• Feature

    Beating Burnout

    Its causes are many. So are the ways in which PTs and PTAs can address it and reinvigorate their careers.

    Burnout

    Meredith Castin, PT, DPT, was tired of "being expected to be 3 places at 1 time," then having multiple parties express frustration with her when she failed to do the physically impossible.

    There also was the psychological toll of constantly being outed in what therapy staff called "the log of shame"—a ledger in which they were required to list their billable units at the end of each day. If they hadn't met the hospital's productivity requirements, they had to explain why they'd failed to do so. Housed in the charting alcove, the log was readily accessible to every physical therapist (PT), occupational therapist, and physical therapist assistant (PTA)—who thus could see which individuals were making the performance grade and which weren't.

    Never mind that the southern California PT's productivity was compromised by multiple factors outside her control, such as being scheduled to work in different units simultaneously, having insufficient time to document, needing to remember ever-changing entry codes on doors, and having constantly to walk back and forth among units.

    "I couldn't help but feel inadequate when, for the 10th day in a row, I had to slink to the log to try to justify my 'subpar' productivity," Castin recalls.

    She'd earned her PT license at 31, having found an earlier career as a web designer isolating and wanting to make a bigger difference in people's lives. But now, just a few years later, she was wondering if she'd made the right choice.

    Similarly, a few years ago Sean Hagey found himself working 60-plus hours a week as a home health PTA in the Kansas City area. His patient load of up to 12 visits per day might have been barely manageable—even though he also was driving 100-plus miles per day—if not for the documentation demands.

    "Documentation requirements for EMR [electronic medical records] vary by employer," Hagey observes, "but this particular agency's documentation system was very involved. The form was multiple pages long and required a lot of typing. To do it right, you couldn't cut corners. But that meant that I typically was documenting at home for a couple of hours each night."

    Things finally got to the point that Hagey felt "completely fried."

    Stressed, exhausted, and concerned that he might begin to feel "compassion fatigue" toward his patients, he started seeing a mental health counselor. At the same time, he often was feeling less than fully present in his work. "If a patient tells you his blood sugar was really high last night, but your brain is in a different spot because you're thinking 'I've got to get caught up on this note' or 'I need to call that person,' you might not properly follow up," he observes.

    Hagey, like Castin, felt that something in his work life had to give. The PT and the PTA addressed their situations in different ways.

    Castin first shifted from patient care to health care writing. She then created a resource for people in the therapy professions seeking to leverage their degree without facing untenable productivity requirements, documentation demands, and other problematic elements of patient care. That website, The Non-Clinical PT, started simply as an information resource but has become, to Castin's surprise, an online business as well.

    Hagey, on the other hand, decided he needed to have a "hard discussion" with his employer. "I told the agency, 'I just can't maintain this pace,'" he says. The PTA outlined the reasons he felt it would be best for him and his patients that his schedule be restructured. He was prepared to seek other employment should his appeal go nowhere.

    The agency hardly lauded him for his candor. "They weren't happy about having the discussion," Hagey says. "Still, they did agree to reduce my workload—I think because they made the calculation that it was better for them to keep me than to let me walk, even if I was going to be 'less productive' than they would have preferred." The agency also switched EMR vendors, he notes, which "helped reduce the amount of time spent on documentation, because the previous EMR system had been redundant and was not at all user-friendly."

    The changes reduced Hagey's stress level and made his job manageable, although he "still felt pressure to take on additional patients," he says, and sensed resentment from some of the agency's administrators.

    "It's been my experience, having worked in the outpatient, skilled care, and home health settings, that some companies and agencies place a high value on patient care, achieving good clinical results, and promoting a healthy work culture," Hagey says, "while other employers seem only to care about the bottom line—making a profit. "I have been fortunate," he adds, "to have worked for some outstanding employers along the way."

    While both Castin and Hagey pushed past bleak moments to come out on the other side, they feel that they narrowly dodged a bullet that, they say, continues to claim far too many of their colleagues. That projectile's name is burnout.

    'Rampant and Getting Worse'

    The extent and causes of burnout among PTs and PTAs has been the subject of scant study. It's widely acknowledged, however—both anecdotally and by APTA—as an area of concern for the profession. (For more on the studies, and on association efforts, see "Ripe for Additional Research" and "APTA Tackles Burnout" on pages 31 and 36, respectively.)

    Castin goes so far as to say that burnout in physical therapy is "rampant and getting worse." She bases that statement not only on increasing interest in her website from PTs and PTAs (as well as from those in occupational therapy and speech-language pathology) who express disaffection with clinical practice, but also on popularity of a blogpost1 she wrote for a former employer, CovalentCareers.

    Type the words "physical therapy burnout" into any search engine and you're likely to quickly encounter a piece with the provocative title "Physical Therapy Burnout is Destroying Our Profession." Posted in October 2017, Castin's piece attracted nearly a half-million views in its first 12 months online, and it has brought her communication from scores of clinicians who say they see themselves—and little hyperbole—in the headline.

