Qualitative Study on Student Debt: Implications for Physical Therapists’ Professional and Personal Lives

Qualitative Study on Student Debt: Implications for Physical Therapists’ Professional and Personal Lives | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Qualitative Study on Student Debt: Implications for Physical Therapists’ Professional and Personal Lives Stefany Shaibi, Bailey Robinson, Yongyue Qi, Angela Lampe, Brenda Coppard, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6701681/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background The increasing cost of higher education has led to significant levels of student debt among new graduate physical therapists (PTs). This financial burden impacts graduates and likely has broader implications for the physical therapy profession. The profound consequences of student debt are still not fully understood. The purpose of this study is to determine to what extent significant student debt affects early PT’s personal and professional lives. Methods An exploratory, qualitative study design, grounded in a constructivist paradigm and informed by phenomenological principles, was used to explore the experiences of PTs with high student debt. Participants included PTs that graduated between 2018 and 2022 with a self-reported minimum student debt of $ 100,000 from their education. Semi-structured interviews were used to explore the effects of student debt on participants personal and professional lives. Using an inductive, interpretive approach, the data was analyzed by two investigators to determine consensus on themes. Results Ten participants completed the study, revealing 7 main themes: the role of COVID, cost containment strategies, loan repayment plans, the effect of loans (professional), the effect of loans (personal), mental health, and financial literacy. Conclusions This study highlights both known and unknown consequences of high student debt in young PTs. There are more professional effects of high student debt than what is currently known. Early PTs are making career decisions based primarily on loan repayment plans. This may be to the detriment of their overall professional goals. All of the participants mentioned ways that their student debt has affected them personally, including increased mental health concerns. Many of the participants also discussed how COVID masked the reality of their student loan situation. It is recommended that physical therapist education programs improve financial literacy of their students and provide transparency regarding costs, including potential unanticipated costs. student debt physical therapists graduate school financial literacy Background The increasing cost of higher education has led to significant levels of student debt among new graduate physical therapists (PTs), a trend that poses profound challenges to their overall well-being, job satisfaction, 1 and sustainability 2 in the profession. According to data from the American Physical Therapy Association (APTA), the average student loan debt for PT graduates in 2022 was approximately $ 152,000, 3 a staggering figure that significantly exceeds the starting salaries for entry-level positions in the field. This financial burden not only impacts individual graduates but also has broader implications for the physical therapy profession, influencing career decisions, job satisfaction, and access to care in underserved areas. 3 Because loan repayment obligations can consume a significant portion of one’s income, one of the most immediate implications of high student debt is the limitation it places on new graduates' financial freedom. When third year PT students were surveyed nationally, 80% indicated they were concerned about loan repayment and over 90% expressed concerns about their ability to make major purchases in the future, such as a house or a car. 4 Indeed, when Webster and North 5 investigated the effects of student debt on those who were at least 5 years post-graduation, they found that decisions related to housing, number of hours worked, initial job selection, and ability to save for the future were the most negatively impacted. This financial stress associated with student debt burden can also exacerbate mental health concerns and burnout, as PTs may feel compelled to work excessive hours or take on multiple jobs to manage their debt. 1 , 6 Dickson and colleagues’ 1 retrospective study of PTs in Virginia showed that those with higher student debt worked more hours per week and had more working years until retirement. They also found that income and job satisfaction had an interaction effect on student debt. For example, those with lower levels of income had a stronger, negative relationship between their debt and job satisfaction, as compared to those with higher income. In addition to burnout and job satisfaction, Webster and North 5 also noted that the financial stressors contributed to the mental health decline in PTs that were at least 5 years post-graduation. This included anxiety, frustration, and guilt. They also expressed frustrations with the inconsistencies between the expectations and realities of practice. Associated with student debt and job satisfaction is also the reality that new graduates may have to compromise their practice setting of choice due to loan repayment constraints. In a survey of new graduate PTs (0–5 years) in Florida, Ambler 7 found that the choice of practice setting may be influenced by student debt among PTs, posing a significant barrier to practice and career decisions in the field. Such pressures can detract from job satisfaction, wellbeing, and ultimately impact the quality of care provided to patients. 8 While there is no direct evidence linking high educational debt to patient outcomes, existing research suggests that the financial strain of student debt influences career decisions and job satisfaction among physical therapists, 1 which can lead to burnout. Burnout has been shown to directly affect the quality of patient care. 9 The effects of student debt may also extend beyond personal finances and possibly influence career trajectories within the field of physical therapy. Graduates with heavy student debt are less likely to pursue lower-paying opportunities in areas of high need, such as rural or underserved communities, where salaries may not align with their financial obligations. This trend highlights the broader challenge of tackling healthcare provider shortages in these regions, which remain underserved due to existing economic disparities. 10 Additionally, the burden of debt may deter individuals from pursuing advanced certifications or specializations, hindering their professional development and reducing the diversity of expertise within the field. 11 Given the high student debt loads associated with physical therapist education programs, it is imperative that physical therapy and other healthcare students have financial literacy prior to applying to a graduate program. Pabian and colleagues 12 used publicly available data from the US Bureau of Labor statistics to study salaries of doctoring professions. They found that students in doctoral healthcare professions of medicine, pharmacy, and physical therapy must be mindful of their borrowing habits and the institutional costs of their education to prevent financial difficulties as they begin their careers in their chosen field. Physical therapy students, in particular, face a high risk of accumulating unmanageable debt due to the costs of education and their limited earning potential early in their careers. 12 While student debt has increased substantially in recent years, the profound consequences of high student loan debt are still not fully understood. As such, the financial demands of completing a doctorate in physical therapy and the resultant impact of those demands on life decisions post-graduation are of growing concern in the medical community. Thus, the purpose of this study is to determine to what extent, if any, significant student loan debt affects early physical therapists’ personal and professional lives. Methods An exploratory, qualitative study design, grounded in a constructivist paradigm and informed by phenomenological principles, was used to explore the lived experiences of physical therapists with high student debt. This study (IRB#2003974) was approved and determined to be exempt by Creighton University’s Institutional Review Board. Participants included physical therapists who graduated from Creighton University’s Doctor of Physical Therapy (DPT) educational program. Participant inclusion criteria included a graduation year between 2018 and 2022 and a self-reported minimum student loan debt accumulation of $ 100,000 from their physical therapy degree. Alumni email addresses provided by the institution were used to access the participant sample. Participants were given information regarding the study and consented through email. Investigators conducted interviews of physical therapists through the Zoom platform. The interviews were transcribed by zoom. The semi-structured interview and probing questions were developed by the researchers based on a literature review. The questionnaire used in this study is provided in Additional file 1. The questions were reviewed by four occupational and physical therapy faculty members with knowledge of the federal student loans process and revisions were made to the interview questions. The researchers completed training in conducting interviews prior to data collection. The qualitative data was used to answer two research questions: 1) what is the context of physical therapists who are post-graduation one to five years and who have more than $ 100,000 in student debt? and 2) what is the impact of high debt on their personal and professional lives? Ten randomly selected respondents were emailed to gain their permission and consent to be interviewed and to determine dates and times for the interview. All interviews were completed using Zoom and a recorded transcript was utilized for data analysis. Interviewees were emailed a copy of the transcript to serve as a member check to ensure accuracy and to offer an opportunity to add any further information. The researchers took notes during the interviews. Interviews lasted approximately 30–60 minutes. Each transcript was assigned a number to maintain anonymity for reporting purposes. The data were analyzed through an inductive, interpretive approach, utilizing constant comparison for both within-case and cross-case analysis. 