Jeannette Lang* met me for dinner after a long day at the clinic. As the sun dipped behind the restaurant, I realized that it was already approaching 7:45 on this balmy summer night. “Sorry,” she sighed, as she slid into her seat. “My last patient was 20 minutes late, and I had to finish some charting before I left.”
After I assured her everything was fine, we started catching up on life.
Lang had been working two jobs since we graduated from PT school together in 2010. On weekdays, she worked from 10-7 for a chain of busy outpatient orthopedic sports clinics, often seeing up to 30 patients per day. Every other weekend, she worked a per diem acute care shift for a major hospital. She spent her lunch breaks charting, contacting doctors’ offices, and completing other work-related tasks that would otherwise cut into her productive patient care time. On her days off, Lang frequently visited the coffee shop near her apartment, spending hours of unpaid time catching up on documentation.
She was always tired, but she saw no end in sight. “I’m still working on paying off my PT school loans,” she explained.
Lang is generally the picture of health; a former fitness model, she has competed in multiple triathlons, eats well, and works out on most days. But when we met for dinner, I noticed that she had developed an acne problem, and she revealed that she had recently contracted shingles. While she loves physical therapy and enjoys patient care, she had been struggling to prioritize her health, and she told me she was feeling burned out as a result. She and her boyfriend would love to get married, but they wonder how they will ever pay for a wedding and how they will afford to care for children.
Sadly, Jeannette Lang's story is not unique. Many physical therapists work well over 40 hours per week and are uncompensated for the overtime, even when they’re paid as hourly employees. Yet, these same employees are subject to being “flexed off” during slow days, which costs them either time or PTO.
Today’s PTs find themselves spending many hours outside of already demanding workdays, completing documentation and catching up on other tasks that have accumulated during the week. Several of my classmates have taken on leadership roles as clinic directors and owners, as well as staff supervisors. They tell me that they work at least 50-60 hours a week, and many have expressed frustration that they sometimes make lower salaries than they did as treating PTs, once the unpaid overtime is factored in. Yet they stay put in these jobs. It seems to them, there’s really nowhere to go in the PT profession.
This is not entirely true, as we’ll discuss later, but nonetheless, it’s a sentiment endemic in the physical therapy profession.
The most troubling aspect of this scenario is that we’re barely past the point of being considered “new grads,” and many of us are nowhere near the point of paying off student loans. Even more troubling is the fact that one of the top three articles on the site I co-founded, NewGradPhysicalTherapy.com, is “8 Non-Clinical Jobs for Physical Therapists.”
When I realized that I answer at least one email per day from a physical therapist asking how to leave patient care, I realized that we have a very, very big problem on our profession’s hands, and that I have a very uncomfortable article to write.
What causes physical therapy burnout?
To really understand this, one has to look at many factors that are leading to physical therapists feeling burned out and short of options. These factors include a rising cost of education, expectations of the career vs the reality, changing reimbursement structures, unrealistic productivity demands, the traditional “pecking order” in medicine, lack of non-clinical career opportunities for physical therapists, and the glaring omissions of PT school education itself.
Cost of education
Originally, one could become a physical therapist with an associate’s degree/certificate. It was an inexpensive price for entry into a highly rewarding, relatively low stress career. PTs were generally happy and enjoyed a low debt-to-income ratio. Even after physical therapy became a baccalaureate (bachelor’s degree) level program in the 1980s, many students could still pay off debt relatively quickly, and they made respectable salaries, enjoying regular raises that rewarded performance and loyalty; these raises were true raises, rather than cost-of-living increases.
When the degree became master’s-level, and now, doctorate-level, things began to change dramatically.
A graduate degree of 2-3 years means 2-3 extra years of lost income, along with cost of living expenses. Students rack up debt during the process, often remaining woefully ignorant to the ramifications of variable interest rates. Despite the fact that the cost of physical therapy school has more than tripled since 1999, students continue to flock to PT school. When I attended my own PT school, the first term I attended, we paid roughly $6000 per term. This quickly escalated to around $7200 per term, then jumped to approximately $8000 per term by my third year. If you consider the fact that my tuition rose over 30% in just 3 years, that’s quite concerning.
Despite turbulent financial skies for aspiring PTs, students are still signing up in droves to get their DPTs. Competition for acceptance to PT school remains high. More and more PT schools are opening and accepting students. One of NewGradPhysicalTherapy.com’s top two articles is how to get into PT school. Student debt is not unique to the PT profession, as we are all well aware. But PTs are starting to talk about the debt-to-earning ratio and what it means to the future of our profession.
Max Prible released an article about the rising costs of PT education, and Alex Engar PT, DPT recently performed a cost analysis of whether it makes more financial sense to become a physical therapist or a physical therapist assistant. He posted his results on a Facebook group (Doctor of Physical Therapy Students), generating a fascinating debate. He found that, even when using a very conservative estimate of what a DPT would accrue in loans, it would take 10 years for that DPT to reach the financial break-even point of a PTA.
With PT salaries only increasing annually at a rate to match inflation (2.6%), but with the tuition of school increasing from 4-8% annually, it certainly seems that it’s an unwise financial decision to become a DPT.
