Forced Unemployment for New Grads

It’s May. That time of year where schools across the country are graduating thousands of new physical therapists that are excited, motivated, and eager to enter the amazing profession they’ve worked 3 hard years towards. These new graduates are searching for and accepting jobs, ready to bring their fresh new knowledge-base to clinics as employees. And, just as importantly, to start digging out of the weight of student loans that have added up over the years. Exciting right? Unfortunately, this isn’t what many new graduates of doctor of physical therapy programs actually experience!

Thanks to recent changes in the administration of the national licensing exam, many graduates have to wait over 2 months from graduation before they will be able to take the exam and begin working. That is already 2 months taken out of the 6-month grace period before student loans have to start being paid off. That’s 2 months that if you try to find jobs you hear “That’s too far in the future, call back when you have a license”. That’s 2 months that the knowledge accrued isn’t being used practically, and well, you know the familiar saying,  “If you don’t use it, you lose it.”

In the past, The Federation of State Boards of Physical Therapy (FSBPT) offered continuous-testing, meaning you could take the National Physical Therapy Exam (NPTE) any day you wanted. In other words, you could technically have your license and begin working within a week of graduation. This flexibility in the exam date reduced the need for states to provide a temporary license to those waiting for an exam date. In fact, from 2008 to 2012 the number of jurisdictions that offer a temporary license decreased from 34 to 26. The temporary license is a license based on the assumption that you have just completed a CAPTE approved program and therefore know enough entry-level information to practice safely under the supervision of a licensed physical therapist. Temporary licenses are provided for a specified length of time (usually 90 days), and/or completion or failure of the National Physical Therapy Exam (NPTE).  Some states elected kept the temp license for those who wanted to work, but delay taking the exam.

Unfortunately, due to a myriad of unfortunate events and compromised exam security, the FSBPT had to switch from continuous to fixed-date testing to preserve the integrity of the exam. This means that instead of taking the exam whenever you wanted, the exam availability was reduced to 4 dates throughout the year: January 29, April 30, July 23-24*, and October 30 (an extra date was added in July due to increased demand). The downfall of this reduced availability is that many, many programs graduate in May, making it difficult, if not impossible to take the April exam. For these May graduates, the only option is to wait over 2 months until the late July test date. This results in high demand for that date and all the scheduling problems associated with high demand at the Prometric testing sites as well as 2 months of forced unemployment for those residing in states without the availability of a temporary license.  A DPT graduate living in Texas can quickly get a temporary license and begin work, but a student in Colorado, for example, has no option but to wait to take the exam and find work doing something other than the degree they just paid thousands of dollars for!

It may seem like 2 months is a short time to wait to work, but the complicating factor lies in the timing of this period of forced unemployment. Students have just come off almost an entire year completing clinical rotations. This is a time where they’re paying tuition to their university, holding down 40+ hour work weeks in a clinic (and generating revenue for the clinic), yet receive no income beyond loan disbursements. Further, they’ve also had to fork over $400+ to apply to take the national license exam. These are students who have been full time students for more than 7 years! The well certainly is quite dry at this point. To add more complicating factors, those without jobs lose eligibility for health insurance from their universities. This is not a pretty 2 month wait.

This hardship could be reduced by more jurisdictions offering a temporary license for new graduates, or offering more dates to take the NPTE sooner after graduation to allow those without the option for a temporary license to seek employment sooner. These options would allow students to get engaged; giving back to their new profession and start climbing out of the student-loan hole they’re in without losing precious time. There’s no more eager professional than the one who just graduated. We need to find a way to let them work!

Critical Thinking Vs Clinical Reasoning

During #DPTstudent chats, there has been many great conversations and debates. However, it seems that some of the debates end with phrases along the lines of, “that’s where clinical reasoning comes in,” or “that’s where we use critical thinking.”  What are these vague terms and what is a #DPTstudent supposed to do when that’s the final, definitive statement of an interactive discussion?!

