Feature Reckoning With Reentry Stepping out from full-time practice looks different from how it once did. The options during and after a hiatus vary for PTs and PTAs. By Eric Ries | April 2020 A lot has changed in the profession of physical therapy since 1994, when Beth Domholdt, PT, EdD, FAPTA, conducted a question-and-answer interview on "Reentering Practice" for this publication's predecessor, PT Magazine. Back then, Domholdt — not yet a Catherine Worthingham Fellow of APTA — was dean of the Krannert School of Physical Therapy at the University of Indianapolis. The school offered a "clinical update" program geared in part toward "inactive" PTs returning to the profession after an extended absence. The most typical reason for those hiatuses, the article noted, was pregnancy and childrearing, with nearly 40% of female APTA members, according to the association's 1993 Active Member Profile Report, having reported one or more career interruptions of unspecified length. Domholdt described the refresher course as "a week-long program that covers the health care system, basic evaluation techniques, clinical neuroanatomy, treatment techniques for neurological and orthopedic conditions, thermal agents and electrical stimulation, and current issues in physical therapy." For longtime PTs, that description is a trip down memory lane to a time when modalities played a much bigger role in the physical therapy plan of care than they do today. It's also, says Domholdt — now director of the School of Health Sciences at Cleveland State University and a professor at the school — a window on a time when full breaks from the field likely occurred significantly more often than they do today. "Although I don't have any data to back it up, my perception is that completely interrupting one's career is far less common today than is slowing it down or working part-time," Domholdt says. A big reason for that ties to an observation she had made in that 1994 piece: Full career interruptions reportedly were less common at that time among female physicians than they were among female PTs. "One theory," Domholdt told her interviewer, "is that the more time a person invests in acquiring professional knowledge and credentials — and the more money a person invests in that acquisition — the less likely he or she is to take a leave of absence." "As PT education has moved from the baccalaureate level, where it was when I started my career, to the entry-level doctorate, you've got more skin in the game," Domholdt observes. "You've invested more time and money than you did in the old days — when some PTs perhaps felt freer to completely stop out. Most recent graduates have student loans to repay. Now more than ever, you're looking to maximize the return on your investment." "The second piece that's changed a lot," Domholdt adds, "is that very few states used to require continuing education to maintain your license. Most PTs could do so by just sending in a relatively small check every couple of years." Now, according to the Federation of State Boards of Physical Therapy, every state except Maine and Massachusetts requires some number of continuing competence/education units. This means, Domholdt says, that "the therapist who isn't currently working in the field still needs to invest time and some amount of money to attain the continuing education hours required to maintain their license." Most PTs, she observes, "do not want to be in the position of needing to retake a licensure exam many years after having received their initial education." Another factor in keeping up with the profession while on hiatus, she notes, is that compared with 1994, "there are many, many more ways to see what's going on in the profession and to educate yourself, via online continuing education and other web resources." Stephanie Kelly, PT, PhD, dean of College of Health Sciences at the University of Indianapolis, says the school stopped offering its "clinical update" program more than 10 years ago for lack of registrants. In addition to the factors cited by Domholdt, she adds that the growth of transitional DPT programs seemed to be meeting many of the needs of "return-to-practice" individuals. One thing that hasn't changed in the past 25 years, however, is that PTs — and PTAs, of whom nearly one in five reported having had one or more career interruptions, per APTA's 1992 Affiliate Membership Profile Report — still are taking time out to have and raise children. While APTA no longer keeps statistics on career interruption, the observations and experiences of five individuals interviewed by PT in Motion shed additional light on the forces described by Domholdt and Kelly, and on how those factors shaped each person's reentry strategy. Spa Break Sherri Berner, PT, had been a clinician for nearly 20 years when she decided to take a "detour" in 2003 to open a day spa in her native Florida. She jumped with both feet into the opportunity to continue to serve clients in a hands-on way while avoiding such hassles as dependence on physician referrals and