Thursday Thoughts: Thinking about Residency or Fellowship? | Modern Manual Therapy Blog

Thursday Thoughts: Thinking about Residency or Fellowship?

Sunrise Of A Mountain With Lake And Mist
“To strive, to seek, to find. And not to yield” –Alfred, Lord Tennyson

Do you like having financial debt? Do you like studying? Do you like stress, self-doubt, and constant failure? Do you like giving up your nights and weekends and all your vacation time for travel, class work and mentorship? If you answered yes to all these questions, a residency and/or fellowship program might just be for you!
In full disclosure, I am of the opinion that it should be MANDATORY for any physical therapist that wants to work in outpatient orthopedic physical therapy go through at least a 1-2 year residency/fellowship program. Bottom line–PT school does a good job of preparing new grads to take the board exam. It generally does a less than adequate job of preparing PTs to treat patients. (See previous post: http://www.realpttalk.com/one-solution-to-the-rising-cost-of-pt-education/).
Over the past 5 years, we have seen reimbursements, I mean payment (sorry Jerry) for our services slashed and the number of treatment visits reduced. We have been under attack from other health care professions (Chiropractic, acupuncturists, and even personal trainers) regarding our scope of practice. How then to push back on this onslaught challenging our profession? One way is to raise the quality and standard of care by being better at what we do. At least on twitter, I have seen the level of passion and discussion among PTs and DPT students rise, and that gives me hope. If you’ve followed my blog in the past, you’ll notice this has been an overriding theme. It’s like the saying goes in sports, “winning fixes everything.” In physical therapy, being better at what we do should fix a whole lot. Of course, we can argue what exactly does being better mean and how do we measure/determine what is better. But let’s put that aside for now.
Individuals who seek out residency and fellowship programs are usually very self-driven and have a strong desire to learn. They know what they don’t know. They consistently want to get better. They realize how little PT school actually prepared them to treat patients. They are frustrated with only being able to apply a small handful of things learned from weekend CEU courses, and they can’t effectively answer the most basic question, why? From an intervention standpoint, if you can’t answer why with anything other than “because I’ve seen it done before,” you shouldn’t be doing it! It goes right into what Simon Sinek writes in Start With Why, “people don’t buy WHAT you do, they buy WHY you do it!
One thing that often holds PTs back from jumping into residency and fellowship programs, understandably, is the financial burden. Dr. Ben Fung (@DrBenFung), recently wrote on this very topic on his excellent blog, www.drbenfung,org.Lowering Costs and Improving Compensation. He addresses the fact that the increasing cost of higher education is becoming an unfair burden on physical therapists. He goes on to suggest thoughtful and creative alternative strategies to the education process.
To highlight this fact, the current in-state tuition at my alma mater, Virginia Commonwealth University, at $400 per credit hour, would run just north of $50,000 for the three-year doctoral program. That’s approximately $15K more than it was when I went through 12 years ago. Shenandoah University, a private university also in the great state of Virginia, comes in at $813 per credit hour. (That, alone, by the way, is why I chose to attend VCU over Shenandoah). Washington University in St. Louis is consistently ranked #1 in terms of PT school. You can attend it, providing of course you get in, for the low, low price of $150,000 for your three-year journey. Are you three times the physical therapist when you graduate? I doubt it. And that’s just the cost of tuition. Most people also have to find somewhere to live, bathe, see in the dark, eat and drink sustenance, and partake in some fun during their time in school. So, don’t get me wrong, I understand the daunting task of taking on another $12,000 to $15,000 for more education. But if you want to become a better outpatient orthopedic physical therapist, in my opinion, it’s the best way.
Think of it like this: Have you ever bought a non-fiction book? Do you know how long the author spent researching the material, writing, re-writing, and then editing before final production? You were able to purchase that book, for, say, $15 (or $7.99 on kindle). In 6-8 hours, you can access all that information that likely took the author several years to produce. Remember the movie “The Matrix?” By doing a residency and/or fellowship, you can be like Neo, downloading how to fly a helicopter in mere seconds. Granted, those seconds are 1-2 years and the $15 is multiplied by one thousand, but you get the idea. Hey, you’ve already spent between $50,000 to $150,000 in tuition alone, what’s another $15,000? Your grandchildren’s children will be paying it off anyway :) .
I will also mention another frequently posed question: why not just take a bunch of CE courses? A valid point. As someone who still takes multiple CE courses a year, and teaches CE courses, I can tell you that there is just way too much information to pack into a single weekend.  And here’s another harsh reality: our ability to retain information is limited. The Ebbinghaus Forgetting curve shows that most people will retain only half of what they learned at three weeks. Other estimates are as high as 90% in one month! The degree of retention decline is altered by one major thing—PRACTICE. (See http://www.realpttalk.com/in-pursuit-of-excellence/)
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How do we improve this? Training our working memory is one way. Repetition is a better way. In a residency or fellowship program, you will be inundated with information. You will eat, sleep, and breathe it.  My residency program trough the Ola Grimsby Institute consisted of class work (basically a CE course) twice a month, as well as 150 hours of on-site mentorship with a fellow or OGI instructor. How much better do you think my retention was? I can tell you, in my clinical practice, it has made all the difference in the world. Two of my classmates have opened their own practices, two of us lecture in academic institutions as well as teach CEUs, and one of us writes a blog that at least tens (not a typo) of people read :) .
However, residency and fellowship training does not always directly result in money, fame, and fortune. Of course, I always make sure a red carpet is rolled out for me when I enter the clinic each morning, but you can choose how you want to do it :). In most professions, increased training, knowledge, skill, and experience often result in an increased salary. Good news–that also happens to a degree in physical therapy! Just in time to start paying off that debt. Bad news–it might with strings attached. In many clinical settings, higher salaries come from advancing to an arbitrary clinician level, achieving managerial status, or climbing the corporate ladder. I don’t know about you, but I did a residency and fellowship to enhance my clinical skills and knowledge to better help patients, not look at numbers on a computer screen. So, unless you want to do that, your new financial windfall might be limited, unless you can justify it by treating more patients. In the insurance-based model that most of us operate in, I understand that financial reasoning. However, there is a point when an inverse relationship exists between quantity and quality. In addition, last time I checked, most of us only have two hands, and I don’t believe techs should be used to run an exercise program. We’re supposed to be the exercise experts, right? So why outsource it? Again, that can be for a discussion at another time.
More good news: better clinicians often get patients better faster. Corporate PT companies usually love that. They’re paying you a higher salary, and instead of averaging 10-12 visits per patient, your average is maybe 6-8. Wouldn’t they be better off hiring a new grad, paying them a lower salary, and enjoying the profits that come from multiple extra treatment visits? To recap, they’re paying you more–you’re making them less. Guess who’s happy? You are, and the patient is. And there IT is–the WHY for doing residency and fellowship: To get better to help more patients get better. As I mentioned in a previous post, most physical therapists have a Peace Corps mentality–how often do we give away our services for free? So if you’re working in insurance-based healthcare, this will be the ultimate expression of that. With residency and fellowship training, you’ll be proving Lexus service at a Kia price.
In Start With Why, Simon Sinek points out that not everyone is YOUR customer. If physical therapy is a health care commodity, (see any tweet from @Jerry_DurhamPT), then like all commodities, you have certain types of customers who are the ones you want to attract. The ones you want are the ones who value what you value and believe what you believe. For example, I believe, that with the rising cost of healthcare, our patients/customers will have to become more savvy healthcare consumers. Not all will, of course, but the customers/patients you want to attract will.
In the Law of Diffusion of Innovations as Sinek describes, innovators (2.5% of population) will lead to the early adopters (13.5%), and eventually the early majority (34%). These are the patients that we see every day that “get it.” These are the patients that appreciate and understand the value they are getting from your services. They are the ones who can discern “good PT” from “sub-par PT.” These are the patients that tell their family, friends, and neighbors. Now, I know what you’re thinking—you already have patients like that. So my next question is, and be honest; is it because you’re making them simply feel better, or truly be better? If it’s the former, it’s a good start, but you’re missing a piece. Soft tissue mobilization and a TENS unit can help people “feel” better (temporarily). But we need to hold ourselves to a higher standard and expect more not only from ourselves, but also our patients. We need to meet our patients’ goals, while at the same time striving to help them reach a level they previously thought unobtainable.  Ask yourself WHY you became a physical therapist. Really think about your answer. You might agree that even higher education is the path to what should be the standard in the profession.
“It’s not who you think you are that holds you back. It’s who you think you’re not.” Unknown