13 Two investigators independently coded the transcripts to create the initial case record. They then convened to establish a coding scheme and identify emerging themes from each transcript. The researchers also sought disconfirming evidence or negative case analysis and practiced reflexivity during research meetings. 13 Consensus on the themes was achieved by generating descriptive summaries. Results The sample contains ten participants, seven females and three males. There are six that work in an inpatient hospital setting (ICU, acute care), three that work in outpatient orthopedics, and one that works three PRN positions. The participants are living in seven different states. The qualitative analysis revealed 7 main themes. Seven themes emerged from the interviews. These included the role of COVID, cost containment strategies, loan repayment plans, the effect of loans (professional), the effect of loans (personal), mental health, and financial literacy. Theme 1: The Role of COVID The first theme was the role of COVID. Many of the PTs who were interviewed reported that their loans had been in forbearance due to COVID. This had provided many of them a respite from paying their loans and likely masked the reality of their debt burden. One participant mentioned: “After the whole COVID forbearance thing, I mean, it was at $ 0 that entire time” and, when asked about making payments during COVID, “Yeah. My wife and I, because it was interest free at that point, we pretty much used that time to pay off all the capital interest and start making payments on principal.” Another participant mentioned, “Because I graduated in 2020, it was kind of a mess… like the COVID pandemic and then the Cares Act, and everything that kind of put a freeze on student debt. And then I ended up going to [redacted] for my residency, for my neurologic residency. So then, that also put kind of a damper on things. So, I didn't really pay anything during that time”. Some participants voiced their frustration with the fact that they were paying full tuition even though they were not on campus. One participant said, “Being a Covid student, a Covid grad student, I was kind of surprised that we were paying full tuition to be online learning for so long.” Theme 2: Cost Containment Strategies Participants shared examples of cost containment strategies both during school and after graduation. For example, one participant stated, “During that time I tried to live, you know, below the means as best as possible. I definitely took it into consideration. Throughout school I lived with 2 other roommates, so, you know, I really kind of took those into consideration.” Another participant stated, “We were, you know, buying day old bread.” Lastly, a participant mentioned, “We were budgeting heavily. We were trying to be really frugal with cutting costs.” Theme 3: Loan Repayment Plans Every participant discussed their current loan repayment plan. All had a good understanding of their repayment plan. For example, those in the Public Service Loan Forgiveness (PSLF) plan know that they must remain in a non-profit setting for 10 years in order to have their loans repaid. One participant mentioned working at a Veterans Affairs hospital in the Midwest in order to qualify for their 5-year loan repayment plan: So now I'm in [redacted] at the VA and this specific position, not all the VA positions have. It offers education, debt, reduction program, and so that one will actually pay up to $200,000 of my student debt over the course of 5 years. So that's kind of this was the end of my first year for that. So that's kind of where the $40,000 came from as I paid that this year, and then we'll continue the next 4 years here in [redacted] at the VA to kinda keep working that debt down. It's the education debt reduction program. Not every position has it. But this year physical therapists were included, and, like the last couple of years, they were included in that. So, it varies on which professions are like kind of high need. And then not every VA will offer it. So that's how I ended up in [redacted]. Others were optimistic about the loan forgiveness that they are participating in: Because Mayo is nonprofit, I wanted to start paying towards the public service loan forgiveness while I'm here. And so, I'm doing that, and I'm doing that on the SAVE plan. So that keeps my monthly payments pretty well. Another participant mentioned, “I feel okay with my student debt. I know it’s a lot, but I also know that I’ll make my way toward forgiveness because I don’t really intend on being out of the PSLF. Or worst-case scenario, if I have to go with the income-driven repayment plan and I feel like I’d be able to make the payments on the income driven plans.” Theme 4: Effect of Loans on Professional Life Due to the qualifications for the loan repayment plans, most of the participants made career decisions based on their debt. Several mentioned that their preferred setting would be in private practice, however, they would not qualify for the PSLF. Therefore, they have compromised to work in a non-profit. One participant recently completed a residency in neurologic physical therapy but is not working in her desired setting to qualify for the PSLF. She is working in an acute care hospital, where she works with patients who have cardiovascular issues. She has taken on a PRN job on the weekends to help pay for her student loans and to obtain the direct patient care hours needed to maintain her board-certification in neurologic physical therapy: Our current population is… a lot more… Cardiopulmonary issues, diabetes and kind of more of like your renal issues tend to be more of like what I'm seeing and especially like in the ICU you know. Now, the goal is, like, to prevent the neurologic impairments that I know that can happen with immobility. But again, it's like, that's not what I really went to Residency for. That's not really what I wanted to spend my time. The PRN job that I do work on the weekends is at an inpatient rehab and so that's kind of one way I'm able to get like those patient populations in and continue to. You know, practice there, because now that I have my special, like, my specialization. I need to keep the hours up as well. And so, it's like when it's not really as readily available at my full-time job. I'm having to make extra effort to make sure I am seeing like that patient population on the weekends, in order to still maintain my certification, too. So, I'd say it kind of has necessitated the need for making sure. I'm still doing an extra job in order to make sure I can keep up my certification that I went to residency. Other participants also mentioned that they are working PRN jobs: Now I'm working 3 PRN positions just because it makes more than a full-time position. So, both of our outpatient or the jobs are about 40 hours a week. And then we're trying to work like 2-ish weekends, two Saturdays a month at the skilled nursing facilities that we both work at and that's for anywhere from like 5 to 8 hours at a time. Another participant chose to stay at their current job because of the loan repayment program instead of a job closer to home: I was offered a different job about a year ago that was a little bit closer to home, and like I could spend possibly a little bit more time with my kid, but it didn’t have the loan forgiveness. And so it was like, well, am I choosing money over my kid?... Right now I work 45 minutes away from my house and so I’m gone probably 8 to 10 hours out of the day, most of the time. And so there’s 4 days that I really don’t get to see my kid that much. Lastly, one participant mentions, “I don’t want to say it prevents me from getting a different job, but it definitely impacts where I can work.” Theme 5: Effect of Loans on Personal Life In addition to the effects professionally, most participants mentioned ways that their student debt affected them personally. This included their ability to make large purchases, have children, and activities to improve their quality of life (e.g. vacations). For example, one participant mentions, “The one that’s probably impacted me the most is I can’t apply for any more loans. So beyond, like our mortgage, we talked about like consolidating some debt and doing all of this. And like I can’t get approved for anything now because of my student loans”. Another discussed strategies to minimize their costs: “We’re driving, you know, beater cars. We were able to buy a house, but that’s why we moved out to [redacted], away from family, because it’s cheaper cost of living.” Lastly, one participant talked about how their student debt played a role in their decision to have children: “My wife and I originally were thinking about trying to get out of student debt before we had kids. And then we realized how late that would have been. We’re like, no, we can’t do that. So, we didn’t do that.” Theme 6: Effect of Loans on Mental Health Almost all of the participants mentioned being stressed or frustrated with their current debt load. One participant mentions their frustrations: “I don’t regret getting my doctorate. I don’t regret any of that, but the fact that, like now, I can’t even get the smallest loan to do anything, even though I make good money, and my payments are not that high is just really frustrating more than anything else.” Another participant reported, “You definitely have that black cloud always hanging over.” Several participants discussed the unfairness of the salaries in the medical systems they work in. For instance, one participant mentioned, “I just talked to my sister-in-law about what she's making hourly and what I'm making hourly, and it's about the same. And I love my nurses and I value them, but like it's a doctorate program. It was not an easy program. So, I can't quite understand, like, why our salaries are so similar.” Theme 7: Financial Literacy The categories that were included in this theme included various sources of financial literacy (e.g., family, undergraduate programs, graduate school), as well as discussions about how they chose their physical therapy program and advice they would give to others. When asked about their knowledge of or comfort in the loan process, participants stated: It can be so confusing, even with people coming in to talk about you. It’s