Episode 40: Physical Therapy Burnout Revisited

[00:02] AD: Alliance Physical Therapy partners in Agile Virtual Physical Therapy proudly present Agile and Me, a Physical Therapy Leadership podcast devised to help emerging and experienced therapy leaders learn more about various topics relevant to outpatient therapy services. 

[00:19] Richard: Welcome back to Agile and Me Physical Therapy Leadership Podcast. I'm excited to invite Meredith Kastinback. So last time we spoke, Meredith, we talked about burnout and it was actually, I think, a few months after the first wave, might even been the second wave of COVID And the world was a very different place, wasn't it? So excited to talk about the subject again and what you've seen since then. So, for those listeners that perhaps haven't listened to the first podcast that we did, would you like to perhaps introduce? 

[00:52] Meredith: Sure, sure. My name is Meredith Castin. I'm a physical therapist by background and I run the Nonclinical PT. It's a website that's a career development platform for PT, OT and SLP professionals, guiding them to explore and pursue and land non clinical jobs. 

[01:13] Richard: And extremely successful, and as we talked about earlier, certainly an influencer within the profession. So thank you for everything you do. 

[01:21] Meredith: Thank you for having me. 

[01:23] Richard: So if we kick off, we've kind of put things into context. Definitely. COVID seemed to have caused additional stress anxiety, not just within healthcare, but across the nation. But certainly health care, I think, were in slightly unique position with regards to having to work under very difficult situation challenges that's passed, I believe, to a significant extent. But there's different challenges now. There always seems to be challenges, don't there? We certainly got economic challenges, political dysfunction, and then also ongoing kind of health care reimbursement challenges. Do you think anything's changed? And if you think things have changed as it regards to kind of health care worker anxiety, stress, burnout, how do you think it's changed? Has the narrative changed since we last spoke, do you think? 

[02:21] Meredith: I definitely think so. I think the main change I've noticed is I think people can openly talk about the burnout and they can openly share their frustrations with the direction that the industry is going and it's no longer painted by some of the powers that be as being a complainer or a whiner. I think there's been a level of acceptance and understanding that this is not a sustainable model. If we want people to enter the field with hundreds of thousands of dollars of debt in some cases, and then not have any real upward mobility in terms of earning power, respect, leadership, things like that, I think there's just a lot more understanding of clinicians frustrations. And that's a really good starting point. Because if you can't have a conversation about something, it will never change. 

[03:10] Richard: Yeah, it's interesting how at least the conversation started now and earlier in my career, it was kind of taboo subject to talk about mental health generally. And if anyone went off work due to burnout, stress, anxiety, mental health generally, the umbrella. It was almost whispered, wasn't it? Was okay to be off with low back pain or neck pain or post surgical, but the idea of being off work because of mental health, oh my gosh, that was kind of a no no, wasn't it? 

[03:43] Meredith: Yes. And I think you really hit on an important topic with mental health. Even recently it was going to get a massage, I think one of the first since COVID and did an intake form. And I remember filling it out. And usually there's some spot for generalized anxiety or depression. And I think sometimes if you have a name for it or ADHD or whatever mental health is going on, for me, I have generalized anxiety. I've been medicated for it for years and very open about that. But for some reason there was no section. It just said mental health. And I felt like, do I click this box? Am I mentally ill? So I think you hit a really important topic because we haven't quite figured out how to discuss things that I think a lot of clinicians feel. A lot of us feel very anxious about going into work. A lot of people feel very depressed about either their financial situation or just the fact that maybe they picked a career where you have to be on all day and don't feel good doing that. It makes you feel sad or depressed or whatever. And so I just think it's important that we sort of come up with terminology that makes us feel comfortable to discuss these things because again, it comes back to having conversations and just being able to share openly what makes us tick as humans. And if we can't take care of ourselves, how can we take care of patients anyway or our families or anybody else who's kind of a key stakeholder in our lives if we want to get business about it? 

[05:11] Richard: Absolutely. So feel that pre COVID. It's funny, isn't it, how we refer to life now as pre COVID and post COVID, isn't it? But the pre COVID world, I think forward thinking entities were willing, able, comfortable to discuss kind of mental health issues anxiety, stress, burnout, post COVID. I think, as you say, it's much more acceptable to talk about this. And you've certainly helped within the PT profession. Do you feel that we've moved even further along that continuum or we still got a very long way to go. It's okay acknowledging it, and then it's great that we're beginning to talk about it. Have we progressed any further than that, do you feel? Or is it we're still in the earlier stages? Which, when you say, that's a really. 