Skeptics of this article might already be rolling their eyes, and I can’t entirely blame them. They’ll be musing, “Why don’t these foolish students do their homework and see that this degree won’t pay off?” Others reading this article will quip that PTs who are willing to hustle can make it work financially. This is certainly true.
But many students pursue PT intending to enjoy a happy, fulfilling career. One with work-life balance and a semblance of life outside of physical therapy. These students truly believe the investment will be worth it, and even if they spend much of their careers paying off debt, it will be worth it for a gratifying, enjoyable profession. When you consider the fact that PTs are burning out on the work itself, irrespective of pay, things really start looking scary.
This article is not about whether PT school is a worthwhile financial investment. This article is discussing why the profession is not what it purports to be. And why nobody is talking about the real elephant in the room: physical therapy burnout.
Leaping before they look
One can hardly blame eager students for leaping before they look carefully at the financial implications of PT school. After all, US News and World Report and CNN and Money magazine continue to pump out articles hailing the splendor of the physical therapy profession. For example, as of the time of this article’s authorship (October, 2017) US News and World Reports ranks PT #16 of the 100 top jobs and 12th best healthcare job. CNN Money ranks PT as the 8th best job a person can have.
So what happened? Sure, the price of educating is increasing, but this is true across the board for all professions. So why aren’t PT salaries keeping up? Why are PTs feeling so overworked?
Reimbursement is plateauing - or even falling - so PTs are working harder
Student loans and educational costs aside, one must look at the factors limiting doctoral level healthcare professionals from making the money necessary to unburden themselves from crippling student debt.
Traditionally, physical therapy has been very much part of the standard medical model. A physician (MD or DO) would determine that a patient could benefit from physical therapy. He or she would write a prescription for PT, and a therapist would perform treatments based on the physician’s stipulations on the prescription. Even as direct access laws have been enacted in all 50 states, with some states enabling PTs to see patients without MD referrals, many insurance companies still require a physician’s prescription to authorize services.
Physical therapists have almost always been paid using a traditional insurance-based model. PTs perform treatments, then submit claims to insurance companies. The insurance companies then reimburse the PT for treatments, as long as the companies deem these treatments to be functionally necessary.
Essentially, PTs’ financial health always rested at the mercy of insurance company reimbursements. What has happened in recent years is that insurance companies are making it more and more difficult for PTs to receive payment for their treatments. Every insurance company pays differently, and the payment varies across states, as well as across different diagnoses and interventions.
Some states have high reimbursement rates for the same treatments under the same insurance companies, while other states have much lower ones. I found the topic entirely confusing, so the first thing I did was contact industry expert, Ben Fung, PT, DPT, MBA, of UpDocMedia.com. He releases the annual PT Job Market Pulse, and he is known for keeping up-to-date with PT trends.
I was expecting clarification on reimbursement rates, but was surprised to learn that the answers I’m seeking simply aren’t there. “The public data out there just isn’t clear,” explained Fung. “There doesn't seem to be much rhyme or reason to reimbursement rates, which is why it can be so challenging for clinic owners to provide consistent raises and bonuses."
Across the board, clinic owners are complaining that insurance rates are stagnating, at best. In many cases, they’re dropping. Increased loan burden leads to entry-level DPTs asking for higher salaries than their employers can afford. This is a recipe for disaster, unless we change how we practice. Some clinic owners are, indeed, rising to the occasion. Many PTs have opted to create cash-pay clinics, or only accept certain insurance plans. Others are getting creative with marketing directly to the public, selling products, or hosting onsite classes or CEU courses.
But not all clinic owners are prepared to get creative with income, so they’re failing to create healthy work environments for new PTs, who are struggling to pay off loans.
One can always argue that the solution is to practice in a state with better reimbursement. This theoretically solves some problems for cash-strapped new grads. But the issue is that reimbursement rates fluctuate so quickly that moving to a new state might only be a temporary solution. And, frankly, many PTs are being sold a false bill of goods. They often sign up for school and take out loans with astronomically high interest rates, only to reach the real world and find a very low glass ceiling. Unless they go the cash pay route or go in a very different direction. I’ll get into that later.
But financial concerns are only part of the problem. Stress over money isn’t always a consideration, and it certainly doesn’t always lead to therapist burnout.
In fact, many therapists would argue that, if money is the reason you’re pursuing your DPT, you’re making a huge mistake. I’d be inclined to agree; one can make a much better living in other fields, especially when you consider the length of time you spend in school, accruing debt while simultaneously unable to take advantage of perks that you’d have at a normal job, such as 401k matching, health benefits, and bonuses.
Clearly, other factors besides money come into play.
Set up to fail
One therapist with whom I spoke, Brent Davis*, works in the ICU of a major hospital system. He is the primary PT in this large ICU (which contains both a medical and surgical wing). He is unabashedly proud of his role and told me, “I love patient care. I love it so much, but the day-to-day grind is wearing on me because we’re set up to fail.”
When I asked him to expand on that statement, he continued, saying, “Our hospital requires us to be 100% productive. And when a therapist quits, regardless of the reason, we cannot replace him or her until we reach 100% productivity.” Davis went on to tell me that losing a therapist results in gross understaffing, causing therapists to scramble from floor to floor to cover more patients in a day, which not only decreases their overall efficiency, and productivity, but also causes feelings of burnout and resentment.
