Abstract
Background In 2011–2012, despite comprising 35% of the US population, minorities comprised 20% of applicants to and 15% of enrolled students in accredited physical therapist education programs. Solutions aimed at addressing current disparities in health care may include educating physical therapists in environments reflecting the increasing diversity of the US population.
Objective The purposes of this study were: (1) to describe the underrepresented minority (URM) applicant pool to Physical Therapist Centralized Application Service (PTCAS) member programs and (2) to investigate differences in application patterns between white and URM applicants in 2010–2012, including total number of programs to which they applied, likelihood of applying out of state, and application to programs with minority faculties.
Design This was a national, retrospective descriptive study.
Methods De-identified data for 11,690 applicants in 2010–2011 and 13,462 applicants in 2011–2012 were obtained, including applicant demographics, selected metrics, and admission decisions. Descriptive statistics and analysis of variance with multiple comparison procedures (Tukey honestly significant difference test) were used to investigate differences between white and URM applicant metrics and application patterns.
Results White applicants achieved significantly greater grade point average and Graduate Record Examination scores than Hispanic and African American applicants. Although there were no significant differences in the average number of programs applied to between white and URM applicants, Hispanic applicants were significantly more likely to apply to programs within their state of residence. Underrepresented minority applicants were significantly more likely to apply to programs with minority faculties.
Limitations This study did not attempt to generalize the results beyond PTCAS institutions.
Conclusions Hispanic applicants demonstrated a significantly increased likelihood of applying within their state of residence. Underrepresented minority applicants demonstrated a significantly greater tendency to apply to PTCAS member institutions with minority faculties.
According to 2010 US census data, the racial/ethnic minority population has grown substantially over the last decade. The greatest growth occurred among the Asian and Hispanic populations, each over 40%. In 2010, Asians comprised 4.8% and Hispanics 16.3% of the total US population. The African American population grew 12.3% to comprise 12.6% of the total population. Overshadowed by the growth of minority populations, the white population sustained a meager 5.7% growth in 2000–2010.1 Despite currently comprising 72.4% of the total US population, by 2045, non-Hispanic whites are projected to no longer constitute a majority of the population.2
In contrast to the increasing diversity of the US population, minorities remain underrepresented in the physical therapy profession. According to US census data from 2006–2010, 80.9% of all physical therapists were white. Only 4.5% self-identified as Hispanic, 3.9% as African American, 9.4% as Asian and less than 1% as American Indian, Alaskan, or Native Hawaiian or Pacific Islander.3 Among members of the American Physical Therapy Association (APTA) as of 2010, only 2.1% of physical therapists were Hispanic, 4.7% Asian, 1.4% African American, and less than 1% American Indian, Alaskan Native, or Hawaiian or other Pacific Islander.4
In response to health care inequities and disparities, APTA's Vision Statement for the Physical Therapy Profession5 and Guiding Principles to Achieve the Vision6 support increased enrollment of physical therapists from underrepresented racial and ethnic minority groups. Although total enrollment within physical therapist education programs has increased approximately 55% since 2003, white student enrollment has maintained a steady majority of around 80%. Also, although the US Hispanic and African American populations have grown by 43% and 12.3%, respectively, in the last decade, Hispanic and African American enrollment declined by nearly 17% and 30%, respectively, from 2004 to 2011.7 In 2011–2012, minorities comprised a meager 15% of enrolled students in accredited physical therapist education programs. Hispanic enrollment (4%) and African American enrollment (3.4%) were appreciably underrepresented compared with the general population.7 The decline of minority enrollment of these races in particular will only contribute to an already disproportionate representation within the profession.
The Need for Diversity
Although there is a paucity of evidence addressing the benefits of diversity in physical therapy, analogies may be drawn from medicine. The recent Institute of Medicine (IOM) report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care8 cited substantial evidence that minorities are less likely than whites to receive needed services, including clinically necessary procedures, even after correcting for access-related factors, such as insurance status. Although the reasons for this disparity are likely multifactorial, the underrepresentation of minorities in medicine and health care presents a clear challenge to public health. While a direct link between a more diverse health care workforce and improved patient outcomes has not been fully revealed, a strong framework in support of diversity within medicine has been established. A recent review by Saha and Shipman9 demonstrated minority physicians were more likely than whites to serve individuals from their own racial backgrounds and to provide care to underserved populations. Moreover, African American and Hispanic physicians are disproportionately more likely to provide care for patients receiving Medicaid and uninsured patients than white or Asian physicians.10 Patient-provider racial and ethnic concordance among minorities also has been shown to positively influence use of health care services and patients' view of the quality of those services.9 Although the focus of research has been on the physician workforce, it may be surmised that the impact of increased minority representation may likewise apply to other professions, including physical therapy.