just a confusing process. I would say, yeah, pretty blind. I feel like I had in my head, like, oh, people take out loans all the time. I can do it too. But you know that’s not a very good strategy. I definitely wish I did a little bit more research as to what the cost of each program was. When asked about advice they might provide to others: I am very grateful for my education, but at the time, I also didn’t realize the difference between, like, a public-school cost and a private school cost. So just consider that based on whatever’s best for that individual. Make sure that they try and save as much as they can prior and live as frugally as they can during. That’ll help reduce the costs. And whatever they don’t use at the end of every semester, throw back. When asked about budgeting and planning during their physical therapy education, several students mentioned the unanticipated costs associated with completing their DPT. A main source of this was related to their clinical sites being out of state. Due to the lottery system to choose clinical sites, most of the participants had to travel and pay for housing in another city. Several of them mentioned having to pay rent in two places during this time or being creative to lower their costs. For example, one participant mentioned: Our first 16 week one… I got to split that with a classmate. So that would have been like the only one because… we were in North Carolina, so it was more expensive to live there than it was in Omaha. So that would probably be the only time that I… felt like I probably spent a little bit more and was like a little tighter. Another participant mentioned how clinical placements could affect expenses, “I guess the only [costs] that I really didn't anticipate was… expenses related to clinicals, especially if, you know, you were placed in a spot that you weren't anticipating getting, and then you have to figure in living situations or depending what part of the country you're in depends on, you know, expenses.” Discussion The cost associated with becoming a physical therapist is unmanageable for the majority of US students. According to Shields and colleagues, 14 “29% of physical therapy students graduate with more debt than could be supported by entry-level salaries.” This study highlights both known and unknown consequences of high student debt load in young PTs. These include the effects on personal and professional finances, mental health, and career choices. The results of this study show that there are more professional effects of high student debt than what is currently known. Early PTs are making decisions regarding their careers based primarily on loan repayment plans. This may be to the detriment of their overall professional goals. For example, choosing to work in a setting that is not related to their board certification or choosing to work at a location because of the loan repayment plan, but in a city where they do not have any social support. A systematic review investigating the risk factors associated with physical therapist burnout found that unsatisfactory social support and lack of partnership in the home (single, separated, divorced, or widowed) were risk factors for burnout. 15 In addition to professional effects, all of the participants mentioned ways that their student debt has affected them personally. They continue to live frugally and are unable to make large purchases and go on vacations. Some of them have chosen to live in areas with a lower cost of living. High student debt is also affecting young professionals’ mental health. This ranged from expressing frustration with their situation to feeling stressed, depressed, anxious, and/or embarrassed about their student debt. These results are in agreement with a study assessing stress in health professions students. 16 In this study, they found that “health professions students in a public academic medical center had a “medium amount” of stress, on average, from financial debt. Students also appeared to base their post-professional career aspirations, at least in part, on the stress they experienced from financial debt. For example, choosing a job based on the salary instead of their preferred setting. This is in agreement with other studies that show a strong relationship between student debt and stress for DPT students. 17 – 18 In the same study by Dickson and colleagues, 16 stress was associated with the amount of student loans students expect to accrue and their financial self-efficacy. Financial self-efficacy was found to be a potential moderator for debt-related stress. Other studies have found a correlation between self-efficacy and financial anxiety for physical therapy students. The authors recommend implementing education on strategies to manage student debt to improve self-efficacy and decrease financial stress. 18 One aspect of student debt that has not been investigated is the role of COVID. Many of the participants discussed how COVID masked the reality of their student loan situation. When these PTs graduated, most of them went into automatic forbearance because of COVID. Some chose to pay down their loans during this time. Others chose to save money for other things (retirement, emergency fund). When these interviews occurred, the forbearance had just ended. During COVID, the government allowed for a pause in student loan payments and interest rates were set at 0%. This ended in September 2023, which was around the time of the interviews. Many of the participants we interviewed were able to join programs through their employment or the government that allowed for very low payments. This has led to many concerns about how their loan repayment plans are at the mercy of the government and the current administration. This has added to their anxiety and stress. Since COVID likely hid the reality of their student loan situation, the participants had not actually experienced the true effects of holding onerous and overwhelming student debt. Therefore, they likely have not begun to experience the grave personal or professional effects, such as delaying major life milestones. The final category from this study was related to financial literacy. Many of the PTs felt unprepared from a financial literacy standpoint as they started their graduate programs. While most of them knew the cost of their education, they did not have a strong understanding of loans or loan repayment programs prior to graduation. Financial literacy programs should be implemented prior to graduation to assist students with student debt management, as students with higher levels of student loan debt have been shown to have lower financial literacy. 19 If financial literacy can effectively decrease the amount of student loans early professionals take out, it will decrease their overall debt load due to interest as well. At a minimum this should include budgeting techniques while in school and a comprehensive review of the loan repayment programs available. Sawyer and colleagues 20 recommend integrating financial literacy into DPT curricula and increasing awareness of financial resources available. A recent national study of third year DPT students showed that those individuals that received debt management education during their PT program had, on average, $ 3,520 less student debt and $ 570 less credit card debt compared to those that did not. 4 While these amounts may appear small in comparison to the total amount of debt many DPT students take on, over the course of the loan repayment period it adds quite a bit more to the total amount that must be repaid by the debtor. Conclusion Based on the results of this study, it is recommended that physical therapist education programs improve financial literacy of their students and provide transparency regarding costs, including potential unanticipated costs. It is imperative that this information be made available to potential applicants of physical therapy programs. The APTA 21 recommends several actions to reduce the impact of student debt. These include promoting awareness of the debt to income ratio for PTs, financial literacy programs, alternatives to student loans (e.g., grants, work study), education on loan forgiveness and employer assistance programs, changing DPT curriculum, and increasing research in these areas. Significant student debt has substantial consequences for young clinicians. Addressing the student debt crisis in physical therapy requires systemic solutions, including increased advocacy for loan forgiveness programs, financial literacy education, and strategies to reduce educational costs. By alleviating the financial pressures faced by new graduates, the profession can better support a workforce that is motivated, well-distributed across diverse practice settings, and equipped to meet the growing demand for physical therapy services. Without such interventions, the sustainability of the profession and the accessibility of care for patients may be jeopardized. Limitations This study used a convenience sample, and the participants were graduates of one institution, which may limit generalizability or transferability to other PTs. Additionally, this small sample size may not have captured the full range of perspectives on the effects of student debt. Declarations Ethics approval and consent to participate This study was approved by the Creighton University’s Institutional Review Board under reference number 2003974-01. All procedures performed in this study involving human participants were conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Written informed consent was obtained from all individual participants included in the study. Consent for publication Not applicable Availability of data and materials The datasets generated and analyzed during the current study are not publicly available to protect the privacy and confidentiality of study participants. Data access may be granted upon reasonable request and subject to approval from the corresponding author and Creighton University’s Institutional Review Board. Clinical Trial Number Not applicable Competing interests The authors declare that they have no competing interests. Funding Creighton University, George F. Haddix President's Faculty Research Fund Authors' contributions SS assisted with project conception, performed one-on-one interviews, helped analyze the data, and was the primary author for this manuscript. BR assisted with data