    Dotted with pseudonyms to protect the identities of the therapists she profiled, Castin's nearly 9,000-word essay kicked off with the story of one of her PT school classmates, who'd been working 2 jobs and logging 40-plus hours per week for over 7 years in order to repay her student loans. "She was always tired but saw no end in sight," Castin wrote.

    The post didn't get cheerier from there. Subsequent subheads read "Set Up to Fail," "You Are Only As Good as Your Productivity Levels," "A Thankless Job," and "Nowhere to Grow." While emphasizing that "the highs of physical therapy are higher than any I will ever feel in another job in my life," Castin added, "the joy is being taken out [of clinical practice] on so many levels."

    Her essay offered a number of suggestions for addressing and mitigating burnout's causes, and quoted advice from PT experts in areas such as financial planning, fair-pay research, clinical mentorship, and mastering work-life balance. Still, the piece ended only with Castin's modest hope that her words would, at the very least, console burned-out PTs that "they are not alone."

    Justin Berry, PT, DPT, PhD, is among the rare individuals who has formally studied burnout in physical therapy. (Again, see "Ripe for Additional Research.") He calls it "a serious issue, due to factors such as productivity requirements, documentation demands, the pressures of student loan debt, reimbursement challenges, and salaries that aren't rising commensurate to the financial demands on PTs." Not only do his studies show that burnout is real, but Berry, like Castin, has been a magnet for disaffected PTs and PTAs due to his association with the issue.

    "A number of PTs and PTAs who've seen my name on studies have thanked me for highlighting this subject, and they've shared their personal burnout stories with me—typically centering on productivity challenges and the burden of student debt," says Berry, who directs the PTA program at Northland Community & Technical College in East Grand Forks, Minnesota.

    While Hagey deems burnout a "huge" problem across the profession, he emphasizes that along with universal causes such as "productivity metrics," some sources of burnout are more PT- or PTA-centric.

    "Obviously, PTAs aren't carrying the debt load from education that most PTs are," he notes. "On the other hand, though, in some clinics PTAs are treated like glorified techs and made to feel that their input isn't welcome. That," he says, "is a recipe for demoralization and burnout."

    Drivers of Burnout

    "The number-one issue related to burnout that I hear from the PTs who contact me is unrealistic productivity requirements, which have 2 devastating effects on clinicians," says Castin. "Unreasonable demands make PTs feel as if there aren't enough hours in the day to optimally do their jobs. They also feel that the way they're being asked to work is compromising the safety of their patients."

    The latter concern was addressed in an article2 that appeared last spring in Federation Forum, a publication of the Federation of State Boards of Physical Therapy (FSBPT). Summarizing a presentation Berry had made at the organization's annual meeting in 2017, the piece was titled "Occupational Burnout in Physical Therapy: Clinical Implications and Strategies for Reduction."

    "A big factor in burnout is feeling compelled to act unethically," the FSBPT publication quoted Berry as having said. "This feeling can happen in some institutions if people are persuaded to overbill due to high productivity requirements or to complete documentation off the clock. With the unethical comes moral distress. Researchers have found that when professionals want to do the right or ethical thing in a situation but can't, due to institutional constraints, they become more morally distressed about their job, leading to a corresponding increase in the rates of burnout."

    Berry had given FSBPT a brief primer on the Maslach Burnout Inventory (MBI), which he'd described as the "gold standard" for assessing burnout. First published in 1981 and the primary basis ever since for most burnout research, it's a 22-question measure of 3 dimensions of burnout—emotional exhaustion, depersonalization (instances in which the clinician feels indifferent toward and distant from patients), and feelings of low personal accomplishment.

    Those burnout dimensions are robustly evident in physical therapy, Berry told the FSBPT—due not only to productivity and billing practices, but also to factors that prominently include "the impact of the increasing cost of physical therapy education and the large debt incurred by students to obtain that education."

    In the decade that ended with the 2014-2015 school year, Berry told the federation, "the cost of PT programs, tuition, and fees went up about 100% at private institutions and about 50% at public institutions." A recent research study of 533 students within 4 months of their graduation, he added, "found that the average loan debt was almost $94,000. Seventy percent [of those recent graduates] had concerns about repaying their student loans." (He'd culled those figures from a 2016 article3 by Diane Jette, PT, DSc, FAPTA.)

    "Debt robs new graduates of options and choices," Berry told FSBPT. "Students with high student loan debt may have to postpone buying homes, having children, or putting money into retirement accounts, leading to personal stress.

    "Student loan debt may influence the choice of setting in which a provider works," Berry continued. "New graduates may take a job they don't necessarily want because it pays more money, leading to an unhappy provider and contributing to burnout."

    In 2017, APTA surveyed recent graduates (2013-2015) of PT and PTA education programs to learn more about their student debt load and experience. Among the 2,839 PT and 588 PTA responses, 87% of PT respondents had debt from their PT education program. Those with PT education debt owed a mean amount of $107,000. Among PTAs surveyed, 53% reported debt from their PTA education program. The mean debt load from PTA education of those PTAs was $23,000.

