Speaker 1:
Speaker 2:
Good day, it's Jared. Today I want to talk about burnout in physiotherapy and our related professions. This is unfortunately becoming a significant problem and in today's episode, I want to tackle this problem head on. So in this episode, we're going to be basing our conversation loosely on a recent editorial in the Journal of Physiotherapy by Kai Win that I think lays out the empirical picture elegantly, and the numbers are sobering enough that I think we must take them seriously.
Speaker 2:
So I have a personal stake in this topic. I left full-time private practice two years into my career in part because of burnout. That experience went on to reshape my career and arguably my life, and I think it's worth talking about openly rather than just treating it as something that just happened to me before I became whatever I am now. So this episode is going to do three things. I want to lay out what we know about burnout in our profession. I want to push back on the dominant framing, which I think misses the point, and I want to share what helped me both structurally and more importantly in terms of how I came to see the work itself. So let's rip in. Let's start with the data. The recent editorial in the Journal of Physiotherapy by Kai Win summarizes decades of research on burnout in our profession.
Speaker 2:
The headline numbers are pretty rough. Most studies report burnout prevalence in physiotherapy between eight and 23%. Some specific populations show rates closer to 60%. The rates are similar across Australia, across Europe, Asia, and the Americas. Similar between public and private settings and similar between men and women. It doesn't appear to be an isolated problem, rather a profession problem. Then there's attrition. Up to 65% of recent physiotherapy graduates plan to leave the profession within 10 years. Only 25% predicts a long-term career in physiotherapy in Australia, between 700 and a thousand physios leave the profession every single year. Most attrition happens within the first five to 10 years of practice. Burnout can also rear its ugly head. Early in a clinician's career, practitioners report high levels of stress and burnout within only one to five years of starting their career. And once it's present, it doesn't seem to just affect the clinician in isolation.
Speaker 2:
It affects their problem solving ability. It seems to compromise working memory. It even influences task attention. It increases clinical management errors and sadly, it reduces or decreases patient satisfaction. It can even reduce empathy. What this means is that the cost of burnout isn't just absorbed by the burnt out person. It's actually distributed to every patient that they see. And hopefully you can imagine the negative consequences of this. So when we talk about burnout in physiotherapy, we're talking about a population level phenomenon that the profession has broadly speaking, not addressed. So I wanna put a sentence in your head before we go any further, and you can mull on it throughout this episode. If you are burning out or you have burnt out or you are sitting at the precipice of it, hopefully not. I just want you to know that you are not broken, rather you are correctly diagnosing a broken situation.
Speaker 2:
Now let's unpack this broken situation. Let's explore or unpack why this is happening because I think the dominant framing that burnout is essentially a problem of individual resilience fixed by self-care misses most of what's going on by a wide margin. The climate of musculoskeletal practice has become strained and difficult. Not, not exactly because of clinical complexity, although that's certainly a feature but difficult in a different way, something that is affecting the conditions of our work. Consider what a thoughtful and caring clinician now has to navigate in musculoskeletal practice. Contradictory evidence on almost every clinical question. Senior researchers and social media influencers and leaders of labs disagreeing with each other in public, sometimes Uncivilly University teaching, being retracted or revised or challenged. Sometimes within just a few years of graduation, patients arriving with opinions formed by Instagram and chat GPT, and then expecting you to either confirm or refute them on the spot without context.
Speaker 2:
Then we have workplace pressure to perform interventions. You have growing reasons to doubt. We have the rise of ai, the inexorable rise of ai, which raises the unsettling and awkward question of what happens to a profession built on knowledge when knowledge itself becomes free. And underpinning all of that, we have financial and career sustainability. The anxiety about whether the money will be enough, whether the work will still feel meaningful in 5, 10, 15 years, whether your body will hold up for 40 years of this, whether your mental state can endure the demands of day in, day out, helping people with persistent or complex, painful conditions. I don't think any of those pressures is on its own catastrophic, but together they constitute a climate, and the climate is what produces the slow erosion that people eventually describe as burnout. This is why I want to push back on the resilience framing.
Speaker 2:
When we tell clinicians they need to manage their stress, they need to set boundaries, meditate, sleep more, exercise more, drink less, give up smoking, we're not wrong. Exactly. Those things help to be sure, and I'm certainly not advocating to stop any of those things, particularly if you find them helpful. But I think what we're doing here is we're treating burnout as a private failure, a private failure of coping rather than as a predictable response to a difficult environment. And then we let these like structural systemic drivers off the hook. Look at what the editorial identifies as the factors most consistently associated with burnout in physiotherapy. There is a lack of mentorship, inadequate workplace support, unsatisfactory remuneration, poor work relationships, ethical and moral conflict between individual and workplace values, administrative burden, limited career progression. All of these are features of how the work is organized, not really features of the people doing it.