[06:01] Meredith: Good question, and to be honest, I don't know that I'm fully equipped to answer it for everybody. But I can speak from my perspective and say I think we've done a good job of moving forward. And I think a big part of that, again, anecdotally this is very much filtered through my own perspective. But when we do these non clinical spotlights that I do for my website, I've just noticed a lot more people have cited mental health concerns or considerations as a reason for leaving the field, and they're quite frank about it. And I just think back to maybe five years ago when I started, and I don't think people I interviewed on the site, myself included, would have necessarily put that into our spotlights had we done it then. But I just think over time, there were a few people early on who and here I am. I was going to say I don't want to mention them by name because I don't want to call them out, but I'm thinking, gosh, these people spoke about it on a spotlight that goes out to 30,000 readers. But I don't want to say the people's names specifically, but there were a few, I'd say a few years ago, who sort of opened up that gate and said I was having anxiety, my mental health was suffering. And I've just noticed that the highest performing spotlights, maybe not for pure click rate, because people don't know what they're going to get when they click something. But when we talk about engagement comments, questions asked, people saying, this one really resonated with me. They almost always come down to the ones where people are discussing their mental health. And I think that's really interesting because, I don't know, we're all human beings and the work that we do as clinicians, whether we practice or not, it can be very taxing. I still think about patients, I haven't treated a patient, I think in seven years now, and I still think back to certain patients and feel a spike of anxiety, like, did I do something wrong? Did I do the right job? Did I do a good job with this patient? I hope they went somewhere else if I wasn't able to help them. There's this one young woman with hip pain, and I always think, man, I just didn't know what I was doing. It was my first year out of school and I asked everyone and read everything I could and I just could not help this person. I hope she got the help she needed. But the fact that I'm still perseverating on that seven years later, like, okay, I don't know where I'm going with all of this, honestly, but I just really feel like mental health is a big component of what makes us doubt ourselves as clinicians and what makes us kind of sometimes even obsess. In my case, maybe obsess a little bit about what could have been done differently or what I would do differently in the future, if that makes sense. 

[08:39] Richard: Yes. 

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[09:25] Richard: With the economic challenges we have, do you think the conversation around Burnout is going to take a backseat or do you think that will continue? Obviously, the newest challenges that we experience in society, is that going to perhaps crowd out or supersede or hide the Burnout conversation? 

[09:48] Meredith: Yes, I think that's a really good question. And it's one of those things where to quote one of my friends who does a podcast, he was like, there's always a seat at the table for everybody and he's talking about podcasters. But if you think about issues that we have in the profession, I think there are many, many seats on the bus. When you're talking about the professional issue bus just speeding down the highway at high speed, there are lots of issues. And obviously if someone stands up really loudly and starts shouting about something, they're going to get more attention. And I think maybe that's what's going on with some other issues. We had staffing shortages because of COVID and we have mental health and all these considerations, but Burnout kind of plays into all of those other issues. You could even argue that the Burnout bus is one of the many buses on the line. And I think as far as Burnout goes, there's so many factors that relate to it. I often look back and go, oh, if I were medicated for my anxiety back then, would I have felt so overwhelmed? Who knows? Because I started on my med like right before I left patient care. But I hear from a lot of people where they are feeling anxious. This is interesting because I have this non clinical networking group and there's the ability to post anonymously in there and some people choose to be anonymous and some people don't. But when people share about their mental health, interestingly, quite a few people or they say that they're burned out and it's sort of a certain vibe or certain kind of key markers that people will share. Oh, I feel a sense of impending doom when I walk in the clinic every day or any of those things that anyone of us who has generalized anxiety disorder would recognize as a hallmark. Oh, if you wake up with the feeling of impending doom every day, you might have anxiety. So I've noticed that a lot of people will kind of chime in and say, hey, I know you're saying that you feel burned out, but have you considered addressing your mental health? Have you seen a therapist? Have you considered getting on medications if you are seeing a therapist? And so those conversations can't really happen exclusively because so often I think that Burnout does play in with these other factors, one of them being mental health, but that's one of many. Another one would be debt, or even if someone isn't in debt, if you live in a high cost of living area, like for example, the San Francisco Bay Area, so expensive, even if you don't have loans and you're just trying to get by on a PT salary, it's going to be tough. So you might have a sense of impending doom walking in every day, where if you moved more to the center of the country, into the heartland, or somewhere more rural, where there isn't so much competition or high cost, of living, that aspect of your sense of impending doom. The financial aspect might get taken away, but it might get filled with something else. And so I think if we ask, does burnout get overshadowed by these other conversations? If it does, we're doing it wrong, because Burnout has so many tentacles that reach into all these different areas cost of living, the stress of paying off loans, feelings of mental or not feelings of mental health, but mental health issues, just lack of satisfaction with where you're going in your career. Some people are this is getting a little bit off topic, but a lot of people score type three on the Enneagram, which is one of my favorite personality tests, and that's the achiever. And quite a few Pts are achievers by nature. We wanted to go into PT because it's helping, but it's also because it lets you grow and you have a career path, we thought. But the reality is when you've got reimbursements kind of driven by an outside force that you can't really impact, that takes away all of your agency of how much can I earn? And so, sure, people can say you can add a cash based component, but not everybody's able to convince the owner of their company to completely redo their business model so that they can earn a cash based component. And so you've got that factor weighing in, these sort of achievement based people who say, I really want to help people, but I also really want to grow my career at the same time. That's what I was sold when I picked PT. I might have picked a different career if I didn't realize that 50% of what I wanted helping people and growing professionally while the growing professionally is out the door. All you get to do is help people. Oh, and by the way, you can only help people if your management is supportive of this and values that over your productivity. And so I just think that there are so many conversations around Burnout that can be attributed to leadership, or poor leadership, lack thereof, or just perceived ideas of how things have always been done in a given environment. And maybe a new grad comes in with all these ideas and doesn't feel like they can share them. Or maybe a new grad is expected to come in and fix a dumpster fire that's been burning forever. And they say, oh, we need some fresh blood. So they hire a new grad and then burn them out and chew them up and spit them out, and the song continues. So I know I'm getting kind of philosophical here, but there are just so many components to burnout, and I think for many people, burnout looks very different from what it looks like for someone else. For me, burnout looked very much like getting bored because I'm a variety seeker, and so I would work at a clinic for a year and feel super bored and want to change. I think everybody's got a different feeling for what they want out of their career, but we have to, as a profession, recognize that everybody's different, give them the guidance to pick the right career path for themselves and then really encourage and coach. And if someone is very performance based and they want to grow and earn more and get better titles and get more recognition, then we need to realize that maybe encouraging them to go into certain paths of PT. They might be a phenomenal therapist in that field, but they're going to burn out really fast because they don't get any of these markers that's going to make them feel like they're growing professionally. 