    Castin says "the school debt-to-income burden" ranks right behind productivity-related concerns among the reasons the PTs she's interviewed, and those who've contacted her, give for their feelings of burnout. While her own debt load was manageable—thanks to savings from her earlier career, scholarship money, and other factors—what Castin often hears from early-career PTs, including those who are otherwise happy in their jobs, is, "I'm barely getting by financially." Many have taken on extra jobs, she says, while others have turned, at least temporarily, to more lucrative employment options such as becoming a travel PT.

    The later scenario is fine for PTs who aren't tied to a particular place, but it might not be ideal or stress-free, Castin says. "Some people," she notes, "are put in the position of deciding, 'I guess I can pay off some of my loans if I leave my significant other behind for a year while he or she stays home and takes care of the kids or pets.'"

    But productivity- and debt-related pressures are hardly the only drivers of burnout in PTs and PTAs. Individuals contacted for this article also cite the roles played by unrealistic expectations, feeling undervalued, feeling stuck in their current position, and lacking the support of enriching mentorship.

    Unrealistic expectations. "When students graduate from their DPT program they have a natural tendency to think they know everything," says Rich Severin, PT, DPT, a clinical assistant professor at Baylor University and a visiting clinical instructor in the University of Illinois at Chicago's Department of Physical Therapy who is a board-certified clinical specialist in cardiovascular and pulmonary physical therapy. "You think you can do anything and manage any case. But it's called clinical 'practice' for a reason," he notes. "Experience matters. Levels of comfort and expertise evolve over time. The learning process never ends. Once you realize and accept that, it actually makes things more interesting and exciting."

    Andrew Kneeburg, PT, wonders if instructors always give students an accurate picture of clinical life in 2019. "Some professors are still practicing clinicians, but others may not have been active in the clinic for 25 years," he observes. "Physical therapy's changed a lot in the past quarter-century, in terms of payment, productivity requirements, and other pressures those academicians didn't face in their day."

    Kneeburg, who practices at Back in the Game Physical Therapy in the Atlanta area, graduated from PT school in 2016. He wrote a blog post titled "Physical Therapy Burnout: What Leads to It and How to Avoid It" that appeared last June on the website NewGradPhysicalTherapy.com.

    "I had a lot of confidence issues when I was fresh out of school," he says. "You quickly find that not everything in 'real life' lines up with what you learned and were told as a student."

    Feeling undervalued. For Castin, it wasn't just that her best efforts to meet what she saw as impossible demands were yielding her nothing more than a starring role in the "log of shame." It also was that every time she tried to add to her knowledge and skills base, positive reinforcement was nowhere to be found.

    "I always felt like I'd take these continuing education classes and learn new skills that I wanted to use and share with my colleagues, but nobody really cared," she recalls. "As far as many of my employers were concerned, I was there to keep their productivity numbers up, and that was about it."

    For PTAs, Hagey notes, feelings of being undervalued or outright disrespected sometimes come from the very practitioners who should know best what PTAs have to offer.

    "What I've seen in some of the places I've worked is that there are PTs out there have little or no respect for PTAs, do not value our opinions or input on clinical decisions, and think we're there only to do exactly what they say," Hagey says. "That certainly doesn't describe all or even most PTs, but the message we get from these few is that PTAs bring nothing to the table. And that's a big problem—not only because PTs and patients benefit from the questions we ask and the insights we share, but also because if you start to feel that your role is meaningless, you're going to lose whatever enthusiasm you had for your job."

    Feeling stuck. Castin has noted an interesting dichotomy among her fellow PTs since she opted for a nonclinical role in the profession. On the one hand, she feels "stigmatized" by some of her peers, who see patient care as the noblest and, frankly, the only calling of the "real" PT. On the other hand, many PTs, she finds, are intrigued by her shift, want to know more about it, and wonder what nonclinical options might allow them to use their degree in ways that still feel meaningful. Castin created The Non-Clinical PT to delve into those possibilities and to share her findings. She now also offers an online course that's designed to help interested parties identify their strengths and passions, find potential nonclinical matches, create an employment plan, and better ensure nonclinical success—all while remaining engaged in the physical therapy world.

    Castin has spoken, as well, to many PTs who feel dissatisfied in their clinical role but can't imagine leaving patient care. Her advice to them is to consider changing employers and perhaps even practice settings before giving up on the clinic. "A lot of PTs find that their feelings of burnout decrease significantly or disappear altogether when they switch to a new organization with a different culture," she says. "Also, if you've only ever worked for a single employer or type of setting, you may be doing yourself a disservice by not exploring other workplaces or avenues. Do you like pediatrics but can't stand the outpatient grind? Perhaps look into school-based PT jobs. Seeking an alternative to working at a skilled nursing facility? Consider outpatient orthopedics—and vice versa."