Speaker 2:
So that's the th first thing I want to say. Clearly you are responding rationally to a difficult situation. You are not failing. You are doing serious work in a climate that nobody really prepared you for. But I don't wanna stop there because if I stop there, I leave you with a simple diagnosis and no path forward and there is a path forward. I'm optimistic of that. I just don't think it's the one that most of the burnout conversation has focused on. Hither two, So as I mentioned in the introduction to this episode, I have a personal stake in burnout. Let me give you my story to humanize this concept of burnout. So I spent the first two years of my career in private practice straight from graduation. I was a good clinician, I think at least by the standards I had at the time. I worked hard, I cared about my patient. I was even fully booked by external measures. Things were going well, but internally, something was wrong. The work I was doing didn't match what I'd been told it would be. I was seeing person after person with persistent complex problems in time slots that didn't allow me to think properly. Applying techniques and frameworks I was increasingly unsure about. The more I read, the less confident I was that the things I'd been taught at university were true.
Speaker 2:
I'd ask my boss questions and the answers I'd get were either dismissive, patronizing, or unconvincing. I started to feel like I was performing physiotherapy rather than practicing it. At some point, I burnt out, but at the time I, I didn't know what was happening. I was questioning whether I had chosen the right career path and was seriously considering going back to uni to study medicine. Thank God I didn't. What I did next was to escape. I went overseas. I removed myself from the environment that had become unsustainable and in that space almost by accident, something changed before anything else did. What changed First was how I was relating to the work itself. I started reading voraciously, which I hadn't had time before when I was struggling seeing 70 to 80 patients a week in clinical practice. As a 23-year-old man, I was mainly reading research papers and philosophy.
Speaker 2:
I was reading books that asked the kinds of questions I'd been suppressing for years or I couldn't find satisfactory answers for. I started cold emailing researchers whose work I had admired to just chat with and ask questions. Many never replied, but some did and went out of their way to help me. I remember vividly being invited by a prominent London rheumatologist for coffee in the private library of the Royal College of Physicians. He listened to a curious early career physio he'd never heard of, and over time he became a mentor. Slowly I started building something else. I started creating content, which I was initially terrified of doing, but I was relentlessly encouraged to do so by my now wife. I started the Shoulder Physio podcast, which was originally a simple YouTube channel. I went back to do a PhD. I started running shoulder workshops. I ran my first one in 2019.
Speaker 2:
Over the course of about a decade, I rebuilt my professional life around the things that had drawn me to physiotherapy in the first place. And today, I have a stimulating mix of seeing patients conducting research, mentoring and creating content. And I love what I do, but I want to be careful about how I tell my personal story because the obvious moral lead clinical practice and become a researcher problem solved is not the moral I want you to take from it. Most clinicians can't and shouldn't leave clinical practice. Clinical practice is the heart of the profession, and if everyone who got disillusioned left, there'd be no profession left to fix. The thing that changed for me wasn't the change in role. It was something that happened earlier and underneath I, I think that I stopped performing physiotherapy. Instead, I started inquiring into it. I started to examine it.
Speaker 2:
That shift in orientation, that change in how I was holding the work, proceeded anything else. And I've come to believe that shift is available to any clinician in any setting. It doesn't require leaving the clinic. It just requires changing what you bring into it, and that's what I want to talk about next. So two clinicians can sit in the same difficult system or climate and have very different experiences of it. They can have the same workload, they can see the same patients, they can have the same pressures, but one is drowning. The other is engaged, curious, and in some ways thriving. The difference between them is not usually resilience in any cliche sense of the word. The difference is what I'd call disposition. A disposition is the way you hold the work. It's a way of being a clinician. The stance you take towards your knowledge, your patients, and the uncertainty of clinical practice.
Speaker 2:
And unlike personality or temperament or the structural features of your job, disposition is something you can actually build. I wanna give you the three components I think matter most, and which I've come to see as the antidote to the slow erosion or burnout the climate has started to produce. These are the same three I teach in my mentorship work. So they'll be familiar to some of you, but they're worth stating clearly because they form the core of what I wanna leave you with today. The first is intellectual honesty. Patients don't need you to be certain. They need you to be open, honest, and authentic. Knowing the boundaries of your knowledge, being able to say, I'm not sure, or the evidence on this question is contested, or We used to think X, but the picture has changed. So now we think Y. This is freeing. The pressure to perform certainty is one of the most exhausting things in clinical practice.
Speaker 2:
The feeling that you have to know everything about every single clinical condition for every single individual's clinical context is exhausting. When you let yourself off that hook, the work becomes lighter. A clinician with intellectual honesty doesn't pretend that exercise works because it strengthens a single muscle. When the evidence shows that strength actually explains a very small fraction of the treatment effect, they tell the patient something truer. The treatment still helps. It just helps for different reasons than we were taught. And there are many more examples of this. The second is treatment pluralism. This is the argument that I made in a recent J-O-S-P-T paper. No single intervention is reliably superior for most of the conditions we treat. There is no hierarchy, there is no winner. A denial of this pretending that your favorite technique is. The answer is one, failure of imagination, nihilism, concluding that nothing works.