Often, it seemed the terms clinical reasoning and critical thinking were being used interchangeably. So, I began to wonder what these terms meant, how they are different, and how they are the same. Is this some sort of common denominator for all PT-speak? Or, are people just applying these terms willy-nilly? I decided to investigate.

According to: The Foundation for Critical Thinking, critical thinking is:

1) A set of information, belief generating and processing skills

2) The habit, based on intellectual commitment, of using those skills to guide behavior.

And more importantly, is Not:

1) The mere acquisition and retention of information alone, because it involves a particular way in which information is sought and treated;

2) The mere possession of a set of skills, because it involves the continual use of them

3) The mere use of those skills (“as an exercise”) without acceptance of their results.

In other words, critical thinking is the process of constant evaluation and application of available information, including analyzing your results. To me, it sounds a lot like another oft-employed term: evidence-based practice.

In the article: Thinking and Reasoning in Medicine, (Vimla L. Patel, Jose F. Arocha, and Jiajie Zhang) describes three components of clinical decision making:

(a) Choice options and courses of actions

(b) The belief about objective states, processes, events, outcomes and means to achieve them

(c) Ideas of the consequences associated with the outcomes of each action-event combination.

The overlap, and thus breakdown, between clinical reasoning and clinical decision-making occurs with confirmation bias, or searching for evidence to confirm a preconceived hypothesis. Critical thinking is constantly required to recognize these biases we all possess, and continue to analyze and challenge them by considering other potential courses of action.

A classic example I have observed in my short time in the clinic is the SI joint confirmation bias conundrum. In school, we learned how poorly reliable, and questionably valid many SI joint tests are. We also learned how many manual therapy effects are not specific in terms of spinal level, or even side. However, when assessing SI joints, many therapists hold tenaciously to their belief that they can detect, and then treat specific biomechanical malpositions of this very firmly structured joint.  “Do you feel that? Yep, that’s an upslip on the right,” I would hear so many times. Follow-up questions would be posed in a format of confirmation rather than pure inquiry. Confirmation bias. Clinical reasoning fail.

In his famous book about diagnostic clinical reasoning, “How Doctors Think,” author Jerome Groopman cautions that a primary rule for becoming a great diagnostician is to not get boxed into one frame of thought. That sounds reasonable enough to me. Perhaps this is much more difficult in practice, especially considering the nuances to becoming a good clinical thinker.

Critical thinking and clinical decision making are difficult. It certainly isn’t for the faint of heart, when so often we’re forced to face honest assessments of how little we actually know.  So, next time your ideas and opinions are questioned and you feel cornered, don’t resort to the catch-phrases of critical thinking and clinical reasoning as a defense. They’re not a “get out of jail free” card. Recognize the opportunity to expand you understanding of other methods and models of thought that you’re perhaps less familiar with.

Don’t be afraid.

I’ll leave you with one of my favorite quotes:

“But, if thought is to become the possession of many, not the privilege of the few, we must have done with fear. It is fear that holds men back — fear lest their cherished beliefs should prove delusions, fear lest the institutions by which they live should prove harmful, fear lest they themselves should prove less worthy of respect than they have supposed themselves to be.”

~ Bertrand Russell (Principles of Social Reconstruction)


How Do I Twitter Anyway? #DPTstudent

Twitter is an amazing place. I get smarter everyday by observing and connecting on the platform. However, I’m routinely astonished at the reluctance of the vast majority of the students I teach to engage. The #DPTstudent tweetchat has been a great conversation, but it’s only a droplet of the approximately 8000 of PT students currently in school.

One barrier to Twitter engagement is the requirement to spend time figuring it out. Twitter without filters and careful content curating is like trying to drink from a fire hose. It’s just not going to be a very comfortable event.

To that end, Mary Derrick (@Mary_PT2013), a Texas State DPT student who is mere weeks from graduating has crafted a handy and excellent user guide for those folks interested in playing along on the #DPTstudent chat. It’s also great for anyway who would like to figure this Twitter thing out! Enjoy!

(I suggest you expand this prezi to full screen size for optimal viewing.)