I wish that I could say that I am stunned, but I have worked in acute care and experienced this very phenomenon. It sometimes seems that all that matters is how productive you are.
You are only as good as your productivity levels
Productivity has become a hot topic in the physical therapy world. In every single setting in which I worked as a PT, productivity was a major, if not the primary, consideration regarding one’s work performance.
Productivity is essentially how much of your time on the job is spent performing productive (billable) tasks. There is no gold standard as to what is considered productive across settings. In some hospitals, any sort of patient-related tasks, gathering of equipment, chart review, or conversing with an interdisciplinary team, is considered productive time.
Not where I worked. Whether it was true or not, one of the hospitals in which I worked explicitly told me the only billable time I worked was 1-on-1 patient care.
Consider the fact that patients’ schedules in acute care are rarely predictable. You might try to see a post-op patient, only to discuss the case with the MD, who informs you the patient got a blood clot and cannot be mobilized. The time you spent discussing a patient’s case is not considered billable, yet your productivity reflects nothing but the fact that you didn’t treat a patient during that time.
PT productivity is scrutinized more and more these days. One hospital went so far as to create a logbook for each therapist to fill out at the end of each day. Each therapist was required to record his or her units billed for the day, along with a detailed explanation for the reasons why they didn’t make the productivity goal that day. It was unceremoniously dubbed “the log of shame” by one OT because, while management stated that therapists should not look at each others’ numbers for comparison, the very nature of a public book with everyone’s information in it lended itself to that very action.
Not long after "the log of shame” was introduced, therapists were being called into the supervisor’s office, being told to sign a document to signify that they were aware of their productivity shortcomings. We found out later that our department was chided by HR for doing so; it was never cleared with HR and was a clear violation of hospital policy.
But the damage was done. With "the log of shame” still in full force and therapists still terrified of losing their jobs or not receiving even cost-of-living raises, I began to notice two things occurring amongst staff members:
- Fraudulent billing practices.
- Making haste with patients.
Interestingly enough, many physical therapists opt to combat burnout by working in a hospital setting. Acute care offers a notoriously autonomous schedule, and it is easier to take days off because of the nature of the work. But even acute care settings are feeling the strain of productivity, as noted above. The irony of productivity being a measurement stick in the acute care environment is that patients are admitted and pay a single bundled amount for their stay. Regardless of whether a PT or OT bills 6 units or 3 units for a treatment, the patient will not owe the hospital any more or less for the stay.
It begs the question of why PTs would be judged on productivity, rather than patient outcomes.
Darren Horne*, a New York PT with 15 years of experience, voiced his concerns, saying, "Therapists often struggle to keep up, as documentation time is not billable in and of itself, although completing timely, accurate and thorough charting is directly correlated with higher reimbursement.” He revealed that therapists are expected to devote personal time to completing this task when overtime is generally not offered and compensation is already limited. Horne also added that electronic medical record (EMR) programs designed to make this task more efficient sometimes make it even more tedious, as they’re riddled with technological glitches that cause disruptions or delays. I asked him how he felt these rules affected his feelings on patient care.
Horne reluctantly shared, “This has negative effects on patient care, patient satisfaction, quality of documentation, and, ultimately, reimbursement. We haven't even mentioned the implications on job satisfaction. Therefore, it should come as no surprise that clinicians must figure out methods to cut corners in multiple ways.”
Yikes. For the record, I’ve been working with Horne to help him transition into a non-clinicalcareer path where he can leverage his PT degree in a less demanding role.
A thankless job
Ask any physical therapist, and he or she will tell you: the true joy of physical therapy is watching your patients’ faces when they take steps in living their lives that they never thought possible. Patients’ tears of joy following sweaty hours of heavy lifting during gait training are often reflected in PTs’ own shining eyes.
The highs of physical therapy are higher than any I will ever feel in another job in my life.
I once asked Lila Anderson*, a 50-something year-old therapist, what kept her going when she felt frustrated by work’s demands. Her eyes welled up with tears, and she answered, “It’s just that one patient you get...every so often. Their gratitude makes it all worth it.” These moments are why many of us become PTs, OTs, and SLPs. We genuinely enjoy helping others, and it makes us feel like a million bucks to be part of a patient’s recovery story.
But the joy is being taken out of the job on so many levels. Overburdening therapists with rules and regulations has compromised therapist safety and mental health.
Brent Davis*, the ICU therapist, shared a frustration with me. “I’m strong, but a patient can still hurt me. I rely on co-treating and co-evaluating heavy and mentally compromised patients,” he explained. When he was first hired at his hospital job, he received stellar performance reviews, annual raises, and plenty of support from management to co-treat appropriate patients.
Now, his performance reviews are, as mentioned above, heavily based on productivity, even though high productivity does not mean higher reimbursement in an acute care setting. Raises have become more and more sparse. While 4-6% raises used to be standard, Davis has grown accustomed to 2% raises on a good year.
But, he tells me, the worst part is the inability to co-treat, which is simply sucking the joy out of his job.
Co-treating occurs when a PT and an OT or SLP treat a patient together. This has many benefits.
- Many patients are unwilling to work with any type of therapy discipline more than once per day. By combining a treatment, two disciplines can work with a patient, increasing the benefits of skilled interventions.