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[16:14] Richard: Yeah, we changed Tact a little bit. One estimate that's been banded around was over 20,000 therapists left employment during COVID Physical therapists. I'm not sure how accurate is, but certainly I believe that a lot left the workforce, and I'm sure burnout was a contributing factor towards that, along with practical aspects like childcare, et cetera. Are you seeing or do you believe that clinicians will return and in what capacity? 

[16:54] Meredith: Yeah, I'm sure some of them will because they'll have no choice, or they'll believe that they have no choice. They'll say, well, this is what I was trained to do and this is what I'm going to do. And I think some people will return because they'll be attracted to things like the ability to work PRN or the ability to have a part time schedule and sometimes still get some benefits. And then I think for some people, they will never come back again because they found something that fits them better. And I've been having a lot of conversations with some friends of mine because one of them did take time off to raise kids, not even because she chose this. It was because it made more sense having multiple children to just take the time off and raise the kids rather than pay for these sky high daycare costs. So then the question comes, well, when all the kids are in regular school, what do I do then? Do I go back to clinical care or do I go back to a different non clinical job? And this is kind of an existential question that we've been chatting about a lot and I think in this case, she is one of the best clinicians I've ever met in my life. Just absolutely always been top of her game and that has, if anything, been a challenge for her because in some clinical environments, she's so good and she's so effective at getting patients better and teaching them the tools to get themselves better. Really good therapeutic alliance. She is too good at her job to the point where she doesn't get enough visits. And so those are the conversations that really stick with me with this, and thinking, yeah, she's one of those ones that left during COVID for numerous reasons that you just stated. I don't know if she's going to go back. She doesn't seem to want to. Which kind of breaks my heart a little bit, because I know that if I don't go back, big freaking deal, right? I was never that good of a clinician. I was fine, I wasn't going to hurt people. But with her, it's a little heartbreaking because she's so good. And those are the ones that are starting to really get under my skin a little bit, is the people who are really good clinicians really care about their patients and they're choosing to leave for some of these reasons we're talking about. And I'm trying to remember verbatim how she put it, but I think she said, I'm never working in a clinical environment again because it's so incredibly shady. She was saying that they were forced to use modalities, basically like, you use a modality or we're going to let you go. And she was like, the patient doesn't need it in this case and they said, use it anyway. And so when you think about these people where we try to teach our clinicians to be evidence based, and then someone who's just trying to do a good job, raise some kids, be a good parent, and they're being told these things when they go into work, like, you can't do your job the way you're really good at it. You have to actually change this so we make more money. You're not going to see any of that money, but we'll make more money. And I don't blame her for wanting to leave at all and not say, leave, I guess, just stay gone. And we talk about that a lot because this woman's smart, she's got a ton of great skills, and I think even personally, I drag my feet a little bit on encouraging her to really pursue non clinical work. Because there's that part of me that's like we are one clinician shorter of a really good person who could really help so many people. So part of me keeps being like, maybe there's going to be that magical clinic where it's going to be different for her or maybe she can open her own cash based clinic or maybe she can do this. But the reality is not everybody wants to do that. Not everybody can do that. And I don't think that in order to work in a clinic where you feel like things are, how should I say it? Like on the morality up and up, for lack of better term, but to feel like you're working somewhere where you can really practice at the top of your game and not be told what to do. Because for whatever reason, management isn't making enough money. And I sympathize with managers because I know how hard it is with falling reimbursements, but I just think it's really hard to tell people like her, well, I guess you got to open your own clinic if you really want to feel like you're not being sketchy at your job. In what world did this happen? And if we really trace it back, I think a lot of it comes back to it's just so freaking expensive to get a DPT degree these days and a lot of people don't know what they're doing. They pull out these incredibly high loans, not realizing you can look at a salary of a PT when you're 20 and say, wow, $75,000 is really high. Most people graduate college and maybe come out at 45 or 50,000 for their first job. That's a really high salary. I think this is going to be worth it. But they don't realize that then it's going to stay there and then all their peers are going to go up and not have the debt that we had. I don't know. It's getting a little existential here, but I hope I'm following a stream that's easy to follow. Sometimes I go on. 