Emphasizing diversity and providing all students, including nonminority students, with curricular and extracurricular opportunities to address racial and multicultural issues have been previously associated with widespread beneficial effects on student cognitive and affective development.10–12 White medical students educated in schools with a more racially diverse student population were more likely to rate themselves as highly prepared to care for minority populations and expressed more positive attitudes about equitable access to care than those in less diverse schools.11 Medical students also have reported that a diverse educational environment enhanced classroom discussions, challenged values when racial conflicts occurred, and prepared them to work more effectively with diverse patients.12 Addressing the underrepresentation of minorities in many health care professions, including physical therapy, and implementing planned diverse educational experiences may affect the disparity of health care delivery, as cited in the IOM report.
Diversity in the Health Professions and Physical Therapist Education Programs
Given the disparity in health care delivery, the increasing diversity of the US population, and the benefits of diverse educational experiences, there is a clear need for increased representation of minorities among health professional students. The underrepresentation of minority students is not limited to physical therapy but is reflective of similar challenges facing other health professions. White applicants comprised 61.9% of all applicants to US medical schools in 2012. Hispanic applicants composed a mere 8.2%, and African American applicants composed 8.4%.13 Among applicants to US physician assistant programs in 2011–2012, 65.6% were white, far surpassing the numbers of Hispanic (8.4%) and African American (3.0%) applicants.14 Whites comprised 82% of all students enrolled in master's-level occupational therapy programs in 201115 and 84% of students enrolled in master's programs in speech and language pathology.16 Similarly, among students enrolled in bachelor of nursing programs, 72% were white.17
According to the Commission on Accreditation in Physical Therapy Education (CAPTE), enrollment of white students remained essentially unchanged from 2003–2004 (80.9%) to 2011–2012 (81.3%).7 Despite this finding, the profession has experienced meager growth in minority applications to education programs. In a 2000 national study of physical therapy applicants, Goldstein and Gandy18 identified 83.3% of the applicant pool as white, not of Hispanic origin. In 2010–2011, white applicants comprised 66.74% of all applicants to Physical Therapist Centralized Application Service (PTCAS) member programs.19 Although a portion of this shift in race can be accounted for by applicants who declined to state ethnicity, an option not available in 2000, the Hispanic, African-American, and American Indian/Alaskan Native groups together grew from 7.5% in 200018 to 11.5% 2012.20 Collectively, all minority groups comprised 20.9% of the total applicant pool to PTCAS institutions in 2011–2012.20 Table 1 shows the percentages of applicants and matriculants in 2010–2011 and 2011–2012 compared with 2000.
Percent of Total Applications to Physical Therapist Centralized Application Service (PTCAS) Member Programs in 2010–2012 by Race/Ethnicity Designation
Factors Affecting Minority Applicant Patterns to Physical Therapist Education Programs
Although several studies have described various minority recruitment strategies in physical therapy, few have sought to describe actual minority application patterns and address possible reasons for minority underrepresentation relative to the general population. Factors influencing physical therapist program choice have been shown to differ between underrepresented minority (URM) and white applicants and matriculants. Program cost and financial considerations,21–24 presence of minority faculty,22,25 and student diversity22,24 have all been shown to influence minority applicant decisions. In a survey of first-year physical therapist students, URM students were more likely than white students to consider cost in selecting a physical therapist education program.22 In a similar study of students at 10 physical therapist programs, Johanson23 found a significantly higher percentage of URM applicants identified availability of financial aid as an important or deciding factor in program choice (P<.003). Among African American students, 84.2% identified availability of financial aid as an important and deciding factor compared with 62.3% of whites studied. Financial issues also have been identified by URM students as one of the largest nonacademic challenges faced during program completion.24
Prior research also indicates that URM students value faculty diversity (P<.001) in program selection.22 In a study of 76 physical therapist education programs, Splenser et al25 identified a significant correlation between full-time minority faculty and minority applicants (r=.426, P<.01). However, this association did not translate to a significant correlation between minority faculty and first-year students or graduates (r=.173, r=.219). In contrast, Gabard et al26 found that although a lack of ethnic diversity within physical therapy faculty was identified by URM students, it was not a deterrent in pursuit of physical therapy as a career. Despite this evidence, no research examining minority application patterns to doctoral programs has been conducted utilizing a large national sample.