    Hagey, too, has come across PTAs who feel stuck where they are. He likewise encourages them to move on and to consider thinking creatively.

    "There's a huge need for more people in the field of quality assurance," he notes. "PTAs can become certified in OASIS auditing and coding," Hagey says, referring to the Outcome and Assessment Information Set that's used in home health. "They can become involved in developing standards for specialized programs in falls prevention and other areas. PTAs," he notes, "can play many different roles in health care."

    Lacking mentorship. "I'm a strong believer in the value of mentors to both develop your potential as a clinician and to guard against stagnation that can contribute to feelings of burnout," Kneeburg says. "My boss has been a great mentor to me. He's taught me valuable manual therapy and patient-communication skills. I tell my peers to surround themselves with the right people—people who complain less and educate and inspire more."

    Alicia Backer, PTA, "kind of went through the motions and didn't really grow a lot" in her first couple of years out of school. The biggest problem, she reflects now, is that neither she nor her supervising PT at the time knew much about mentorship or understood its value. When she began working with PTs who "saw things in me that I didn't necessarily see in myself" and started seeing her potential as an integral member of the PT-PTA team, Backer felt transformed.

    "In many ways, mentorship has defined me as a valued and valuable PTA," says Backer, who also serves as clinic administrator at her employer, RehabAuthority in Thief River Falls, Minnesota. "Mentorship builds trust between PTs and PTAs and reveals the best ways to use the strengths of both parties to benefit patients."

    Strategies

    The PTs and PTAs interviewed for this article propose a variety of strategies for both guarding against and mitigating burnout.

    Productivity and documentation requirements. Generally speaking, there's little downside—and potentially considerable benefit—to prompting conversations and seeking solutions to untenable situations related to productivity demands and documentation dictates. Hagey's aforementioned "hard discussion" yielded positive results for him.

    Similarly, Castin says, "Your boss might be thinking, 'I'm just adding 1 more [documentation] form, so it's no big deal.' But if it's a form that's always causing time-consuming glitches in the EMR, that's a good opportunity to engage your boss in a wider discussion," she advises.

    "Bring it up in a way that's constructive, and say, 'There are problems with this particular form, but the broader issue is that we're being socked with more and more paperwork. Can we talk about ways of streamlining the process—of making some tweaks in the EMR to create a better flow, so that therapy staff aren't panicking at the end of the day about how backlogged we are on our documentation?"

    Kneeburg agrees that documentation demands can "overwhelm" any given clinician. "It's probably the worst part of being a physical therapist," he says. But both employers and PTs and PTAs can do things to decrease the burden.

    "At our practice we've worked together to create a template that cuts down on the amount of time needed to complete a record," Kneeburg says. "For example, if you know what measurements you're going to take with a patient with neck pain, and what special tests you're going to conduct, you can insert pertinent passages from the template and individualize them as needed."

    Kneeburg adds that PTs and PTAs should ask themselves whether they're documenting as efficiently as they can.

    "I'll do some documentation during lunch and first thing in the morning," he says. "I may start a patient's notes before he or she arrives, based on what I already know and can anticipate, then change details later as necessary. I don't just wait until the end of the day. I try to stay on top of it as best I can."

    One failsafe way to ease productivity metrics and some paperwork is to switch to an environment in which documenting for reimbursement isn't a factor. And that's not a reference to Castin's nonclinical options.

    "Many of my colleagues who have opened or now work at cash-based private practices tell me they're so much happier than they ever were before," says Ellen Zambo Anderson, an associate professor in the physical therapy program at Rutgers University in New Jersey who wrote a doctoral dissertation on stress and burnout in PTs.

    Student debt. APTA has created a Financial Solutions Center that offers PTs, PTAs, students, and prospective students resources related to student loan refinancing, financial education, engaging a certified financial planner, scholarship and grant opportunities, and more. The association also addressed the issue in a PT in Motion article4 that explored techniques and strategies for minimizing and managing PT education costs ranging from loan-forgiveness programs, employer assistance, and scholarships to ideas for earning extra money during and after the school years.

    PTs and PTAs interviewed for this piece picked up on those themes.

    "I have $114,000 in student debt," Kneeburg says. "I worked with a company that helped me refinance my student loan. I'm making a larger payment, but it's at a lower rate. That's going to save me 15 grand in the long run."

    "I'd encourage new grads to seek ways to make a little money on the side and gradually chip away at their debt, if they can do so without adding to their stress," Kneeburg adds. "Maybe you can put in a few extra hours working at a hospital or in a nursing home over the weekend. Perhaps you can start an online business of some kind, depending on what your company allows. I know some recent grads and current students who drive for Uber or Lyft."

    Castin reiterates that becoming a travel PT, at least for a year or 2, is a lucrative way to make a fast and significant dent in one's student debt load—"provided that's something that works for you in your current life. But, if frequent moves are going to add an undue amount of stress because of the strains they create in your relationships and family life," she adds, "then it's important to recognize that it might not be a good option."