collection and provided feedback on the manuscript. JQ helped analyze the data and edit the manuscript. AL assisted with project conception, helped analyze the data and edit the manuscript. BC assisted with project conception, helped analyze the data and edit the manuscript. GD assisted with project conception, performed one-on-one interviews, helped analyze the data, and edit the manuscript. Acknowledgements We would like to thank the participants for their time and input for this study. Authors' information SS is an associate clinical professor of physical therapy at Creighton University in Phoenix. She earned her Doctor of Education from Arizona State University and her Doctor of Physical Therapy degree from the University of Southern California. She is board certified by the American Board of Physical Therapy Specialties in both orthopedics (emeritus) and geriatrics (emeritus). Her current research is focused on student debt and first-generation college students in healthcare programs. BR is a doctoral physical therapy student at Creighton University in Phoenix pathway. She also serves as a student research assistant. YQserves as an Assistant Professor of Occupational Therapy at Creighton University, with more than 15 years of experience in research design, statistical analysis, and assessment. His engagement extends to teaching in both entry-level and post-professional OTD programs. AL is an Associate Professor of Occupational Therapy at Creighton University and the Director of the Post-Professional Occupational Therapy Doctoral Program. She shares her expertise and research interest in leadership, health care accreditation, management/administration, program development, and quality with students in the entry-level and post-professional OTD programs. BCis a Professor of Occupational Therapy at Creighton University. She has over 30 years of expertise in academic administration, leadership, health care professions assessment and leadership. She teaches in the entry-level and post-professional OTD programs. GD is a professor of Physical Therapy at Creighton University in Phoenix. Dr. Del Rossi holds a PhD in Sports Medicine and has a background in exercise and sport sciences. His research interests include pre-hospital emergency care, educational outcomes and higher education. References Dickson T, Mulligan EP, Hegedus EJ. Impacts of educational debt on physical therapist employment trends. BMC Med Educ. 2023;23(1):459. Handlery K, McQueeney S, Handlery R, Regan EW, Fritz SL. Factors contributing to physical therapist attrition: A qualitative study. J Allied Health. 2024;53(1):E1–12. American Physical Therapy Association. Impact of student debt on the physical therapy profession [Internet]. 2020 [cited 2024 Nov 27]. Available from: https://www.apta.org/apta-and-you/news-publications/reports/2020/impact-of-student-debt-on-the-physical-therapy-profession Berry JW. A national survey of student loan debt accrued by Doctor of Physical Therapy students. J Phys Ther Educ. 2021;35(1):12–8. Webster P, North SE. 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Additional Declarations No competing interests reported. Supplementary Files AdditionalFile1InterviewQuestionnaire.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 17 Feb, 2026 Reviews received at journal 19 Jun, 2025 Reviews received at journal 18 Jun, 2025 Reviewers agreed at journal 15 Jun, 2025 Reviewers agreed at journal 13 Jun, 2025 Reviewers invited by journal 13 Jun, 2025 Editor assigned by journal 11 Jun, 2025 Editor invited by journal 23 May, 2025 Submission checks completed at journal 22 May, 2025 First submitted to journal 22 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6701681","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":471433231,"identity":"adc06880-9ac9-41eb-9bc1-3a892660b7e4","order_by":0,"name":"Stefany Shaibi","email":"data:image/png;base64,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","orcid":"","institution":"Creighton University","correspondingAuthor":true,"prefix":"","firstName":"Stefany","middleName":"","lastName":"Shaibi","suffix":""},{"id":471433233,"identity":"3dacef7b-e40e-4442-aa95-520bdce90e6b","order_by":1,"name":"Bailey Robinson","email":"","orcid":"","institution":"Creighton University","correspondingAuthor":false,"prefix":"","firstName":"Bailey","middleName":"","lastName":"Robinson","suffix":""},{"id":471433234,"identity":"3d99fc62-8a07-48b5-ae72-8f3fb3da13f3","order_by":2,"name":"Yongyue Qi","email":"","orcid":"","institution":"Creighton University","correspondingAuthor":false,"prefix":"","firstName":"Yongyue","middleName":"","lastName":"Qi","suffix":""},{"id":471433235,"identity":"bcf6f405-1cb5-4b14-8435-03ee0a1b4a25","order_by":3,"name":"Angela Lampe","email":"","orcid":"","institution":"Creighton University","correspondingAuthor":false,"prefix":"","firstName":"Angela","middleName":"","lastName":"Lampe","suffix":""},{"id":471433242,"identity":"0288f1f7-e2fa-45c4-96cd-a7326a0bbedd","order_by":4,"name":"Brenda Coppard","email":"","orcid":"","institution":"Creighton University","correspondingAuthor":false,"prefix":"","firstName":"Brenda","middleName":"","lastName":"Coppard","suffix":""},{"id":471433243,"identity":"f08affe7-b132-4f86-b309-b443ce2a880f","order_by":5,"name":"Gianluca Del Rossi","email":"","orcid":"","institution":"Creighton University","correspondingAuthor":false,"prefix":"","firstName":"Gianluca","middleName":"Del","lastName":"Rossi","suffix":""}],"badges":[],"createdAt":"2025-05-19 19:38:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6701681/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6701681/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84695238,"identity":"cec802c5-c5c2-40bf-aa22-28d0152883ae","added_by":"auto","created_at":"2025-06-16 10:32:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":501913,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6701681/v1/fd43d922-5c76-40b4-818b-44ed1741b4de.pdf"},{"id":84694793,"identity":"ad76d81e-5987-4456-a415-246eeb63f347","added_by":"auto","created_at":"2025-06-16 10:24:54","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":16339,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile1InterviewQuestionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-6701681/v1/2e0bbc4749b0c1542d4aaa8d.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Qualitative Study on Student Debt: Implications for Physical Therapists’ Professional and Personal Lives","fulltext":[{"header":"Background","content":"\u003cp\u003eThe increasing cost of higher education has led to significant levels of student debt among new graduate physical therapists (PTs), a trend that poses profound challenges to their overall well-being, job satisfaction,\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e and sustainability\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e in the profession.\u003c/p\u003e \u003cp\u003e According to data from the American Physical Therapy Association (APTA), the average student loan debt for PT graduates in 2022 was approximately \u003cspan\u003e$\u003c/span\u003e152,000, \u003csup\u003e \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e \u003c/sup\u003e a staggering figure that significantly exceeds the starting salaries for entry-level positions in the field. This financial burden not only impacts individual graduates but also has broader implications for the physical therapy profession, influencing career decisions, job satisfaction, and access to care in underserved areas. \u003csup\u003e \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e \u003c/sup\u003e \u003c/p\u003e \u003cp\u003eBecause loan repayment obligations can consume a significant portion of one\u0026rsquo;s income, one of the most immediate implications of high student debt is the limitation it places on new graduates' financial freedom. When third year PT students were surveyed nationally, 80% indicated they were concerned about loan repayment and over 90% expressed concerns about their ability to make major purchases in the future, such as a house or a car.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Indeed, when Webster and North\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e investigated the effects of student debt on those who were at least 5 years post-graduation, they found that decisions related to housing, number of hours worked, initial job selection, and ability to save for the future were the most negatively impacted.\u003c/p\u003e \u003cp\u003eThis financial stress associated with student debt burden can also exacerbate mental health concerns and burnout, as PTs may feel compelled to work excessive hours or take on multiple jobs to manage their debt.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Dickson and colleagues\u0026rsquo;\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e retrospective study of PTs in Virginia showed that those with higher student debt worked more hours per week and had more working years until retirement. They also found that income and job satisfaction had an interaction effect on student debt. For example, those with lower levels of income had a stronger, negative relationship between their debt and job satisfaction, as compared to those with higher income. In addition to burnout and job satisfaction, Webster and North\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e also noted that the financial stressors contributed to the mental health decline in PTs that were at least 5 years post-graduation. This included anxiety, frustration, and guilt. They also expressed frustrations with the inconsistencies between the expectations and realities of practice.\u003c/p\u003e \u003cp\u003eAssociated with student debt and job satisfaction is also the reality that new graduates may have to compromise their practice setting of choice due to loan repayment constraints. In a survey of new graduate PTs (0\u0026ndash;5 years) in Florida, Ambler\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e found that the choice of practice setting may be influenced by student debt among PTs, posing a significant barrier to practice and career decisions in the field. Such pressures can detract from job satisfaction, wellbeing, and ultimately impact the quality of care provided to patients.