Addressing diversity within the profession of physical therapy through increasing URM representation is but one potential solution addressing current disparities in health care delivery. A greater understanding of patterns of application to physical therapist programs may provide a foundation upon which strategies to advance diversity may be rooted. The purposes of this study were: (1) to describe the URM applicant pool to PTCAS member programs and (2) to investigate differences in application patterns between white and URM applicants in 2010–2012, including total number of programs to which applied, likelihood of applying out of state, and application to programs with minority faculty.
Method
Participants
Following execution of a data use agreement with APTA, de-identified applicant data from 2010–2012 were provided by Liaison International (Watertown, Massachusetts), developer and manager of PTCAS. The sample consisted 11,690 applicants to 128 member institutions in 2010–2011 (PTCAS11) and 13,462 applicants to 146 member institutions in 2011–2012 (PTCAS12). An applicant was defined as a prospective student who completed all PTCAS requirements in submitting a verified application to at least one PTCAS member institution. Based on annual accreditation report data provided by CAPTE, physical therapist programs with at least one full-time or part-time minority core faculty were identified.
The Association of American Medical Colleges' (AAMC) definition of underrepresented in medicine was applied to identify URM applicants to physical therapist programs. In 2003, the AAMC modified its definition to include all racial and ethnic populations that are underrepresented in the medical profession relative to the general population.27 In accordance with this definition, Hispanic/Latino, African-American, American Indian/Alaskan Native, and Hawaiian/Pacific Islander applicants were considered to be underrepresented in physical therapy based on census data. Asians remain overrepresented relative to US population (4.8%)3 among applicants (PTCAS11=7.65%, PTCAS12=8.27%),19,20 accepted applicants (PTCAS11=6.82%, PTCAS12=6.9%),19,20 and practicing physical therapists (9.4%).3 According to PTCAS procedure and in compliance with US Department of Education reporting requirements, applicants could select one or more racial or ethnic categories. Race and Hispanic origin are separate concepts; thus, the “Hispanic/Latino” category was a separate field within the PTCAS application. Applicants with multiple minority racial categories selected were categorized as “2+ Race/Ethnicity Designations” for this study.
Data Analysis
Descriptive statistics were used to summarize sample metric characteristics, including science and cumulative grade point averages (SGPA and CGPA, respectively) and quantitative, verbal, and analytical Graduate Record Examination (QGRE, VGRE, and AGRE, respectively) scores for all applicants in both PTCAS11 and PTCAS12. An analysis of variance (ANOVA) was used to assess differences in metrics between URM and white applicants. Tukey honestly significant difference (HSD) post hoc testing was performed to compare all possible pairs of means between white applicants and each minority applicant group. Prior research identifying variables predictive of success in physical therapist education programs28,29 and on the National Physical Therapy Examination30,31 were utilized to guide the selection of metric variables. Furthermore, we sought to extract the data most readily available from PTCAS and available to the majority of PTCAS institutions. The PTCAS computes several standardized grade point average (GPA) calculations to assist participating programs in evaluating applicants using uniform and consistent criteria, regardless of different undergraduate institutional transcript policies. In accordance with PTCAS GPA calculation procedure, all grades (including repeated classes) are entered into the GPA calculation. The SGPA calculation includes anatomy and physiology, biology, chemistry, and physics course work. Math, movement science, social/behavioral science, and other science courses were excluded from all SGPA calculations. The CGPA calculations included all undergraduate, graduate, and professional courses completed.32 In the instance of multiple Graduate Record Examination (GRE) scores, the highest score for each subtest was utilized as the independent variable. To maintain consistency in GRE score reports, revised GRE scores using the new scoring system were recoded to the old system using Educational Testing Service concordance tables.
