Captain of the U.S.S. ABC Therapeutics - private practice near Buffalo, NY. Part time educator and full time stirrer of pots, happily responding to people's needs from deep within the "darkness of free enterprise."
There is an alarming increase in the number of accepted applicant and developing occupational therapy programs in New York State. The current entity responsible for the accreditation of these programs is the Accrediting Council for Occupational Therapy Education (ACOTE), a function of the American Occupational Therapy Association (AOTA).
There are two additional developing masters-level degree programs, ten applicant doctoral-level programs, and one applicant masters-level program. Of the developing and applicant programs, approximately half are new and the other half are existing accredited programs that are seeking to add an additional degree level.
The question that is never asked is “How many occupational therapy educational programs can be reasonably supported in a single state?” California has 11 accredited occupational therapy programs and 6 accredited occupational therapy assistant programs. Florida has 12 accredited occupational therapy programs and 21 accredited occupational therapy assistant programs (half are from a single educational entity, an interesting issue unto itself). Pennsylvania has 18 accredited occupational therapy programs and 12 accredited occupational therapy assistant programs. Texas has 11 accredited occupational therapy programs and 19 accredited occupational therapy assistant programs.
New York currently has more occupational therapy educational programs than any other state. Even more are being developed.
In contrast, there are large swaths of the country where there is very little opportunity for students to pursue an occupational therapy degree locally. New Mexico has one occupational therapy program and two occupational therapy assistant programs. Nevada has one occupational therapy program and one occupational therapy assistant program. Montana has nothing.
This issue is important on several levels. People living in low-access areas have decreased access to occupational therapy as a service. Additionally, these areas also represent some historically under-represented population groups. The occupational therapy profession already has a severe problem with diversity; the overwhelming majority of the profession is white and female. Maldistribution of educational programs contributes to this problem.
Education deserts are defined as geographic localities where college opportunities are few and far between. As reported, “Place still matters; in fact, the majority – 57.4 percent – of incoming freshmen attending public four year colleges enroll within 50 miles from their permanent home.” Also, distance education does not mitigate structural problems with access because of poor broadband availability in many of these rural areas (Hillman & Weichman, 2016). Clearly, there is a severe problem with occupational therapy education deserts - so what is AOTA and ACOTE doing to address this problem?
Applicant programs are required by ACOTE to demonstrate that fieldwork agreements are sufficient in scope and number to allow completion of graduation requirements in a timely manner. It is commonly repeated that there are inadequate numbers of available fieldwork sites even for existing programs – so much so that in recent years three has been a ‘relaxing’ of standards with the allowance of ‘emerging’ fieldwork sites and doctoral capstone experiences where the onsite supervisor does not even need to be an occupational therapist. Also, new fieldwork supervision models have been proposed for part time ‘faculty-led’ supervision and even single supervisors overseeing multiple students. The occupational therapy literature is replete with studies that document concerns with fieldwork capacity (Evenson, et.al., 2015; Roberts & Simon, 2012; Stutz-Tanenbaum, Hanson, Koski, & Green, 2015).
In such a context, it is difficult to understand how and why all of these new educational programs in saturated areas are being granted developing status. This is an area for AOTA and ACOTE to have some transparency over because the disconnect between the stated concerns in the literature and the unfettered approval of new programs in overly-saturated geographies is startling.
This is also disturbing given the propensity for occupational therapy academicians, a population responsible for all of this maldistribution, to lecture the profession about equity and justice (Hemphill, 2015). The occupational therapy profession needs to have a look in the mirror over this issue.
Additionally, ongoing concerns that have been expressed during the profession’s ‘doctoral debate’ led to a newly developed memorandum of understanding between AOTA and ACOTE. There are still concerns about the inherent conflicts of interest present when an educational accreditation function is housed within a membership organization. These also require transparent discussion in that accreditation decisions are not at full arms-length from a group that benefits from increased membership from students.
For all of these reasons, ACOTE and AOTA need to have more open conversations about these concerns with the broad community of stakeholders that are being impacted by the severe maldistribution of educational programs.
In particular, there needs to be immediate attention given to the problems that are being caused in places like New York State where the artificially inflated supply is far outstripping the actual demand.