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e While there is no direct evidence linking high educational debt to patient outcomes, existing research suggests that the financial strain of student debt influences career decisions and job satisfaction among physical therapists,\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e which can lead to burnout. Burnout has been shown to directly affect the quality of patient care.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe effects of student debt may also extend beyond personal finances and possibly influence career trajectories within the field of physical therapy. Graduates with heavy student debt are less likely to pursue lower-paying opportunities in areas of high need, such as rural or underserved communities, where salaries may not align with their financial obligations. This trend highlights the broader challenge of tackling healthcare provider shortages in these regions, which remain underserved due to existing economic disparities.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Additionally, the burden of debt may deter individuals from pursuing advanced certifications or specializations, hindering their professional development and reducing the diversity of expertise within the field.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eGiven the high student debt loads associated with physical therapist education programs, it is imperative that physical therapy and other healthcare students have financial literacy prior to applying to a graduate program. Pabian and colleagues\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e used publicly available data from the US Bureau of Labor statistics to study salaries of doctoring professions. They found that students in doctoral healthcare professions of medicine, pharmacy, and physical therapy must be mindful of their borrowing habits and the institutional costs of their education to prevent financial difficulties as they begin their careers in their chosen field. Physical therapy students, in particular, face a high risk of accumulating unmanageable debt due to the costs of education and their limited earning potential early in their careers.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhile student debt has increased substantially in recent years, the profound consequences of high student loan debt are still not fully understood. As such, the financial demands of completing a doctorate in physical therapy and the resultant impact of those demands on life decisions post-graduation are of growing concern in the medical community. Thus, the purpose of this study is to determine to what extent, if any, significant student loan debt affects early physical therapists\u0026rsquo; personal and professional lives.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e An exploratory, qualitative study design, grounded in a constructivist paradigm and informed by phenomenological principles, was used to explore the lived experiences of physical therapists with high student debt. This study (IRB#2003974) was approved and determined to be exempt by Creighton University\u0026rsquo;s Institutional Review Board. Participants included physical therapists who graduated from Creighton University\u0026rsquo;s Doctor of Physical Therapy (DPT) educational program. Participant inclusion criteria included a graduation year between 2018 and 2022 and a self-reported minimum student loan debt accumulation of \u003cspan\u003e$\u003c/span\u003e100,000 from their physical therapy degree. Alumni email addresses provided by the institution were used to access the participant sample. Participants were given information regarding the study and consented through email. Investigators conducted interviews of physical therapists through the Zoom platform. The interviews were transcribed by zoom. The semi-structured interview and probing questions were developed by the researchers based on a literature review. The questionnaire used in this study is provided in Additional file 1. The questions were reviewed by four occupational and physical therapy faculty members with knowledge of the federal student loans process and revisions were made to the interview questions. The researchers completed training in conducting interviews prior to data collection. The qualitative data was used to answer two research questions: 1) what is the context of physical therapists who are post-graduation one to five years and who have more than \u003cspan\u003e$\u003c/span\u003e100,000 in student debt? and 2) what is the impact of high debt on their personal and professional lives? \u003c/p\u003e \u003cp\u003eTen randomly selected respondents were emailed to gain their permission and consent to be interviewed and to determine dates and times for the interview. All interviews were completed using Zoom and a recorded transcript was utilized for data analysis. Interviewees were emailed a copy of the transcript to serve as a member check to ensure accuracy and to offer an opportunity to add any further information. The researchers took notes during the interviews. Interviews lasted approximately 30\u0026ndash;60 minutes. Each transcript was assigned a number to maintain anonymity for reporting purposes.\u003c/p\u003e \u003cp\u003eThe data were analyzed through an inductive, interpretive approach, utilizing constant comparison for both within-case and cross-case analysis.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Two investigators independently coded the transcripts to create the initial case record. They then convened to establish a coding scheme and identify emerging themes from each transcript. The researchers also sought disconfirming evidence or negative case analysis and practiced reflexivity during research meetings.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Consensus on the themes was achieved by generating descriptive summaries.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe sample contains ten participants, seven females and three males. There are six that work in an inpatient hospital setting (ICU, acute care), three that work in outpatient orthopedics, and one that works three PRN positions. The participants are living in seven different states. The qualitative analysis revealed 7 main themes.\u003c/p\u003e \u003cp\u003eSeven themes emerged from the interviews. These included the role of COVID, cost containment strategies, loan repayment plans, the effect of loans (professional), the effect of loans (personal), mental health, and financial literacy.\u003c/p\u003e\n\u003ch3\u003eTheme 1: The Role of COVID\u003c/h3\u003e\n\u003cp\u003eThe first theme was the role of COVID. Many of the PTs who were interviewed reported that their loans had been in forbearance due to COVID. This had provided many of them a respite from paying their loans and likely masked the reality of their debt burden. One participant mentioned: \u0026ldquo;After the whole COVID forbearance thing, I mean, it was at \u003cspan\u003e$\u003c/span\u003e0 that entire time\u0026rdquo; and, when asked about making payments during COVID, \u0026ldquo;Yeah. My wife and I, because it was interest free at that point, we pretty much used that time to pay off all the capital interest and start making payments on principal.\u0026rdquo;\u003c/p\u003e \u003cp\u003eAnother participant mentioned, \u0026ldquo;Because I graduated in 2020, it was kind of a mess\u0026hellip; like the COVID pandemic and then the Cares Act, and everything that kind of put a freeze on student debt. And then I ended up going to [redacted] for my residency, for my neurologic residency. So then, that also put kind of a damper on things. So, I didn't really pay anything during that time\u0026rdquo;.\u003c/p\u003e \u003cp\u003eSome participants voiced their frustration with the fact that they were paying full tuition even though they were not on campus. One participant said, \u0026ldquo;Being a Covid student, a Covid grad student, I was kind of surprised that we were paying full tuition to be online learning for so long.\u0026rdquo;\u003c/p\u003e\n\u003ch3\u003eTheme 2: Cost Containment Strategies\u003c/h3\u003e\n\u003cp\u003eParticipants shared examples of cost containment strategies both during school and after graduation. For example, one participant stated, \u0026ldquo;During that time I tried to live, you know, below the means as best as possible. I definitely took it into consideration. Throughout school I lived with 2 other roommates, so, you know, I really kind of took those into consideration.\u0026rdquo; Another participant stated, \u0026ldquo;We were, you know, buying day old bread.\u0026rdquo; Lastly, a participant mentioned, \u0026ldquo;We were budgeting heavily. We were trying to be really frugal with cutting costs.\u0026rdquo;\u003c/p\u003e\n\u003ch3\u003eTheme 3: Loan Repayment Plans\u003c/h3\u003e\n\u003cp\u003eEvery participant discussed their current loan repayment plan. All had a good understanding of their repayment plan. For example, those in the Public Service Loan Forgiveness (PSLF) plan know that they must remain in a non-profit setting for 10 years in order to have their loans repaid.\u003c/p\u003e \u003cp\u003eOne participant mentioned working at a Veterans Affairs hospital in the Midwest in order to qualify for their 5-year loan repayment plan:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eSo now I'm in [redacted] at the VA and this specific position, not all the VA positions have. It offers education, debt, reduction program, and so that one will actually pay up to $200,000 of my student debt over the course of 5 years. So that's kind of this was the end of my first year for that. So that's kind of where the $40,000 came from as I paid that this year, and then we'll continue the next 4 years here in [redacted] at the VA to kinda keep working that debt down. It's the education debt reduction program. Not every position has it. But this year physical therapists were included, and, like the last couple of years, they were included in that. So, it varies on which professions are like kind of high need. And then not every VA will offer it. So that's how I ended up in [redacted].\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOthers were optimistic about the loan forgiveness that they are participating in:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eBecause Mayo is nonprofit, I wanted to start paying towards the public service loan forgiveness while I'm here. And so, I'm doing that, and I'm doing that on the SAVE plan. So that keeps my monthly payments pretty well.