Differences in number of total applications submitted among URM and white applicants were assessed using ANOVA. In post hoc testing, each racial/ethnic group included in the URM definition was compared with white applicants using the Tukey HSD test. Similarly, differences in application patterns between white and URM applicants relative to number of applications to in-state versus out-of-state programs and to programs with and without minority faculty were studied. Analysis of variance was first used to assess for differences between whites and URM applicants as a group, with post hoc Tukey HSD testing utilized to identify differences between white applicants and each minority group. Based on the initial results, a secondary analysis was performed on Hispanic in-state applicants to assess for differences in rates of application to public and private institutions. Statistical analyses were performed with Statistical Package for the Social Science software (IBM SPSS 19.0, IBM, Armonk, New York). A P value of ≤.05 was considered statistically significant.
Results
Descriptive statistics of applicant metrics for individual URM groups compared with white applicants are summarized in Table 2. In PTCAS11 and PTCAS12, non-Hispanic whites achieved significantly higher GPA and GRE scores than African American and Hispanic/Latino applicants (P<.05). With the exception of American Indian/Alaskan Native applicants, SGPA and CGPA rose for all applicant groups from PTCAS11 to PTCAS12. Although not consistent across all groups, increases in GRE subscale scores also were noted between the 2 cycles.
Descriptive Statistics–Applicant Metricsa
In PTCAS11, URM applicants as a group applied to an average of 4.73 programs, minimally less than the average of 4.81 programs for non-Hispanic white applicants (P=.878). Both white and URM applicants applied, on average, to a greater number of programs in PTCAS12 (5.29 and 5.31, respectively) but again without significant between-group differences (P=.997). Results of ANOVA with multiple comparison procedures for each applicant group are displayed in Table 3. Among all applicant groups, Asians applied to the greatest number of programs in both application cycles. Asian applicants, applicants of 2 or more races/ethnicities, and applicants who declined to state race or ethnicity applied to a significantly greater number of programs in 2010–2012 compared with white applicants (P≤.001).
One-Way Analysis of Variance for Total Applications, by Cyclea
Although there were no significant differences between white and Hispanic applicants in total number of programs to which they applied, Hispanic applicants demonstrated a significantly increased likelihood of applying within their state of residence and a correspondingly decreased likelihood of applying out of state in both PTCAS11 and PTCAS12 cycles (P<.05). The average numbers of in-state and out-of-state programs applied to by white and URM applicant groups are displayed in Table 4. Consistent with an increased total application rate, Asians applied to significantly more in-state and out-of-state programs than white applicants in both application cycles (P<.001). Secondary analysis of Hispanic applicants to in-state programs revealed a significantly increased likelihood of applying to private as opposed to public institutions (P<.001). The numbers of private and public in-state programs applied to by Hispanic applicants are displayed in Table 5.
In-State Versus Out-of-State Applications, by Cyclea
Hispanic/Latino In-State Applicationsa
In both PTCAS11 and PTCAS12, URM applicants as a group were significantly more likely to apply to PTCAS member institutions with minority faculty than white applicants (PTCAS11: URM=3.20, white=2.80, P<.001; PTCAS12: URM=3.42, white=2.94, P<.001). Based on program data provided by CAPTE, 115 programs were identified as possessing at least one full-time or part-time minority core faculty (X̅=2.14, SD=1.47). Results of ANOVA with multiple comparison procedures for each applicant race in PTCAS11 and PTCAS12 are displayed in Table 6. Hispanic and African American applicants were significantly more likely than white applicants to apply to programs with minority faculty and correspondingly less likely to apply to programs without minority faculty (P<.05). A similar pattern was observed among American Indian/Alaskan Native and Hawaiian/Pacific Islander applicants in combined data from 2010–2012, but this relationship failed to reach statistical significance.