References: See embedded links, and…
Evenson, M.E., Roberts, M., Kaldenberg, J. Barnes, M.A., & Ozelie, R. (2015). National Survey of Fieldwork Educators: Implications for Occupational Therapy Education. American Journal of Occupational Therapy; 69 (Supplement_2):6912350020p1-6912350020p5. doi: 10.5014/ajot.2015.019265.
Hemphill, B. (2015) Social Justice as a Moral Imperative, The Open Journal of Occupational Therapy: Vol. 3: Iss. 2, Article 9.Available at:http://dx.doi.org/10.15453/2168-6408.1150
Hillman, N. and Weichman, T. (2016). Education Deserts: The Continued Significance of “Place” in the Twenty-First Century. Viewpoints: Voices from the Field. Washington, DC: American Council on Education
Roberts, M. E., & Simon, R. L. (2012). Fieldwork challenge 2012. OT Practice, 17(6), 20.
Stutz-Tanenbaum, P., Hanson, D. J., Koski, J., & Greene, D. (2015). Exploring the complexity of the academic fieldwork coordinator role. Occupational Therapy in Health Care, 29, 139–152.
I was wondering today how many students were paying attention to the early presidential primary activities. During Joe Biden's kickoff presidential rally in Pittsburgh yesterday he discussed the problems with over-credentialing and how it can serve to restrict competition in the marketplace.
He framed his basic presentation in context of lower wage earners and Union jobs, but does his argument apply to health care other middle income licensed occupations?
"They do the same thing with occupational licenses. Why should someone who braids hair have to get 600 hours of training? It makes no sense. It's designed to keep the competition down.
Look, folks, you can't just transfer your licenses across one state to another. They're making it harder and harder in a whole range of professions all to keep competition down."
He also talked about reclassification into exempt categories in order to prevent paying overtime. That made me think of all my colleagues working in long term care facilities and their productivity requirements.
Twelve years ago, the occupational therapy profession was featured in the Chronicle of Higher Education in an article entitled 'Credential Creep.' The concern at the time was that credentialism, or the gradual increasing of requirements to enter a profession, was driven by professional associations and often served to cheapen doctoral education in what was referred to as a 'race to the bottom.'
Have these issues ever really been addressed? It does not seem that they have.
In our recent professional discussions it seems that there has been a majority opinion that there is not enough evidence to support credentialism in occupational therapy. There are still those who disagree and would like to see increasing degree requirements.
Who benefits from credentialism? Small liberal arts based teaching focused schools are not equipped for doctoral education - at least at a level that would avoid criticism about the relative value of the degrees. Credentialism means that elite schools that can churn out doctoral degrees are better positioned to feed the hungry higher education industry - a system bloated on college debt that now exceeds $1.5 trillion.
On the flip side of the coin, occupational licensing theoretically helps workers in the field from competition by raising barriers to entry into a profession. In most market economies, such barriers provide what are called 'rents' to the protected classes - often in the form of higher wages. This is the missing piece in the economics of credentialism in the occupational therapy profession: there has been no corresponding increase in the 'rents' associated with all the inflation that has been promoted by the educational institutions. This is something that occupational therapy students know all too well - the only pathways that many have toward higher pay is to take horrendous travel positions with low mentoring and high productivity requirements. They learn quickly that many jobs in their local environments can't offer the salaries they require to pay down debt and begin their adult lives.
So the clear 'winners' are only the educational institutions who restrict their competition and continue to feed from the student debt trough. Not enough occupational therapists are fluent in economics of the health care workforce to really engage the issue. Instead, too many people simply deferred to the professional association - a group primarily populated by educators and their students. And the students are left all searching for jobs that pay the highest possible wage to mitigate their student debt. That causes many young health care professionals to burn out on their careers too early - a problem so severe that policy analysts are now discussing how to model for burnout prevention in their overall health care reform schemes.
This is a dangerous configuration - and the higher education industry will only be able to continue with this model until the day comes when the students come to understand who put their nose rings in and what purpose they are primarily serving.
It is easy for occupational therapy practitioners who have been embroiled in the intraprofessional debate about entry level credentials to lose sight of a larger perspective. Sometimes the closer you are to a concern, the more challenging it is to understand the more broad ramifications of something that happened.
The grass roots effort that pushed against a mandated escalation of the entry level degrees in the occupational therapy profession made a very broad social and cultural statement. It was a historic example of a professional group that argued against some of its own leadership in an effort that ultimately serves the more broad public interest. It was an amazing testimonial to the nature of occupational therapy practitioners, their common sense and pragmatism, and their interest in fairness, diversity, and inclusion on many levels. The effort highlighted the very best of the occupational therapy profession, even if it was a contentious and at times divisive argument.
