I graduated from NYU’s DPT program five years ago and, like many new grads, found myself anxious about everything surrounding what was to be my first real job. Despite numerous uncertainties, I considered myself fortunate in that I had always known that I wanted to work in outpatient orthopedics unlike some of my counterparts who spent more time trying to decide on a setting than actually sending out resumes. The issue constantly in the back of my mind, however, was patient volume.
"Would I ultimately end up a burnt-out therapist, one chronic low back pain patient away from running out of the clinic screaming?"
Between the various observations and clinical affiliations required during PT school I experienced my share of private practice settings, and they all seemed to have one thing in common: calculated chaos. The sheer patient turnover scared me and at times made me question whether or not I wanted to go into orthopedics. As a new grad I realized that seeing multiple patients an hour was likely inevitable, but I questioned how many was too many? Would I ultimately end up a burnt-out therapist, one chronic low back pain patient away from running out of the clinic screaming? Fast-forward five years, I’m still doing orthopedics in the private practice setting, but I now only see one patient per hour and the threat of burning out is a mere dot in the rearview mirror. What I want to focus on for the remainder of this soapbox spiel is the time in-between then and now, and how it served as a springboard that allowed me to become the therapist I am today.
For physical therapists in NYC, high-volume is part of the territory, and on average I treated three patients an hour, translating anywhere from 14-24 patients a day, depending on the length of the day. Now, some may immediately be “put off” by these numbers and question the quality of care provided in a twenty-minute treatment. I contend that while very demanding and perhaps ultimately unsustainable, initially these time constraints force one to become a better therapist. The caveat is that you must care, and must want to provide the highest level of treatment to each and every one of your patients, despite the ticking of the clock.
If we liken physical therapy to the hospital, high-volume PT clinics are akin to the ER, in which there is no time for trial and error; decisions need to be made based on effectiveness and efficiency, and time management is everything. Two of the areas in which new grads struggle the most is undoubtedly time-management and session planning, often resorting to performing a general massage and then handing their aides a list of 25 exercises, one of which hopefully addresses whatever it is the patient is there for. Administering targeted manual treatment, prescribing condition-specific corrective exercises, and creating a condensed home exercise program that the patient will do are all skills that are fostered when a therapist is given a finite amount of time to work with a patient. A mentor can provide priceless insight and direction to help acquire these skills. Additionally, seeing lots of patients means seeing lots of different cases, different surgeries, different injures, different presentations, different body types, different personalities, different everything.
"...and the ability to develop that ever elusive ‘feel’..."
For those of you who are fond of research, this means a far greater sample size and subsequently an increased ability to observe trends, extrapolate data, and test hypotheses. From a manual therapy perspective, seeing more patients means more hands-on experience, and the ability to develop that ever elusive ‘feel’ that your professors and clinical instructors talked about; and use as rationale for why you have no idea what you’re doing when you first start treating.
So if more is better, why do I currently only see one patient an hour? While it’s tempting to reply, “because I can,” in reality the answer is that my skill-set has grown such that longer sessions with fewer visits has become the most efficient and successful model. This treatment model was made possible by the foundation developed during my handful of years spent embracing the grind. It’s important to note however, that diminishing returns is real when it comes to patient volume. Clinical settings with conditions such as more than three patients per hour, ten minute total treatment times, double-booking, or ridiculous caseloads that don’t allow for meaningful interactions with your patients are not only illegal (depending on the billing situation), but are also detrimental to all parties involved.
Conversely, the calculated chaos that comes with treating two to three patients per hour can be beneficial. It sets the stage for garnering skills to not only manage various personality types, but to be able to proficiently move from assessment to targeted treatment in a single session while simultaneously using all the information gathered to formulate a projected timeline for discharge. The skills to be gained from working in such a setting is one of the main reasons that I discourage new grads from immediately going into low-volume out-of-network or cash-based clinics when it comes to choosing a first job. Despite a high GPA and a penchant for spending hours reading journal articles (don’t get me started down that rabbit-hole), new grads simply have not YET developed the skills to appropriately treat patients within such a model. Before you flood the comments section with a diatribe on why I’m wrong, please notice the inclusion of the word ‘yet’ in that statement. The skills will come, and success right along with it, but it’s going to take time.
Grateful for the Grind
So, would I recommend taking the job with the highest caseload, the longest hours, and the greatest likelihood of burnout all in the name of skill acquisition? Clearly not.
"But there's something to be said about investing "time in the trenches" so to speak, and coming out as a volume veteran, able to handle most anything thrown your way."
And no, it’s not a matter of "I did it so you have to do it too because you’re the low man on the totem pole". Quite the contrary. The path I took has allowed me to achieve great success, and I want the same for you. They say hindsight is 20-20, and despite how crazy it was at times, looking back on it, I’m definitely grateful for the grind.