Applications to Programs With Minority Faculty, by Cyclea
Discussion
This study revealed significant differences in applicant metrics and application patterns among white and URM applicants to PTCAS member programs in 2010–2012. With a few exceptions, URM applicant groups reported lower average GPA and GRE scores than white applicants. These findings are consistent with prior studies of the academic metric profiles of URM applicants in other professions. Medium to large standardized mean differences in undergraduate GPA (0.5–0.9) have been demonstrated between African American and Hispanic applicants in comparison with white medical school applicants.33 African American and Hispanic medical school applicants achieved lower average Medical College Admission Test (MCAT) scores in 2009 compared with white applicants. However, in refute of test bias, URM and white groups have achieved academic success at rates equal to those predicted by MCAT scores.33
Lower metric profiles may disadvantage URM applicants. In a 2008 study of US and Canadian medical schools, standardized test scores and undergraduate GPAs were rated as the most important factors for deciding who to invite to submit secondary applications and interview.34 Among applicants to physical therapist programs in 2008–2011, SGPA was the greatest predictor of successful admission to PTCAS member programs.35 It is important to note that this analysis identified average scores among applicant groups and does not suggest uniformly high or low intellectual capability as evidenced by GPA and GRE scores for all applicants in various racial groups. A high level of variability is generally acknowledged within each group. Furthermore, statistically significant differences may not equate to academically meaningful determinants of success within physical therapist programs. Despite the inherent variability, admissions policies with sole regard for GPA and standardized test measures may disadvantage URM applicants. These results may provide further evidence supporting a broader review of applicant qualifications. The AAMC, for example, supports balancing applicant metrics with experiences and attributes through holistic review. Experiences may include educational background, employment history, research experience, or experience in a health care setting. Applicant attributes include such abilities as oral communication, critical thinking, integrity, motivation, intellectual curiosity, and empathy. Using this framework, applicants are evaluated by criteria that are institutional specific and mission-driven. Diversity, as defined by the AAMC, is a student-specific, multifaceted concept that extends beyond race and ethnicity.36
Increases in applicant metrics across nearly all applicant ethnic groups, combined with an increase in total applicants from PTCAS11 to PTCAS12, provide evidence of increasing competition for admission to physical therapist education programs. As a result, programs may consider academic enrichment or related pipeline programs to boost profiles of URM applicants. Such programs beginning as early as the secondary level may serve to generate increased awareness of physical therapy as a career choice and prepare future applicants for academic success. Prior research has provided evidence of positive outcomes associated with racial/ethnic minority and disadvantaged students' participation in structured pipeline programs.37,38 Intensive premedical enrichment programs have been shown to increase the chances of medical school acceptance among minority applicants even after controlling for grades, standardized test scores, and other variables.38 Programs in medicine and those currently in existence in physical therapy may serve as examples for increasing URM applications to all physical therapist education programs.
Although overall application rates did not differ significantly between white and Hispanic applicants, Hispanic applicants demonstrated a greater likelihood of applying to in-state versus out-of-state programs. This finding is consistent with prior research on undergraduate program choice and perhaps illustrates the importance of familism in the Hispanic culture. Desmond and López Turley39 defined familism as a social pattern in which individual interests, decisions, and actions are conditioned by family, which takes precedence over the individual. Hispanic adults and adolescents have been shown to value interdependence and family obligations and thus may desire to enroll in a program in proximity to home, upholding family ties that shape their identity. Compared with other ethnicities, Hispanic high school seniors are more likely than other racial/ethnic groups to value living at home while attending college.39 With this finding in mind, physical therapist education programs may find it most beneficial to target recruitment and career exploration to Hispanic applicants within their local area.
In addition to familism, it is possible that Hispanic applicants were influenced by financial considerations. This study provided interesting results related to the impact of financial considerations on the increased likelihood of applying to in-state programs among Hispanic applicants. Although it is difficult to demonstrate a direct relationship between program cost and application rates, the increased likelihood of applying to in-state private as opposed to public institutions was not consistent with prior research21–24 when known differences in average tuition rates were considered. According to CAPTE data, the average tuition at a private institution was more than twice that of public institutions in 2011–2012.7 Other factors beyond tuition, such as increased availability of financial support at private institutions, or additional nonfinancial factors, such as increased student body diversity, which could not be measured in this study, also may have influenced these results.
Although the findings did not consistently reach significance among all URM applicant groups, this study does provide evidence as to the importance of minority faculty in URM student recruitment. Unfortunately, the overall disparity of URM applicants to physical therapist education programs is paralleled by a lack of racial and ethnic diversity among program faculty. In 2011–2012, African American and Hispanic faculty combined composed slightly more than 5% of all core faculty at CAPTE-accredited programs. Furthermore, more than 40% of all programs lacked URM faculty.7 The importance of a diverse faculty has been cited by medical students as a strong contributor to the overall impact of diversity on educational experiences.40 Based on our study, enhancing URM applications appear to be associated with the need to further enhance faculty diversity. It also is possible that the increased rate of application to programs with minority faculty demonstrated in this study is a consequence of regional demographic differences in the general population rather than representing an intentional decision of minority applicants. Underrepresented minority applicants may apply to certain geographical areas or programs for many reasons, such as a desire to stay close to home. Programs in the applicant's local area may happen to also have a greater representation of minority faculty. Nonetheless, physical therapist education programs may consider striving to create an environment attractive to both the increased recruitment and retention of URM students and faculty.
