An orthopedic manual physical therapy fellowship training’s impact on professional development, involvement, personal lives, and income – A survey study

Abstract

Introduction: Little research exists investigating the personal and professional outcomes of postprofessional physical therapy (PT) training. Therefore, the purpose of the current descriptive, web-based survey study was to determine self-reported outcomes from a postprofessional PT fellowship program, including graduate professional, educational, and research involvement; perceptions of the impact of training on clinical and professional attributes; changes in employment and income; and barriers to training.
Methods: Graduates of a part-time, hybrid-model, multisite orthopedic manual PT fellowship program were invited to complete the web-based survey. Descriptive data analyses were performed for all quantitative data, and responses to questions were analyzed and categorized into themes.
Results: Of the 77 fellowship graduates, 75 (97%) completed the survey. Graduates were involved in teaching; 43% (32/75) filled lead instructor roles in PT education programs. Further, 75% (57/75) were involved in research. The mean (SD) and median (range) increase in annual gross income was 9560(9560 (17,545) and 2,500(2,500 (0-$125,000), respectively. Perceived areas with the largest impact of training included clinical reasoning, patient-centered and evidence-based practice, and professionalism. Life balance and family commitments were frequent barriers during training.
Discussion: Graduates noted substantial perceived professional, clinical, and financial benefits to fellowship training. Limitations included lack of a control group and surveying participants from a single program. Future research should determine the influence that program and participant-related factors have on personal and professional lives of graduates and on clinical outcomes.
Level of Evidence: Descriptive survey, level 3.

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An orthopedic manual physical therapy fellowship
training’s impact on professional development,
involvement, personal lives, and income – A survey
study
Julie M. Whitman, Mark Shepherd, Brett Neilson, T. J. Janicky, William J.
Garcia, Seth Peterson & Barbara J. Stevens
To cite this article: Julie M. Whitman, Mark Shepherd, Brett Neilson, T. J. Janicky, William J.
Garcia, Seth Peterson & Barbara J. Stevens (2020): An orthopedic manual physical therapy
fellowship training’s impact on professional development, involvement, personal lives, and income –
A survey study, Journal of Manual & Manipulative Therapy, DOI: 10.1080/10669817.2020.1748333
To link to this article: https://doi.org/10.1080/10669817.2020.1748333
Published online: 10 Apr 2020.
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An orthopedic manual physical therapy fellowship training’s impact on
professional development, involvement, personal lives, and income –A survey
study
Julie M. Whitman
a,b
, Mark Shepherd
a,b
, Brett Neilson
b
, T. J. Janicky
c
, William J. Garcia
b,d
, Seth Peterson
e,f
and Barbara J. Stevens
a,b
a
Orthopaedic Manual Physical Therapy Program, Bellin College, Green Bay, WI, USA;
b
Department of Physical Therapy, Evidence In Motion,
Louisville, KY, USA;
c
Department of Physical Therapy, Active Life Physical Therapy, Baltimore, MD, USA;
d
Department of Physical Therapy,
California State University, Sacramento, CA, USA;
e
Department of Physical Therapy, The Motive, Oro Valley, AZ, USA;
f
Arizona School of
Health Sciences, A.T. Still University, Mesa, AZ, USA
ABSTRACT
Introduction: Little research exists investigating the personal and professional outcomes of
postprofessional physical therapy (PT) training. Therefore, the purpose of the current descrip-
tive, web-based survey study was to determine self-reported outcomes from a postprofessional
PT fellowship program, including graduate professional, educational, and research involve-
ment; perceptions of the impact of training on clinical and professional attributes; changes in
employment and income; and barriers to training.
Methods: Graduates of a part-time, hybrid-model, multisite orthopedic manual PT fellowship
program were invited to complete the web-based survey. Descriptive data analyses were
performed for all quantitative data, and responses to questions were analyzed and categorized
into themes.
Results: Of the 77 fellowship graduates, 75 (97%) completed the survey. Graduates were
involved in teaching; 43% (32/75) filled lead instructor roles in PT education programs.
Further, 75% (57/75) were involved in research. The mean (SD) and median (range) increase
in annual gross income was $9560 ($17,545) and $2,500 ($0-$125,000), respectively. Perceived
areas with the largest impact of training included clinical reasoning, patient-centered and
evidence-based practice, and professionalism. Life balance and family commitments were
frequent barriers during training.
Discussion: Graduates noted substantial perceived professional, clinical, and financial benefits
to fellowship training. Limitations included lack of a control group and surveying participants
from a single program. Future research should determine the influence that program and
participant-related factors have on personal and professional lives of graduates and on clinical
outcomes.
Level of Evidence: Descriptive survey, level 3.
KEYWORDS
Education; manual therapy;
fellowship; survey
Introduction
The American Board of Physical Therapy Residency and
Fellowship Education (ABPTRFE) defines fellowship
training (FT) as a ‘postprofessional planned learning
experience comprised of a curriculum encompassing
the essential knowledge, skills, and responsibilities of
an advanced physical therapist within a defined area of
subspecialty practice’[1]. As of February 2019, there
were 52 fellowship programs accredited by the
ABPTRFE, and 32 of them focused on orthopedic man-
ual physical therapy (OMPT) [2]. Further, the ABPTRFE
reports that over 1700 physical therapists (PTs) gradu-
ated from an accredited fellowship from 1999–2017
[3]. Although it is commonly believed that standar-
dized postprofessional training such as FT may be
superior to the traditional route of continuing educa-
tion and professional development [4], little has been
published investigating the benefits of these programs
during their 30-year history in the United States.
Leaders in the profession have called for exploration
of the benefits of residency and fellowship training for
PTs [5–7] and for investigation of the potential factors
that influence learning and outcomes, such as contin-
ued professional development and expertise [7,8]
Others have indicated a need to identify the outcomes
of graduates’leadership and professional skills, teach-
ing and learning strategies, and curriculum competen-
cies [8].