- It’s safer for everyone. Patient falls are a sad reality in any hospital job, but they can largely be avoided by having plenty of support staff. While some hospitals do have “lift teams” or techs available to help with heavy treatments, therapists are often loathe to utilize these services. "It takes the tech 20 minutes to get to the room,” explained Davis. “By that time, my productivity is in the toilet. It’s easier to just see the patient at bedside.”
- Therapists learn from each other during co-treats. Part of the joy of patient care is learning how to become better at it. By co-treating with other disciplines, PTs and OTs can learn extra skills, techniques, and even communication styles to make their jobs more enjoyable and improve their patient care. But the therapists I interviewed, revealed that managers are cracking down on co-treating, and therapists are now being told to only co-treat on rare occasions, if at all.
When you take away the joy, you take away the safety, and you put therapists in a position where they’re disincentivized to use support staff because their performance reviews will be penalized, things can only go downhill.
Davis sighed, “It’s only a matter of time before someone gets hurt so badly that they’ll have to consider changing this policy.”
Patient satisfaction is huge. But what about employee satisfaction?
The fact that patient satisfaction scores are directly influencing hospital policy is definitely part of the problem. This is no surprise, and focusing too much on making patients happy is directly associated with poorer overall health outcomes. Nonetheless, the hospitals continue use this benchmark for everything from marketing campaigns to gauging clinicians’ performance reviews.
Here’s where the system continues to break down. Much of what a patient experiences is out of a clinician’s direct control. I worked in an outpatient clinic where the overall patient satisfaction score was only around 20% based on how I personally did as a therapist.
The rest of it? Patients dinged us on many factors that were out of our control: The temperature of the waiting room! The channel playing on the waiting room TV! The upholstery color of the waiting room chairs! It didn’t matter that I had a stack of positive feedback forms from patients. The fact that our waiting room chairs were dated and stained meant that I could never get any more than a 2% annual raise at that job. Just enough to keep my salary falling steadily below cost of living increases.
Will Butler, DPT, a PT-turned-financial advisor, told me that most PTs don’t pursue the profession because they love business. But a number of PTs then feel compelled to open their own private practices, either to pay off loans, enjoy more autonomy, or provide for loved ones. The lack of business acumen quickly becomes evident.
Butler divulged, “Many of these inexperienced business owners and practice managers do not create a pay raise budget, and when numbers are reviewed or projected, the margins aren’t available to offer an attractive raise. Therapists are dissatisfied that their hard work goes unrecognized, and things quickly spiral.”
Using a colorful example, Butler added, "This blemish of a situation isn’t simple, like a rogue pimple you pop and move on." With inflation hovering around 2%, he pointed out that private practices must provide 2% raises simply to prevent staff PTs from losing money for each year they remain employed. “And,” he concluded, “it’s not the staff PTs’ fault the business model sucks.”
DJ Katz*, a PT in private practice, told me that employers love giving patient-facing surveys of the facilities, yet they rarely provide a similar survey to the therapists as to how they "feel" in the company. If PTs and OTs could rate the quality of patients that the marketing team had attracted, or the lack of upward mobility options for career growth, would anything change?
Katz continued, saying, “A lot of the time, we are not listened to regarding the smaller things, like getting more supplies, getting people to come in and clean the office more often, and dealing with building management issues, like fixing the heating and AC.”
This doesn’t just apply to small clinics, either. Ella Ward*, a former colleague of mine, recently began work at a major hospital system. I asked her how her job was going. While she is mostly happy in her new role, she said, “One thing is the same wherever I go. There are never enough walkers or supplies. NEVER.”
I can say from experience that hunting down supplies has never helped a therapist’s productivity level. Most hospitals say you cannot bill searching for supplies as productive time. Yet another factor making therapists feel like the scale on which their worth is measured is woefully out of their control.
Walkers are not only basic to a physical therapist’s job in the hospital (not having a walker would be the equivalent of expecting a computer programmer to do his or her job without a computer), they are vital to the safety of patients when nurses ambulate the patients, based on PTs’ recommendations. So, not having walkers is setting both therapists and patients up for failure. At the end of the day, Davis says, the measurement standards don’t even make sense for therapists. He mused, “Nurses work with patients in 12 hour shifts. We might have 20-40 minutes with a patient, but we’re judged by the same set of standards on those surveys. We’re simply set up to fail.”
Terri Albers*, an occupational therapist in the D.C. area, recently told me that her hospital uses an app, called JabFab, to enable patients to rate their practitioners on the fly. This has resulted in practitioners living in fear that they’ll be negatively dinged on the app, adding to the stress of an already emotionally and physically taxing job.
Darren Horne*, the aforementioned outpatient PT in NYC, agrees that therapist well-being is not being prioritized by employers. He shared, “For many clinicians in direct patient care roles, burnout is inevitable. Most of us were ill-prepared to handle the degree of physical strain on our own bodies - even those who are extremely fit or athletic are subject to and suffer from work-related injuries." Horne also pointed out that many PTs lack the tools to address the emotional stress that is associated with caring for patients with critical illnesses and progressive or chronic conditions. "I do not recall this topic being adequately addressed in my PT school curriculum,” he mused.