problematic insurance authorizations. "I wanted to work on the prevention side of health care, and, as a survivor of malignant melanoma, I had a special interest in skin care," she says. Berner became a licensed esthetician and nail technician, and built her business from the ground up. "I liked that people were coming to see me of their own choice — that they wanted to be there and were willing to pay out of pocket. I was doing everything from body treatments, facials, manicures, and pedicures to building maintenance, hiring and firing, payroll and bookkeeping, and marketing," she says. Over the course of the three-and-a half years, Berner's staff grew from two employees to nine. Then, in 2005, something unexpected happened. "Lo and behold, at age 41 our one and only child was born," Berner recounts. She sold the day spa to become a stay-at-home mom. It wasn't until 2009, when her son reached preschool age, that she returned to work as a PT — in home health, a setting in which she'd worked earlier in her career. She'd been away from the profession for more than five years. Away from it, but not completely apart from it — by design. "There was no way I ever would have let my physical therapy license lapse. I'd worked too hard for it," Berner says. "And I love the field of physical therapy. The body of knowledge that PTs have and the many ways that we can help people are incredible." Florida required completion of 24 continuing education hours every two years. "If I attended a conference of our state chapter, I usually could find a course in a skillset that could be applied to both physical therapy and the spa industry, such as reflexology," she explains. "Attending those conferences also helped me keep track of what was going on in the profession legislatively and politically." An added intangible was that Berner's husband is a PT. "So, even though I wasn't practicing, I was still 'speaking the language' throughout that period," Berner says. "That helped me feel connected, as well." Returning to practice wasn't that big an adjustment for her a decade ago, she says, but she wonders how she'd have felt if the changeover to electronic health records (EHRs), in their varied manifestations from employer to employer, had occurred during her absence rather than after her return. "When I came back, documentation still was being done on paper," Berner notes. "Recently, I hired on with a company whose EHR system is night-and-day from the one I used where I'd worked before. A day and a half of my new-employee orientation was spent on documentation alone. For this old-school girl, that's challenging! But it certainly helped that I'd already had years of experience using EHRs." Berner's advice to PTs who are planning or embarking on a timeout from clinical practice? "The first thing is, maintain your license in your state," she says. "That to me is a no-brainer. Take continuing education courses that interest you, and keep up with the profession as best you can by visiting the websites of your chapter and APTA, reading their publications, and attending professional meetings in person if you can." A Lengthy Observation Jen Cohen, PT, on the other hand, did allow her license to lapse. She readily admits that the amount of time and effort it took to reinstate it was substantial. Still, she says, it all was for the best. "I graduated from PT school in 1999 and began my career in the Chicago area, where I'm from. But I stopped working as a PT in 2005, when I was pregnant with my first child," she recounts. "I was living in New York at the time and we had no family to help us. I knew I wanted to be a stay-at-home mom. After my third child was born we moved back to Chicago to be closer to family. Once my youngest was in school I was ready to return to work." That was in 2016. "I decided to start my own business making organic personal care products," Cohen continues. "I did that for about a year, but I found that it just wasn't fulfilling in the way that being a PT had been. So, I looked into what I would need to do to get my license reinstated in Illinois. That turned out to be 360 hours of clinical observation and 40 continuing education hours. It was either that or sit for my boards and take the licensing test all over again." She chose the first option. "It was daunting," she concedes. "It had been a long time since I'd worked as a PT, and I hadn't been taking any courses or reading research papers." Like Berner, Cohen didn't feel completely out of the loop because she had a relative — a sister — who's a PT. "She would talk about her work and classes she was taking. But, still, that was very different from practicing." When she started her observation hours — which took her about six months to complete — "I felt overwhelmed. There was a lot of rust — going through the screening process and trying to remember all the special tests and their indications. Things like documentation and coding took some time to get used to again," she says. As she continued fulfilling her observation requirement, however, "it