Only a few studies have investigated the non-direct
patient care outcomes of residency or fellowship train-
ing [9–12]. In 1999, Smith et al. [12] surveyed orthopedic
PT residency graduates who reported enhanced clinical
reasoning and clinical skills when taking on additional
teaching roles after their training. Jones et al. [10]inves-
tigated the professional development and leadership
outcomes of PT residency graduates and reported they
CONTACT Mark Shepherd mark.shepherd@bellincollege.edu Orthopaedic Manual Physical Therapy Program, Bellin College, Green Bay, WI
JOURNAL OF MANUAL & MANIPULATIVE THERAPY
https://doi.org/10.1080/10669817.2020.1748333
© 2020 Informa UK Limited, trading as Taylor & Francis Group

were more likely to continue to FT, obtain board certifi-
cation, serve as clinical or academic instructors, and
receive a higher annual income than PTs who did not
graduate from residency programs. A recent qualitative
survey of 13 OMPT fellowship graduates from a part-
time, hybrid-model, multisite program found that they
perceived improvements in time management, practice
satisfaction, professional connectedness, active and
open listening skills, professional evolution, and meta-
cognition [11]. Briggs et al. [9] reported that employers
of residency-trained and fellowship-trained PTs rated
these employees higher in the domains of leadership,
communication, clinical aptitude, teaching, scholarship,
and evidence-based practice than colleagues who had
similar professional experience.
To our knowledge, only one study directly exam-
ined whether completing FT results in superior clinical
outcomes [13]. Rodeghero et al. [13] performed
a retrospective study examining the differences in out-
comes and efficiency (improvement per number of
treatment sessions) between those with and without
completion of a credentialed residency or fellowship
program. Results showed that those with FT achieved
more efficient care and greater overall functional
improvement than residency and non-residency
trained PTs [13]. Although additional quantitative
research is still needed, Robertson and Tichenor [7]
emphasized the need for additional quantitative and
qualitative research in order to ‘fully paint the picture
of the true outcomes and benefits of residency and
fellowship education.’(pg. 58).
Based on the scant information available in the
literature regarding the impact of FT on graduates’
personal and professional lives, and in response to
the call for additional quantitative and qualitative
research regarding residency and fellowship education
[7], we sought to describe graduate outcomes from
a single postprofessional PT fellowship program.
Specifically, we aimed to describe multiple types of
educational outcomes, including graduate profes-
sional, educational, and research involvement; percep-
tions of the impact of FT on clinical and professional
attributes; access to FT; and changes in employment
and graduates’annual income. We also sought to pro-
vide an initial description of the perceived barriers of
PTs when completing FT.
Methods
Participants and training
For the current study, we recruited graduates of
a multisite, hybrid, OMPT fellowship program. The pro-
gram was credentialed by ABPTRFE and recognized by
the American Academy of Orthopedic Manual Physical
Therapists (AAOMPT). See Appendix 1 for curricular
details and program requirements. All program graduates
(N = 77) from the start of the program in 2009 through
February 2017, when data collection for the current study
was begun, were invited to participate. Though it is pos-
sible that more recent graduates may respond somewhat
differently than those who graduated many years prior,
we included all graduates in order to provide
a comprehensive picture of graduate perceptions.
Survey
For the current study, we specifically created an online
survey based on studies evaluating outcomes of clinical
residency programs [10,12] and on expert recommen-
dation [7]. The survey (Appendix 2) included questions
about the impact of FT on professional attributes and
skills, self-perception of professionalism, scholarly activ-
ities, and professional involvement. Participants also
reported on the impact of training on salaries and
annual gross income. Survey items asking about the
impact of FT on professional attributes, skills, self-
perception, and income were assessed on an 11-point
Likert-like scale, where −5 was significant negative influ-
ence, 0 was no influence, and 5 was significant positive
influence. We also assessed access to FT, including
access to Fellow of the American Academy of
Orthopedic Manual Physical Therapists (AAOMPT)-
credentialed mentors and in-residence OMPT programs
and whether the graduate would have pursued FT with-
out access to a hybrid-model program. Optional open-
ended questions asked how training impacted gradu-
ates professionally and personally. They also asked
about perceived barriers to FT and about life situations
and responsibilities that had to be balanced alongside
the program. The survey required approximately
20–30 minutes to complete. SurveyMonkey software
(SurveyMonkey, Inc., San Mateo, CA, www.surveymon
key.com) was used to create the survey and gather data.
Six PTs participated in pilot testing of the online
survey. The survey scored at an 8.8 grade level on the
Flesch-Kincaid Grade Level Readability test [14] and
had a Flesch Reading Ease [14] score of 42.3. The
survey’s reading ease score indicated appropriateness
for readers with a college-level education and beyond.
As such, we considered the survey appropriate for our
target population [15].
Procedures
All study procedures were approved by the local insti-
tutional review board. Informed consent was obtained
and the rights of the participants were protected.
Participants were recruited through social media and
e-mail. The beginning of the online survey contained
information about the study and informed consent to
participate. To incentivize participation, 8 randomly
selected respondents were offered 25 USD gift cards
at completion of the study. Only 1 member of the
2J. M. WHITMAN ET AL.

research team, who was not the program director, had
access to participant identities in order to send addi-
tional invitations as necessary and to contact partici-
pants awarded gift cards. Non-respondents to the
initial invitation were contacted up to 3 additional
times by telephone or e-mail at approximately
2-week intervals. The survey remained open for
a 3-month period (February to April 2017). When the
survey closed, the team member with access to the
online survey results de-identified and downloaded
the data into SPSS (IBM SPSS Statistics for Windows,
version 24.0. Armonk, NY) for analysis.