    Unrealistic expectations. In his presentation to FSBPT, as described in the Federation Forum, Berry encouraged PT and PTA education programs to follow the lead of the University of New Mexico School of Medicine, which, he said, "provides all of its students with a wellness toolkit that addresses work-life balance and how to assess for burnout."

    Berry advised, too, that state physical therapy boards might significantly expand their role in combatting occupational burnout. Such an expansion, he argued, could consist of "communicating with licensees and trying to educate them on the symptoms of burnout," as well as providing them with resources to manage signs of the condition.

    "I also think that sometimes we're too hard on ourselves as new grads," Kneeburg says. "From the very start, I wanted to be able to help every patient in some substantial way. It was a bitter pill for me to swallow when I realized that, in some cases, there was only so much I could do to help. That's why I think self-reflection is important. View everything as a learning experience, and try to come to the perspective that all you can do is your best."

    Feeling undervalued. "Finding an employer that shares your values is key," Backer says, adding that her current work environment plays a big role in why she doesn't feel burned out. "There's an emphasis here on collegiality, working together to benefit patients, and having fun. They only hire what they call 'OKGs'—'Our Kind of Girl' or 'Our Kind of Guy.' That means that each new hire is someone who's going to fit in with the way we want our clinics to run. The atmosphere is professional but relaxed. Patients always are telling us, 'I'm going to miss coming here'" Backer says.

    "We have 2 PTs and 2 PTAs," she continues. "The PTs introduce the PTAs during the initial patient visit and convey right off the bat that we're all part of a team that's going to ensure a great patient experience."

    Hagey urges PTAs and PTs alike to speak up if they're feel sidelined or marginalized.

    "In the case of PTAs, sit down with your supervising PT and say, 'I'm not feeling like my input is being sought or heard. What can we do to change that?' Don't assume that you're going to get shut down," Hagey says. "Your supervisor might not even have been aware there was a problem. He or she might say, 'We'd love for you to play a stronger role.'"

    Confidence issues, too, can affect whether an individual feels valued and valuable, Kneeburg observes. He has benefited, he says, by seeking out books on building confidence.

    Feeling stuck. An obvious way to conquer inertia and exit a bad or unproductive situation is to seek a fresh start. That might mean a lateral move within one's existing practice area or a complete change of setting. If, however, "you're simply not happy treating patients, for whatever reason—from productivity and documentation requirements, to the physical toll, to realizing that being around people who are in pain and sometimes take it out on you isn't your thing"—think about exploring nonclinical PT routes, Castin advises.

    She cites a few of the many ways in which PTs can "leverage their degree outside the treatment room." They include medical device training and sales, consulting, informatics (information science), marketing, utilization review, health care copywriting or content writing, and rehab intake management.

    "I know a PT who went from a clinical role to educating nurses on how to use sensor technology to relieve pressure ulcers," Castin notes. "I think that a lot of opportunities are going to open up for PTs in sensor tech, because it requires understanding how people move, and PTs are the movement experts."

    There are other ways to "unstick" oneself besides changing jobs, Hagey notes. "I've spoken at CSM, and I chair the Public Relations Committee of APTA's Home Health Section. Stretching myself in those ways has been rewarding and motivating," he says.

    Mentorship. Looking back on her lackluster first years in the profession, Backer says, "I should have educated my supervising PT on my areas of strength, my passions, and my goals—as well as on my weaknesses and areas of uncertainty—so that that, together, we could set objectives and develop a plan for achieving them. If you don't seek out mentorship," Backer warns, "your professional growth may get lost in the shuffle."

    For that reason, say the PTs and PTAs interviewed for this article, it's important that staff and supervisors alike seek out continuing education opportunities and offerings at professional conferences that center on mentorship and on strengthening PT-PTA teamwork.

    "In addition to my boss, I have a virtual mentor who's helped me with confidence issues," says Kneeburg. He ran across the service in a Facebook ad. "The money I pay is well worth it. I've learned a lot about good ways to handle some of the pressures and challenges we face as new grads."

    Involvement in APTA and the community. "I was not an APTA member until a PT who would become a mentor came to work at my clinic," says Backer. "This is a small community, and my viewpoint was pretty narrow. I didn't think I could have any sort of impact in the wider world."

    That changed, however, when Backer's mentor, Stephanie Weyrauch, PT, DPT, convinced her to join APTA and enlisted her to participate in a presentation at CSM last year on "Fostering the PT-PTA Relationship to Improve Culture and the Patient Experience."

    "Speaking at that conference was a huge experience for me—something I never would have thought I'd be doing," Backer says "It opened up other doors, such as speaking before the [APTA] Private Practice Section late last year. It's been so inspiring. It keeps me motivated and driven."

    Similarly, Severin says that attending CSM as a student and seeing firsthand the breadth of the profession was an "eye-opening" experience for him that left a lasting mark.

    "Being an active member of our professional organization is important," he says. "It expands your horizons and makes things more interesting. It makes you a part of enacting the laws and effecting other changes you want to see for physical therapy. It gives you an insider's voice to express disagreement with association stances, as well."

