Abstract
The occupational therapy profession in the United States is considering another shift in the level of entry-to-practice education. Currently, all accredited U.S. occupational therapy education programs offer graduate-entry master’s degrees or clinical doctorates. In 2014, the American Occupational Therapy Association Board of Directors published a position statement supporting the idea of moving all entry-level occupational therapy education programs to the clinical doctorate level by 2025. This article provides an overview of the proposed reasons for doing so and the potential impact of this move on future students, education providers, clients and families, employers, and third-party payers and funding bodies along with the implications for the occupational therapy profession internationally. An open, informed, transparent, multiperspective, comprehensive debate about this education paradigm shift is recommended. In August 2015 the Accreditation Council for Occupational Therapy Education decided that the entry-level qualification will remain at both the master’s and the doctoral degree; it is anticipated, however, that the move toward the entry-level clinical doctorate will continue.
Previously considered a “semiprofession” in the health care sphere (Etzioni, 1969), occupational therapy is now recognized as a full-fledged profession (Clouston & Whitcombe, 2008; Turner, 2011). Characteristics often ascribed to professions include a defined body of empirically based knowledge, formal recognition by society that the profession possesses a unique skill set, an ethical code of practice, and a prolonged period of education and training that the professional body controls during which new graduates learn about the nuances and lexicon of the profession (MacDonald, 1995). Along with occupational therapy’s movement along the profession spectrum have been changing and evolving formal education requirements that students need to achieve to gain entry into the field (Coppard & Dickerson, 2007).
Occupational therapy formally developed as a field in the early part of the 20th century. Occupational therapy education started with short courses for “reconstruction aides” or rehabilitation workers that lasted a few months and included coursework and hands-on skills training (Gutman, 1995). Later, education led to a certificate and then a diploma, with formal recognition of practice-related credentials. The American Occupational Therapy Association (AOTA) published the first education standards for nonemergency war courses in 1923, and formal accreditation of occupational therapy education programs started in 1935 in partnership with the American Medical Association (Quiroga, 1995).
In the 1960s and 1970s, all occupational therapy education was offered at the baccalaureate level as a minimum. However, as early as the 1960s, occupational therapy education was available at the graduate level with the nation’s first 2-year, entry-level master’s degree in occupational therapy being offered at the University of Southern California in 1962. The next major shift in occupational therapy entry-level education came with the passing of Resolution J by AOTA’s Representative Assembly, which supported the move of entry-level occupational therapy education in the United States being offered at the postbaccalaureate level (Walls, 1999). This move was endorsed by the Accreditation Council for Occupational Therapy Education® (ACOTE®) and mandated to occur by 2007.
At the same time, several entry-level clinical doctorate (OTD) programs were being offered across the United States, the first at Creighton University in 1999 (Mu & Coppard, 2007). Not all universities that offer entry-level clinical doctorate programs in occupational therapy use OTD as the degree title. For example, the Department of Occupational Therapy at University of the Sciences, Philadelphia, offers a clinical doctor of occupational therapy (DrOT). However, OTD is the most commonly used degree title.
In April 2014, the AOTA Board of Directors published a position statement articulating its view that all entry-level occupational therapy education programs should move to the OTD level by 2025. Two separate advisory committees made recommendations to AOTA about this issue. The Future of Occupational Therapy Education Ad Hoc Committee was formed to examine and recommend strategies for the future of occupational therapy education, and an AOTA Board of Directors subgroup was asked to consider the issue of entry-to-practice education at the doctoral level. The AOTA Board of Directors can only make recommendations; ACOTE has regulatory authority to mandate that the entry-level degree for occupational therapy education is the OTD.
AOTA (2014) in its position statement outlined the following five reasons for endorsing the idea of moving to entry-level OTD education by 2025:
The existence of two entry-level degrees (currently a master’s degree and clinical doctorate) is confusing to external audiences and the profession itself.
There is a need for occupational therapists who are “able to rigorously implement evidence-based practice, [understand] care delivery models, and [are] prepared to meet the future occupational needs of society” (p. 18).
New occupational therapy graduates need to exhibit professional autonomy so they can take on leadership positions within the health care system.
The “increased focus on primary care, interprofessional care teams, and specialization in practice has required increased content in the entry-level academic programs” (p. 18).