felt like riding a bike after a while. I'd been very fortunate in having had some outstanding mentors earlier in my career, and the people at Bannockburn were great." That was Bannockburn Chiropractic and Sports Injury Center in the eponymous Illinois city, which was sufficiently impressed by Cohen's abilities that it hired her once her license was reinstated in fall 2018. While Cohen doesn't quite advise others to take the route to reentry that she did — "If you're going to leave for 10 years, you might want to be keep an eye on what you need to do to maintain your license, and plan accordingly," she wryly suggests — she has no regrets. "I learned so much during those observation hours and regained the confidence that I needed to return to practice," Cohen says. "If I'd kept up with my continuing education, yes, I'd have acquired additional knowledge and tools. But the best part about completing those courses is taking what you learn back to the clinic and applying it — which I would not have been able to do." In fact, Cohen couldn't be happier with the way things worked out. "I made a lifestyle choice at the time that was right for me and my family," she says, "and now I'm back to doing what I love — helping people in a profession that's constantly evolving and adding to my knowledge base every day." Change of Direction There's a certain irony, says Krissa Reeves, PTA, MEd, in the job she now holds. But in a very real sense, her career hiatus and what she did during that time — in addition to taking care of as many as four children — led to a change of direction within the profession. Reeves had worked for 10 years as a PTA in outpatient orthopedic clinics until, about a year after her first child was born, she elected to become a stay-at-home mom. Over the course of the next three years she had another child. Her sister, who wasn't able to stay at home, had two — the second of whom was born prematurely — who Reeves also looked after. "Four kids was kind of crazy, but I loved being home with them," she says. "It was such a blessing that my sister's second child, especially, was able to stay with family rather than being put in daycare." But Reeves also loves physical therapy. She knew that she'd return to the profession. Wisconsin, where she lives, requires 20 hours of continuing education every two years. She not only met that requirement, but she stayed active with her state chapter and APTA, attending conferences and keeping up to date with developments in advocacy, research, and other realms. Reeves, who had been a clinical instructor for PTA students before her hiatus, took the training to become an onsite reviewer for the Commission on Accreditation in Physical Therapy Education. "I did a couple of site visits a year, which helped me stay current and involved," she says. That and her clinical instructor experience prompted her to enter Auburn University's online master's degree program in adult education. Those steps and all the networking she'd done within the state chapter proved critical when Reeve learned that the position of PTA program director had opened up at Chippewa Valley Technical College in Eau Claire. "I had discovered that I really enjoyed working with PTA students when I was a clinical instructor," Reeves says. "So, when the position at Chippewa Valley came available, I jumped on it. I'd already begun the master's program. Because of my continued involvement in the profession and all the connections I'd made, I had good references. In fact," she adds, "a plug from our chapter president helped me get the job." The school hired her as an instructor in August 2017 with the understanding that she'd assume directorship of the PTA program when she completed the master's program. She earned the degree in December 2018 and became director the following month. The irony was that she'd spent years vowing to her mother, an elementary school teacher, that she'd never follow in her footsteps as an educator — having visited her classrooms and seen what a handful a classroom of children can be. "It's definitely a different kind of teaching in a PTA program," she says. "But my mom and I laugh about where my career is now. She'll say, 'So, let's review the situation: You have an education degree now, and you're a full-time academic.'" What her experiences tell Reeves, who also is a member of APTA's PTA Caucus, is that involvement in the profession is critically important to reentry. "Without the connections I made and the confidence-building activities in which I was involved while I wasn't working as a PTA, I'm not sure where I would be now," she says. The Entrepreneurial Route "My boss is amazing — best boss ever!" exclaims Carrie Pagliano, PT, DPT. She's laughing as she declares this. Since February 2018, when Carrie Pagliano Physical Therapy opened its doors in Arlington, Virginia, she's been happily self-employed. Pagliano's office schedule — 12 to 15 hours per week of patient care — is highly accommodating of her family life; she and her husband have an 8-year-old son