    Castin concurs. "Being a part of something bigger than just your individual role in physical therapy is a powerful and motivating thing," she says. "And my feeling is, if you don't pull your weight and do your part as an APTA member, you can't complain or get mad when things that you don't like are happening in physical therapy, or when the association is doing things with which you don't necessarily agree."

    Severin says that participating in any activity that's directed toward a greater good can be enriching, motivating, and burnout-battling.

    "I chair the Social Media Committee for PT Day of Service," he notes, referring to the global volunteering initiative. "It takes you outside yourself and enhances pride in what PTs and PTAs do."

    Hagey says community involvement also is part of something that's antithetical to burnout: maintaining a healthy work-life balance.

    "I volunteer at our local food pantry," he says. "It's important to have outside interests and pursuits. If everything in your life is your job, that's unhealthy."

    Stress-management and self-care. Last, but far from least, advise the PTs and PTAs interviewed for this article: Don't underestimate the power of relaxation and the value of giving yourself a break from the grind.

    "Relaxation techniques are valuable in mitigating stress," Anderson notes. "We discuss them in class. I tell my students about the merits of regularly practicing techniques such as deep breathing, progressive muscle relaxation, and meditation."

    Castin notes that some employers offer calming services such as free massages. She encourages PTs and PTAs who work in such settings to avail themselves of such perks.

    "Use your vacation time," Castin further advises. "You're entitled to it, you've earned it, and typically you need it. Don't be guilted into leaving it on the table. When you skip vacations, it affects your mental state and overall health—and certainly how you feel on the job."

    Finally, Castin says, "Don't be too tough on yourself for feeling burned out. It doesn't mean that you're a bad PT or PTA. It just means that you're facing challenges and obstacles that are wearing you down."

    "The important thing," she says, "is to take action to address the reasons you're feeling burned out. Be honest with your managers, and see if you can help them streamline processes and eliminate bottlenecks that make achieving productivity goals feel impossible."

    Eric Ries is the associate editor of PT in Motion.

    References

    1. Castin A. Physical therapy burnout is destroying our profession (blogpost). http://covalentcareers.com/blog/physical-therapy-burnout/. Accessed November 1, 2018.
    2. Berry J. Occupational burnout in physical therapy: clinical implications and strategies for reduction. http://www.fsbpt.org/Portals/0/documents/free-resources/Spring2018ForumOccupationalBurnoutinPhysicalTherapy.pdf. Accessed November 1, 2018.
    3. Jette DU. Physical therapist student loan debt. Phys Ther. 2016;96(11):1685-1688.
    4. Tepper DE. How to cope with health care education costs. PT in Motion. 2014;6(2):34-43.

    Ripe for Additional Research

    Justin Berry, PT, DPT, PhD, started conducting research on burnout in PTs and PTAs when he discovered that the pickings were slim—and old.

    "It's an under-researched area," Berry says, "and most of the studies that have been conducted took place a long time ago, before many of the changes that now characterize the health care and physical therapy landscape, and are seen as contributing to burnout, had occurred—things like productivity requirements, rising education costs, and the use of electronic medical records."

    Ellen Zambo Anderson, PT, PhD, noticed the same thing when she was exploring possible dissertation subjects while seeking a doctorate of philosophy in health sciences. She came upon a 2002 study of about 300 PTs and occupational therapists in New York City that found that 58% reported feeling "emotionally exhausted."1 Going farther back, a 1997 study found "relatively low" burnout levels in a group of about 400 orthopedic PTs in the Midwest.2 A "high percentage" of 40 surveyed PTs and occupational therapists working in head injury rehab were found in a 1995 study to have a "considerable" amount of emotional exhaustion.3 A 1993 study involving rehab hospital PTs in Massachusetts found "moderate" burnout among 129 respondents.4

    "What struck me was that there'd never been a nationwide study of burnout in physical therapy," Anderson says. She decided that her dissertation would change that. The result, "Stress and Burnout in Physical Therapists,"5 determined that 29% of 1,366 responding APTA-member PTs were "experiencing high emotional exhaustion" and that "13% have burnout," based on their answers to the Maslach Burnout Inventory (MBI) and supplementary demographic questions.

    "It's interesting to see that emotional exhaustion among PTs is high across the country," Anderson says, adding that the implications of this finding may extend beyond the well-being of the PTs themselves.

    "Other health care professions have been looking at burnout for quite some time," she notes. "We know, for example, that when physicians have it, their patients don't adhere to their plan of care as well, take their medications as faithfully, or show up for appointments with the same frequency. Nurses with high emotional exhaustion may not respond as quickly in emergency situations as do those who aren't emotionally exhausted."

    Berry's studies of burnout in PTs and PTAs have been more localized. One of them, "A Regional Survey & Analysis of Burnout Among Physical Therapists in Frontier Counties,"6 found that burnout levels among 113 responding PTs in sparsely populated areas of the upper Midwest and West were low to moderate—perhaps in part, the study posited, because they tended to know their patients better and have a deeper sense of community.