There has been a trend within other health care professions toward making the clinical doctorate their standard entry-level education to practice, and occupational therapy needs to remain competitive.
The report generated by the AOTA Maturing of the Profession Task Group’s review of the profession’s maturation (AOTA, 2013) “determined that the move to a single doctoral-entry-level degree will best position the profession to meet the growing needs of society and fulfill its potential in the 21st century” (AOTA, 2014, p. 18).
In August 2015, ACOTE determined that, for now, the entry-level qualification for occupational therapists in the United States will remain at both the master’s and the doctoral degree. ACOTE’s (2015) rationale included that
(1) limited outcomes differentiate master’s and doctorally prepared graduates; (2) the academic infrastructure of many institutions is not sufficient to meet the occupational therapy doctorate standards, especially with respect to faculty resources and institutional support; (3) the readiness and capability of institutions to deliver quality fieldwork and experiential components of the program is constrained; and (4) retaining two entry levels allows for flexibility of the profession to assess and address the changing health care needs of individuals and populations. (para. 1)
Nevertheless, it is probable that the trend toward more occupational therapy education programs offering entry-level clinical doctorates will continue.
Although the proposal by AOTA (2014) may appear to be another major paradigm shift in a long line of shifts in occupational therapy education (even in light of the decision made by ACOTE [2015] to continue to have two education entry points to the profession), both the AOTA Board of Directors and the ACOTE decisions represent the final point in the natural maturation of a profession. Virtually all of the well-established health professions such as medicine and dentistry have undergone academic-degree paradigm shifts, all ending with the doctorate as the terminal degree we are all familiar with today. For example, in medicine, the first degree awarded in the United States was the bachelor of medicine in 1768. In just 70 years, by 1838, the entry to practice was fully transitioned to the doctor of medicine (MD) degree (Royeen & Lavin, 2007). Since then, physicians with an entry MD degree who want to expand their knowledge and skill set get specialized training through postdoctoral studies, residencies, and fellowships in specific areas.
Regardless of how natural this paradigm shift is in the maturation of a profession, it raises several questions, including What are the driving forces behind the increasing number of programs offering the entry-level OTD? and What are the implications for the groups directly affected by this move? This article provides a brief overview of the reasons for moving all U.S. entry-level occupational therapy education to the clinical doctorate level and a discussion of the potential impact of this move on future students, education providers, clients and families, employers, and third-party payers and funding bodies. The potential implications for the occupational therapy profession internationally are also briefly considered.
Reasons for Moving to an Entry-to-Practice Doctorate Degree
Several reasons have been put forth about why the increasing move to an entry-level OTD is needed in the United States. The scope of practice of occupational therapy has become more complex, and the skill set required to meet these demands can be met only with new graduates with well-honed clinical reasoning, problem-solving, interprofessional, evidence-based practice, and leadership abilities. It is believed that occupational therapy graduates with this set of professional skills can be achieved only at the OTD level. Many occupational therapists have also moved into nontraditional and emerging areas of practice that require higher skill levels and professional acumen consistent with the level of the clinical doctorate (Smith, 2007).
No health care profession exists in a vacuum. Therefore, each profession affects other professions and is in turn affected by other professions. In addition to medicine and dentistry, many health care professions currently mandate the clinical doctorate as the entry-to-practice credential. These professions include osteopathy, clinical psychology, chiropractic, optometry, podiatry, pharmacy, physical therapy, audiology, and advanced nursing practice (Clement, 2005; Royeen & Lavin, 2007). The discussion about movement to the entry-level doctorate in occupational therapy is often characterized as “keeping up with the health care professional Joneses” or “credential creep” (La Belle, 2004). However, the fact remains that the health care system is inherently hierarchical and competitive, and if occupational therapy wants to maintain or improve its status in that pecking order, it will likely need to adopt the entry-level clinical doctorate.
Impact on Future Students
It has been argued that the growing move to an entry-level OTD will potentially have positive and negative effects on future occupational therapy students. The major argument against the entry-level OTD is that it will increase the length of time and cost to students compared with the master of science or master of occupational therapy (MSOT/MOT) degree and that it will make it more difficult for students from lower socioeconomic and disadvantaged backgrounds to gain admission to an occupational therapy education program. These concerns need to be questioned for several reasons.