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant mentioned, \u0026ldquo;I feel okay with my student debt. I know it\u0026rsquo;s a lot, but I also know that I\u0026rsquo;ll make my way toward forgiveness because I don\u0026rsquo;t really intend on being out of the PSLF. Or worst-case scenario, if I have to go with the income-driven repayment plan and I feel like I\u0026rsquo;d be able to make the payments on the income driven plans.\u0026rdquo;\u003c/p\u003e\n\u003ch3\u003eTheme 4: Effect of Loans on Professional Life\u003c/h3\u003e\n\u003cp\u003eDue to the qualifications for the loan repayment plans, most of the participants made career decisions based on their debt. Several mentioned that their preferred setting would be in private practice, however, they would not qualify for the PSLF. Therefore, they have compromised to work in a non-profit.\u003c/p\u003e \u003cp\u003eOne participant recently completed a residency in neurologic physical therapy but is not working in her desired setting to qualify for the PSLF. She is working in an acute care hospital, where she works with patients who have cardiovascular issues. She has taken on a PRN job on the weekends to help pay for her student loans and to obtain the direct patient care hours needed to maintain her board-certification in neurologic physical therapy:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eOur current population is\u0026hellip; a lot more\u0026hellip; Cardiopulmonary issues, diabetes and kind of more of like your renal issues tend to be more of like what I'm seeing and especially like in the ICU you know. Now, the goal is, like, to prevent the neurologic impairments that I know that can happen with immobility. But again, it's like, that's not what I really went to Residency for. That's not really what I wanted to spend my time. The PRN job that I do work on the weekends is at an inpatient rehab and so that's kind of one way I'm able to get like those patient populations in and continue to. You know, practice there, because now that I have my special, like, my specialization. I need to keep the hours up as well. And so, it's like when it's not really as readily available at my full-time job. I'm having to make extra effort to make sure I am seeing like that patient population on the weekends, in order to still maintain my certification, too. So, I'd say it kind of has necessitated the need for making sure. I'm still doing an extra job in order to make sure I can keep up my certification that I went to residency.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOther participants also mentioned that they are working PRN jobs:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eNow I'm working 3 PRN positions just because it makes more than a full-time position.\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003eSo, both of our outpatient or the jobs are about 40 hours a week. And then we're trying to work like 2-ish weekends, two Saturdays a month at the skilled nursing facilities that we both work at and that's for anywhere from like 5 to 8 hours at a time.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant chose to stay at their current job because of the loan repayment program instead of a job closer to home:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI was offered a different job about a year ago that was a little bit closer to home, and like I could spend possibly a little bit more time with my kid, but it didn\u0026rsquo;t have the loan forgiveness. And so it was like, well, am I choosing money over my kid?... Right now I work 45 minutes away from my house and so I\u0026rsquo;m gone probably 8 to 10 hours out of the day, most of the time. And so there\u0026rsquo;s 4 days that I really don\u0026rsquo;t get to see my kid that much.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eLastly, one participant mentions, \u0026ldquo;I don\u0026rsquo;t want to say it prevents me from getting a different job, but it definitely impacts where I can work.\u0026rdquo;\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003eTheme 5: Effect of Loans on Personal Life\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eIn addition to the effects professionally, most participants mentioned ways that their student debt affected them personally. This included their ability to make large purchases, have children, and activities to improve their quality of life (e.g. vacations).\u003c/p\u003e \u003cp\u003eFor example, one participant mentions, \u0026ldquo;The one that\u0026rsquo;s probably impacted me the most is I can\u0026rsquo;t apply for any more loans. So beyond, like our mortgage, we talked about like consolidating some debt and doing all of this. And like I can\u0026rsquo;t get approved for anything now because of my student loans\u0026rdquo;.\u003c/p\u003e \u003cp\u003eAnother discussed strategies to minimize their costs: \u0026ldquo;We\u0026rsquo;re driving, you know, beater cars. We were able to buy a house, but that\u0026rsquo;s why we moved out to [redacted], away from family, because it\u0026rsquo;s cheaper cost of living.\u0026rdquo;\u003c/p\u003e \u003cp\u003eLastly, one participant talked about how their student debt played a role in their decision to have children: \u0026ldquo;My wife and I originally were thinking about trying to get out of student debt before we had kids. And then we realized how late that would have been. We\u0026rsquo;re like, no, we can\u0026rsquo;t do that. So, we didn\u0026rsquo;t do that.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTheme 6: Effect of Loans on Mental Health\u003c/h3\u003e\n\u003cp\u003eAlmost all of the participants mentioned being stressed or frustrated with their current debt load.\u003c/p\u003e \u003cp\u003eOne participant mentions their frustrations: \u0026ldquo;I don\u0026rsquo;t regret getting my doctorate. I don\u0026rsquo;t regret any of that, but the fact that, like now, I can\u0026rsquo;t even get the smallest loan to do anything, even though I make good money, and my payments are not that high is just really frustrating more than anything else.\u0026rdquo;\u003c/p\u003e \u003cp\u003eAnother participant reported, \u0026ldquo;You definitely have that black cloud always hanging over.\u0026rdquo;\u003c/p\u003e \u003cp\u003eSeveral participants discussed the unfairness of the salaries in the medical systems they work in. For instance, one participant mentioned, \u0026ldquo;I just talked to my sister-in-law about what she's making hourly and what I'm making hourly, and it's about the same. And I love my nurses and I value them, but like it's a doctorate program. It was not an easy program. So, I can't quite understand, like, why our salaries are so similar.\u0026rdquo;\u003c/p\u003e\n\u003ch3\u003eTheme 7: Financial Literacy\u003c/h3\u003e\n\u003cp\u003eThe categories that were included in this theme included various sources of financial literacy (e.g., family, undergraduate programs, graduate school), as well as discussions about how they chose their physical therapy program and advice they would give to others. When asked about their knowledge of or comfort in the loan process, participants stated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIt can be so confusing, even with people coming in to talk about you. It\u0026rsquo;s just a confusing process.\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003eI would say, yeah, pretty blind. I feel like I had in my head, like, oh, people take out loans all the time. I can do it too. But you know that\u0026rsquo;s not a very good strategy.\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003eI definitely wish I did a little bit more research as to what the cost of each program was.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhen asked about advice they might provide to others:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI am very grateful for my education, but at the time, I also didn\u0026rsquo;t realize the difference between, like, a public-school cost and a private school cost. So just consider that based on whatever\u0026rsquo;s best for that individual.\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003eMake sure that they try and save as much as they can prior and live as frugally as they can during. That\u0026rsquo;ll help reduce the costs. And whatever they don\u0026rsquo;t use at the end of every semester, throw back.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhen asked about budgeting and planning during their physical therapy education, several students mentioned the unanticipated costs associated with completing their DPT. A main source of this was related to their clinical sites being out of state. Due to the lottery system to choose clinical sites, most of the participants had to travel and pay for housing in another city. Several of them mentioned having to pay rent in two places during this time or being creative to lower their costs. For example, one participant mentioned:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eOur first 16 week one\u0026hellip; I got to split that with a classmate. So that would have been like the only one because\u0026hellip; we were in North Carolina, so it was more expensive to live there than it was in Omaha. So that would probably be the only time that I\u0026hellip; felt like I probably spent a little bit more and was like a little tighter.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant mentioned how clinical placements could affect expenses, \u0026ldquo;I guess the only [costs] that I really didn't anticipate was\u0026hellip; expenses related to clinicals, especially if, you know, you were placed in a spot that you weren't anticipating getting, and then you have to figure in living situations or depending what part of the country you're in depends on, you know, expenses.\u0026rdquo;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe cost associated with becoming a physical therapist is unmanageable for the majority of US students. According to Shields and colleagues,\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e \u0026ldquo;29% of physical therapy students graduate with more debt than could be supported by entry-level salaries.\u0026rdquo; This study highlights both known and unknown consequences of high student debt load in young PTs. These include the effects on personal and professional finances, mental health, and career choices.