Albers added that her OT and PT colleagues have felt frustration that they’re not rewarded for loyalty at a job, which tempts them to jump ship. She revealed that several of the more seasoned therapists at her job had tried working as rehab managers, but they found they were miserable. They experienced “role creep,” meaning that they were constantly covering for absent therapists, while still being expected to complete their managerial and administrative tasks. This, consequently, led to a lower likelihood of therapists succeeding in their roles and moving further up the corporate career ladder.
“You can leave if you want”
Chandra Essex*, a longtime physical therapist at a major teaching hospital, shared an unfortunate story with me. Her department was struggling with its leadership’s unrealistic performance (productivity) expectations, so an EAP (Employee Assistance Program) representative was called in, to work with the team of disgruntled and burned out therapists.
“You won’t believe what happened,” exclaimed Chandra. “He told us if we weren’t happy, we could leave.” Because this hospital system exists in a big city with several PT schools, I guess he could technically say this. But it doesn’t make it right. And it’s going to lead to a shortage of high-quality therapists down the road.
Nowhere to grow
DJ Katz*, the aforementioned outpatient PT, has worked in the same orthopedics role since he graduated, and hasn’t had a raise in 2.5 years. This is surprising, considering the fact that he has earned numerous accolades and certifications, including the coveted OCS (orthopedic certified specialist) designation. As his sky-high NYC rent increases and gas prices rise, his pay does not increase. He has asked his clinic managers for raises, but to no avail.
I asked him why he thinks that is. “Because they’re cheap,” he retorted. Is this really the case? I set out to find out what, exactly, is preventing clinic owners from giving their employees raises. It turns out that it’s not so simple.
The struggles of running a clinic are respectable and many. But it’s never easy to tell whether you’re being underpaid, unless the clinic owner opts to be 100% transparent with earnings. And, if you’re like Jeannette Lang*, and you have no paid documentation time and see 25-30 patients per day, you can be quite confident that you are bringing in more than the equivalent of $33/hour.
Keith Mahler, a San Diego PT, was frustrated by the income ceiling in physical therapy. His answer was to open his own clinic. “Most young PTs don’t open their own practices because they want to, but because they have to,” he told me. “It’s much easier to have your weekends and evenings free to do what you want, but this is the only way I can make the money I need.” When you have student loans looming and feel the back-breaking pressure of seeing 25 patients a day, Keith believes the pros of ownership outweigh the cons. But he’s still opting to retire this year, and he’s concerned. He has been trying to sell his profitable practice, and he’s finding that nobody wants the headaches of clinic ownership.
“Young PTs don’t want to deal with the headaches involved,” he explained. “They’d rather do something like cash pay PT and avoid the hassles of insurance.” But many young PTs do jump from the proverbial frying pan, straight into the fire.
Mahler told me that, without a solid understanding of what is involved with owning one’s own clinic, many aspiring clinic owners find it difficult to step away from patient care tasks to focus on the financial health of the practice. This leads to both owner burnout, and in less savory cases, as those mentioned by Will Butler, feelings of frustration amongst employees who feel that they’re not being given proper management, mentorship or financial rewards for their performance. It’s no wonder why many young outpatient PTs switch jobs every year or so.
After all, studies show that switching jobs more frequently is the easiest way to increase pay.
Over-promised and under-delivered: new grads are being severely overworked
Many prominent physical therapy companies advertise excellent mentorship opportunities for new graduates. Sounds appealing, right? Yet a Glassdoor audit reveals a darker picture. Quite a few of these “dream companies” actually wind up sucking in hapless new grads with the promises of mentorship, only to run them ragged with unrealistic productivity, billing, or patient satisfaction expectations.
Many therapists are required to clock out or log a break if they work more than a certain number of hours. However, quite a few of these organizations slyly pressure therapists to work off-the-clock (once the "lunch punch" is adequately documented to meet labor laws).
Terri Albers* expressed her frustration, saying, “These labor abuses are rampant and accepted by many (particularly new graduates) as normal, day-to-day operations. Unfortunately, companies continually take advantage of the young and impressionable new grads, resulting in burnout and high turnover rates as soon as the therapists figure out that there are better places to work!” Again, at Jeannette Lang’s clinic, she was not the only therapist who caught shingles. It went around the office. Most - if not all - of the therapists who got sick have since decided to leave.
With declining reimbursements, many therapists - even new graduates - are forced to see 20+ patients per day in outpatient. Many therapists report being unable to simply step away for a “pee break.” Taking sick leave is not as easy as you’d think. Coverage is always an issue, and even when you’re sick with a contagious flu, bug, or skin condition, employers often expect you to come in and treat patients.
A PT friend of mine, Kathy Shields*, has a designated scarf she always wears to work when she is ill. It is thick enough to catch her coughs and avoid showering her patients with germs as she performs their manual treatments.
Darren Horne* reveals that he believes the DPT itself has caused more harm than good in our field. He shared, “While our field has pushed the DPT in the name of achieving autonomy, its graduates are drowning in debt, without any immediate way of distinguishing themselves as it's now a level playing field. The respect and compensation associated with earning a doctorate as a therapist is not valued to the same degree as compared to professionals who possess doctorates in other fields. Therapists are expected to attain the highest terminal degree and programs are structured to push this agenda as the only option, despite the high cost of education, disproportionate pay and limited earning potential."