Data analysis
Descriptive analyses were used for participant demo-
graphics (eg, sex, age, years of clinical practice, highest
academic degree) and for all closed-ended survey
responses related to professional attributes (view of
self, attributes, and knowledge), participation in pro-
fessional activities and research (involvement in pro-
fessional organizations, presentations, publications of
research), employment information (current and past
work experience), perceptions of clinical expertise (rea-
soning for clinical decisions), and reasons for selecting
this particular program. Open-ended responses were
analyzed using an inductive approach without prede-
fined categories from the raw narrative data.
Responses were analyzed by 2 team members (WG,
BJS), who independently categorized the participant
comments into themes. Any disagreement between
themes was resolved by a third team member (JMW)
until consensus was established. SPSS version 24.0 was
used for all statistical analyses.
Results
Seventy-seven graduates were invited to participate,
and 75 (97% response rate) completed the survey.
Most participants were male (55/75, 73.3%) with
a mean (SD) age of 39.9 (7.8) years and 8.9 (7.4) years
of clinical practice before entry to the FT program
(Table 1). The mean (SD) time to complete the program
was 32.1 (7.1) months. Participants worked in a variety
of primary and secondary work positions, but orthope-
dics was the most common practice area of focus (69/
75, 92.0%) (Table 2). Detailed demographic, employ-
ment, and practice characteristics are provided in
Tables 1 and 2.
Perceived impact of fellowship training on
professional attributes and income
Mean scores for survey items related to perceived
impact on professionalism, application of knowledge,
and impact of FT on patient outcomes ranged from 3.7
to 4.7 points (Table 3). The highest mean (SD) scores
were reported for viewing oneself as a professional (4.7
[0.7] points). Mean (SD) impact on confidence in men-
toring ranged from 3.4 (3.2) points for mentoring fel-
lows-in-training to 4.3 (2.0) points for mentoring peers
in the clinic or community. Full results for perceived
impact of fellowship training on professional attributes
are reported in Table 3. Mean scores for impact on
clinical reasoning skills in all phases of the care process
ranged from 3.9 to 4.7 points (Table 4). Impact on
technical skills varied from 3.6 to 4.4 points, except
for application of modalities (mean [SD] = 0.7 [1.8]).
The increase in annual gross income for all graduates
who completed the survey was as follows: 1) mean
(SD) of 9560 USD ($17,545); 2) median (range) of 2500
USD ($0-125,000). The majority of graduates (44/17,
59.0%) augmented their annual income with addi-
tional work (mean [SD] = 9020 USD [$11 123]), and
20% (15/75) received raises in gross salary ($6100
[$6054]).
Perceived impact of fellowship training on
professional, educational, and research
involvement
Respondents were involved as members and leaders
of professional associations and in scholarly work and
educational activities (Tables 5 and 6). Almost all
graduates were members of the American Physical
Therapy Association (APTA) (72/75, 96.0%) and the
AAOMPT (73/75, 97.3%), and 22.7% (17/75) had held
official positions in these organizations (board or
committee member) (Table 5). Additionally, 24.0%
(18/75) had served in their state chapter or district
as a state delegate, board member, or committee
member. Most (57/75, 76.0%) were involved in
research during fellowship or since graduation
(Table 6). More than a quarter (21/75, 28.0%) had
published in peer-reviewed journals and professional
texts, and conducted professional platform presenta-
tions (24/75, 32.0%), presented posters (23/75, 30.7%),
or were invited speakers at national (15/75, 20.0%)
and district or state level (28/75, 37.3%) professional
meetings.
Graduate involvement in education was a common
finding in this study. After FT, 42.7% (32/75) were lead
instructors in entry-level postprofessional PT pro-
grams, and 53.3% (40/75) were lead instructors for
continuing education seminars (Table 6). About half
had developed curricular content for entry-level
(40.0%, 30/75) or postprofessional PT education online
and onsite lab courses (57.3%, 44/75). Clinical mentor-
ship was a reported for many; 89.3% (67/75) reported
involvement as mentors for peers in clinical practice,
entry-level DPT students (from 65 programs), residents
(from 23 credentialed programs), or fellows-in-training
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 3

(from 9 credentialed programs) (Table 5). Most (53/75,
70%) reported that FT positively influenced their con-
fidence in teaching and mentoring.
Graduates reported 5-year professional goals
(Table 5), including involvement in teaching in entry-
level (24/75, 32.0%) and postprofessional (47/75,
62.7%) PT programs, presenting at conferences (56/
75, 74.7%), disseminating research in peer-reviewed
journals (36/75, 48.0%), expanding involvement with
the APTA or AAOMPT (47/75, 62.7%), obtaining
a terminal doctoral degree (40/74, 53.3%), and conti-
nuing research activities (43/75, 57.3%).
Access to fellowship training and program
selection
Table 7 provides data related to access to FT.
Graduates (46/75, 61.3%) would not have pursued FT
if a hybrid learning program were unavailable, while
25% (19/75) would have but only if a geographic relo-
cation was not required. Approximately half (35/75,
46.7%) indicated the nearest in-residence program
was more than a 2-hour drive away, and only about
half had access to a qualified mentor within a 1-hour
drive (39/75, 52.0%). Over half of the graduates noted
that they chose this program for the following reasons:
‘I could maintain work and a salary while going
through the program’(94.7%, 71/75), ‘I respected the
faculty’(93.3%, 70/75), ‘I liked the clinical reasoning
model taught’(74.7%, 56/75), ‘I liked the research-
based approach’(73.3%, 55/75), and ‘I was unwilling
or unable to relocate’(66.7%, 50/75) (Appendix 3).
Perceived impact of fellowship training on
professional and personal life
Of 75 completed surveys, 67 graduates (89%) responded
to the optional open-ended questions about how FT
impacted them professionally and personally. Nine
themes emerged –expertise, clinical reasoning, evi-
dence-based practice, teaching, communication, traits/
values, professionalism, collaboration, and difficulties.