\u003c/p\u003e \u003cp\u003eThe results of this study show that there are more professional effects of high student debt than what is currently known. Early PTs are making decisions regarding their careers based primarily on loan repayment plans. This may be to the detriment of their overall professional goals. For example, choosing to work in a setting that is not related to their board certification or choosing to work at a location because of the loan repayment plan, but in a city where they do not have any social support. A systematic review investigating the risk factors associated with physical therapist burnout found that unsatisfactory social support and lack of partnership in the home (single, separated, divorced, or widowed) were risk factors for burnout.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn addition to professional effects, all of the participants mentioned ways that their student debt has affected them personally. They continue to live frugally and are unable to make large purchases and go on vacations. Some of them have chosen to live in areas with a lower cost of living.\u003c/p\u003e \u003cp\u003eHigh student debt is also affecting young professionals\u0026rsquo; mental health. This ranged from expressing frustration with their situation to feeling stressed, depressed, anxious, and/or embarrassed about their student debt. These results are in agreement with a study assessing stress in health professions students.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e In this study, they found that \u0026ldquo;health professions students in a public academic medical center had a \u0026ldquo;medium amount\u0026rdquo; of stress, on average, from financial debt. Students also appeared to base their post-professional career aspirations, at least in part, on the stress they experienced from financial debt. For example, choosing a job based on the salary instead of their preferred setting. This is in agreement with other studies that show a strong relationship between student debt and stress for DPT students.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn the same study by Dickson and colleagues,\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e stress was associated with the amount of student loans students expect to accrue and their financial self-efficacy. Financial self-efficacy was found to be a potential moderator for debt-related stress. Other studies have found a correlation between self-efficacy and financial anxiety for physical therapy students. The authors recommend implementing education on strategies to manage student debt to improve self-efficacy and decrease financial stress.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOne aspect of student debt that has not been investigated is the role of COVID. Many of the participants discussed how COVID masked the reality of their student loan situation. When these PTs graduated, most of them went into automatic forbearance because of COVID. Some chose to pay down their loans during this time. Others chose to save money for other things (retirement, emergency fund). When these interviews occurred, the forbearance had just ended. During COVID, the government allowed for a pause in student loan payments and interest rates were set at 0%. This ended in September 2023, which was around the time of the interviews. Many of the participants we interviewed were able to join programs through their employment or the government that allowed for very low payments. This has led to many concerns about how their loan repayment plans are at the mercy of the government and the current administration. This has added to their anxiety and stress. Since COVID likely hid the reality of their student loan situation, the participants had not actually experienced the true effects of holding onerous and overwhelming student debt. Therefore, they likely have not begun to experience the grave personal or professional effects, such as delaying major life milestones.\u003c/p\u003e \u003cp\u003e The final category from this study was related to financial literacy. Many of the PTs felt unprepared from a financial literacy standpoint as they started their graduate programs. While most of them knew the cost of their education, they did not have a strong understanding of loans or loan repayment programs prior to graduation. Financial literacy programs should be implemented prior to graduation to assist students with student debt management, as students with higher levels of student loan debt have been shown to have lower financial literacy. \u003csup\u003e \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e \u003c/sup\u003e If financial literacy can effectively decrease the amount of student loans early professionals take out, it will decrease their overall debt load due to interest as well. At a minimum this should include budgeting techniques while in school and a comprehensive review of the loan repayment programs available. Sawyer and colleagues \u003csup\u003e \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e \u003c/sup\u003e recommend integrating financial literacy into DPT curricula and increasing awareness of financial resources available. A recent national study of third year DPT students showed that those individuals that received debt management education during their PT program had, on average, \u003cspan\u003e$\u003c/span\u003e3,520 less student debt and \u003cspan\u003e$\u003c/span\u003e570 less credit card debt compared to those that did not. \u003csup\u003e \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e \u003c/sup\u003e While these amounts may appear small in comparison to the total amount of debt many DPT students take on, over the course of the loan repayment period it adds quite a bit more to the total amount that must be repaid by the debtor. \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBased on the results of this study, it is recommended that physical therapist education programs improve financial literacy of their students and provide transparency regarding costs, including potential unanticipated costs. It is imperative that this information be made available to potential applicants of physical therapy programs. The APTA\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e recommends several actions to reduce the impact of student debt. These include promoting awareness of the debt to income ratio for PTs, financial literacy programs, alternatives to student loans (e.g., grants, work study), education on loan forgiveness and employer assistance programs, changing DPT curriculum, and increasing research in these areas.\u003c/p\u003e \u003cp\u003eSignificant student debt has substantial consequences for young clinicians. Addressing the student debt crisis in physical therapy requires systemic solutions, including increased advocacy for loan forgiveness programs, financial literacy education, and strategies to reduce educational costs. By alleviating the financial pressures faced by new graduates, the profession can better support a workforce that is motivated, well-distributed across diverse practice settings, and equipped to meet the growing demand for physical therapy services. Without such interventions, the sustainability of the profession and the accessibility of care for patients may be jeopardized.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study used a convenience sample, and the participants were graduates of one institution, which may limit generalizability or transferability to other PTs. Additionally, this small sample size may not have captured the full range of perspectives on the effects of student debt.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eEthics approval and consent to participate\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Creighton University’s Institutional Review Board under reference number 2003974-01. All procedures performed in this study involving human participants were conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all individual participants included in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConsent for publication\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAvailability of data and materials\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available to protect the privacy and confidentiality of study participants. Data access may be granted upon reasonable request and subject to approval from the corresponding author and Creighton University’s Institutional Review Board.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eClinical Trial Number\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCompeting interests\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eCreighton University, George F.\u0026nbsp;Haddix\u0026nbsp;President's Faculty Research Fund\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAuthors' contributions\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eSS assisted with project conception, performed one-on-one interviews, helped analyze the data, and was the primary author for this manuscript.\u003c/p\u003e\n\u003cp\u003eBR assisted with data collection and provided feedback on the manuscript.\u003c/p\u003e\n\u003cp\u003eJQ helped analyze the data and edit the manuscript.\u003c/p\u003e\n\u003cp\u003eAL assisted with project conception, helped analyze the data and edit the manuscript.\u003c/p\u003e\n\u003cp\u003eBC assisted with project conception, helped analyze the data and edit the manuscript.\u003c/p\u003e\n\u003cp\u003eGD assisted with project conception, performed one-on-one interviews, helped analyze the data, and edit the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAcknowledgements\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the participants for their time and input for this study.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAuthors' information\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eSS\u0026nbsp;is an associate clinical professor of physical therapy at Creighton University in Phoenix. She earned her Doctor of Education from Arizona State University and her Doctor of Physical Therapy degree from the University of Southern California. She is board certified by the American Board of Physical Therapy Specialties in both orthopedics (emeritus) and geriatrics (emeritus). Her current research is focused on student debt and first-generation college students in healthcare programs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBR\u0026nbsp;is a doctoral physical therapy student at Creighton University in Phoenix pathway. She also serves as a student research assistant.