Limitations
Because this research focused on PTCAS application data, this study did not attempt to generalize the results beyond PTCAS institutions. However, the PTCAS applicant database provided the best available data reflective of the national pool of applicants to physical therapist education programs in 2010–2012. Approximately 70% of all accredited programs were PTCAS members in 2011–2012. In comparing applicant metrics, one must recognize variation in admissions processes and requirements across physical therapist education programs. The GRE is not required by all PTCAS member programs and thus is not a uniform variable. Moreover, in 2010–2011, GRE scores were self-reported by the applicant and not verified by PTCAS. The impact of applicants who decline to state racial or ethnic status also may have a profound impact on future conversations of admissions and diversity. Approximately 13% of applicants declined to report racial or ethnic status to PTCAS in 2010–2012. Other professions have speculated that this group may comprise white and mixed race applicants and applicants who simply are uncomfortable talking about race.41 Although the true composition and reasoning behind nonreporting are unknown, this group could have affected the findings of this study. Future research identifying possible reasons for declining to state racial and ethnic status and the degree to which these applicants willingly contribute to conversations related to diversity in the classroom may serve the profession. The impact of financial considerations such as differences in financial aid availability at public and private institutions and student minority representation within programs also would contribute to a more thorough understanding of URM application patterns.
Unlike medicine, the extent to which a diverse physical therapist workforce addresses disparities in access to quality care experienced by underserved populations is not well established in the literature. Future research should identify the degree to which the same conclusions can be drawn in physical therapy. Furthermore, this study investigated one aspect of applicant diversity: race and ethnicity. Addressing the current health care needs of our society and improving diversity within our profession extend well beyond racial or ethnic origin. In a broad sense, diversity is a multifaceted concept encompassing demographics, personal characteristics, abilities, and experiences. The profession would benefit from further research investigating additional factors affecting diversity beyond race and identifying the presence of differing attributes and noncognitive variables between URM and white applicants. Further qualitative evaluation of recruitment and retention policies at those programs that matriculate and graduate the greatest number of URM applicants also may guide the profession toward closing the disparity gap.
In conclusion, today's physical therapists pose little resemblance to the diverse population they serve. Together, Hispanic/Latino, African American, American Indian/Alaskan Native, and Hawaiian/Pacific Islanders comprise 30% of the total US population1 but only 9.1% of the US physical therapist population3 and only about 12% of applicants to PTCAS member programs. Even less resemblance will result in future years if our profession fails to address the current disparity. This study examined the metric profiles and application patterns of white and URM applicants to PTCAS member institutions in 2010–2012. The results of this study indicate that non-Hispanic whites achieved significantly higher GPA and GRE scores than African American and Hispanic/Latino applicants. Furthermore, URM applicants demonstrated a significantly greater tendency to apply to PTCAS member institutions with minority faculty, and Hispanic applicants demonstrated a significantly increased likelihood of applying within their state of residence. In accordance with the IOM's recommendation to increase the number of health professionals as a key component in the elimination of health disparities, the physical therapy profession may use this data to guide future URM recruitment efforts.
Footnotes
The author thanks Libby Ross, Director, Academic Program Services, American Physical Therapy Association, for her consulting and assistance in securing accurate de-identified data from Liaison International. The author also appreciates the assistance of colleagues Dr Wendy Rheault and Dr Judith Stoecker for their assistance and support throughout this project.
The research proposal was approved by the Rosalind Franklin University of Medicine and Science Institutional Review Board.
A portion of the data from the manuscript was given as a poster presentation at the Combined Sections Meeting of the American Physical Therapy Association; February 4–7, 2014; Las Vegas, Nevada.
- Received November 25, 2013.
- Accepted August 24, 2014.
- © 2015 American Physical Therapy Association
References
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