Metacognition and clinical skills were identified as char-
acteristics of expertise. Graduates identified FT as having
a positive impact on clinical reasoning, including both
critical thinking and decision-making, and on confidence
with teaching. For professionalism and collaboration,
graduates indicated they had a broader view of the
profession after training and that they had developed
a network of colleagues to consult and collaborate with.
Table 1. Demographic characteristics of graduates of a postprofessional physical therapy fellowship
training program (N = 75).
Demographic characteristic No. (%) Mean (SD) Median (range)
Sex
Male 55 (73.3)
Female 20 (26.7)
Age, y
Current age 39.9 (7.8) 37 (29–65)
On entry to program 35.7 (7.5) 35 (25–60)
Years clinical practice
Current total 14.0 (8.0) 11 (3–38)
Current total in primary orthopedic/sports setting 13.0 (7.2) 11 (3–38)
On starting fellowship 8.9 (7.4) 6 (0–31)
First professional degree
Baccalaureate 13 (17.3)
Master’s 23 (30.7)
Doctorate 39 (52.0)
Highest academic degree
Baccalaureate 0 (0)
Entry-level master’s 1 (1.3)
Postprofessional master’s 1 (1.3)
Clinical doctorate in physical therapy (DPT) 68 (90.7)
Terminal doctorate (PhD, DSC, etc) 5 (6.7)
Year of fellowship program graduation
2010 3 (4.0)
2011 3 (4.0)
2012 10 (13.3)
2013 7 (9.3)
2014 11 (14.7)
2015 18 (24.0)
2016 21 (28.0)
2017 2 (2.7)
Relationships during program requiring time and attention
Significant other during >50% of program 73 (97.3)
Children at home elementary age or younger 33 (44.0)
Children at home junior high or older 10 (13.3)
Caring for aging parents 3 (4.0)
Other family situations* 15 (20.0)
*Examples were spouse with cancer, parent death, newborn child, moving, stressful pregnancy, pregnancy and delivery of
multiple children, bought/sold home, sick children, child in intensive care unit, working on PhD, and military move.
Abbreviations: DSc, doctor of science; PhD, doctor of philosophy; SD, standard deviation.
4J. M. WHITMAN ET AL.

Table 2. Primary and secondary professional positions of program graduates before and after the
fellowship program (N = 75).
Survey Item Before After
Primary position
Staffphysical therapist 33 (44.0) 13 (17.3)
Clinical specialist, senior staffphysical therapist 12 (16.0) 16 (21.3)
Clinical supervisor or director 15 (20.0) 10 (13.3)
Partner in a physical therapy practice or business 2 (2.7) 9 (12.0)
Sole owner of a PT practice or business 6 (8.0) 6 (8.0)
Academic faculty member 5 (6.7) 9 (12.0)
Clinical educator (entry-level or postprofessional) 0 (0) 3 (4.0)
Academic administrator (first-professional or postprofessional) 0 (0) 4 (5.3)
Director of physical therapy education program 0 (0) 1 (1.3)
Clinical researcher 2 (2.7) 1 (1.3)
Other (retired, director of rehabilitation center of expertise, hospital transition specialist) 0 (0) 3 (4.0)
Primary position geographic location
Uniformed health, military, or veteran’s association NA 4 (5.3)
Metropolitan or urban NA 36 (48.0)
Suburban NA 26 (34.7)
Rural or remote NA 12 (16.0)
Other (mountain resort, professional sports, small city, retired, non-clinical academics) NA 5 (6.7)
Primary position type of facility
Hospital inpatient 1 (1.3) 1 (1.3)
Hospital outpatient 17 (22.7) 16 (21.3)
Hospital emergency care 1 (1.3) 1 (1.3)
Outpatient private practice 46 (61.3) 32 (42.7)
Physician-owned PT practice 2 (2.7) 1 (1.3)
Outpatient rehabilitation center 3 (4.0) 3 (4.0)
Academic institution (teaching) 4 (5.3) 12 (16.0)
Academic student health clinic 0 (0) 1 (1.3)
Military/uniformed health 1 (1.3) 1 (1.3)
Other (retired; hospital system with inpatient, outpatient, and home care; community
nonprofit services; university outpatient student health; sports facility; home office
administrative)
1 (1.3) 6 (8.0)
Clinical practice area of focus
Orthopedics NA 69 (92.0)
Sports NA 19 (25.3)
Administration/business NA 11 (14.7)
Women’s health/pelvic health NA 1 (1.3)
Chronic pain NA 23 (30.7)
Neurologic rehabilitation NA 1 (1.3)
Emergency care NA 1 (1.3)
General practice (no focus area) NA 1 (1.3)
Other (retired, concussion, primary care PT, academic institution with no clinical
appointment, additional academic appointment postprofessional residency)
NA 5 (6.7)
Secondary positions held 10 (13.3) 30 (40.0)
Staffphysical therapist 8 (10.7) 4 (5.3)
Clinical specialist, senior staffphysical therapist 0 (0) 2 (2.7)
Clinical supervisor or director 0 (0) 1 (1.3)
Partner in a PT practice or business 0 (0) 0 (0)
Sole owner of a PT practice or business 1 (1.3) 4 (5.3)
Academic faculty member 1 (1.3) 3 (4.0)
Academic administrator (first-professional or postprofessional) 3 (4.0)
Director of physical therapy education program 0 (0) 2 (2.7)
Clinical educator (first-professional or postprofessional) 0 (0) 8 (10.7)
Clinical researcher 0 (0) 0 (0)
Other (canine conditioning, CEO of physical therapy company, director of education and
mentoring)
3 (4.0)
Secondary position type of facility
Hospital inpatient 3 (4.0) 0 (0)
Hospital outpatient 1 (1.3) 4 (5.3)
Hospital emergency care 0 (0) 0 (0)
Outpatient private practice 2 (2.7) 11 (14.7)
Physician-owned PT practice 0 (0) 0 (0)
Outpatient rehabilitation center 0 (0) 0 (0)
Academic institution 1 (1.3) 8 (10.7)
Research center 0 (0) 1 (1.3)
Military/uniformed service 0 (0) 0 (0)
Fitness center 0 (0) 1 (1.3)
Professional education company 0 (0) 3 (4.0)
Home health agency, extended care, or skilled nursing 3 (4.0) 1 (1.3)
Other (postprofessional continuing education teaching, office, fitness center, public health
service rural medical clinic, postprofessional program in private practice and hospital
clinics)
0 (0) 6 (8.0)
Weekly hours spent in direct patient care 39.0 (8.9)
40.0
(8–60)
26.9 (14.6)
30.0
(0–50)
Data are reported as no. (%) except for weekly hours spent in direct patient care, which is reported as mean (SD) and
median (range).