Student debt from higher education is at a crisis point in the United States. Here are some stark facts about the very real problems about debt faced by students who are forced into a system with ever-escalating degree and credentials:
Consider the report written by the group American Student Assistance (2015) that indicates the following: • 27% of respondents to ASA’s survey said that they found it difficult to buy daily necessities because of their student loans; • 63% said their debt affected their ability to make larger purchases such as a car; • 73% said they have put off saving for retirement or other investments; and • The vast majority—75%—indicated that student loan debt affected their decision or ability to purchase a home. Survey respondents indicated that in addition to limiting their ability to make major purchases, student loan debt also impacts their important life decisions: • 30% responded that their student loan debt was the deciding factor, or had considerable impact, on their choice of career field; • 47% indicated it was the deciding factor, or had considerable impact, on their decision or ability to start a small business; • 29% indicated that they have put off marriage as a result of their student loans; • 43% said that student debt has delayed their decision to start a family.
The cost of entering a professional degree program is becoming increasingly difficult for many students, limiting access to the profession - a severe problem for occupational therapy in particular that is overwhelmingly white and female.
Moreover, there was never any concrete evidence offered to support the need to advance the degree or credentialing - just vague beliefs about what practitioners would 'need for the future' or some requirement that would be valuable to get 'a seat at the table.'
In a context where other professions continue to escalate their degree requirements, occupational therapy practitioners around the country stood up and loudly said, "NO!" Perhaps it was the pragmatism that is so commonly found within the members of the profession. Perhaps it was their own socioeconomic standing - most OT practitioners are middle-income earners and know all too well the impact of college costs and degree escalation on their own families. Perhaps it was a sense of fairness and concern for the risk that degree escalation placed on diversity and inclusion on the professional ranks.
I think it was all of these things.
But it was also something more.
Occupational therapy practitioners believe in helping people to participate - all people - in all things. The more elite and exclusive that you make an enterprise, the fewer people will be able to participate. It really is that simple.
For 100 years of the profession's history occupational therapy practitioners have been engaging in meaningful training programs so that they can be well equipped to accomplish a task that is simple in concept but complex in implementation. They try to help people so that they can do things that they find meaningful again. Many argued that a bachelor's degree was enough, but the profession accepted escalation to a master's degree. Twenty years later some wanted to escalate it to a doctoral degree, and the members of the profession said, "No."
This does not mean that occupational therapy practitioners are not 'keeping up' with other professions. It does not mean that they are not trained 'enough.'
It does mean that a group of pragmatic and caring and inclusive professionals stood up to the industry that continues to try to escalate degrees and credentials and loudly said - 'Enough is enough.'
It is a small attempt to say something about rising costs of education and rising costs of medical care. Occupational therapy is the mouse that roared, and we will all be better for this effort.
To understand the problems with the wording changes you need to read and understand the first policy as it is written in the policy manual. Then you have to read and understand the motion that was submitted to update. Then you have to read and understand what the RA actually passed. All of this has to be considered in context of an unknown relationship between AOTA and ACOTE. There is no way to dive into the weeds of this issue without reading all of the materials. There is simply no way to condense it.
The original policy E.6 states
The motion that was submitted to update the policy used specific language that mirrored the current policy and that was last reviewed in April 2011. The same language was recommended so as to eliminate unnecessary wordsmithing. In sum, if the language was good enough for the current policy then it would probably be close to good enough for the updated policy. Please note that this language has been present as AOTA policy for MANY YEARS and no one has ever before considered that this policy caused any confusion.
The motion to update the policy was submitted as follows:
IT SHALL BE THE POLICY OF THE ASSOCIATION THAT:
1. The Association recommends and supports entry-level education at the associate and bachelor degree level for occupational therapy assistants.
2. The Association recommends and supports entry level education at the master’s and doctoral degree levels for occupational therapists.
3. Consistent with the Association’s desire to improve practice, education, and research, the Association will take active steps to promote new programs and to assist existing programs to develop in ways that are congruent with the preparation of graduates who have the ability to frame, analyze, and solve complex practice problems. Any active steps taken by the Association must be within the parameters that are outlined in this Policy, specifically, with support of dual levels of entry for the OTA (associate and bachelor level) and dual levels of entry for the OT (master's and doctoral level).