Evidence suggests that college admissions in general are on the rise and are expected to set new records (U.S. Department of Education, 2010). Additionally, according to the U.S. Census Bureau (2013), 2002 to 2012 saw higher increases in master’s (43%) and doctoral (45%) degree graduates than in any other degree level. Specific to occupational therapy, the ratio of applicants to places available in entry-level programs has been consistently higher for OTD than for MSOT/MOT programs (AOTA, 2014). As Fisher and Crabtree (2009) have asserted, these socioeconomic issues are not necessarily barriers to the entry-level OTD but are important concerns that must be addressed by all professions.
The causes of low admission rates of low-income and minority students are far more complicated than what threshold marks the entry into a profession. According to Dounay (2008), for example, the challenges to university entry faced by low-income and minority students include ambiguous information about postsecondary options and cost, misalignment of the high school curriculum and postsecondary entrance requirements, gaps in career counsellors’ knowledge, complicated college application and financial aid processes, and lack of family support and acknowledgment of potential students’ ability to handle university-level study. However, no one can be certain about the impact of the doctoral entry mandate in occupational therapy on the profession’s ethnic and cultural diversity mix. In occupational therapy, 82% and 78% of all students enrolled in 2013 self-identified as White in entry-level master’s and OTD programs, respectively (AOTA, 2014).
The U.S. Department of Education (2005) noted that a professional practice entry-level doctorate degree “is awarded after a period of study such that the total time to the degree, including both preprofessional and professional preparation, equals at least six full-time equivalent academic years.” Interestingly, the MSOT/MOT program typically requires a minimum of 6–6.5 years of postsecondary study already (e.g., 3–4 years for an undergraduate degree plus 2–2.5 years for an entry-level professional graduate degree; AOTA, 2014). Although ACOTE standards prescribe a minimum of a 24-week (960-hour) Fieldwork II experience for both degrees (MSOT/MOT and OTD) and an additional 16-week (640-hour) experiential component for the OTD, neither degree has a uniform credit or contact hour requirement (ACOTE, 2012). In other words, MSOT/MOT and OTD programs may vary in duration, depending on the school, and several MSOT/MOT programs may already meet or exceed the duration requirements for an entry-level doctorate.
Independent of the type of degree awarded, the cost to students varies depending on curriculum; tuition and other fees; and living expenses, which are based on the location of the school. Therefore, the profession must select the degree level wisely by carefully considering program duration and associated costs to students. Additionally, it must ensure that the curriculum optimally prepares entry-level practitioners who are competent to meet the expectations of stakeholders and are accepted as equal partners by peer professionals. New graduates will likely expect higher salaries that match their extended period of undergraduate- and graduate-level professional training.
The increasing move to the OTD as the entry-to-practice qualification for occupational therapists raises the question of whether entry-level education for occupational therapy assistants will also transition upward, perhaps to a master’s degree. However, for the present time, ACOTE (2015) has stated that “the entry-level-degree for the occupational therapy assistant will [continue to] be offered at both the associate and bachelor’s degree” (para. 2). In addition, many currently qualified therapists with bachelor’s or master’s degrees may wish to pursue an OTD, so bridging programs for them may need to be created. Many questions need to be answered in relation to the impact of the entry-level doctorate on future occupational therapy students.
Impact on Education Providers
Given the range of universities and colleges where occupational therapy education is currently offered (e.g., public and private, research intensive, education focused, special focus, master’s and doctoral degree granting), the move to an OTD will not be a big transition for some institutions but will be for others. For example, teaching- and education-intensive universities that do not offer programs beyond the master’s degree level may have to either discontinue offering occupational therapy courses or convince the university administration and related regulatory agencies that a move to the clinical doctorate level is warranted and viable.
Many universities are already transitioning to an entry-level OTD program or submitting proposals for new occupational therapy programs at the clinical doctorate level. The United States has seven education programs that now offer entry-level OTDs (AOTA, 2015a). However, because at least 26 other U.S. universities are currently in the development or initial accreditation phase of launching new programs (i.e., 14 universities are in the OTD academic program candidate phase and 12 are in the applicant phase), the number of U.S. OTD programs is expected to grow (AOTA, 2015b, 2015c). Moreover, the physical therapy profession is moving at a rapid pace toward the doctor of physical therapy (DPT) becoming its new standard entry-to-practice credential (American Physical Therapy Association [APTA], 2014); as a result, a pathway has been created for occupational therapy education programs to also move up to the clinical doctorate level.