and a 6-year-old daughter. While it's true that a business owner's work never is really done, given the wide variety of associated administrative and business development demands, it nevertheless "doesn't feel like work," she says. "I choose the hours I want to work, based on my kids' schedules, child care, and whatever else is going on," she notes. "I can flex my patient care and administrative hours. I can work more or less in person or virtually via telehealth, depending on the patient's and my needs." Pagliano has company. Nearly two years ago, she and Lauren Sok, PT, MPT, a friend with whom she'd gone to PT school, started a Facebook group called PT Mompreneurs that had grown to include more than 700 members by the beginning of this year. "It's a community of people who gather online to share ideas and resources, answer each other's questions, and provide reassurance that moms can do this even if they don't have any business training," Pagliano says. "A lot of entrepreneur groups out there are predominantly male and tend to be very pedal-to-the metal. At PT Mompreneurs, people aren't afraid to say that they have family responsibilities and may need to take things a little slower. "I've been shocked and thrilled by the amount of interest and excitement this site has generated," she adds. "It's empowering for women to see that they're not the only ones doing or attempting this. People are happy to share the experiences they've had, the mistakes they've made, and the lessons they've learned, in hopes of making things a little easier for others who are seeking entrepreneurial opportunities." Pagliano worked full-time for more than 10 years prior to her first pregnancy. She alternated between PRN, full-time, and part-time work over the next several years before testing the waters with what she calls a "side hustle" in 2017. "There's a lot of flexibility in pelvic health physical therapy," says Pagliano — who should know, as immediate past president of APTA's Academy of Pelvic Health Physical Therapy. "I thought, 'Maybe I can do home care and work with pre- and postpartum moms.' I explored the market within a small geographic radius and soon built enough of a caseload that I felt 'I can do this as a private practice. This is going to be sustainable.'" She's quick to tout pelvic health as an attractive practice area for women reentering the workforce after pregnancy and childrearing, given its wealth of opportunities for PRN work and entrepreneurship. And it's a great way to give back, adds Pagliano, who's a national media spokesperson for APTA on issues such as the importance of the "fourth trimester" — the early months after delivery when health care involvement remains vitally important to ensure optimal recovery from pregnancy for the mother and optimal postpartum care for the child. "A lot of the PTs and PTAs join the academy after they have kids," Pagliano notes. "Many shift over from another area — pediatrics, geriatrics, orthopedics — because they learned a lot through their own experiences and want to know more. It's natural to them, then, to want to share that knowledge with women who are going through the same things they did." Which leads her to a piece of advice about which she feels very strongly. "One challenge for PTs and PTAs who step out from their career can be whether to maintain membership in APTA — especially if money is tight. But I always urge individuals to do so. The resources that the association and its sections offer are invaluable, and the opportunities to continue feeling connected to the profession are so important." "I distinctly remember writing an entire Combined Sections Meeting presentation while I was on maternity leave with my second child," Pagliano says. "Fortunately, she was a great sleeper." A Matter of Degree When Gretchen Milanese, PT, DPT, gave birth in January 2010, she took a leave from her 12-year career as a PT that lasted until May 2015. But she wasn't completely inactive. She often was able to put in two or three four-hour per diem shifts per week at a hospital system. She also did some consulting for her most recent pre-break employer, a private practitioner. Both activities held her in good stead when she returned to a regular job as a PT. "Per diem allowed me to keep my skills fresh," Milanese says — "the flow of evaluations, the variety of treatment plans, and the juggling of caseloads. It also was an opportunity for me to learn from a lot of different therapists — how each of them managed certain conditions, the treatments they selected, and the exercises they prescribed. I developed a network of PTs who I still seek out for guidance if I'm struggling with a patient or if I need the services of a specialist that my office doesn't offer." That office is Empire Health and Wellness Center in Latham, New York; Milanese had retained a connection with the facility during her hiatus through the consulting work. Its owner offered her a job there when she returned to regular PT work in 2015. That was great, but it wasn't the end of her reentry