I am excited to have a new regular contributor to The Manual Therapist, Dr. Andrew S. Rothschild, PT, DPT, OCS, FAAOMPT of RealPTTalk.com. This means more content, with a different perspective, but continues the high quality you expect from this blog. Welcome Andrew!


3 comments:

  1. I agree with changing the way programs function. I went out of state to UPitt, and while I thought it was a great program, I spent a lot of time learning things I knew I wasn't going to make part of my profession. I think it is time for a separation of outpatient orthopedics and inpatient rehabilitation. I say this with the knowledge that I use neuro aspects daily.

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  2. Kenny,
    Thank you so much for reading and for your comments--very insightful. One thing I do with my posts is choose one position on a topic and then argue for it for the sole purpose of fostering discussion just like this. Very often, as in this case, there are multiple directions from which to approach it and there is no one "right" answer or simple solution.

    In the case of residency/fellowship, I am biased, and make no apologies for it :) The main point I hoped to make was that the cost of entry-level PT education is too high for the value and the lack of preparedness (at least in the outpatient ortho clinical setting). I have written on that topic specifically over at RealPTtalk.com and would welcome your thoughts on it. I think PT school should be less expensive and many school's curriculum probably need to be overhauled to adapt to the current clinic climate that students are coming out into. But since that process is likely to be either very slow or non-existent, in order to create better prepared and trained therapists, residency and fellowship is a logical next step, in my opinion.

    There,in fact, is some research to suggest that more clinically significant and meaningful outcomes are produced as a result of fellowship training over residency or no further training: (Rodeghero J et al JOSPT 2015), but I know there are other studies that suggest no significant differences. Outcomes, as we all know, are multifactorial, with the clinician being just one aspect.

    Overall, I think knowledge is power and more education should be celebrated, not vilified. Cost /outcomes etc. are obviously important factors and need to be considered by an individual interested in going the advanced education route.

    Thanks again for reading and your comments.

    -Andrew

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  3. Bill,
    Thanks for reading and for your comments. I think that having some general exposure to all areas of PT is important, not only for the board exam, but because of the fact that you may have the opportunity to change areas of focus within the field at some point in your career, if you so choose. However, I think after a year of "general education" requirements, the remaining two years should be in the particular area of focus that you choose, ortho, acute, rehab, neuro, etc.

    Thanks again for reading and commenting

    -Andrew

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