    Another study conducted by Berry, "A Survey and Analysis of Burnout Among Physical Therapist Assistants" (unpublished but presented at CSM in 2017), primarily targeted PTAs in Washington state but also surveyed PTAs in the Dakotas. Berry received 255 responses and found "moderate levels of emotional exhaustion, low levels of depersonalization [feelings of disconnection from patients], and high levels of personal accomplishment"—those being the 3 measures that the MBI comprises.

    That study also concluded that "PTAs with a productivity standard and those who work longer hours are at increased risk for emotional exhaustion, while PTAs with over 10 years of experience are at higher risk of depersonalization."

    At the time that he was interviewed by PT in Motion, Berry was preparing to present results from a more recent survey at CSM 2019. That study found that among nearly 300 responding Wisconsin PTs, "those with a productivity requirement had statistically higher levels of burnout."

    References

    1. Balogun JA, Titiloye V, Balogun A, et al. Prevalence and determinants of burnout among physical and occupational therapists. J Allied Health. 2002;31(3):131-139.
    2. Wandling BJ, Smith BS. Burnout in orthopaedic physical therapists. JOSPT. 1997;26(3):124-130.
    3. Schlenz KC, Guthrie MR, Dudgeon B. Burnout in occupational therapists and physical therapists working in head injury rehabilitation. Am J Occup Ther. 1995;49(1):986-993.
    4. Donohoe E, Nawawl A, Wilker L, et al. Factors associated with burnout of physical therapists in Massachusetts rehabilitation hospitals. Phys Ther. 1993;73(11):750-756.
    5. Anderson EZ. Stress and burnout in physical therapists [dissertation]. https://rucore.libraries.rutgers.edu/rutgers-lib/47324/. Accessed November 1, 2018.
    6. Berry JW, Hosford, CC. A regional survey & analysis of burnout among physical therapists in frontier counties. PT-PAL. 2015;15(3):1-11.

    APTA Tackles Burnout

    APTA's interest in addressing some of burnout's leading causes—productivity requirements, documentation requirements, and the cost of education and student debt—is reflected in the association's words and actions.

    "APTA strongly objects to regulatory burdens that hinder physical therapists' ability to render timely, patient-centered care at the full scope of licensure by using evidence-based guidelines and exercising clinical judgment and decision-making skills," says Kara Gainer, APTA's director of regulatory affairs. Unduly burdensome regulatory and administrative requirements are a leading driver of paperwork demands that sometimes threaten to overwhelm PTs and PTAs.

    To name a few recent or pending regulatory changes for which APTA successfully lobbied, Gainer cites elimination of functional limitation reporting under Medicare, elimination of the functional independence measure in inpatient rehabilitation facilities (effective October 1 of this year), and reduction in the number of required assessments in skilled nursing facilities (also effective October 1). She notes that APTA last fall submitted a comprehensive set of recommendations to the Centers for Medicare and Medicaid Services (CMS)—building upon previous comments to the agency—for reducing regulatory burdens in Medicare and the Medicare Advantage program. Gainer adds that that the association is providing input to the House Ways and Means Committee as that congressional panel develops legislation to ease excessive regulatory requirements.

    APTA was instrumental in achieving the fix to the Medicare therapy cap, she notes, and APTA's Physical Therapy Outcomes Registry will help reduce administrative burden by using standardized metrics to secure data.

    "The association will continue to advocate for changes to policies and recommendations that reduce redundancies, eliminate administrative burden, and increase efficiency," Gainer says.

    APTA was a signatory in 2014—along with the American Occupational Therapy Association and the American Speech-Language-Hearing Association—of a "Consensus Statement on Clinical Judgment in Health Care Settings" (http://integrity.apta.org/ClinicalJudgment/) that delivered the message that inappropriate administrative mandates, quotas, and productivity standards should never stand in the way of clinical judgment and "may be a violation of payer rules, may be in conflict with state licensure laws, and may even constitute fraud."

    Employer policies that compromise practitioners' clinical judgment "can cause frustration, hardship, and moral distress," the consensus statement notes. It acknowledges that "practitioners can feel isolated in their work setting, or face negative repercussions when they question these practices." The statement urges individuals witnessing or learning of possibly unethical and illegal behaviors and actions to "use networks, associations, and groups to talk about the problems or situations you face, and provide feedback to your state and national associations." The statement also suggests that individuals consider reporting questionable billing practices to facility or corporate compliance officers—and, if that response is insufficient, to the US Department of Health and Human Services Office of Inspector General or to CMS.

    Regarding student debt, APTA has created a Financial Solutions Center (www.apta.org/FinancialSolutions/) that offers an APTA-member discount on student loan refinancing; a customizable financial education platform; guidance on finding a certified financial planner; information on APTA scholarships, awards, and grants; and more.


