stabilization (DNS), even if they don’t take insurance. You might even seek out a board-certified therapeutic massage therapist (BCTMB) to begin treatment and then ask for a referral for a physical therapist that they’ve worked with personally.
Good luck out there — and think twice about incentives when you’re receiving healthcare in the US. Our providers make more when you stay sick. 😷