The motion that the RA approved this weekend is quite different:
IT SHALL BE THE POLICY OF THE ASSOCIATION THAT:
1. The Association require entry level education at the associate or bachelor degree level for occupational therapy assistants.
2. The Association require entry level education at the master's or doctoral level for occupational therapists.
Question one: WHY was there a recommendation to insert the word 'requires?'
Changing the words 'recommends and supports' to 'requires' changes the plain meaning of the motion. That also changes the implication of the conjunctive 'and.' Stating that the association 'requires' entry level education at Level A AND Level B could have been confusing. That may be why they changed to 'requires' entry level education at Level A OR Level B. Or was someone with knowledge of the AOTA and ACOTE relationship attempting to use this motion as a prop for the AOTA's position of authority over this matter?
Still, there is an unintended consequence hidden within the language. We do not know the relationship of AOTA and ACOTE at this time, and presumably neither did the members of the RA. It is clear that AOTA asserts authority over the accreditation function, even though that is problematic, and it is also clear that ACOTE has previously deferred to the recommendations of AOTA, even if they have had technical authority over many aspects of accreditation.
IF ACOTE became an independent entity tomorrow, they could interpret the new Policy E.6 as saying that AOTA requires entry level education at Level A OR Level B. This is actually a wishy-washy statement. We know that ACOTE previously wanted the doctorate, so they could easily say, "Since AOTA does not explicitly state that they recommend and support both - but instead state they will require A OR B, then we will set the standard at the doctoral level!"
This is the peril in changing words and in changing conjunctions without carefully measuring the full implication.
Question two: Why was all of the language under Point Three removed?
We were told in the business meeting that all of the language previously listed under Point 3 was removed, as was all of the parallel language that was suggested in the original motion as an update. We were told that it was removed because it was 'aspirational.' It is unclear what is meant by 'aspirational.'. That kind of language has been AOTA policy for the last eight years at least - so why was it necessary to remove that language now?
It is especially problematic to remove that language now because it was the only aspect of the motion that might have clarified the actual intent of dual entry that was absolutely muddied with the other wording changes.
WHERE WE NOW STAND:
Right now, Amy Lamb (President of AOTA) indicates that the intent of the motion is to support dual entry. That was also the intent of the motion's originator, by report, but that is not what the motion can now possibly mean. I am uncertain if everyone understands that the motion as written can be interpreted in other ways. It is also very unclear why this level of wordsmithing was done at the RA level. These changes have carried the motion so far afield of its very clear original wording. In particular, removing the clarifying language under Point 3 is disastrous.
By report, AOTA and ACOTE will issue a joint statement in the near future.
There were a multitude of other problems with this process - some previously blogged about. Now we have additional problems with whether or not the proceedings were confidential as some participants believed they were supposed to be. We also have problems with why a motion that was submitted for the Fall meeting would be wordsmithed like this at the last moment and with potentially perilous results. This could have all been avoided with increased transparency, more careful tracking of changes, obtaining feedback on the tracked changes, and having those with legislative crafting skill sets have their eyes on the process to assist with interpretation and meaning changes with various wording options.
Immediately after this motion passed I was contacted by members who were confused about whether they passed something that may have multiple interpretations. People were talking about the different interpretations that could be obtained with the wording changes as soon as it was passed. Certainly some people knew that this was coming - because the issue spread around like wildfire as soon as the RA voted. It seems to me that some people clearly have the skill set to understand the implications of wording/conjunction changes and deleting the clarifying Point Three. Others clearly do not.
Now the membership has to hope for more information on the AOTA/ACOTE relationship, and perhaps re-craft this language to more accurately reflect the intent of support for dual entry.
Problems with breaches of confidentiality expectations, transparency, and process all need to be fully vetted and addressed. That does not mean that it should be done out of sight of the membership. As this in particular is an issue with broad public impact (educational accreditation), it must also be done in full sight of the public.
The AOTA and its members should be more mindful of differential skill sets of participants, because entire meaning can be changed with something as simple as the change of a conjunction or as the change in the placement of a comma or in the deletion of qualifying or clarifying statements. That is why the process needs to be more open and transparent - to everyone. These are unforced errors and can be avoided by an open and participatory process.