Abbreviations: CEO, chief executive officer; NA, not applicable; PT, physical therapy; SD, standard deviation.
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 5

Graduates indicated improved communication skills in
their professional and personal lives. Enhanced humility,
commitment, confidence, and life-long learning skills
were traits and values identified as positively impacting
graduates professionally and personally. Life balance,
family commitments, and marital strain were difficulties
Table 4. Perceived impact of fellowship training on clinical reasoning and application of selected intervention techniques for
program graduates (N = 75).
Area of impact Mean (SD) Median (range)
Clinical reasoning in the patient history
Conducting a focused and skilled patient interview 4.7 (0.9) 5 (−1-5)
Establishing hypotheses, including recognition of common clinical syndromes 4.6 (0.9) 5 (1–5)
Asking appropriate questions and evaluating the need for medical referral/consultation, referral to
additional healthcare provider
4.6 (0.9) 5 (0–5)
Planning appropriate physical exam based on patient presentation 4.7 (0.9) 5 (0–5)
Establishing a good relationship/rapport with the patient 4.3 (1.1) 5 (0–5)
Clinical reasoning in the physical exam
Conducting a skilled physical examination specifically tailored to the patient’s complaint, diagnosis, and
presentation
4.6 (0.8) 5 (1–5)
Performing appropriate tests to evaluate the need for medical referral/consultation, referral to additional
healthcare provider
4.5 (0.8) 5 (0–5)
Performing appropriate tests to establish a physical therapy diagnosis 4.5 (0.8) 5 (1–5)
Establishing clinical findings for reassessment of the effectiveness of treatment interventions that are
meaningful to the patient
4.7 (0.6) 5 (3–5)
Synthesizing findings from physical exam to select appropriate interventions 4.6 (0.8) 5 (1–5)
Clinical reasoning in the intervention process
Selecting and performing the most appropriate interventions 4.5 (0.8) 5 (2–5)
Reassessing the patient’s status to progress their treatment appropriately within session and over the
course
4.6 (7.9) 5 (1–5)
Selecting and instructing the patient in the most appropriate home exercise program 4.3 (1.0) 5 (1–5)
Adjusting your communication content and delivery method based on the patient needs 5.4 (1.0) 5 (1–5)
Clinical reasoning in discharge planning
Establishing a prognosis 5.2 (0.9) 5 (1–5)
Clearly communicating the prognosis to the patient and other key stakeholders (family, caregiver, referring
physician, etc.)
3.9 (1.2) 5 (0–5)
Preparing for discharge and prevention of recurrence from the initial evaluation and throughout the course
of care
4.0 (1.1) 4 (1–5)
Impact on technical skills
Manual therapy non-thrust techniques 4.4 (1.0) 5 (1–5)
Manual therapy thrust techniques 4.4 (0.8) 5 (1–5)
Therapeutic exercise prescription 3.6 (1.8) 4 (6–11)
Modalities 0.7 (1.8) 0 (−4-5)
Targeted home exercise program and self-management strategies 3.8 (1.3) 4 (0–5)
Patient education 4.2 (1.0) 5 (2–5)
Data are based on an 11-point Likert-like scale where −5 = significant negative influence, 0 = neutral, and 5 = significant positive influence.
Abbreviation: SD, standard deviation.
Table 3. Perceived impact of the fellowship program on professional attributes and outcomes for program graduates (N = 75).
Survey Item Mean (SD) Median (Range)
View of self as a professional 4.7 (0.7) 5 (2–5)
Impact on professional attributes
Demonstration of high level of communication skills with colleagues 4.3 (1.0) 5 (1–5)
Demonstration of high-level communication and collaboration skills with multidisciplinary colleagues 3.7 (1.2) 5 (0–5)
Commitment to lifelong learning 4.4 (1.1) 5 (0–5)
Commitment to investing or giving back to the profession (legislative or professional associations) 3.8 (1.3) 4 (0–5)
Commitment to teaching/leading peers in the clinical setting or professional community 4.7 (0.7) 5 (0–5)
Commitment to using one’s unique professional skills to serve the local community 4.0 (1.3) 4 (0–5)
Impact on professional knowledge
Evidence-based practice 4.4 (1.1) 5 (0–5)
Patient-centered practice 4.5 (1.0) 5 (0–5)
Biopsychosocial model of clinical practice 4.5 (0.9) 5 (2–5)
Impact on application of knowledge
Evidence-based practice 4.5 (0.9) 5 (0–5)
Patient-centered practice 4.6 (0.9) 5 (0–5)
Biopsychosocial model of clinical practice 4.6 (0.8) 5 (2–5)
Influence of fellowship training on patient outcomes
Ability to achieve optimal outcomes 4.5 (0.8) 5 (1–5)
Ability to treat efficiently 4.4 (0.9) 5 (1–5)
Impact on confidence in teaching and mentoring
Peers in clinical practice or the community 4.3 (2.0) 5 (1–5)
Entry-level DPT students 4.2 (2.1) 5 (0–5)
Residents 4.01 (2.7) 5 (0–5)
Fellows-in-training 3.4 (3.2) 5 (0–5)
Data are based on an 11-point Likert-like scale where −5 = significant negative influence, 0 = neutral, and 5 = significant positive influence.
