Invited cmmentary.

Student recruitment and selection into professional physical therapist education programs is an issue of contemporary importance to the profession and especially to the physical therapy academic community. On an annual basis, academic programs are charged with evaluating the credentials of applicants to programs and to make predictive judgments about applicant appropriateness and likelihood for success as a physical therapist. The outcomes of these decisions have enormous effects on the applicant, on the program, on the institution where the program resides, and, ultimately, on the physical therapy profession and the community. It is to this process that Utzman and colleagues make timely and important contributions.

The authors address 2 important questions facing admissions committees: (1) Will this student complete the program without academic difficulty? and (2) Once graduated, will this student pass the National Physical Therapist Examination (NPTE)? The answers to these questions are determined by the ability and motivation of the applicant and the strength and expectations of the faculty and curriculum. It is examining these questions using a national representative sample of physical therapist education programs and a systematic method to study demographic, program, and academic variables affecting student outcomes where the authors shine a light on these issues. The focus of these studies is to identify predictive characteristics of applicants that can assist with admissions decision making. In doing so, they affirm some basic tenets of admissions decision making related to applicant qualifications and also uncover some issues that need the attention of the profession.

The authors affirm some basic dogma ascribed to by physical therapy admissions committees. Students need to be well prepared academically to learn in a physical therapist education program. This is the message that needs to be understood by people who are considering physical therapy as a career choice. In the first study, (1) the authors identified undergraduate grade point average (uGPA), verbal Graduate Record Examination score (vGRE), and quantitative Graduate Record Examination score (qGRE) as predictive factors for the likelihood of student academic difficulty. Applicants with lower uGPA, vGRE, and qGRE scores were more likely to experience academic difficulty in a physical therapist education program. In the companion study, (2) the authors made an identical finding that the same lower prematriculation academic scores were independently associated with an increased likelihood of the candidate failing the NPTE at least one time.

In both studies, the authors make a most useful contribution to the admissions process in the development of a prediction formula that can be used to identify program applicants who are at higher risk for academic difficulty or failure on the NPTE. They also make a strong argument that admissions committees should consider use of the Graduate Record Examination (GRE) as a tool in the decision-making process. In doing so, they also point out that there is a significant amount of intraprogram variability, so it would not be correct to use these tools outside the context of the program's mission and goals.

It would be easy for admissions committees and academic programs to stop at this point and take comfort in this reaffirmation of what is known and generally accepted. It also would be easy for the state licensing boards and agencies to read these results as a reaffirmation of the NPTE as a stable measure of candidate fitness for practice. It is in the other findings in these studies that questions emerge that force us to rethink the obvious and face some more thorny issues. These issues are: the effect of student age on academic performance, the effect of the program on the likelihood of passing the NPTE, the effect of the version of the NPTE on the likelihood of passing the NPTE, and the experience of minority students in our academic programs and on the NPTE.

In the study on academic difficulty, the authors found that while a uGPA of 3.50 or higher was related to a reduced risk of academic difficulty, this finding was erased if the student was older (ie, greater than age 27 years). In fact, students over age 27 years with a high uGPA had twice the odds of difficulty as a younger student with a similar prematriculation uGPA. This finding is not unique to physical therapy but should cause concern about the needs of these students and the resources needed to facilitate the success of otherwise qualified applicants. (3,4) In medicine, older medical students have been found to be more likely to perceive their school performance as lower and are more likely to be treated for depression. (5,6) Kick et al (7) found that older medical students had increased family responsibilities, perceived less respect from more experienced students, and had different learning strategies than their younger peers. These findings should cause academic programs to consider the experience of older students in physical therapist professional education. It may require a review of student services and advisement resources provided to older matriculating students.

Students who have lower pre-matriculation uGPA and GRE scores also are more likely to fail the NPTE at least once. In a recent study, Kosmahl (8) found that students in one program who had lower program GPAs and who did worse on a comprehensive examination designed by program faculty also were more likely to not pass the NPTE. In addition to test-taker ability, Utzman et al identified program factors and the version of the NPTE as being associated with student performance on the NPTE. They conclude that "academic program was predictive of NPTE failure." This should cause reflection by all programs and the Commission on Accreditation in Physical Therapy Education (CAPTE). More work is needed to understand the reasons for this effect, but faculty, institutions, and CAPTE do have a responsibility to assure applicants, current students, and the public that program quality is sufficiently satisfactory to meet the expectations of the licensing boards.

