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The NPTE, Graduation, and Professional Identity

Physical therapy students in the United States are unable to practice unconditionally until they graduate from an accredited program and pass the National Physical Therapy Exam (NPTE).  Many states permit students to sit for the NPTE within 90 days of graduation.  Even in these states, however, program directors at the university level must authorize these students to take the exam.  In Ohio, for example, program directors must certify that pre-graduation NPTE applicants are “bono fide candidates”.  In other words, program directors, not state and federal adjudicators, ultimately control when a physical therapy student is eligible to take the NPTE.  Any physical therapy student within 90 days of graduation, however, is effectively a “bona fide candidate”.  A program director’s written endorsement of a candidate should therefore be more of an administrative formality than a permission slip.

Completing and ultimately passing the NPTE prior to graduation expedites loan repayment and maximizes potential job opportunities.  Tuition costs alone often leave novice physical therapists a few hundred thousand dollars in debt.  Moreover, they await some of the lowest entry-level salaries among clinical doctors despite similar educational costs.  Time is financial independence.  Nevertheless, some program directors refuse to permit students to take the NPTE within 90 days of graduation despite state policies to the contrary, allegedly because initial pass rates might improve when less employable candidates are held hostage over the summer with no professional or academic responsibilities besides exam preparation. Would this line of reasoning hold up if a student took his/her program to court?  Luckily for these universities, physical therapy students are in too much debt to afford an attorney.  Program directors should not be granted veto power over matriculating students seeking to maximize their earning potential and begin their careers when state provisions are otherwise respected.

That the discretion of individual program directors should supersede state and federal doctrine is rationalized by the following explanations:

  1. Students are more likely to pass the NPTE after graduation when they can prepare for the exam without having to complete coursework or clinical affiliations.  While in theory this supposition seems reasonable, where is the data?  Moreover, even if this data exists, students within 90 days of graduation should be permitted to sit for the NPTE despite the higher potential for failure.  The idea that the program director knows what’s best for the student is a microcosm for the paternalism that still pervades much of graduate education.  Graduate students are adult professionals, not children who shouldn’t be trusted to make consequential decisions.  Additionally, there are few other disciplines outside of academia in which the autonomy of a customer paying upwards of $100k for a product is deemed so irrelevant relative to the statistical interests of the service provider.
  2. Clinical instructors (CIs) complain that students are less focused during their clinical affiliations while preparing for the NPTE.  Assuming this postulation is correct, the CI is just as complicit for failing to manage expectations.  Students aren’t eligible to take the NPTE until they’ve already completed one or more clinical affiliations.  Deficiencies in a student’s clinical ability should be identified and addressed prior to the latter affiliation(s).  Additionally, CIs and program directors should be able to advise students about how to systematically prepare for the NPTE in a way that won’t interfere with clinical experiences.  Assuming a mid-April NPTE date, one could review notes for no more than 30 minutes each weeknight beginning in January, complete practice questions for 2-3 hours during weekends, and be sufficiently prepared.  That’s 66 hours of studying over the course of 12 weeks, which is more than adequate. Test preparation is often such a mystery because students in medical disciplines are bombarded with information but rarely told what’s really important to learn, not just regurgitate from memory.  There are only so many ways a question can assess a particular concept.  If something is really important to retain, that expectation shouldn’t be a surprise on an exam.  Moreover, people only do what’s expected of them. If taking the NPTE prior to graduation were to become the norm, everybody would adapt.  Students spend more time managing NPTE anxiety than they do legitimately preparing for the exam. That taking the NPTE within 90 days of graduation is deemed so controversial perpetuates this unwarranted hysteria.
  3. Students can pass the NPTE but still fail a course or clinical affiliation.  And?  So the NPTE is out of the way and said students retake the class or recomplete the affiliation at a later time.  Students who pass the NPTE but fail their final semester still aren’t licensed to practice.  State boards require proof of graduation, even with a passing NPTE score, before they will license new graduates.  A student’s inability to pass a course or clinical affiliation during his/her last semester is a systemic failure as much as it is an individual one.  At what point do entry-level programs cease to be a game of survivor?  Programs that are concerned about students failing courses during their final semester should enforce higher admissions standards and front-load the most difficult blocks of instruction; better to identify students who aren’t capable of completing the program on the front-end instead of the back-end.  Again, this refutation supposes a causal relationship between preparing for the NPTE and failing a course.  This construct is likely more theoretical than empirical.  Moreover, the final semester of physical therapy programs is typically less demanding than the previous ones, even when accounting for a clinical affiliation.

Every argument against taking the NPTE prior to graduation essentially amounts to gatekeeping and can easily be rectified if adequate countermeasures are implemented (e.g. CIs not permitting test review during clinical hours). The NPTE isn’t this enormous rite of passage. Entry-level DPT programs can prepare students for the exam without forbidding all other pursuits. The NPTE is a test of minimal competency, basic concepts, and safety, not something that requires candidates to learn new information. Moreover, program directors shouldn’t be able to override the intent of state and federal policies despite the technical demand to validate that a candidate is in “good standing”.  State boards permit students to take the NPTE before graduation regardless of the potential outcome.  Favorable status with CAPTE shouldn’t be valued more than a new graduate’s earning potential and freedom to choose.  Neither are these aims dichotomous.

The burden is on entry-level programs to prepare students for the NPTE in conjunction with other coursework and clinical experiences. Program directors and preceptors don’t coddle medical students during the physician credentialing process. Physical therapy will never achieve the level of autonomy it wishes for if it refuses to empower its own people. True direct access providers are health care leaders. The rebuttals to the original question posed here do little to promote professional leadership. They paralyze the profession with fear of failure.  Empowering students advances the profession’s political interests more than delaying NPTE preparation. Physical therapy hashtag movements are futile without emboldening professionals early on in their careers.  Other medical professionals and the public will continue to regard physical therapy as subservient as long as #GetPT1st treats its own people as such.

Should be #cultivateleadershipandconfidencewhiletakingcareofyourpeople1st