Abbreviation: DPT, doctorate in physical therapy; SD, standard deviation.
6J. M. WHITMAN ET AL.

experienced during FT. Selected representative written
responses related to each theme are provided in
Appendix 4.
Discussion
The current study described the graduate outcomes
from a single postprofessional OMPT fellowship pro-
gram. We specifically investigated graduate percep-
tions of the impact of their FT on various professional
attributes, professional development and involvement,
employment, and income. We also investigated per-
ceived barriers to FT and the perceived personal
impact of FT. To our knowledge, the current study is
the first to describe the professional impact of FT on
the lives and careers of postprofessional fellowship
graduates for this specific type of program.
Graduates were overwhelmingly positive about the
impact of FT on their professional and personal lives.
Their self-perception as PT professionals was increased,
and they reported an extensive impact of FT on their
clinical skills and professional attributes and on their
personal lives, communication skills, and relationships.
Further, graduates reported widespread involvement
in research, scholarship, teaching, and professional
leadership and service roles; and they indicated an
interest in continuing professional development in
these areas in the near future.
Graduates were positive about the impact of train-
ing on their communication skills and on their clinical
skills, especially in clinical reasoning. These findings
are similar to those of Smith et al. [12], where resi-
dency graduates rated the clinical reasoning process
as the most valuable skill obtained during their
Table 5. Leadership and professional involvement for program graduates (N = 75) after
graduation.
Survey item No. (%)
National organization membership and leaderships
APTA membership 72 (96.0)
AAOMPT member 73 (97.3)
Served in AAOMPT or at the national or section level of the APTA 17 (22.7)
AAOMPT executive 2 (2.7)
AAOMPT committee chair 2 (2.7)
AAOMPT committee member 6 (8.0)
AAOMPT special interest group chair 1 (1.3)
APTA board 1 (1.3)
APTA committee 3 (4.0)
APTA section committee 5 (6.7)
ABPTRFE position 2 (2.7)
Exam item writer for NPTE or board specialty exam 3 (4.0)
Other (APTA Human Movement Summit delegate, APTA media corps) 2 (2.7)
State chapter of district level of the APTA 18 (24.0)
State delegate 6 (8.0)
State chapter board of directors 4 (5.3)
State chapter committee 11 (14.7)
District board 5 (6.7)
District committee 5 (6.7)
State committee task force legislative efforts 8 (10.7)
Other (mentor volunteer for state new graduate PT program) 1 (1.3)
Clinical mentorship of peers 67 (89.3)
Entry-level DPT students 55 (73.3)
Residents from same organization completed FT with 33 (44.0)
Residents from other programs 24 (32.0)
Fellows-in-training from same organization completed FT with 42 (56.0)
Fellows-in-training from other programs 18 (24.0)
Colleagues in primary clinic 52 (69.3)
Other unspecified 2 (2.7)
Professional aspirations (current to next 5 years)
Teach continuing education courses 55 (73.3)
Teach in a postprofessional PT education program 47 (62.7)
Teach as adjunct faculty in an entry-level PT education program 44 (58.7)
Teach as ranked faculty in an entry-level PT education program 24 (32.0)
Present at conferences 56 (74.7)
Disseminate research in peer-reviewed journals 36 (48.0)
Perform a clinical administrator role 17 (22.7)
Perform a hospital administrator role 3 (4.0)
Start or continue in private practice ownership 24 (32.0)
Expand my current private practice ownership 16 (78.7)
Expand involvement in professional organizations (APTA, AAOMPT) 47 (62.7)
Obtain a terminal doctoral degree (DSc, PhD) 40 (53.3)
Participate in a case report or case series 44 (58.7)
Participate in higher-level clinical research 43 (57.3)
Other (run for public office, unspecified research) 2 (2.7)
Abbreviations: AAOMPT, American Academy of Orthopedic Manual Physical Therapists; ABPTRFE, American Board of
Physical Therapy Residency and Fellowship Education; APTA, American Physical Therapy Association; DPT, doctor
of physical therapy; DSc, doctor of science; FT, fellowship training; NPTE, National Physical Therapy Exam; PhD,
doctor of philosophy; PT, physical therapy.
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 7

program. Previous research has also shown that clin-
icians with FT have better adherence to clinical prac-
tice guidelines [16], achieve better efficiency and
effectiveness in their clinical outcomes [13], and are
rated by employers higher than residency-trained
employees in the area of clinical aptitude [9]. In
another study, MacPherson et al. [17]identified
reported gains in self-awareness and metacognition
in fellowship graduates through qualitative methods,
and these gains extended into perceived improve-
ments in the graduates’personal lives. Fellowship
programs generally emphasize reflection and deliber-
ate practice, and the program of the current study in
particular devotes extensive resources to developing
the reasoning and communication skills of each fel-
low-in-training (Appendix 1). Reflection and deliber-
ate practice have been associated with the
development of domain expertise [18,19], which
may be one explanation for the results of our study
and other studies.
Nearly 90% of graduates were involved in entry-level
and postprofessional clinical mentorship, including
Table 6. Research and scholarship activities for program graduates (N = 75) during or after graduation.