During the last year, minutes from the Board meetings of the American Occupational Therapy Association indicate that there has been discussion on two matters that have an important impact on the Wilma West Library, home of the collected resources that catalog the history of occupational therapy.
Around last year, discussion apparently started getting more specific related to sale of AOTA's current building. In May 2018 the board authorized the (re)allocation of funds necessary to pay off the mortgage on the building and exploration of new sites for the organization's operations. It is unclear if a new location has been identified, but in the recent February 2019 meeting a current board member will provide consultation regarding redesign and build out of the new space, indicating that the process is moving forward.
Also noted in the February 2019 minutes is that AOTA will take sole responsibility and ownership for the Wilma West Library, excluding graduate theses and dissertations, effective July 1, 2019. This motion will now go to the American Occupational Therapy Foundation Board for their consideration.
This is interesting, because I believed that the library was a function of AOTF - it is listed as one of their primary activities on their Form 990s. However, on the AOTA website they indicate that some of the library functions are jointly operated. It may be that some of the archives technically belong to AOTA but are housed within the AOTF library. Such convolution of function is not unusual for AOTA; they previously had such tangled relationships with AOTCB (NBCOT) and now with ACOTE.
In any event, the issue should be of interest to the occupational therapy profession because of the long history of trouble with appropriately maintaining the occupational therapy archival history. In fact, this topic was the focus of an article in the American Historical Association's online magazine entitled 'From Chaos to Archives: The Records of the American Occupational Therapy Association.'
The article was written in 1998 and talks about how AOTA's records were initially kept in the homes of early leaders, including an iconic story about how Eleanor Clarke Slagle kept records in the kitchen of her New York City apartment. Reportedly, between 1920-1960 there was a very haphazard method employed for record-keeping. I was pleasantly surprised when I made a trip to the Wilma West library a couple years ago and was able to locate a treasure trove of archival material - certainly, not all of the records were lost or tossed. According to the article, the start of organization can be credited to the efforts of the Blocker History of Medicine Collection in the Moody Medical Library in Galveston and Robert Bing. In 1992, the records were all relocated to the Wilma West Library, reportedly a function of AOTF.
Ongoing efforts by AOTF (?) librarians were undoubtedly helpful over the years. I have had interactions with several people who were always helpful and interested in more organizational efforts. I was told by several librarians over time that digitization was often a dream (particularly of some of the early historical documents), but the resources required to complete the task were out of reach.
The Wilma West Library is currently located within the AOTA building, but now it appears that the building is being sold and new space is being considered - and that AOTA will take over the operations of the library. This is a significant undertaking and it would be good to hear from both AOTA and AOTF about what the plans for this material will be in the future. Given the concerns of the past related to maintenance of the occupational therapy profession's archives, this is an important topic and several questions need to be asked:
1. Who owns the archives? 2. Who will be responsible for its maintenance? 3. Will there be more resources available to make the archives accessible to researchers? 4. Will there be dedicated space for these materials in the new AOTA space? If not, where will these materials be housed? 5. Will access to the archives still be possible for researchers given the move and the transfer of responsibility?
I am hopeful that we can hear a lot more public discussion about the plans for the Wilma West Library.
Occupational therapy started on a simple premise - that man, through the use of his hands as they are energized by mind and will, can influence the state of his own health. That statement was provided to the profession by Mary Reilly, our greatest theoretician.
It is a simple concept, borne out of a core philosophy of pragmatism and infused with a dose of all the good intentions of the moral treatment movement. If you carefully read that core philosophy of occupational therapy you will hear the Emersonian reverberations of self-reliance: 'Trust thyself: every heart vibrates to that iron string.' That is what occupational therapy seeks to nurture in the spirit of people: Independence, harmony with the self, harmony with nature, and a satisfaction in authentic work and effort and purpose and meaning.
Occupational therapy is a concept that was designed to create solutions for the problems of living - and was field tested in the settlement house projects of Chicago and Boston, in the gardens of Consolation House, in the pottery and rug making and other craftwork shops along the Eastern seaboard from Massachusetts to Newfoundland to Labrador, and then in the base hospitals in Europe during the Great War. Do things with your own hands, be productive, find meaning - and you can heal your own life.
In the last twenty years it has been determined in the United States that the occupational therapy idea is so complex that it requires graduate degree training and now even a doctoral degree in order to be qualified to do the work. There has been very little justification offered for why this determination has been made, but more significantly, there has been very little conversation on the matter. What is it that has philosophically changed that should up-end the traditions of occupational therapy training?
