Background

Medicine has often been framed as the “ideal” profession, leading other health fields to emulate it when pursuing their own professionalisation. American medicine’s current education system came about during the early-twentieth century, as part of a multi-decade campaign to enhance the profession’s status by restricting education to an elite few, thus producing fewer and better doctors. As a part of the campaign, the Carnegie Foundation sent educator Abraham Flexner to visit all 155 medical schools in the US and Canada. He rated their science education content, quality of laboratory spaces, and level of faculty research. The Flexner Report argued that all but 31 medical schools in the US and Canada should be closed.

In reality, half of US medical schools were forced to close or consolidate between 1904 and 1920. Many of the shuttered schools were educationally deficient, but the goal had always been to close them, not to improve them. In the wake of the Flexner Report, just one women’s medical college and two primarily Black medical schools survived. These closures greatly diminished opportunities for immigrants, racial/ethnic minorities and people from lower class backgrounds to pursue a medical education. With fewer medical schools and higher standards of admission, including multiple years of baccalaureate-level science courses, the medical profession became more white, male, and upper class.

Physical Therapy

In physical therapy (PT), leaders and educators came to believe that to be a “true” profession, PT needed to be closely modelled after Flexner’s ideals. This meant graduate entry-level training, selecting students with a strong science background, and requiring faculty research. However, as PTs celebrated and applied Flexner’s recommendations for enhancing their own profession, they consistently overlooked the 1910 report’s more insidious outcomes. Indeed, despite fifty years of efforts to increase the prevalence of underrepresented racial/ethnic minority students the PT field has remained disproportionately white.

For Flexner, women’s fields were all but disqualified from professional status. Early PTs, who in the US were [almost] all women, hoped that a scientific identity would help them to overcome these gender dynamics. As part of this, some of the earliest PT education standards, going back to the 1920s, required a significant college-level background education in both chemistry and physics. By mid-century, their professionalisation efforts had paid-off. In 1946, the US Civil Service identified PTs as professional workers, and in 1956 the US Department of Labor did similarly. These government reclassifications helped raise PTs’ professional status and during this period, PT education moved from hospitals into academic settings. From a Flexnerian perspective, this was the context in which professionals needed to be trained.

Raising Training Standards

In 1960, the APTA decreed that the minimum entry-level would be a bachelor’s degree. Over the next decade, a handful of entry-level PT master’s programs also emerged, and in 1979, the APTA provided a resolution calling for all entry-level PT education to be post-baccalaureate by 1990. There was considered not enough time in a four-year bachelor’s program for students to acquire both a liberal arts background and train as professional PTs. In the early 1980s, APTA took over full control of accrediting its education programs, which it had previously shared with the American Medical Association. The transition to required post-baccalaureate entry-level education by 1990 however, proved to be overly ambitious. Many PT practitioners and education programs resisted and delayed the change, unconvinced by the APTA leaders’ ambitions to enhance the profession’s status through increasing its entry-level. However this transition was completed in1999.

During this period a few PTs argued that raising the field’s entry-level could undermine its parallel efforts to increase the profession’s racial/ethnic diversity. The demographics of existing PT master’s programs revealed that such concerns were well-founded. A 1994 survey showed that, while the Black and Latinx representation in PT bachelor’s programs were 7.3% and 5.1% respectively, respondents from master’s programs were less than 1% Black and less than 0.5% Latinx. The insidious aspects of the Flexnerian revolution threatened diversity in PT education as well. Requiring a four-year bachelor’s degree plus two or three years of PT education was cost prohibitive for many students, especially underrepresented racial/ethnic minorities. As in medicine, professionalisation strategies promised to make the field more elite, but also threatened the accessibility of education for marginalised populations.

As the universal entry-level DPT transition came to fruition during the early 2010s, Flexner’s ambitions for medicine a century earlier continued to strongly inform PT leaders’ next steps. Faculty research was fundamental to the status of health professions and, following Flexner’s advice to the medical profession, the APTA held that all core PT faculty should have active research agendas. In 2016 the Commission on Accreditation in Physical Therapy Education (CAPTE), the APTA’s accrediting arm, mandated that 50% or more of all core faculty in DPT programs would possess an academic doctorate—PhD, EdD, or ScD. This was a unique requirement among clinical doctoral professions, even including medicine. Since most PT faculty began their careers as DPTs, the 50% requirement meant that many would be pressured to obtain a second doctorate. In 2019, less than 8% of PT core faculty were underrepresented racial/ethnic minorities. Studies have consistently shown that minority students preferentially select PT programs that have minority faculty members and benefit from concordant mentorship. By adding another hurdle to PT faculty status, Flexnerian objectives threatened the accessibility, as well as the appeal, of a PT career for many minority students.

Conclusion

Since the early 1970s, PT leaders and educators have sought to increase the racial/ethnic diversity of their field, but achieved little success. This failure has likely been the product of limited accessibility and mobility in PT education. PT leaders’ and educators’ diversity goals frequently came in conflict with Flexnerian efforts to enhance the profession’s status. The latter ambition was consistently prioritized.

The inaccessibility of PT education resulted from choices made within the field, as well as from structural barriers and academic elitism that were prevalent throughout higher education and health professions training. PT leaders and educators had many opportunities to recognise these endemic issues and respond by making professional PT education more accessible to historically marginalised populations. Instead, they consistently focused on emulating medicine’s Flexnerian ideals and refused to consider more inclusive approaches.

References

Excerpts from Hogan, AJ. (2024). Accessibility in health professions education: The Flexner Report and barriers to diversity in American physical therapy. Social Science and Medicine, 341, 116519, 1-8. Accessed online at https://www.sciencedirect.com/science/article/pii/S0277953623008766?via%3Dihub