When I pressed for details, he explained that those individuals who completed their programs before the inception of the DPT also face challenges as they are phased out of certain job options despite years of experience as compared to their younger counterparts, simply because they don't hold a doctorate. "While the DPT has been a key component in utilization of the direct access model," he told me, "it cannot be substituted for clinical experience.”
Of course, any frustrations must always be taken with a grain of salt; as many have noted, only unhappy employees seem motivated to review employers online, not to mention contribute to articles such as this one.
Taking a breather
As anyone in therapy will tell you, being a physical therapist can be extremely taxing - on both a physical and an emotional level. As Terri Albers* points out, “It can be truly draining. It’s exhausting work to bargain, cajole, wheedle, bribe, and ultimately convince sick people who are in pain (and have often not made great choices in life) to do things that are painful and difficult.”
Being a therapist is immensely rewarding, but it is hard work. Albers added that many patients will manipulate and abuse therapists (both physically and emotionally), and therapists often turn to managers and other staff members for support, and have very little. While this is changing, many PTs and OTs are still considered ancillary staff in a hospital setting, and are flippantly ordered to “walk a patient” on physicians’ or nurses’ whims. If this occurs toward the end of the therapist’s day, he or she must decide whether to risk punitive results from unapproved overtime, or whether to upset the staff physicians.
The simple solution to any job that’s getting you down is to take a vacation. But Albers also mentioned that simply taking a break from patient care was a touchy topic in her acute care workplace.
She revealed, “Therapists are not being encouraged to use all of their vacation time because, in addition to being classified as a 'necessary service,' therapists are so scarce and PRN staff are so costly.” She explained that some of the for-profit rehab companies out there have quotas that limit the amount of therapy staff that can be on vacation at one time in each discipline. This leads to therapists working on coveted weekends and holidays, even when they try to give ample advance notice. In addition, many therapists are expected to find their own coverage on vacation days, which adds a level of stress that makes the idea of a vacation often seem like more trouble than it’s worth.
Who gets the massages?
I worked for a major hospital system for several years. This hospital system was ranked one of the best places to work in my city and, if you took the time to speak to anyone in an admin, business, or food services role, you could understand why.
One of the perks for employees was 6 free 15-minute massages each year. There were plenty of other benefits, such as free wellness fairs, healing arts sessions, and more. However, peeling back the layers reveals that the very people who likely need the massages the most - the nurses, CNAs, techs, and therapy staff who are exhausted from the heavy lifting demands of the job, are often unable to take the time to enjoy a free massage.
Therapists are so overworked by demanding patients and dominated by productivity expectations, they can hardly find the time to snag that 15-minute massage. Nurses have the same issue, being overworked and often saddled with too many patients to be considered safe.
The tree and the log
I first started thinking about writing about physical therapy burnout years ago. At that time, I was working for the aforementioned major hospital system in San Diego, and I was feeling burned out for many of the reasons above. I attended a career fair, excited by the hospital’s mission to retain all good employees, ensuring that hard workers had clear career paths in the system.
This is a good time to add that I never revealed my feelings of frustration or burnout. Not to my therapy colleagues, not to my managers, and certainly not to my patients. Yet, I had mentioned to a boss that I’d like to explore other areas of hospital employment, and I understood we had a program where you could observe other employees in their roles for a day at a time. Unfortunately, her answer was that per diem employees were not eligible to participate in the program.
I was working per diem because I was struggling to make it through each day of work, so I felt stuck. I knew that patient care was not sustainable for me in the long-run. I was feeling mentally and physically drained, and I felt no excitement at the prospect of leaving patient care to manage other frustrated therapists, as all of my supervisors seemed unhappy.
So, I decided to attend a generic hospital career fair. I awoke early on the day of the career fair, and I made sure to don my pressed suit and have plenty of resumes to hand out.
Career reps flocked to me and one began to ask me what I as looking for. Unfortunately, when she found out I was a PT, her face fell a bit. She explained that PTs could not hold roles like case managers in our hospital system. She said that I could specialize (referring to specializing within patient care). She said that I could move into management (jumping from the frying pan into the fire). And she handed me a sheet.
On the nursing side, out of the ground arose a beautiful tree. Its branches and twigs led to all sorts of different career journeys, even when one only focused on non-clinical options. Some of these included:
- Healing touch practitioner (essentially reiki and essential oils)
- Case manager
- Unit clerk
- Clinical supervisor
- Diabetes educator
- Health informatics specialist
On the physical therapy side, the options were a bit more sparse. Out of the ground, a fat log sprung forth. From this log grew 3 small twigs: supervisory roles (ending at department manager. Nothing further), specialization roles (simply “specialized physical therapist”), and “advancement” - PT I, PT II, PT III.
I will admit - I had a moment of pure anger.
It was more than a moment. If my career options in a large hospital system were limited to management (which is notoriously stressful and unappreciated in the therapy realm) and clinical care, why did we need doctorates? Why didn’t we stop at master’s degrees, or even bachelor’s degrees, if our profession would be viewed in the same way that a trade school job would be?
The reason I include this story is to make a point - there really isn’t anywhere to go in physical therapy if you’re not set on taking the physical therapy path.
What are we doing to change this?