Reilly also told us, "The wide and gaping chasm which exists between the complexity of illness and the commonplaceness of our treatment tools is, and always will be, both the pride and anguish of our profession." I like to consider the medical complexity of one of the first 'official' occupational therapy patients - George Barton - who describes his own condition that led to his need for treatment: "Four attacks of tuberculosis, four surgical operations, including an exploratory laparotomy and an amputation, morphinism, hysteria, gangrene, and paralysis." His treatment consisted of gardening, working a drill press for carpentry projects like building pigeon coops, and mechanical drawing/drafting. Are patients today situated with any more complexity with their disabilities? Ironically, many treatment techniques commonly used by occupational therapists have gotten more simple: how many people routinely see patients in a long term care facility working on arm bikes and with stacking cones.
You need a doctoral degree for that?
How is it that for so many years occupational therapists managed to bridge the divide that Reilly was concerned about by using the simple philosophy of engagement - but now in order to mindlessly place clothespins on a dowel or swing a foam pool noodle at a balloon you need a doctoral education?
The answer to the problem of therapists abandoning their philosophical beliefs is not to escalate the degree level. The correct answer lies in a re-examination of core values and a re-commitment to curriculum development that properly orients and educates new therapists to the 'magnificent purpose' that Reilly extolled.
The abandonment of philosophy is not restricted to long term care facilities. You can find the same lack of direction and lost purpose with OTs across many practice settings. This is in part facilitated by academia and the endless fascination with the philosophical drift that has OT students imagining roles for themselves in all kinds of 'emerging areas' that don't even reflect occupational therapy practice. Now the ultimate betrayal of curricular and pedagogical logic is manifest in the fact that for the capstone experiences for doctoral education of occupational therapists, the student does not even need to be supervised by an occupational therapist.
The good ship Occupational Therapy is not only un-moored from its dock. It has sunk to the bottom of the ocean.
Correction starts with a halt to the escalation of degree requirements for entry into the profession. From there it proceeds with building an awareness that educators need to revise their curricula and re-locate and re-embrace their philosophical roots. Practicing clinicians can help by pointing to high quality and occupation-based treatment as a standard to be expected.
Without these steps, the occupational therapy profession will be an anachronism in twenty years - a profession that destroyed itself by abandoning its original simple purpose.
Perhaps the greatest point of misinformation that is routinely spread when academicians discuss the 'need' for escalating the entry level degree to the doctoral level is that master's level OT programs can vary between 80 and 100 credit hours, depending on the school. This is not a factual statement.
There are some OT schools who are configured in a 4+1 or 3+2 model and the number of graduate credits is only around 30-40. In these schools, the bulk of the occupational therapy curriculum is delivered at the undergraduate level.
Throughout the conversation, I have heard educators and practitioners both attempt to get AOTA and ACOTE to acknowledge that not all educational programs are experiencing the same kind of 'credit pressure.' People use different terms to describe this concern; most explain it in terms that some programs are requiring more credits than are necessary or perhaps even typical for granting a masters degree.
It is true that some programs may require 80-100 credit hours for a masters degree in occupational therapy. These programs find themselves in this situation because they designed their curriculum to be delivered at the graduate level only.
One of the arguments for transitioning to doctoral level is that these schools can't compete with other programs that offer a doctoral degree for a similar number of credits. That is a legitimate concern, particularly in consideration that some states are talking about 'capping' the number of credit hours for masters programs.
What has been missing from the conversation, and never addressed in any forum that I have seen or heard, is the question of why AOTA or ACOTE has not discussed promoting or encouraging a different configuration so that schools do not experience this 'credit pressure.' Why have we not heard any of those conversations? Why have there been no studies or ad hocs looking at this curriculum design issue?
It is a free world, and nothing stops schools from designing their programs any way that they want, but it is irresponsible to use this 'credit pressure' as a justification for advancing a degree when there are some programs who have responsibly promoted an economic 3+2 or 4+1 model with a reasonable and typical number of graduate credits.
If AOTA and ACOTE can 'suggest' changes in standards, and in fieldwork models, and is residency models, then they certainly can also 'suggest' greater economy in the way that programs are delivered. However, there is no evidence that this has happened, and everyone repeats the incorrect statement that every masters program has 80 to 100 credits, which is patently false.
