Physio is just physio

I’m going to start this, my first post of 2018, by thanking the people who helped me get some content over the line in 2017; thank you all of my most esteemed, learned and brilliant colleagues! Although this blog evidently has a small readership, I’ve enjoyed the process of writing more than anything else. Collaborating and learning from others has been a massive bonus on top of everything.

The ultimate aim to this blog was to begin the process of writing and broaching some individual fears and barriers for me – putting out content for everyone to judge. In that small aim, it has been a success. Some failures have been the consistency with which I’ve written in 2017; it has been pretty random and I was not able to complete some content that I was most interested to put out. Namely;

Ditch the plinth bro’‘

Specialisation and titling; where is the profession leading us?’

‘Triple M and evidence based practice; gurus, senseis, and the average physio’

‘Open letter to the APA’

These topics will hopefully be reincarnated in some form in the coming year. For now, I only want to thank those involved who helped me get the fairly unimpressive 14 blogs that I got out; hopefully I’m going by the quality over quantity mantra. All in the growing process..

Moving on..

As I move to a non-clinical leadership position, I’m forced to recall a lot of friends who have also left clinical roles; at the far end of spectrum a lot of friends have left the profession entirely. It seems a lot of physiotherapists do it at some stage. It is obviously prevalent in other professions, but a recent look at Australian physiotherapy registration data may tell an ominous tale for us; after the age of 40 the registration rates are 46% of those in the age group 25-29 (Ref). This, of course, is just one way to look at the data. You could also look into this as a profession that has gone from 23,300 registrants to over 30,000 in five years and proportionally those under 40 years of age remain about 60% of the profession whilst those over 40 years of age remain about 40% from 2012 to 2017. We have remained a young profession, on the whole, and maybe this can’t be looked at too much further without reviewing some causative data.

And so in this chapter of my life, I have to say maybe I’m not that special or unique. Is this a deeper sign of widespread frustration at the profession as a whole?

I’ve alluded to some intermittent frustration at the profession throughout my (albeit expressly ‘mid-range’ career length; so judge this as you please) career (Ref), and some might say this is just another ‘generation Y’ aiming for things that are unrealistic or buying into a sense of entitlement. I do think that some of what has pushed my friends out of the door of this profession must be narratives in a lot of physiotherapists’ careers; hell I even see these deep undertones in the most popular of blogs. What exactly is in this frustration?

Is it lack of responsibility?

The glass ceiling is low and that is a product of a few things in the physiotherapy profession. A lack of firm prescribing, imaging and referral rights produce a lot of frustration for mid-career physiotherapists like me and something I have written about before. But there is merit to the counter-argument that we should improve our internal practices before we branch into more responsibility in the medical system.

So, to follow this argument, Physiotherapy’s constant internal review is a real strength and only serves to improve what we already do. But it does tend to add to a sort of sense of nihilism about Physiotherapy’s capacity to improve any condition that most physiotherapists see on a day to day basis.

Is ‘physio-bashing’ hurting the profession?

Moving toward a very strong evidence informed practice has pushed a lot of what made the practice of Physiotherapy, ‘Physiotherapy‘ into the world of anecdotal and unsubstantiated ‘guru-ism’. It has brought doubt into a lot of pre-existing practices but also thrown a lot of commonplace practice under the bus. Simple is best, and there may be some overly complicated practices that are nothing better than placebo remaining in the backbone of our profession.

Although this sounds very doom and gloom, I think it will only ever serve to make Physiotherapy a profession that is honest and confident enough in its practice to have such a strong critically reflective cohort. In fact, much of medicine suffers from the same scrutiny; we – as physiotherapists – practice some of the best evidence based practice. Non-specific effects dominate any treatment scenario and it is the awareness of these that will specific effects to be used more efficiently. Better evidence and reflection on the practices that involve a lot of non-specific effects – like manual therapy – will also improve the efficacy of their use.

Therein, I think the profession is healthier now than it ever has been and most likely the minority of those who leave the profession during their career will possibly even strengthen it to ensure those that are left are practising and adhering to the strong evidence informed models that are continually improved.

So, while a sense of nihilism comes along with ‘Physiotherapy-bashing’, it’s actually a very healthy component of Physiotherapy.

Is it a career thing?

The options remain limited at the top of our profession, and I will make no bones about this being a limiting factor for myself. But as things improve I know he structure for mid-career physiotherapists will similarly improve; otherwise we are going to have a lot of masters-level qualified physiotherapists with not much else to show for it other than a piece of paper on the wall.

What this comes down to for me is the definition of a career-path; in most other professions it is very clearly depicted, but with physiotherapy it is muddy and seems to have too many avenues.

Is it burn-out?

I looked into this; empathy burn out for physiotherapists has been documented (Ref). Don’t get me wrong here, I think the very fact that physiotherapists spend more time with each patient is one of the defining facets of the outcomes we are able to have; positive outcomes happen in large part because most physios invest so much time and effort into each patient. But this time takes its toll; more time engrossed in all of the complexities that painful conditions bring with them. Emotional exhaustion has to be high with all of that time dealing with complex patients and unrealistic expectations.

Each physiotherapists takes part in the ‘fun-park’ of pain with every patient, some to a higher degree than others. And here is the important part:

Physiotherapists want to help people, a lot of mid-career physios want to fix people. For the physiotherapists that deal with musculoskeletal pain, this is a condition that is so complex, so intertwined in every patient’s very fabric of being, that it is a fool’s errand to fix. Pain is a waxing and waning phenomenon throughout life, a lot of what we see clinically is simply regression to the mean and I think the best job a physiotherapist can do is to identify those people that are likely to cause a larger burden on health systems (by becoming chronic), and ensure that no nocebos are given. Those patients are treated with carefully constructed language to ensure that they don’t return – even for another problem – worse than the first time. 

So, maybe it is this fact that burns out some physiotherapists; a slow steady realisation of this. I know I have had these thoughts, or maybe I suffer from the same unrealistic expectations as my patients.

To conclude..

So, if you have recently ‘hung the boots up’ I want to hear from you; if by choice, what were your reasons for leaving the profession?

I’m still hanging around, even if I’m in a ‘paper-pushing’.. sorry, leadership role.. I’m aware of the limitations and considering them this year with a cautious eye.

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