For universities to meet the accreditation standards set by ACOTE, all occupational therapy education programs will need to have appropriately credentialed academic staff with a minimum of a terminal degree. Discussions of what is an appropriate terminal degree (either an advanced level or postprofessional OTD vs. an entry-level OTD or a PhD or equivalent) will likely continue at each academic setting, and the decision should be based on the specific needs of the academic unit. Specifically, one question will need to be answered: Are academic staff with postprofessional OTD credentials qualified to teach entry-level OTD students, or will all academic staff need to be qualified at the PhD level? If the occupational therapy profession wants to continue to grow its evidence base and unique body of knowledge, it will need academic staff with research credentials (PhD or ScD, for example) who can conduct original research and academic staff with practice degrees (such as the OTD) who have advanced teaching and practice knowledge and skills.
Impact on Clients and Families
Proponents of moving to an entry-level OTD state that clients and families will receive better care from occupational therapists with this degree because such therapists have an advanced skill set. However, this rationale is still a largely unproven conjecture. No studies in occupational therapy specifically compare level of care provided by therapists educated at the different levels. However, studies have shown that hospitals with a higher percentage of registered nurses with bachelor’s or higher degrees versus associate degrees or diplomas have lower mortality and failure-to-rescue rates with surgical patients (Aiken, Clarke, Cheung, Sloane, & Silber, 2003; Long & Bernier, 2004).
Although the general public will likely not be affected by whether an occupational therapist is or is not called Dr., opponents of the entry-level OTD believe that it will generate more confusion if everyone with whom a client and family interact in the health care context is referred to as Dr. In addition, the proposed move to the entry-level OTD may result in clients and families receiving direct services more frequently from assistant or auxiliary health care personnel and seeing specialist OTD staff only on a consultant basis; thus, the move may actually create more distance between the client and family and the therapist. This concern may be validated if one or more of the following scenarios happens as a result of the move: the total number of occupational therapy programs decreases; the total number of students who enroll and graduate decreases; the number of assistants and support personnel disproportionately increases; and changes are made to the service delivery and reimbursement models, including changes in state law that mandate ratios of professional to technical staff.
Another frequent argument against the entry-level OTD relates to OTD-educated staff likely expecting greater remuneration for their services given their extended education, which would contribute to an increase in health care costs. However, economic models of factors that determine earnings in the United States are well established. These factors include supply and demand, marketability and perceived value of goods or services, uniqueness or exclusivity of the goods or services, skill level, risk factors, and negotiation skills. The expectation that a higher wage will automatically be demanded is misplaced and makes a poor argument in favor of or against the OTD. For example, according to the U.S. Department of Labor (2014), the 2012 annual median wages for audiologists and psychologists (both professions requiring doctoral entry) were $69,720 and $69,280, respectively. The annual median wages for speech–language pathologists and occupational therapists, both with a master’s entry, for the same period were $69,870 and $75,400, respectively (U.S. Department of Labor, 2014). Therefore, the assumption that OTD graduates will receive higher salaries based on their higher levels of education will not necessarily be the case. However, these wages are from 2012, and this situation may change if and when the OTD becomes the standard credential for occupational therapists.
Proponents and drivers for the move to an entry-level OTD overtly claim that this change will directly benefit clients and families through better care but also will indirectly benefit therapists as a result of increased status and recognition of the profession itself. Nonetheless, the possible effects of an entry-level OTD on clients and families, both positive and negative, need further investigation and warrant an open and transparent debate.
Impact on Employers
Employers will need to be informed about the proposed move to the OTD as the entry-to-practice credential for new occupational therapy graduates because it may affect salaries and staffing decisions and change funding procedures. OTD graduates will likely expect higher salary levels to reflect their higher educational credentials. This expectation may lead to employers hiring more less-costly assistant or ancillary staff (e.g., occupational therapy assistants, health care aides, rehabilitation assistants) who are supervised by fewer more-costly OTD-level staff. In addition, insurers and third-party payers may agree to pay only once for a specialist occupational therapy consultant to assess a patient and develop a corresponding program and then fund direct services provided by less-costly assistant-level staff who will implement the programs. However, these concerns are speculative, and it should be noted that annual wage data from other health care professions (such as audiologists and psychologists) whose entry-to-practice credentials are already at the clinical doctorate level indicate that higher salaries have not been negotiated to date (U.S. Department of Labor, 2014).