Repeating this misinformation withholds important data from stakeholders and misrepresents an important component of this curricular problem.
That some, perhaps even many, OT programs have more credits than is needed to grant a masters degree is an indicator of curriculum design and implementation problem that needs to be regulated and monitored. That should be the proper function of ACOTE - but rather than solve the problem responsibly all that we can see is a proposal for degree escalation that has very shaky support and justification.
1. Have there ever been any studies or ad hoc groups that looked at standards and performance to determine if economic 3+2 or 4+1 models perform any differently than 'graduate only' models that have 80 to 100 credits? If not, why not?
2. If 'credit pressure' is a problem acknowledged by everyone, why are the only suggestions for fixing this problem in the single direction of degree escalation (as opposed to economic curricular design and use of 3+2 or 4+1 models)?
3. When most graduate degrees across many disciplines only require 30-50 or so credits, OT masters degrees that require between 80 to 100 credit hours can lead to questions about irresponsible curriculum design and implementation. From an ethical and moral standpoint, where are our conversations about whether or not it is correct to saddle students with this kind of graduate debt, and whether or not it is correct to 'punish' those programs that implemented responsible and economic curricula by requiring them to move their curricula to a doctoral level? Please share this information with your Representative Assembly representatives.
What does it say about a group of professionals that can't agree on what titles to use to describe themselves?
Several years ago I wrote a post entitled "Why students will be making elevator speeches to define occupational therapy for the next 100 years." The issue behind this is that some occupational therapists believe that the public does not recognize what the profession does and that it is important to have a handy 1 minute description. The post describes the fact that the profession serially re-defines occupational therapy and that the constant tinkering with definitions contributes to the confusion.
The problem that some people in the occupational therapy profession have with their self-identity now extends to the title that they want to use to represent themselves and whether or not they want to even use the national credentials that they have earned and that have given them the right to apply for state licensing.
One point of genesis of this problem is with some occupational therapy assistants. Specifically, some of them seem to regret the word 'assistant' in their professional title. Actually, occupational therapy was rather sensitive about the initial name designation because they used the title 'occupational therapy assistant,' implying an assistant to a service - rather than what was done by their physical therapy or medical colleagues who use the title 'physical therapist assistant' and 'physician assistant' implying an assistant to another professional. It is a small difference in designation, but it causes a lot of angst in professional groups, even to the point where they debate changes to their professional designation.
Still, occupational therapy assistants don't have that problem, but there is still evidence of concern about their designation. Sometimes concern is expressed about the use of 'COTA' pronounced as a word. A common statement is 'I don't call you an 'otter, so you should not call me a coata.' It is common to see social media conversations saying that a 'more inclusive' designation like 'occupational therapy practitioner' should be used:
It is interesting to witness the calisthenics performed by occupational therapy students to pass their national certification examination and then study the pressure that is immediately brought to bear by some who then immediately wish to see the elimination of that same credential. It is logical to wonder why people would work so hard to achieve a national credential and then why there is a push to try to immediately eliminate any reference to it.
Given that the the occupational therapy profession took a more evolved stance on designating service assistants as opposed to assistants to other humans, what other factors might be driving the concern, particularly since the vast majority of occupational therapists end up renewing their NBCOT certification and use those initials OTR and COTA?
There is an AOTA policy that expressly states that the designations OT and OTA must be used in all association documents. In fact, reference to the NBCOT certification marks is largely removed from the entirety of the AOTA policy manual, its website, and anything published by AOTA. Here is the relevant policy:
I think it is understandable that some standardization in language is desirable, but how many professions have a policy that parses out 'initial certification' only and then promotes use of credentials (OT and OTA) that are not certification-based?
Of course this is all rooted in the historic legal kerfluffle between AOTA and NBCOT, where it was determined that NBCOT as a separate organization owned the legal 'rights' to those certification marks. Notably, "AOTA created NBCOT's predecessor in interest and outright granted it the power to conduct all certification activities. Now, since it no longer agrees with NBCOT's actions, it seeks to reorder history in its effort to diminish NBCOT's power." NBCOT prevailed in the primary point that they were the 'owners' of those certification marks.
In addition to that issue, NBCOT was also concerned about trademark dilution and trademark disparagement - but at that time it was determined that there was insufficient material evidence to support that claim - it is important to read the full document (linked above) to understand those particulars. However, this is an area where I believe AOTA continues to dance atop thin ice, particularly with their policies as linked above as well as the statements that are made by some of their board members on social media about discouraging people from using their NBCOT credentials and instead using the AOTA-sanctioned terms in their policy above.