Clearly, burnout is not stemming from one single reason. Yes, the cost of education is high. Yes, reimbursement rates are falling and raises are difficult to come by, making paying off debt a daunting task. Yes, therapists are being valued purely for their ability to generate income, and yes, productivity expectations are creating back-breaking levels of physical demand on clinicians.
But anyone who knows me well is fully aware that I’m only OK with complaining if there are solutions in mind. That’s where this article comes in.
I am far from the expert in physical therapy itself, but I do know one topic well, and that’s burnout. And I don’t have all the answers but, from asking around and doing my homework, here are some of the ways to start.
Providing pre-PT students with the facts
I applaud the groups out there who are doing this. The Pre-Doctors of PT Facebook groupand Pre-PT Grind, led by Casey Coleman, SPT and Joses Ngugi, PT, DPT, are doing a phenomenal job of adding a layer of transparency to the PT school application process. And financial experts, like Will Butler PT, DPT and Joseph Reinke of FitBux, are weighing in on options for aspiring PTs, helping them to plan ways to reduce the debt burden in advance.
Butler gave me some sage advice, recommending that aspiring PTs crunch some numbers before entering a DPT program. "I talk to too many clinicians who got into PT solely because they didn’t want to be a nurse or a physician, but they wanted to be in healthcare, and now they regret the decision because it wasn’t what they expected and the financial burden has been smothering,” he revealed. He added that many of his clients feel that the debt burden, physical and emotional toll, and opportunity cost do not justify the title of ‘Doctor.’
“REALLLLLLLY ask yourselves why you’re getting into PT,” he urged, adding, “If you survive your own critical interrogation, do everything you can to keep you loan debt around, or better than, 1:1 with your first year's salary.”
He believes that it’s possible. It might mean personal training, googling and applying for the most random scholarships imaginable, driving for Uber/Lyft, bartending, eating more ramen than you care to, going without Blue Apron, and decreasing alcohol consumption -- make it a game of frugality. “After all,” he added, “a small hinge swings a big door.”
Encouraging young PTs to pursue cash pay and/or per diem physical therapy
Cash pay is becoming more and more prevalent in the PT community. From the more established players, such as Jarod Carter, Aaron Lebauer, and Paul Gough, to the more up-and-coming cash pay folks like Will Gonzaba, cash pay has provided these go-getters with financial freedom that could never be possible if they had simply taken the traditional patient care route.
Gonzaba recommends working per diem to make money while you launch your cash-based PT practice, rather than taking the gamble of leaping in without a safety net.
Embracing new PTs who want to pursue travel physical therapy
Some people don’t burn out on the work itself; they simply burn out on monotony. Sure, patients are always presenting with different conditions, but the repetitive nature of working at a single institution can simply breed boredom. As my father often quips, “familiarity breeds contempt.” Travel therapy is a way to truly shake things up - in a good way. Not only can PT graduates make a true dent in loans by doing travel physical therapy, the constant change in scenery is very helpful to fight burnout.
Joining the APTA
I am guilty of being an armchair critic. I can sit here and express frustration at the state of our industry, but I recently let my APTA membership lapse. Yet, as Karen Litzy, PT, DPT, an exceptionally entrepreneurial PT and influencer, recently pointed out, “The more people join who join the APTA, the bigger our voice is, especially when it comes to things on Capitol Hill.” She also urged PTs to make donations to the PT Political Action Committee, even donations might compete with paying off loans. Litzy added that donations don't have to be huge, and if everyone in the APTA donated $20 to the PT-PAC, we’d have the biggest PAC in the country. After all, money talks, and if our PT-PAC has more funding, the PT profession can push forth initiatives to Congress with more gusto.
Addressing the burnout problem head-on
Quit putting the burden on the new grad. I am a member of several PT groups and forums, and when someone speaks up about burnout, there is often a polarizing effect. Some seem to blame the person feeling burned out, accusing them of being lazy or not researching the field. Rather than saying that someone is “poor at time management” or being whiny or lazy, let’s address what’s happening. Clinicians are burning out. Some as quickly as one year into the career, and the average is at 5 years. Stop judging people for burning out and start supporting them. There’s a reason people say that “PTs eat their young.”
Creating more options to leverage the PT degree
As I mentioned earlier, the DPT is a doctoral level degree. Other doctoral-level professions have many more options open to them. Pharmacist? You can be a pharmacist, teach, work in medical sales, as a medical writer, or in leadership. Physician? Many stay in patient care, but plenty others go onto work in hospital admin or healthcare tech leadership roles. Nurse? There is a veritable tree of options available to these folks, including clinical research, case managers, and clinical rehab liaisons.
Darren Horne pointed out, "Physical therapists who have reached the point of burnout find themselves with few options to continue in their fields, unless they wish to incur more debt and exchange more personal time in pursuit of another degree such as an MBA or MPH to allow a transition to the executive track. If we don't wish to go that route, there seem to be few avenues available.”
We physical therapists owe it to ourselves to provide training and support to those who would be better suited in non-clinical roles. If we invite students to join our profession with oppressive debt, we should at least offer them true career tracks that they can pursue if they decide that patient care is not for them.
One of the reasons I started NGPT and joined its parent company, CovalentCareers, is that I felt that I could best use my degree to help other therapists who were feeling frustrated and burned out. I wanted to help them understand whether they needed to switch settings, adjust their hours, pursue something adventurous, like travel PT, or simply try another path.
