by Ryan Hamic PT, DPT
One thing that has always given me pause in the medical field is the idea of informed consent. I am not even sure it is possible for a patient to give informed consent, nor for a provider to adequately educate a patient to do so. Yet it is a legal requirement that it be obtained before embarking on many interventions. I realize it is a trite rhetorical device to rely on a dictionary definition of a word at the beginning of a paper or speech, but I really can’t get around it here. So in my most eye rolling tone, I give you the dictionary definition of informed consent:
“Permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits”
So many things bother me about that statement. The phrase “full knowledge of the possible risks and benefits”, is particularly troublesome. As a clinician I have thousands upon thousands of hours of didactic material, clinical experience, research literature, education in basic sciences, applied sciences and access to vast amounts of information about the potential consequences of various interventions. I can tell you without a shred of doubt; I have nowhere near “full knowledge of the possible risks and benefits” of any intervention. If I, a reasonably intelligent person with considerable exposure to the subject matter, have no possible way of achieving the level of knowledge required for informed consent, then how on earth can I expect my patient who may be confronting the situation for the first time to do so? Look for a much longer post on this in the future as I just can’t seem to get around this quibble.
So what on earth does this have to do with physical therapy residencies? We are all aware of the prolific rise in residency programs in the last several years. It is a focus of the APTA and is widely becoming considered a natural next step for a new graduate from a DPT program. What’s not to like about the idea? The vast majority of new grads will themselves admit to the need for more training in the specific area of practice they prefer. Most recognize the need for mentorship and additional preparation in order to practice at the top of their license. Residencies of course offer that as their primary benefit. Additionally they offer to prepare those who take them for board specialty certifications.
I get asked often by current DPT students if they should do a residency. I really can’t answer that question, as I have no idea whether or not a residency will truly benefit that particular individual. I tell them that I chose not to and the reasons why and then I point them to some people who did and ask them to evaluate their reasoning and experience. As I have thought more on the matter I am beginning to realize that many students are making the decision without anywhere near the “full knowledge of the risks and benefits”. In this case let’s call the risk, costs.
This is not a post to bash the idea or content of residencies, nor to state whether you should or should not do one. I simply believe that many newly graduating PT’s are not really informed of the cost of doing a residency. I interviewed several students about their residencies after they were completed prior to writing this and although there are various models they all seem to fall in a range of about $15,000-$20,000 paid in either tuition or reduced starting salary or both. When I asked the question “At the end of your career do you think that $15k will be money well spent?” they nearly all stated that it was. That is certainly encouraging for residency programs.
We are not known as a saving culture:
A June 2015 Government Accountability Office analysis found that that average Americans between the ages of 55 and 64 have accrued about $104,000 in retirement savings. Sound like a lot? Not when you realize that sum would translate into a $310 monthly payment if your money were invested in a lifetime annuity.
First of all that is just scary for us as a culture…especially since there is no chance social security is going to survive in its current iteration. Many of the students I see opting for residencies are in their 20’s and retirement savings are far from their mind, but this goes to informed consent on the part of a student choosing a residency. Using the power of my brain and a calculator I thought, what if those students understood what taking that $15-20k and investing it now would mean for their future? Would they still think the cost was worth it? I plugged in $17.5K into an investment calculator earning 7.0% interest per year for the next 40 years (65 year old retirement for a student currently 25 years old). Those of you who think 7% is unreasonable I would point out if you had just invested in an S&P index fund over the past 15 years even with the huge recession from 2008 to 2012 you would have earned that.
When I framed the question in this manner the responses from the students I asked was more or less “I had no idea”. Let’s think about that, simply by taking the differential between an average starting PT salary and what a resident earns in their first year (minus the cost of residency) and investing it in a passive exchange traded fund and contributing nothing for the next 40 years the student would hit retirement age with 2.5 times the amount of retirement savings as the average American.
Still think that residency seems worth it? Maybe it does. I don’t know. I do know that none of the students I asked about this had even thought to frame the question in these terms. Let’s delve a little deeper into this line of thinking. Perhaps residency offers a way to make more money in the future, offsetting the cost of the initial loss of wages? Well if it does I can’t think of it. We practice in a metered environment currently. Whether the unit is performed by a PT tech, a PTA, a PT, an FAAOMPT, or a residency trained PT they all pay the same. This insane affront to our profession aside, it is the fact of the matter. Perhaps residency makes you more employable? 99% employment rate amongst licensed physical therapists in this country seems to knock that bird out of the sky. Well it prepares you for specialty certification! Great, but at what cost? I choose to keep my $262K and self-study for the OCS, thank you very much.
Many have said to me, don’t resident physicians do the same thing? Well yes they do practice at a reduced rate during residency; however the rate of pay increase they experience from a resident to a specialist averages a factor of 6! With all the talk of “value” that is going on in the PT world, I am truly questioning the value of the residency model in our profession. What do you get for the opportunity cost that is worth it?
I must admit it also bugs me that I have heard the line of reasoning that residents earn less because they are training, and this carries cost to the employer. Well maybe it is because I have owned businesses in a different field prior to coming to PT, but what business doesn’t have costs involved in training new hires? Isn’t part of educating a new hire in any profession a loss leader to producing a competent well trained employee for years to come who will help grow your business? Why is that cost deferred to the student in this case? Most of the residents I interviewed worked a minimum of 40 hours, most stated they saw a full schedule of patients and due to the metered system we work in actually generated revenue at a reduced cost to their employer. That is a win/win for someone but not the resident.
Let’s look at another dirty elephant standing in the corner of the room, student debt. Many students I interviewed stated something along the lines of “I already have $XXX,XXX in student loans taken out, what is another $15k?” Well again setting aside the travesty that is the current student loan situation (perhaps a topic for a later post), let’s look at what that extra 15k means.
Assume an average graduating DPT student who was extremely responsible with the loans taken out for school. They will still have roughly $150k in debt at graduation. At a current Stafford loan rate of ~5% interest, it will take 15 years to pay this debt off paying $62k in interest! Assuming an average PT salary of $68k dollars that means they are attributing 21% of their income to a student loan debt for 15 years! Now let’s assume that they took the $17.5k that the residency cost them, and instead used it to pay their loan down at the end of their first year. It would shorten their repayment time to 12 years and reduce their interest payments by 17k dollars. Granted, still not a great situation, but a 20% improvement in loan repayment time shouldn’t be dismissed.
I would like to reiterate that it is not my intention to dissuade the interested student from pursuing residencies, but I believe there is a burden of proof placed on those selling them to provide as close to informed consent as is possible about the risks and benefits that they come with. I also think we need be very careful about moving our model for PT education to one in which a residency is perfunctory. Perhaps we could do something during the course of receiving a doctoral degree that would prepare us to practice in our specialty area without need of such a huge financial burden to students already facing a rather grim debt/income ratio….alas a topic for another blog
Ryan Hamic PT, DPT
*In the interest of full disclosure I receive financial reward from students engaging in the COMT program from PMT. I realize this biases me in this matter and want everyone to know it is so. Part of the reason I pushed for the creation of the COMT through PMT is to offer a path to clinical mastery at a significantly lower cost to clinicians who are seeking specialty training post-graduation. Please judge my words on their merit knowing this information. Thank you.