Survey item No. (%)
Research involvement by type of study or activity 57 (76.0)
Case reports/case series 36 (48.0)
Qualitative/quantitative survey study 19 (25.3)
Randomized trials 15 (20.0)
Systematic reviews/meta-analysis 9 (12.0)
Clinical guidelines 10 (13.3)
Editorial in peer-reviewed publications 4 (5.3)
Other (JOSPT MSK Imaging, observational cohort study, literature review) 3 (4.0)
Research activities by specific role in research 50 (66.7)
Design 18 (24.0)
Grant writing 10 (13.3)
Data collection 39 (52.0)
Manuscript writing 32 (42.7)
Statistical analysis 9 (12.0)
Types of publications or presentations 61 (81.3)
Publications (case studies, book chapters, articles on clinical topics, peer reviewed articles) 21 (28.0)
Platform presentations at professional conferences 24 (32.0)
Poster presentations at professional conferences 23 (30.7)
Development of curriculum (entry-level/postprofessional) 30 (40.0)
Development of educational materials (online/onsite) 44 (57.3)
Professional scholarly activities 62 (82.7)
Lead instructor of a continuing education seminar 40 (53.3)
Guest lecturer or lab assistant in a professional or postprofessional PT education program 54 (72.0)
Lead instructor in a professional or postprofessional PT program 32 (42.7)
Invited speaker at a national level meeting 15 (20.0)
Invited speaker at a district or state level meeting 28 (37.3)
Other (community education) 1 (1.3)
Abbreviations: JOSPT, Journal of Orthopedic and Sports Physical Therapy; MSK, musculoskeletal; PT, physical therapy.
Table 7. Access to training for program graduates (N = 75).
Survey item No. (%)
Nearest FAAOMPT mentor (while in program)
Within my organization 21 (28.0)
Within my town/city 4 (5.3)
Within a 30-minute drive 8 (10.7)
Within a 1-hour drive 6 (8.0)
Within a 2-hour drive 10 (13.3)
Greater than a 2-hour drive 21 (28.0)
Other 5 (6.7)
Nearest in-residence OMPT fellowship program
Within my organization 3 (4.0)
Within my town/city 5 (6.7)
Within a 30-minute drive 3 (4.0)
Within a 1-hour drive 3 (4.0)
Within a 2-hour drive 7 (9.3)
Greater than a 2-hour drive 35 (46.7)
Do not know 15 (20.0)
Other 4 (5.3)
Would you have attended a credentialed fellowship program if you did not have
access to hybrid learning fellowship program?
No, I would not have pursued fellowship training 46 (61.3)
Yes, only if it did not require relocation 19 (25.3)
Yes, even if it did require relocation 3 (4.0)
I am not sure 7 (9.3)
Abbreviations: FAAOMPT, Fellow of the American Academy of Orthopedic Manual Physical Therapists; OMPT, orthopedic
manual physical therapy.
8J. M. WHITMAN ET AL.

teaching in clinical programs outside those affiliated
with the fellowship program. Interestingly, 11% of grad-
uates transitioned into formal teaching roles by gradua-
tion, while the number of graduates practicing full-time
in outpatient orthopedics declined. It is unclear why this
occurred, but graduates could have used the OMPT
fellowship program as an entry to faculty roles. In the
program currently studied, fellows-in-training partici-
pate in a variety of formal teaching assistant roles in
online and live classrooms or laboratory settings. These
experiences may have increased confidence in teaching
and desire to continue teaching after graduation. Others
have found similar results. For example, Jones et al. [10]
found similar increases in professional and postprofes-
sional teaching roles in a sample of orthopedic PT resi-
dency graduates [20], and Briggs et al. [9]foundthat
employers rated employees with residency training or
FT higher than experience-matched colleagues in the
domain of teaching.
Graduates were required to be members of the
APTA and AAOMPT during our program, and they
remained active in these associations. After gradua-
tion, 96% were members of the APTA and the
AAOMPT, approximately one-fifth held official posi-
tions in those organizations, and about the same
number were involved at the state or district level.
Further, most wanted to expand their involvement in
professional organizations in the next 5 years, which
suggested a commitment to the profession and
desire to serve. Similarly, Smith et al. [12]foundthat
80% of residency graduates maintained APTA mem-
bership; about 30% of PTs overall maintain member-
ship [21].
The majority (76%) of graduates in our study had
participated in scholarly activity, including nearly one-
third with peer-reviewed journal or text publications or
with presentations at professional meetings. This scho-
larly activity is higher than that reported for PT ortho-
pedic residency graduates [12] but similar to that of
medical graduates in a neurosurgical oncology resi-
dency program [17]. Our findings may have resulted
from a number of factors, such as entrance of highly
motivated students into the program, a greater under-
standing of the literature, growth in professional criti-
cal review and writing skills during the program,
increased motivation to contribute to the literature,
and successful modeling and mentoring of the
research process by fellowship faculty. Interestingly,
the majority of the graduates intended to participate
in clinical research, publish in peer-reviewed journals,
and present at professional conferences in the next
5 years, suggesting that graduates were driven to
grow and contribute to professional scholarship.
Most students pursuing a career in healthcare accu-
mulate student loan debt [22]. Graduates of profes-
sional degree programs, such as PTs, represent only
10% of those with graduate degrees but represent 42%
of those with over 150 USD 000 in student loan debt
[4]. From 2007 to 2016, the cost of PT education has
increased 2.3 to 3.1 times more quickly than growth in
entry-level salaries, adding to the student debt pro-
blem [22]. Despite concerns about the cost of PT edu-
cation, an APTA task force recently reported students
may be unprepared for clinical practice in a specialty
area and recommended postgraduate residency train-
ing for all PTs [23]. Understandably, critics of wide-
spread postgraduate training in PT have cited student
debt as a concern [24]. In the current study, graduates
reported a mean increase of 9560 USD and a median
increase in their annual gross income, which was about
a 10% increase from the current median national salary
for PT [25]. Although program costs vary, this increase
in mean salary reported by program graduates would
essentially compensate for most fellowship program
tuitions in less than 2 years of graduation. Using
a more conservative median increase of 2,500 USD,
a graduate would still compensate for most fellowship
tuitions within 5–6 years of graduation. A favorable
influence of postgraduate training on salary was also
reported by 76% of orthopedic residency graduates in
a study by Smith et al. [12]. However, it is unclear
whether postgraduate training will continue to be
economical or whether more widespread postgradu-
ate education would affect this outcome.