Speaker 2:
So why bother is the other. Pluralism, I think is the path between them. It's a bounded set of safe, plausible evidence and form treatment options that you can move between as the clinical situation demands. It's freedom within a framework, and I think that summarizes it nicely. A clinician with this disposition isn't grasping for the next technique to solve every patient. What they have is a set of credible options, the skill to deliver them and the judgment to choose between them as the situation demands. That seems to me a much more sustainable way to work. And the third is the therapeutic relationship. When you ask patients what they value in a good musculoskeletal clinician, the qualities they name are almost entirely relational, responsive, ethical, communicative, caring, competent, collaborative. Five of six are relational. Competence is there of course, but it's not the dominant thing. I'm not for a minute saying that we shouldn't be competent.
Speaker 2:
That's completely false. I think we should strive to be as competent as possible, but the therapeutic relationship seems to be something that patients are wanting from us. So this therapeutic relationship is not an adjunct or an afterthought to your manual therapy prowess or your supreme exercise prescription skills. It is indeed a mechanism of your effectiveness. It's also the thing that nihilism can't touch. The one component of clinical care that may never be challenged. I can't see a randomized control trial showing being an. Physio is superior to being a caring physio. Hopefully that study doesn't get done, but I just can't see that being the outcome. Those three things, intellectual honesty, treatment, pluralism, and the therapeutic relationship. They're not personality traits. They're skills. I think they're like stances their habits of mind. They can be cultivated and when they are, they change what the work feels like.
Speaker 2:
Now. Unfortunately, the climate around remains the same unfortunately. But your relationship to that climate has changed, I think for the better. Before we go any further, I want to draw a distinction here because I can imagine someone listening to this and thinking, wait, isn't this just resilience training? It isn't. Resilience talk, as it's typically deployed in healthcare, asks for the individual to absorb the costs of a broken system without changing anything. The system stays the same. You're absorbing punch after punch after punch. It's on the clinician to adapt. If you burn out, you weren't resilient enough. The framing puts the burden squarely on the person doing the work. Whereas I think disposition is different. It's about how you orient yourself to the work itself. It's an active, ongoing, dynamic intellectual project. It asks you to be more curious to read and think more deeply, to hold your models more loosely, to build relationships with the people you treat.
Speaker 2:
The disposition you bring to the work shapes what the climate feels like. Even when the climate itself isn't shifting or indeed worsening. You can have a perfectly resourced workplace and still feel miserable if you're performing a version of physiotherapy that you don't believe in. And you can have an imperfect workplace and still find meaning if you've built a way of working that's resonant with you and your values. So there's an apparent contradiction in what I've been saying. I started the episode by telling you that burnout is not an individual problem, that it's a structural response to a difficult environment. And then I've spent the last several minutes telling you about disposition, which is something you individually can build. So which is it? Is it a system problem or a personal problem? It's both. And these two things actually sit at different levels. The system needs to change, and that's not your individual responsibility.
Speaker 2:
But while the system solely changes or doesn't, there are things within your reach that can change how you experience the work. Holding both at once is I think, the only position capable of warding off the effects of burnout. Treating burnout as purely structural leaves you waiting for a fix that may never come. Treating it as purely individual blames you for a situation you didn't create. Neither is right. With that said, here are four things that I think help. First take the structural drivers seriously. Workload, value, misalignment, lack of autonomy, poor remuneration, inadequate mentorship. Some of these are within your power to change. Some are not. Naming them, articulating them, talking about them lets you stop blaming yourself for what is in many cases, a very predictable response to a difficult environment. Second, work on disposition. Read deeply. Hold your clinical models loosely. Get curious about the things you don't understand.
Speaker 2:
Build the kind of therapeutic relationships that make the work worth doing. Don't view this as extra labor added on top of your job. It is over time what your job becomes. Third, give yourself a longer timeline than feels reasonable. It took me 10 to 15 years to build the working life I have now. There were lean years, there were down moments. I can tell you there were times when I doubted whether any of it would amount to anything. I kept showing up because the alternative was worse and I was passionate about what physiotherapy was and is whatever you're trying to build, it probably won't happen in the timeframe you want it to be patient with yourself. Fourth, find community. This might be one of the most important recommendations. One of the things that surprised me as I built my career around the kind of work I wanted to do is how many other clinicians felt the same way and didn't know where to find each other.
Speaker 2:
The profession is full of thoughtful, intellectually serious clinicians who feel slightly out of place in the system they're working in. Finding those people changes things. It gives you a reference group that isn't measured purely by patient throughput. It reminds you that the way you see the work isn't strange, and there are people with a similar viewpoint. So in concluding burnout, in physiotherapy and related profession, professions is real and it's happening all around the world. It's happening at a high rate. It's widespread, and the dominant framing of it has been too small. If you are burning out again, I want to emphasize that I don't think you are broken. You are correctly diagnosing a broken situation. The structural drivers are a massive problem and we should try to change them. But in the process, I would encourage you to start building a particular disposition that lets you do the work you are proud of.
Speaker 2:
Even inside a climate that is suboptimal. I think this is a different project to self-care. It's slower and harder, but my view is that it's the one that will last. Thanks for listening. I'm Dr. Jared Powell, and this has been another episode of The Shoulder Physio Podcast. We'll chat to you soon. The Shoulder Physio podcast would like to acknowledge that this episode was recorded from the lands of the Ang people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning, and working from every day. I pay my respects to elders past, present, and emerging, and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.