The program finding is mitigated by the observation that the strongest predictor of student performance on the NPTE was the version of the examination itself. The authors took advantage of a natural experiment that occurred when the NPTE changed versions in 2003. The first-time pass rate in 2000-2002 group was about 15% higher than that of the 2003-2004 cohort. After analysis, the authors concluded that the newer version of the examination was more difficult. Of course, it also may be plausible to conclude that the older version of the examination was too easy. Regardless of one's position on this issue, the results do point to the high-stakes nature of the examination and the need to recognize the powerful effect of examination changes on test-taker performance in the light of the public interest.

One of the purposes of the NPTE (in my opinion, the major purpose) is "to protect the public interest in having only those persons who have the requisite knowledge of physical therapy be licensed to practice physical therapy." (9) I believe that the public interest is to ensure that there is an adequate supply of qualified physical therapists to meet the societal need. With this understanding, the public interest is not served when unqualified physical therapist candidates are licensed or when qualified physical therapist candidates are not licensed. The Federation of State Boards of Physical Therapy (FSBPT) and the academic community share a common responsibility to address the public interest in this area. Given that student ability, program quality, and the examination itself are all independently related to the ability of physical therapy to meet the public need, close cooperation among all entities is needed in the future to ensure that the public interest is being met.

In both studies, the authors found that students from minority backgrounds were more likely to have academic difficulty and to fail the NPTE at least once. The risk of NPTE failure for students with minority backgrounds was 200% higher than for white/non-Hispanic students. It is on the issue of increasing minority student numbers in physical therapy that the conclusions of these studies need to be carefully considered by program admissions committees. To their credit, the authors recognize this effect and encourage caution both in implementation of a "one size fits all" prediction formula for admissions decisions and in over-reliance on academic measures at the expense of other factors.

In 2004, the Institute of Medicine (IOM) released a report entitled In the Nation's Compelling Interest: Ensuring Diversity in the Health Care Workforce. (10) Among the report's findings was the following:

   When quantitative variables such as standardized test scores are
   weighted heavily in the admissions process, under-represented
   minority applicants (URM), because of their generally poorer
   academic preparation and test performance, are less successful in
   gaining admission than non-URM applicants. Absent admissions
   practices that allow applicants' race or ethnicity to be considered
   along with other personal characteristics of applicants, URM
   student participation in health professions education is likely to
   decline sharply. (10(p7))

A high priority of physical therapist academic programs needs to be to increase diversity of students and faculty. (11,12) The CAPTE has reported that about 18% of students enrolled in physical therapist education programs in 2006-2007 are from other than white/non-Hispanic backgrounds. (13) This represents a 50% increase in minority student enrollment from 1997-1998. Progress is being made. On the other hand, the prediction tool that Utzman et al propose identifies minority status as a negative predictor of academic success and passage of the NPTE. Applied without context, the effect of this decision on the future of the profession could be as predicted by the aforementioned IOM report. I concur with the authors' conclusion to use caution when applying the prediction formula to an individual program without considering program mission and goals and individual program differences. Furthermore, the FSBPT should consider evaluating the success rate of minority applicants taking the NPTE to determine whether the findings on this admittedly small sample extend to all test takers.

The focus of the studies by Utzman and colleagues was to evaluate and use common quantitative measures of applicant potential in order to assist programs in making admissions decisions. Although it was not the purpose of these studies, I cannot leave this discussion without a brief comment on the qualitative factors important for success in professional education. As discussed in other areas of the IOM report, it is a mistake to infer about attitude, ability, and motivation of applicants only from grade reports and standardized test scores. Recent reports in professional school admissions have pointed out that applicant commitment to health care is not exclusive to academic performance but is best seen in motivation, extracurricular activities, study behavior, empathy, citizenship, ethical behavior, and willingness to work in underserved areas. (14-16) A balanced approach to admissions needs to consider these applicant aptitudes as well as academic record.

