Academia knows best: Mandating doctoral education for entry level occupational therapy practice.

The American Occupational Therapy Association Board of Directors has issued a position statement that future occupational therapists will need to be doctorally prepared for entry-level practice by 2025.  They have arrived at this recommendation after undergoing an insular process that neglected to engage broad stakeholder participation.

I understand that this is a weighty charge, so I will outline the evidence as clearly as possible.

The AOTA Board informed their decision on two workgroups: one an Ad Hoc Board Committee on the Future of OT Education chaired by Dr. Thomas Fisher and the other an internal subcommittee of the Board itself that reviewed the Ad Hoc Committee's findings.

The Ad Hoc Committee was comprised of occupational therapists who also served as Deans, Provosts, or other high ranking University officials as well as the AOTA Director of Accreditation and Academic Affairs.  Task groups were developed to address specific questions.  Specifically, one task group called the "Maturing of the Profession" task group made the specific recommendation for mandatory doctoral level education.  This group consisted of a physical therapy educator/Dean and four occupational therapy academics who all held high ranking University positions.

It is not known who comprised the sub group of the AOTA Board of Directors that looked at the Ad Hoc groups findings.  However, the AOTA Board of Directors is known to be heavily weighted with those who work in academic settings.  Among those who are not currently in academia, most either hold dual academic appointments, have held academic appointments in the past,  or are in senior administrative positions in their work settings.

The fundamental problem with the composition of these committees and task groups is that they are making recommendations that stretch outside the confines of academia.  The recommendation for mandatory doctoral level training is not an academic recommendation.  It is a practice recommendation.

The absence of practitioner or employer or regulatory voices in these task groups is a glaring omission.   The Committees and Task Groups have been meeting over some time, and the results of their work has not even been broadly shared with the occupational therapy community until the release of this recommendation.

I am aware that during the April 23-24, 2013 Program Directors meeting a 'Top 10 FAQ' on entry level OTD education was circulated.  In June 2013 I requested a copy of Dr. Fisher's report but never received an answer to my request.  I am also aware of others who requested a full copy of the report in November 2013 and were never provided a copy.

In addition to restricting the groups to academic voices and opinions, there was an unwillingness to even share information about the work of these groups with the membership.  The reports that are now available only appear after all of the work is completed and after the AOTA Board of Directors already made their recommendation.

There is also the fortuitous timing of an article in AJOT from a group of academics who are supporting the change to mandatory doctoral level education.  The AJOT opinion piece (Case-Smith, et al, 2014) also fails to address pertinent concerns including:

1. What are the ROI impacts for students when we require increasing levels of education with static and shrinking levels of reimbursement?

2. What are the impacts of 'shutting out' students from higher ed by requiring doctoral level training?  What affordability factors are present?
 

3. Do affordability factors disproportionately impact minorities and what impact does this have on initiatives to promote a more diverse workforce?

4. What is the impact of a move to a doctoral level while at the same time decreasing access to community college/OTA levels by proposing OTA move to a baccalaureate level?
 

 5. What is the potential impact of this kind of a proposed change on the cusp on increasing demand for OT services (aging of population, etc.)?

Fisher and Crabtree (2009) brush away these types of questions saying they are 'concerns' but not 'barriers.'  The problem is that I have not seen any evidence that we are doing anything meaningful about the concerns. A survey of OT Program Directors conducted in 2004 and published by Griffiths and Padilla (2006) indicated that Program Directors held opinions in support of OTD education, despite objections from other stakeholders. That is a familiar theme.

How does the proposal square with what little evidence has been collected re: readiness and competence for practice? Mitchell and Yu (2011) conducted a study comparing BS and MS students on a test of critical reasoning, and in their results the students with the BS level actually scored higher than their MS students.  The study has limitations, including convenience sampling of one school and non-parallel admission practices, but these findings should be raising a few more eyebrows.
 

In a study of perceptions of 600 practitioners, Dickerson (2009) found that the majority of respondents did not approve of moving to the doctorate for entry-level practice.  Plain and simple - they did not see the point.  In a smaller study conducted by Smith (2007), there was not a strong opinion whether there is an advantage to a clinical doctorate degree, and only 22% agreed or strongly agreed that they would be interested in pursuing a postprofessional OTD.  Apparently these practitioners also do not see the point.

One might hope that intervening studies that quantify opposition to the proposal would have been considered by Case Smith et. al., but they remain impervious to the evidence even though there is notable and contradictory opinion.  The fact that these studies are excluded from the Case-Smith et.al. analysis is itself an example of academic cherry-picking, and automatically disqualifies their opinion because in fact they are not acknowledging all sides of this issue.  

Leaders of AOTA have a long history of doing what they want and remaining impervious to the evidence.  I will remind everyone that at the American Occupational Therapy Association's Annual Conference in 1999, the Representative Assembly passed Resolution J, mandating post-baccalaureate education for entry into the profession.  Following Resolution J, ACOTE formed a committee to look into the issues. The ESRC (Educational Standards Review Committee) identified some significant concerns about any move toward accrediting doctoral level programs. It seems that someone didn’t care what ESRC had to say because a different committee was formed (the ACOTE OTD Standards Committee) to develop standards for doctoral degrees despite what ESRC reported.  This started the ball rolling, and was prima facie evidence of how AOTA/ACOTE handles these issues.  It seems that history is about to repeat itself and again - once decided - things will go the way that AOTA wants them to go no matter who says what.

As a technical matter, AOTA can only provide an 'opinion' because ACOTE is theoretically a separate entity, but that is like saying the sock puppet is not controlled by the hand it sits on.  That is another whole topic.

So although I don't doubt that this change will happen anyway, I can't in good conscience close my eyes to the fact that many people oppose this, that there is very little evidence supporting this change, and that the issues that have been identified as 'barriers' have not been addressed at all.  Therefore, I predict that moving to doctoral level education without addressing the opinions of stakeholders and without considering the broader impacts on the workforce will contribute to unintended consequences that in the long run will harm the profession and more importantly harm the people who need the profession's services.


It is true that now there is an outlined process where stakeholder opinion will be solicited, but this is just the veneer of integrity.  This is just a superficial listening tour because the recommendation has already been made.  So what is the point?

My personal opinion: I am undecided, but leaning toward the opinion that mandatory doctoral training is at  best unnecessary and at worst could be harmful.  

But it sure would have been nice to solicit opinions before the horse got this far out of the barn. 


References:

AOTA position statements and reports, linked above.

Case-Smith, et.al. (2014). The Issue is... The professional occupational therapy doctoral degree: Why do it?  American Journal of Occupational Therapy, 68, e55-e60.
 
Dickerson, A., & Trujillo, L. (2009). Practitioners' perceptions of the occupational therapy clinical doctorate. Journal Of Allied Health, 38(2), e47-e53.

Fisher, T. F., & Crabtree, J. L. (2009). The Issue Is—Generational cohort theory: Have we overlooked an important aspect ofthe entry-level occupational therapy doctorate debate? American Journal of Occupational Therapy, 63, 656–660.

Griffiths, Y., & Padilla, R. (2006). National status of the entry-level doctorate in occupational therapy (OTD). The American Journal Of Occupational Therapy: Official Publication Of The American Occupational Therapy Association, 60(5), 540-550.

Mitchell, A. W., & Xu, Y. J. (2011). Critical reasoning scores of entering bachelor’s and master’s students in an occupational therapy program. American Journal of Occupational Therapy, 65, e86-e94.

Smith, D. (2007). Perceptions by practicing occupational therapists of the clinical doctorate in occupational therapy. Journal Of Allied Health, 36(3), 137-140.