    Comments

    SOO very glad the concept of burn out is coming to the forefront. As we develop our professional independence and seek more education and potentially more debt the article hit on difficulty faced by many therapists. Those 'trying to start and raise a family" are really feeling the stress. PT and OT. I wonder what the future holds for the profession. Developing strategies for managing the many drivers for burn out cannot be taught enough. Thank you for looking at this area.
    Posted by Terry Sink on 1/31/2019 7:44:46 PM
    As a practice owner of almost 20 years it is amazing to see how much our profession has evolved and in some ways devolved (if that's a word). We have more skills and abilities to help people than ever before but there are so many other factors mentioned in this article that do so much harm to therapists. I have watched young therapists literally break down and cry in my office when talking about the realities of their student loan burden and they were so clueless what they were actually getting into. I've also seen productivity standards become way too emphasized at the expense of therapists overall well being. Thank you Alicia for the kind words you've shared about our company, and I'm glad we've been a place that you feel has invested in you and your overall professional development! You're a credit to the profession.
    Posted by Galen Danielson on 2/1/2019 11:17:40 AM
    Informative article on an important topic. This will be a good spring-board for our agency's clinical supervisors to discuss which factors already address, and what else we might want to do to better support our staff.
    Posted by Cindy Moore on 2/2/2019 1:13:56 PM
    The information and discussion re PT burnout seemed to implicate serious missteps in our profession over the years. I believe a systemic change has occurred, eroding the delivery of physical therapy and rehab services. The payor has become the driver of the system; rather than the patient. Outcome measures, extensive/repetitive documentation, coding, justification of services, and productivity, has taken the focus away from providing treatment. After 38 years as a registered physical therapist, I finally made the sad decision to resign, at age 60; long before I had hoped. The unrealistic demands as an RPT, however, created overwhelming moral and ethical conflicts. Documents had to be completed off-the-clock; oftentimes requiring additional hours. Point of service, as valuable as it is purported to be, was not realistic or fair to the patient or this therapist. It is my humble opinion that patients deserve attention, consideration, expertise, and hands on PT care. This article helped relieve some shame in feeling aged-out and no longer 'good enough'. I am grateful to the APTA and authors of this article for providing a platform for questions about restoring the essence of our profession as physical therapists and retaining those committed to best practices; which is best care. I hope the future of physical therapy will protect the core beliefs of our profession.
    Posted by Amy Bergeron on 2/7/2019 1:05:03 AM
    I'm curious as to what is considered a "realistic" productivity requirement for a PT or PTA in a days work? I'm thinking specifically about outpatient clinical practice. I've worked in clinics that treat on the hour and ones that treat on the 45min schedule, but what management expects and what seems realistic sometimes vary quite a bit. What do "the masses" consider to be realistic in such a setting? Just curious of the responses. Thanks.
    Posted by Michael Miner -> AFS[EI on 2/7/2019 6:59:20 AM
    Referring to the school- to-debt burden, this is NOT the answer: "encouraging new grads to seek ways to make a little money on the side and gradually chip away at their debt, if they can do so without adding to their stress," Kneeburg adds. "Maybe you can put in a few extra hours working at a hospital or in a nursing home over the weekend. Perhaps you can start an online business of some kind, depending on what your company allows. I know some recent grads and current students who drive for Uber or Lyft." I DID NOT GET $100,000 IN DEBT TO DRIVE A CAB to make ends meet! Nor did I get a doctorate to be a productive member of the field to work 7 days a week, as suggested to work at a nursing home on the weekends. We are not burned out, we are morally insulted by the aforementioned how to make a living wage. I work 7 days a week to avoid living hand-to-mouth, covering student loan debt and I will attest it is not sustainable and not humane. I have never been so offended by APTA/ PT In motion.
    Posted by Olivia on 3/10/2019 6:26:06 PM
    I own a private practice that is really supportive of our staff and tries to encourage our PT's to take the time off that they need. The biggest source of financial stress that I see in our field is poor reimbursement for PT services. That is what drives pressure on productivity and billing practices. Our staff need to be paid a wage that supports their need to pay off student loans and to afford the high cost of living in our area. But insurance carriers have not given us a raise in payment in the 15 years that we have owned our practice. Then they force us to participate in "pre-authorization" schemes that essentially disregard the opinions of the treating MD and PT and deny care based on computer generated rubrics. It's demoralizing and burdens our practice financially, making it impossible to support the environment we want for our practice. We need to address that fundamental issue if we are going to talk about the cost of PT education and burn out.
    Posted by Caroline Taylor on 3/29/2019 8:29:00 PM
    I think the productivity requirement is a huge problem causes PTA and PT to commit unethical acts that could be considered Medicare fraud. Another issue is there are a few D PT's especially in Florida who refused to do evaluations, work with or hire ptas.
    Posted by Roberta Abbott on 6/24/2019 4:01:07 PM
    Time for the APTA to start actually fighting for our profession rather than bending over and taking what ever table scraps CMS decides to allow.
    Posted by Oldhess on 7/1/2019 1:00:38 AM

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