Taken to an extreme, one could conclude that the "ideal" applicant to a physical therapist education program would be under age 26 years, would be of white/non-Hispanic background, and would possess a uGPA of 3.5 or greater, a vGRE of at least 450, and a qGRE of at least 530. These applicants are statistically less likely to experience academic difficulty in a program or to fail the NPTE on their first attempt. Students applying to a physical therapist education program also are applying for entry into a profession where trust, fidelity, a caring disposition, and concern for the least well-off in the community are as important factors as knowledge in determining professional success after graduation. The profession also needs to look like the community where it resides and provides services. To do so, we will all have to work hard to meet program and societal goals, ascertain the needed resources to achieve those goals, and make the investments for our future success.

DOI: 10.2522/ptj.2006.0221.0222.ic

References

(1) Utzman RR, Riddle DL, Jewell DV. Use of demographic and quantitative admissions data to predict academic difficulty among professional physical therapist students. Phys Ther. 2007; 87: 1164-1180.

(2) Utzman RR, Riddle DL, Jewell DV. Use of demographic and quantitative admissions data to predict performance on the National Physical Therapy Examination. Phys Ther. 2007; 87: 1181-1193.

(3) Huff KL, Fang D. When are students most at risk of encountering academic difficulty? A study of the 1992 matriculants to US medical schools. Acad Med. 1999; 74: 454-460.

(4) Bush BR, Sanderson MW, Elmore RG. Prematriculation indicators of difficulty in veterinary school. J Vet Med Educ. 2005; 32: 517-522.

(5) Chandavarkar U, Azzam A, Mathews CA. Anxiety symptoms and perceived performance in medical students. Depress Anxiety. 2007; 24: 103-111.

(6) Tjia J, Givens JL, Shea JA. Factors associated with undertreatment of medical student depression. J Am Coil Health. 2005; 53: 219-224.

(7) Kick S, Adams L, O'Brien-Gonzales A. Unique issues of older medical students. Teach Learn Med. 2000; 12: 150-155.

(8) Kosmahl E. Factors related to physical therapist license examination scores. Journal of Physical Therapy Education. 2005; 19(2): 52-56.

(9) Federation of State Boards of Physical Therapy. NPTE: Purpose of the Exam. Available at: http://www.fsbpt.org/exams/ NPTE.asp. Accessed on June 2, 2007.

(10) Committee on Institutional and Policy Level Strategies for Increasing the Diversity of the U.S. Health Care Workforce. Institute of Medicine. Smedley BD, Stith Buffer A, Bristow LR, eds. In the Nation's Compelling Interest: Ensuring Diversity in the Health Care Workforce. Washington, DC: National Academies Press; 2004. Available at: http://www.iom.edu/report. asp?id=18287. Accessed on June 2, 2007.

(11) Curbow Wilcox K, Weber M, Andrew DL. Factors influencing minority students' choice of physical therapist education programs. Journal of Physical Therapy Education. 2005; 19(2): 8-14.

(12) Splenser P, Canlas HL, Sanders B, Melzer B. Minority recruitment and retention strategies in physical therapist education programs. Journal of Physical Therapy Education. 2003; 17(1): 18-26.

(13) Commission on Accreditation in Physical Therapy Education. 2005-06 PT Education Fact Sheet. Available at: http:// www.apta.org/AM/Template.cfm?Section =PT_Programs1&Template=/TaggedPage/ TaggedPageDisplay.cfm&TPLID=132&Con tentID=21559. Accessed on June 2, 2007.

(14) Hulsman RL, van der Ende JS, Oort FJ, et al. Effectiveness of selection in medical school admissions: evaluation of the outcomes among freshmen. Med Educ. 2007; 41: 369-377.

(15) Freeman J, Ferrer RL, Greiner KA. Viewpoint: developing a physician workforce for America's disadvantaged. Acad Med. 2007; 82: 133-138.

(16) Latif DA. Including the assessment of nontraditional factors in pharmacy school admissions. Ann Pharmacother. 2005; 39: 721-726.

R Sandstrom, PT, PhD, is Associate Professor and Chair, Department of Physical Therapy, Creighton University, 2500 California Plaza, Omaha, NE 68178 (USA). Address all correspondence to Dr Sandstrom at: [e-mail].