Encouraging PTs to follow their passion - and stay to patient along the way
Even though many PTs set out to work in outpatient orthopedics, the setting has a notoriously high burnout rate. It’s important to find your passion and harness it. I recommend that PTs participate in events like PT Day of Service, which will reawaken passion for our profession.
Rich Severin, PT, DPT, CCS of PT Reviewer, encourages young PTs to keep their expectations in check and realize that success and career satisfaction take time. You might feel stressed and overwhelmed during your first year, but if you set goals, you’ll make headway toward a career that makes you feel happy. “It’s imperative that you stay on top of your goals and continue to work hard,” he told me.
He encourages PTs to practice “the four Ps,” which are passion, patience, persistence, and pragmatism. “It's easy to get discouraged, especially when you've been accustomed to success. And especially in our age of instant gratification,” he explained. “Although talent and opportunities can influence success, even the most talented person can be unsuccessful if they don't put in the necessary hard work.” What’s vital to remember, though, is that it’s difficult to stay persistent and pragmatic when you’re not passionate about your chosen path.
Finding the right path doesn’t always happen overnight. For Judy Withers*, a young PT in the Midwest, leaving pediatrics was an unexpected, yet vital, move to preserve her sanity. She revealed, “I think I was convincing myself to stay in pediatrics because it was 'easier' than making a change (it was not). I didn't think I was - or would be - skilled and/or excel in other areas, and it somehow just 'made sense' for me to stay put.”
Unfortunately, she found out that staying in a job that made her unhappy was not easier. It did make sense at first, but stopped making sense somewhere in the course of 3 years, so she ultimately decided to take the plunge and try out a brand new setting. She is now happily employed as a Women’s Health PT, and encourages others burned out clinicians to try out other settings before jumping ship from patient care altogether.
“While starting a new path is incredibly scary - I may have cried more than once - and time-consuming, and exhausting, it's so empowering,” she gushed.
Understanding resources to combat physical therapy burnout
While PTs in certain settings - especially anonymous forums - can be a bit harsh with their judgment of each other, I have been blessed to speak with many folks who are ready and willing to assist new PTs with their career journeys. Here are a few:
Will Butler, DPT
Known for his metaphors and analogies, the incredibly warm and encouraging Will is a physio-turned-financial advisor. As an irreverent magnifier, his mission is to change healthcare by improving the lives of clinicians, through education and financial planning. He enjoys few things more than Ben & Jerry’s ice cream; helping clinicians succeed is one of those things. He values humor, knowledge, and a good barbell. He welcomes PTs to schedule a chat with him anytime.
Meredith Castin, PT, DPT
When I wrote this article, I decided that I cannot sit around and be an armchair critic any longer. I have launched The Non-Clinical PT as a resource for anyone who is considering a move out of patient care. I am going to compile as many resources as I can for people to pursue career paths outside of traditional PT, and will do everything I can to help therapists leverage the DPT in creative ways.
Ben Fung PT, DPT, MBA
As the co-founder of UpDocMedia.com, Fung does plenty of research regarding fair pay for physical therapists. He releases the PT Job Market Pulse, which comes out quarterly and covers job market trends, salaries, and compensations for PTs across the U.S.. He told me, “The lesson here is that YOU define your value. Regardless of everything you may have heard, the job market needs to be approached with confidence and with a strong frame of reference. Then, and only then, will you be comfortable with communicating your value, negotiating, and standing up for your career path.”
Karen Litzy, PT, DPT, MS, TPI
Karen is an inspiration to so many physical therapists. She treats patients 24-32 hours per week, runs the podcast “Healthy Wealthy and Smart,” takes on speaking engagements, and organizes the Women in PT Summit each year. She also understands the value of work-life balance, and has invited a panel to speak about non-clinical careers for physical therapists at this year’s summit. If you are a woman seeking to advance yourself in the PT profession, she is an absolutely vital connection.
Don Reagan, PT, DPT, CSCS
Don works at Mountain River Physical Therapy, and he is extremely passionate about clinical mentorship. He has repeatedly expressed his desire to reach out and help clinicians find their footing, especially in an outpatient/sports vein. This applies to PTs of all experience levels.
Removing the stigma of PT burnout.
As for Jeannette Lang*, she finally hit her breaking point recently. She wound up quitting her outpatient rehab job, opting instead to pick up extra hours from her per diem hospital job. I caught up with her and asked her how things were going on her end. She had recently completed an ultra marathon and had moved in with her boyfriend. She was considering unique roles and generally just enjoying time with her family. When I asked her if she’d do it all over again, she said, "absolutely!"
After all, new physical therapists are burning out like crazy, but they’re also harnessing their inherent millennial optimism, and they’re forging their own paths. For those of us with a bit more experience, as Butler says, it’s our job to support them. "It’s up to us to set a standard,” he told me. “We have to care for the new generation of PTs. We must set that standard, determine a process to achieve it, and welcome failures along the way, rather than judging each other.”
I could not agree more, and I can only hope that this article plays some small role in combating physical therapy burnout, if nothing more than by letting other clinicians know that they are not alone.
(* denotes a fictionalized name to protect the interviewee's privacy)