Impact on Third-Party Payers and Funding Bodies
Opponents of the entry-level OTD believe, as with employers and private and public funding bodies, that pay for occupational therapy services will be affected because pay scales will likely rise to reflect the increase in educational qualifications required to become an occupational therapist. Funders of occupational therapy services may expect more detailed documentation to justify the costs they incur or may dictate that direct services be provided by assistant or ancillary staff (who are less costly than therapists) and that therapists with an OTD provide only consultant services. Navigating these possible changes will be challenging for occupational therapists. However, lessons can likely be learned from the physical therapy field, which is moving to the DPT as the required entry-level credential (mandated by APTA [2014] to be implemented by 2020) much more rapidly than occupational therapy is moving toward the OTD.
Although reimbursement models have changed several times in the past and will continue to do so, the perceived disadvantages attributed to the entry-level OTD are not supported by current realities. The largest payer for health care in the United States is the government through its Medicare and Medicaid programs. Occupational therapy and other professions such as physical therapy, audiology, and speech–language pathology have practitioners with varying degree levels. Medicare, Medicaid, and third-party payer sources do not base payment for services on the degree levels of the practitioners in any discipline. The scope of practice and reimbursement by these sources is dependent on the license held by the practitioner, irrespective of the level of education.
International Implications
The appropriate entry-level occupational therapy qualification for a given country will vary according to the contextual forces the profession faces in that country (Lall, Greenwood-Klein, & Brown, 2003; Waters, 2000). However, what happens within the U.S. occupational therapy education sphere will inherently have reverberations internationally. For example, when the United States moved to the entry-level master’s degree requirement, Canada followed suit shortly after (Canadian Association of Occupational Therapists, 2001). Entry-level master’s degree programs have also been developed in the United Kingdom, Hong Kong, Australia, and several European countries. Similarly, modeled after U.S. entry-level DPT programs, entry-level DPT programs have been started in Pakistan and Australia.
An entry-level OTD mandate in the United States may have several implications for internationally educated and trained therapists who graduate from World Federation of Occupational Therapists–accredited programs and then seek employment in the United States but do not have entry-level OTD qualifications. The mandate may make it inevitable that OTD programs will be developed in countries other than the United States. However, the National Board for Certification in Occupational Therapy (NBCOT) or similarly authorized bodies will have to decide whether they will recognize these non–OTD-level qualifications with parity. Currently, only therapists with minimum qualifications at the master’s degree, not baccalaureate, level can take the NBCOT Certification Examination for Occupational Therapist, Registered (OTR; NBCOT, 2015). Although education at any given degree level or in a particular country does not automatically qualify a person to practice in another country, the international community should consider framing competency standards and pathways to allow for greater global mobility of occupational therapy practitioners.
Currently therapists who apply with baccalaureate-level qualifications are not eligible to take the OTR examination; only those with master's-level qualifications are eligible (NBCOT, 2015). The move to the OTD in the United States may cause challenges for the cross-border movement of internationally educated therapists seeking employment opportunities in the United States. Is it inevitable that an OTD program will be opened in non-U.S. jurisdictions? Is an OTD not necessary, and should the occupational therapy profession outside the United States not be concerned that other health care professions are quickly moving toward entry-level credentials at the clinical doctorate level?
Conclusion
There is much to consider with the growing move of entry-level occupational therapy education in the United States to the clinical doctorate level. The saying that the only thing that is constant in the world is change can be applied to the arena of occupational therapy entry-level education because the proposal to move to the entry-level master’s degree was passed by AOTA just 8 years ago. Many forces at work, internal and external to the profession, make it likely that the entry-level OTD will be mandated in the not-to-distant future. Such a move will have reverberations at the local, state, national, and international level professionally. It will also affect future occupational therapy students, the clients and families served, universities, employers, third-party payers and funding bodies, and state and local governments. We encourage an open, informed, transparent, multiperspective, comprehensive debate on all fronts about the ongoing education paradigm shift that is being considered by AOTA and ACOTE.