\u003c/p\u003e\n\u003cp\u003eYQserves as an Assistant Professor of Occupational Therapy at Creighton University, with more than 15 years of experience in research design, statistical analysis, and assessment. His engagement extends to teaching in both entry-level and post-professional OTD programs.\u003c/p\u003e\n\u003cp\u003eAL\u0026nbsp;is an Associate Professor of Occupational Therapy at Creighton University and the Director of the Post-Professional Occupational Therapy Doctoral Program. She shares her expertise and research interest in leadership, health care accreditation, management/administration, program development, and quality with students in the entry-level and post-professional OTD programs.\u003c/p\u003e\n\u003cp\u003eBCis a Professor of Occupational Therapy at Creighton University. She has over 30 years of expertise in academic administration, leadership, health care professions assessment and leadership. She teaches in the entry-level and post-professional OTD programs.\u003c/p\u003e\n\u003cp\u003eGD is a professor of Physical Therapy at Creighton University in Phoenix. Dr. Del Rossi holds a PhD in Sports Medicine and has a background in exercise and sport sciences. His research interests include pre-hospital emergency care, educational outcomes and higher education.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDickson T, Mulligan EP, Hegedus EJ. Impacts of educational debt on physical therapist employment trends. BMC Med Educ. 2023;23(1):459.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHandlery K, McQueeney S, Handlery R, Regan EW, Fritz SL. Factors contributing to physical therapist attrition: A qualitative study. J Allied Health. 2024;53(1):E1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmerican Physical Therapy Association. Impact of student debt on the physical therapy profession [Internet]. 2020 [cited 2024 Nov 27]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.apta.org/apta-and-you/news-publications/reports/2020/impact-of-student-debt-on-the-physical-therapy-profession\u003c/span\u003e\u003cspan address=\"https://www.apta.org/apta-and-you/news-publications/reports/2020/impact-of-student-debt-on-the-physical-therapy-profession\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerry JW. A national survey of student loan debt accrued by Doctor of Physical Therapy students. J Phys Ther Educ. 2021;35(1):12\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWebster P, North SE. Health professions educational debt: personal, professional, and psychological impacts 5 years post-graduation. Front Med. 2022;9:746463.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePew Research Center. The toll of student debt on millennials and professionals in healthcare [Internet]. 2021 [cited 2024 Nov 27]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.pewresearch.org\u003c/span\u003e\u003cspan address=\"https://www.pewresearch.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmbler SB. The debt burden of entry-level physical therapists. Phys Ther. 2020;100(4):591\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHall LH, Johnson J, Watt I, Tsipa A, O\u0026rsquo;Connor DB. Healthcare staff wellbeing, burnout, and patient safety: A systematic review. PLoS ONE. 2016;11:e0159015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuan E, Bustos Sanabria GJ, Culumber J, Hammond RW, Sanchez-Gonzalez MA. Impact of provider burnout on the quality of healthcare services: A brief review. J Prev Complement Med. 2024;3(2):103\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAssociation of American Medical Colleges. These physicians work in underserved communities. The National Health Service Corps helps make that financially feasible [Internet]. 2021 [cited 2024 Nov 27]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.aamc.org\u003c/span\u003e\u003cspan address=\"https://www.aamc.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAssociation of American Medical Colleges. The impact of debt on medical graduates' career choices [Internet]. 2020 [cited 2024 Nov 27]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.aamc.org\u003c/span\u003e\u003cspan address=\"https://www.aamc.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePabian PS, King KP, Tippett S. Student debt in professional doctoral health care disciplines. J Phys Ther Educ. 2018;32(2):159\u0026ndash;68.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCreswell JW, Poth CN. Qualitative inquiry and research design: choosing among five approaches. 4th ed. Thousand Oaks, CA: Sage Publications, Inc; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShields RK, Suneja M, Shields BE, Tofte JN, Dudley-Javoroski S. Healthcare educational debt in the United States: Unequal economic impact within interprofessional team members. BMC Med Educ. 2023;23(1):666.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurri SD, Smyrk KM, Melegy MS, Kessler MM, Hussein NI, Tuttle BD, et al. Risk factors associated with physical therapist burnout: A systematic review. Physiotherapy. 2022;116:9\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDickson T, Mulligan EP, DeVahl J. The toll of student debt: stress among health professions students and the promising role of financial self-efficacy on career choices. J Phys Ther Educ. 2020;34(4):339\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDutton LL, Anderson CE. How stressed are they? Levels and sources of stress in Doctor of Physical Therapy students. J Allied Health. 2021;50(4):277\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMulligan EP, Pabian PS, Dickson T. Socioeconomic influence on physical therapist student financial literacy, self-efficacy, stress, and anxiety. J Phys Ther Educ. 2023;10\u0026ndash;1097.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavila H, Hilliard J. Financial literacy and student debt: Survey of college students [Internet]. 2024. Available from: SSRN 4836687.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSawyer EE, Eigsti H, Gorman I, Reinking M, Struessel T. A financial literacy pilot project: Are matriculating DPT students prepared to manage their debt? J Allied Health. 2024;53(3):196\u0026ndash;202.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmerican Physical Therapy Association. Impact of student debt on the physical therapy profession. Arlington, VA: American Physical Therapy Association; 2020.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"student debt, physical therapists, graduate school, financial literacy","lastPublishedDoi":"10.21203/rs.3.rs-6701681/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6701681/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe increasing cost of higher education has led to significant levels of student debt among new graduate physical therapists (PTs). This financial burden impacts graduates and likely has broader implications for the physical therapy profession. The profound consequences of student debt are still not fully understood. The purpose of this study is to determine to what extent significant student debt affects early PT\u0026rsquo;s personal and professional lives.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAn exploratory, qualitative study design, grounded in a constructivist paradigm and informed by phenomenological principles, was used to explore the experiences of PTs with high student debt. Participants included PTs that graduated between 2018 and 2022 with a self-reported minimum student debt of \u003cspan\u003e$\u003c/span\u003e100,000 from their education. Semi-structured interviews were used to explore the effects of student debt on participants personal and professional lives. Using an inductive, interpretive approach, the data was analyzed by two investigators to determine consensus on themes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTen participants completed the study, revealing 7 main themes: the role of COVID, cost containment strategies, loan repayment plans, the effect of loans (professional), the effect of loans (personal), mental health, and financial literacy.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study highlights both known and unknown consequences of high student debt in young PTs. There are more professional effects of high student debt than what is currently known. Early PTs are making career decisions based primarily on loan repayment plans. This may be to the detriment of their overall professional goals. All of the participants mentioned ways that their student debt has affected them personally, including increased mental health concerns. Many of the participants also discussed how COVID masked the reality of their student loan situation. It is recommended that physical therapist education programs improve financial literacy of their students and provide transparency regarding costs, including potential unanticipated costs.\u003c/p\u003e","manuscriptTitle":"Qualitative Study on Student Debt: Implications for Physical Therapists’ Professional and Personal Lives","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-16 10:24:50","doi":"10.21203/rs.3.rs-6701681/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-17T17:02:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-19T06:45:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-18T05:10:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"326392916088055866617896140456218279301","date":"2025-06-15T08:17:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"120902084059102254849471330383088552580","date":"2025-06-13T10:47:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-13T07:02:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-11T12:41:42+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-23T04:15:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-22T16:59:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-05-22T16:58:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"255bbeb9-8922-422b-bb01-75c6e1dd1f45","owner":[],"postedDate":"June 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-20T08:54:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-16 10:24:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6701681","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6701681","identity":"rs-6701681","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}