story. Her boss and her coworkers inspired her by their example to raise her knowledge and skills to a higher level. Brendan Sullivan, PT, DPT, Empire's owner, hadn't yet earned his clinical doctorate, but he was working on it. Sullivan was pursuing a postprofessional DPT, and his enthusiasm for what he was learning was infectious. "His vision was not only to improve his own skills but also to elevate the practice," Milanese says. "He wanted there to be consistency of evidence-based practice in how patients were being looked at and treated. He wanted patients to have 30 minutes one-on-one with a PT. He was committed to a team approach in which a PT could do manual work with a patient in a private room because a colleague would jump in to keep an eye on that PT's other patient during exercise." All of that matched nicely with the skillset of Milanese's younger DPT colleagues. But with her own skillset, she quickly realized, not so much. "When I went to school there wasn't the focus on evidence-based practice that there is today," she notes. "There was a lot of e-stim, ultrasound, hot packs, then therapeutic exercise. More people come to the outpatient setting now with acute issues and chronic pain," Milanese observes. "The younger PTs with whom I was working really knew the literature." She found their way of thinking to be fresh and modern in a way that hers was not, and their manual therapy skills to be superior to hers. So, Milanese made the commitment to pursue her own postprofessional DPT — and to earn manual therapy certification while she was at it. Most of the work was online, with some traveling and in-person activity required. It took about a year and a half and, all-told, cost about $12,000 — with Empire picking up half the cost. It required a lot of juggling while working 25-hour weeks and meeting family responsibilities. "There were moments," she understates. "Fortunately, I am very organized and have a very supportive family." She adds with a smile, "I used a crockpot a lot." All the work paid off handsomely, she says, in terms of the value she now offers patients and clients. "I treat differently now from how I did earlier in my career," she says. "I'm much more confident in my manual skills and in building treatment plans. I'm so glad I did it." Her message to other PTs? "It's okay to step away, but maintain your license, choose continuing education courses that enhance your knowledge, and, if at all possible, look for a per diem situation that meets your needs," Milanese says. "It's important to keep a finger in clinical practice. It not only helps maintain your skills, but it's also good to be around other therapists — to see what they're doing and to talk with them about the profession and changes they're seeing." Relocation and Reengagement Beth Domholdt has experienced her own career reentry of sorts in recent years. "I still was dean of the Krannert School in 2005 when I experienced a sudden change in my life. My husband died unexpectedly. I needed a change, so I took a job as vice president for academic affairs at the College of St. Scholastica in Duluth, Minnesota. I went from being in a PT academic position to being in an academic position in which I had responsibility for a whole institution. So, I was figuring out what to do with our choral program, chemistry, business and education programs, the whole shebang. It broadened my administrative and leadership skills," Domholdt says, "but it took me further away from the profession." Keeping up with the continuing education necessary to maintain her PT license and remaining at least somewhat active at the national and state levels helped her "feel not entirely out of it," she says. Then, in 2016, an opportunity arose to meet two goals with one move — to be in better position to help her aging parents and to deepen her involvement with physical therapy. Becoming director of the School of Health Sciences at Cleveland State University narrowed her purview and returned her "closer to rehabilitation." She since has resumed a research agenda, as well. "It's made me feel reengaged," she says. Whatever one's reasons for stepping away from profession for a time, "Cultivate a habit of mind of saying, 'I'm going to continue to learn and grow and develop in this profession regardless of how my career develops,'" Domholdt advises. "Try to keep up with the literature and the various resources available through APTA and your state chapter. Also, connect with colleagues when you can. One of the benefits of attending continuing education courses, beyond the knowledge acquisition itself, is networking with other PTs, exchanging ideas, and learning from their experiences." Eric Ries is the associate editor of PT in Motion. SidebarAPTA offers a webpage on Reentering Physical Therapy Practice at www.apta.org/CareerManagement/Reentry/. It features self-assessment tools; evidence-based practice resources; continuing education options; recommended reading; resources related to documentation, payment, integrity, and licensure; and more.