What is best for the profession? How about moving forward? This legal decision was made 20 years ago but it is still sending ripples into policies and actions today. This profession needs to get over this problem because an inability to present a united agreement about something as simple as what initials to use is a distraction that is really not needed.
Here is the solution that lies primarily in the hands of the AOTA:
1. Consider developing a collaborative relationship and stance with NBCOT instead of continuing to take policy positions that demonstrate sour grapes over a generations-old legal battle.
2. Consider the identity costs incurred by this profession of having a professional membership association that takes an actively hostile stance against certification renewal standards set by a filial organization.
3. Send a consistent message - AOTA advantages the initial certification to attract students to its membership. They will partner with NBCOT for a student conclave, and then go ahead and develop exam prep products - but then have policies to never refer to the certification marks ever again. That makes no sense.
4. Encourage your board members to refrain from openly posting comments on social media like 'Some people don't renew their certification, so we should use inclusive language like OT and OTA.' It is factual that the vast majority of people DO renew their certification. This kind of messaging from some of your board members devalues the certification that most people choose to maintain, it undermines the profession, and contributes to this entire identity crisis. In my opinion it also gives fodder to NBCOT on dilution claims - I am not a lawyer - I just look at things from a common sense perspective, but I think it is foolish to take that position in context of the judgement that was already handed down in the US District Court.
The public will continue to have confusion about occupational therapy as a profession as long as the profession itself spends its resources changing its own definitions and hanging onto legal disputes about whether or not the OTR and COTA marks are even referenced in AOTA documents.
It was an understandable but regrettable legal dispute 20+ years ago. Allowing it to continue to negatively impact the profession today is simply stupid. Can we please find a way to move on?
Last year I wrote several blog posts about the devastating advocacy position taken by AOTA to remove the Medicare therapy caps that caused a 'paygo' impact on services provided by occupational therapy assistants.
In short, the Bipartisan Budget Act of 2018 lifted the Medicare therapy caps and was 'paid for' by an agreement that OTA services under Medicare Part B would have to be paid at 85% of the standard rate whenever that therapy was delivered in whole or in part by an OTA.
Professional lobbyists and policy analysts at AOTA were surprised by this 'last minute' inclusion of a payment differential even though the House Rules Committee clearly included this language in the document summary that was sent to the CBO for scoring prior to the legislation being passed. As a result of their inattention, no one was alerted to this dangerous language, no one could advocate against it, and OTA practice was severely damaged. It was a colossal and inexcusable policy and advocacy error.
OTAs who suffer an offset that includes a pay differential for their services, which has a real possibility of spilling over into other payment systems. We don't yet know what the home health offsets will do.
One year later, we see the prediction coming true. Note this letter from an insurer, that is NOT Medicare, announcing that OTA services will now have to be coded distinctly.
The language in the notification, "furnished in whole or in part by an occupational therapy assistant" should leave no doubt about the source of this soon-to-be requirement.
So now occupational therapy practitioners will need to start coding services provided by OTAs, and everyone can be sure that this will lead to payment differentials that are indeed spilling outside of the Medicare system.
The damage caused by this hapless advocacy position to repeal the caps is incalculable and can have a significant impact on facilities' interest in hiring OTAs.
There were a group of providers who were sending cautionary messages about messing with therapy caps for years, but it was something that was serially ignored. The therapy cap 'problem' was primarily a problem for long term care profiteers - something that still is being ignored in the hope that everyone will continue to blindly follow the talking points that come out of professional membership associations.
This is a glaring example of where they did not serve the needs of this profession, and in particular they did not serve the needs of occupational therapy assistants.
1. 95% of people receiving Med B OT were not significantly impacted by the cap.
2. There were significant cost overruns in the system, primarily driven by a very small number of people whose costs were disproportionate to the number of people within that cohort.
3. A more nuanced policy approach would have been to leave the caps in place and to study the factors associated with cost overruns with a small number of people, and then direct policy to address those findings.
This is a glaring example of where they did not serve the needs of this profession, and in particular they did not serve the needs of occupational therapy assistants. Next time they need to listen to people in the field who are expressing concerns about their policy positions. This time it is probably too late for OTAs.