In 2016–2017, ABPTRFE reported 519 available posi-
tions in OMPT fellowships, but only 354 positions were
filled [26], which suggests an excess of available posi-
tions in OMPT fellowship programs in the United States.
In the current study, the majority of graduates indicated
that they would not have pursued FT had a hybrid-
model been unavailable, and 25% would have pursued
FT only if relocation was not required. A potential expla-
nation for this seemingly contradictory finding is that
not all motivated clinicians have reasonable access to
in-residence training and/or qualified mentors. In our
study, only one-third of participants had appropriately
credentialed mentors available in their organizations or
towns, and only 14% had in-residence programs within
a 30-minute driving distance. Further, almost all partici-
pants reported having a significant other during FT,
almost half had children at home, and many had family
situations that required time and attention during their
training. Although many reasons related to the faculty
and the curriculum were noted by graduates as
a rationale for selecting our fellowship program, almost
95% cited the ability to maintain work and continue
receiving a salary as one driver for program selection.
A hybrid, part-time program enables motivated PTs to
continue to work and earn a salary while pursuing FT.
Limitations
The current study had several limitations. Although the
level of perceived improvement of OMPT fellowship
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 9

graduates is important to understand, questions requir-
ing a self-appraisal are inherently biased. Respondents
may have answered favorably to survey questions
knowing that this reflected the program they graduated
from. Being that the survey study only targeted gradu-
ates of this program, we did not collect similar data on
those that have dropped out of FT. In addition, the
current study cannot show a cause and effect relation-
ship between FT and the observed outcomes. For exam-
ple, it is possible that more motivated PTs participated
in FT and, therefore, would have the same degree of
achievement regardless of training. Many graduates
obtained board certification during the FT, which may
impact clinical efficiency [20]. Graduate years of experi-
ence could also be a confounder and may have
impacted clinical outcomes [7]. Although a comparison
group was used in previous studies to better judge the
impact of postprofessional training, no such group was
used in the current study.
Another limitation is that graduates from a single
OMPT fellowship program over a defined period of
time were surveyed. Further, our program is a part-
time, hybrid-model, multisite fellowship. A recent
publication by Hartley et al. [27]identified several
program-level factors that positively influenced grad-
uate outcomes for PT residency programs. In that
study, programs that were a single site or multisite
facility, provided live instruction, charged no tuition,
and paid residents at or above 70% of a full-time
salary were more likely to have their participants
complete the program, pass board examinations,
and become board certified [27]. Interestingly, the
program-level factors identified by Hartley et al. [27]
are in sharp contrast to the FT program included in
the current study. There were different research
designs, assessed outcomes, and levels of training in
these 2 studies that prevent direct comparisons, but
the results of both studies suggest the need for
future research investigating the impact of various
program-level factors on programmatic outcomes.
Current accredited fellowship programs have
a robust diversity in terms of format and delivery
model, treatment philosophy, and clinical reasoning
models. Therefore, results of the current study may
not be generalizable to other OMPT fellowship pro-
grams, other types of fellowships, or residency
programs.
Conclusion
Results of the current study suggested a substantial
perceived impact of part-time, hybrid, multisite OMPT
fellowship training on the professional development and
clinical skills of PTs. Graduates were extensively involved
in teaching and mentoring, research, and professional
leadership activities; and they reported increased annual
income. Most would not have been able to complete FT
if a hybrid-model program had been unavailable.
Limitations included the lack of a control group and
a lack of inclusion of graduates from programs that use
other educational models. Future research should inves-
tigate the influence of program, mentor, and clinician-
related factors on graduate outcomes.
Disclosure statement
The authors declare that we have no financial disclosures or
conflicts of interest to report.
Notes on contributors
Dr. Julie M. Whitman is the former program director of Bellin
College's Orthopaedic and Manual Physical Therapy
Fellowship and Doctorate of Science in Physical Therapy
programs. She has 40+ peer-reviewed manuscripts, and
over 30 published abstracts in the areas of orthopaedics
and manual physical therapy.
Dr. Mark Shepherd is the program director of Bellin College's
Orthopaedic and Manual Physical Therapy Fellowship pro-
gram. He serves as faculty with Evidence in Motion. He is a
fellow of the American Academy of Orthopaedic Manual
Physical Therapy.
Dr. Brett Neilson is the program director of Evidence in
Motion's tDPT and Therapeutic Pain Specialist programs.
He is a fellow of the American Academy of Orthopaedic
Manual Physical Therapy.
Dr. T. J. Janicky is a physical therapist at Active Life and
Sports PT. He is a fellow of the American Academy of
Orthopaedic Manual Physical Therapy. He serves as faculty
with Evidence in Motion.
Dr. William J. Garcia is a full-time Assistant Professor in the
Physical Therapy program at Sacramento State. He is a
fellow of the American Academy of Orthopaedic Manual
Physical Therapy.
Dr. Seth Peterson is the founder of The Motive Physical
Therapy Specialists in Oro Valley, AZ. He is adjunct faculty
in the Physical Therapy program at A.T. Still University. He is
a fellow of the American Academy of Orthopaedic Manual
Physical Therapy.
Dr. Barbara J. Stevens is faculty for Bellin College's
Orthopaedic and Manual Physical Therapy Fellowship pro-
gram. She serves as faculty with Evidence in Motion. She is a
fellow of the American Academy of Orthopaedic Manual
Physical Therapy.
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