Burnout and Character

Therapist burnout is real. You can address burnout with some simple steps.

By Jerry L. Henderson, PT*

When you hear someone say they are burned out, what comes to your mind? I admit that (in my less than empathetic moments) I think, “Oh, come on! You can do this! Get back to work!” My first impulse is to discount the other person’s complaint of burnout, because on one level, my instinct is to assume that “burnout” is just a euphemism for laziness or a lack of character.

But, on reflection, I can think back on times in my life when I have been burned out. When I’ve felt like I just couldn’t do another day, fighting the same battles with little apparent progress. Futility leading to lethargy leading to a lack of a sense of purpose.

So I do believe burnout is a real thing and not a character flaw. I believe that it is primarily due to stress from factors that we feel are not in our control.

Just “getting back to work” isn’t the answer to burnout. To paraphrase the Serenity Prayer: We need to analyze the causes, address the issues that we are able to address, and accept what is truly out of our control.

I believe that there are special stressors in our profession that contribute to physical therapist burnout, and I also believe that most of it is actually within our control.

Addressing Physical Therapy Burnout
In a recent editorial in JAMA, the authors attribute physician burnout to many factors, including greater productivity expectations, increased workload, reduced autonomy, clerical burden, regulatory requirements, and an unprecedented level of scrutiny.

Sound familiar? I think those are largely the same issues experienced in our profession that lead to burnout, some more acutely, some less. Let’s think about some of these burnout factors and propose some solutions:

Productivity Expectations and Compliance
Continual reductions in payment coupled with our ridiculous and complex fee-for-service system is undoubtedly a huge cause of burnout. At a rapidfire pace, all kinds of thoughts hurtle through your mind taking up valuable brain cycles that should be used analyzing your patient’s condition and providing great care:

“Is that a timed code? Untimed code? Did I spend 7 minutes on that procedure or 8? Can I charge for 3 units or 2? If I only charge 2 units, will my productivity metrics suffer? If I charge 3, can I defend it to the payer in an audit? Do I need to do functional limitation reporting on this visit? A progress report? Is there an authorization issue?”

While we wait for the promises of value-based care to obviate these ridiculous fee-for-service rules, the only solution is to automate all of these compliance and regulatory requirements as much as possible. Your systems should take care of aggregating CPT codes properly based on the therapist’s documentation, guide the therapist through all of the regulatory hurdles, and help them document the medical necessity of their patient’s care.

Ideally, therapists should only be required to use best practices to address compliance and regulatory issues: Do a good job of explaining the patient’s problem, documenting what was done, why it was done, and (unfortunately) reconciling treatment time. Therapists shouldn’t have to think about the rules; they should be provided tools that support the rules.

Reduced Autonomy I believe that reduced autonomy in our profession is somewhat self-inflicted. We simply don’t give ourselves enough credit, and we still have a tendency to see ourselves as subservient technicians, rather than autonomous professionals. We need to change that mindset.

This is an area where I believe we need to do some serious introspection. Ask yourself what you did the last time you were totally opposed to the treatment suggested in a physician’s referral? (If you still call it a “prescription” or “order,” there needs to be a whole different discussion.)

In my opinion you have a professional duty to assert your stance as a professional. You have a professional opinion that may be at odds with another professional’s opinion. Get in the debate! State your position! Do the right thing for your patient if you can’t come to a consensus. Being assertive is tough, but acquiescing to ridiculous “orders” will take you down the trail to burnout.

Scrutiny
I have often said that physical therapy is a round peg trying to fit into a square hole in our health care system. We are still a largely misunderstood, isolated outpost with our own language. We are functional specialists in a system that is disease and injury centric. As evidence of my hypothesis, look at ICD-10 codes: They still largely describe injuries and diseases. There are a few codes that we can use to describe the functional deficits we actually treat, but relatively few.*

As another obvious example, think about Medicare’s Functional Limitation Reporting program. The program is an attempt to understand what conditions we treat with an overly simple classification system coupled with an impairment rating to analyze whether or not the patient’s functional impairment improved. The only reason that this program seems to exist is that other information on a claim form (ICD-10, CPT codes) does not adequately describe the conditions treated, and the procedures we use to treat them. Since CMS could not get that information any other way, they developed this system. (It still doesn’t give them any useful information, but that is a topic for a different day.)

So, how do we address all of this scrutiny? We have got to become better communicators and rely on systems to help us.

Get rid of the PT acronyms in reports. Remember, the primary people reading your evaluations and progress reports are not physical therapists. They are physicians, nurse claims managers, and claims managers. They probably don’t know what you mean by PNF, Grade IV PA glides, HEP, etc. So spell it out as simply as possible. Someone reviewing your chart may not ever completely understand the procedures you performed, but they should at least be able to get a general understanding.

Explain the rational basis for your treatment plan. Again, the person reading your reports may not be able to understand the details about your treatment, but they should be able to understand that your plan has a rational basis grounded in realistic goals to improve the patient’s function. Listing a bunch of very impressive special tests is fine, but you need to be able to explain how those special tests relate to the big picture.

Have a non-physical therapist do some chart reviews. Ask them what they understood from reading your reports. If they do not understand the functional deficits and the rationale for your treatment on some level, you are subjecting you and your team to increased scrutiny.

Take Care of Yourself
Finally, it is really important that everyone on your team learn to take care of themselves. Taking a vacation, getting adequate rest, and taking a break from physical therapy is not selfish. It isn’t possible to give your best and provide great care unless you have taken care of yourself first. As flight attendants say on every flight (right after explaining how to buckle a seatbelt), “If the oxygen masks drop, put your own mask on first before helping children or others.”

I think a big part of taking care of yourself is spending some time, every day, for humor. Watch something funny on TV. Ask Siri or Google or Alexa for a Knock Knock joke, and don’t be afraid to use them!

Take Away

Keep It Simple
Figure out what issues you can control and control them. Learn to accept what you cannot and forget them. Put on your own oxygen mask before helping those around you. Take time to laugh, every day.

REFERENCES

1. http://jamanetwork.com/journals/jama/article-abstract/2603408. Accessed May 2017

Jerry L. Henderson, PT, and the vice president of Therapist Success at Clinicient. He can be reached at JHenderson@clinicient.com.