[22:15] Richard: There's definitely been some wage compression over the last ten years and I don't see that changing. When people do leave and obviously you work with that group, essentially, of clinicians that are leaving the clinical role, shall I say? What type of positions roles do these clinicians tend to either gravitate towards or are successful in or available? Kind of three things, I suppose. Hopefully they all marry up. But what type of roles do you tend to see clinicians leaving clinical care to? 

[22:54] Meredith: Yeah, so tons, I would say. What's interesting is as time goes on, they're what I call kind of like the It girls where every couple of years there's like an It celebrity and then maybe they fall out of favor and someone else comes in their place. So when I first started, everybody wanted to go into utilization review and then what happened? I know, yeah, it's funny because I would rather watch paint dry than do utilization review just because it just does not fit my personality type, it doesn't fit my interests. And I can tell just from your reaction that you feel the same. I think there was more push to kind of reduce waste because to the example of my friend from earlier modalities on every patient, even if they don't need them. And so I think that there was a time, and maybe that time has passed, it is not my place to say because I've never even worked in utilization review, but there was a time in the past where it really did feel like a lot of that job was to say, is this really needed? Let's talk about creating clinical practice guidelines and say, okay, if this person really is realistically going to probably need 15 visits and you had them in for 45, they're a little expensive. And I can respect and understand that there's that component of utilization review that we needed and probably still need in some settings. I do think that to your point, it's starting to jump the shark a little bit to where it does feel more like you're describing. And I've heard it on both ends. I've heard people working in this space saying that, and I've heard people who are still clinicians saying this is getting out of hand. And so it's one of those things where I really don't recommend people take that path unless they have. And this comes back to I really think people have to have a good understanding of what makes them happy as a clinician and what's going to make them practice at the top of their professional game. And so if you're the type of clinician who can sit in a room and review charts and you want to create clinical practice guidelines, and you are comfortable not only challenging a clinician who's overusing, but challenging the higher up for maybe saying we're not giving people enough visits for this. I think you'd be good in utilization review because we need to have people who aren't just going to fall in line and go, oh, sure, five visits for a total knee replacement. Plenty. We don't need that either. I think the people who go into utilization review should really know what they're getting into. But I think a lot of people hear, oh, work from home and you're going to get roughly the same salary. Sweet. And I think that's what made it get really popular around 2019, like the PDPM PDGM era when that was happening before COVID and then COVID came along and everybody's like, get me out of here, I don't want to catch this crazy disease we don't know anything about. Why don't I go review charts? And so that was really popular for a while, and people still ask about it and they still want to do it. And again, it's still needed. I just think there are so many people doing it and it's become overkill. So one that I would say is kind of the It girl right now is customer success or client success, which I used to sort of lump in with account management because it was such a new career field that a lot of times a customer success professional would be called an account manager. And now they've really started to pull them out and give them their own titles. And so that one, I think the reason that it's so appealing to people is sort of why a utilization review was so appealing to people. You don't really have to take any extra courses to get there, but it helps if you have a little bit of extra education and you take a course or two, but you don't really need that. You can go in and do this job without formal coursework. I do have to add the caveat that it's become so competitive that you probably do want to take a course, but that's just the world we're in. It's gotten very competitive, but there are lots of other different paths that people take. But those two are the ones where I'd say it shifted from everybody wants to date the utilization review girl, now everybody wants to date the customer success girl, and it's going to change too. And sales is another big one. And I think the reason that sales is appealing is even though sometimes you do need more formal training or companies like you to have it, there is a lot of earning potential. And I've noticed that there's been a huge spike of interest in it since COVID I know COVID is never going to be over, but since it was an emergency situation and I think that's because we were all cooped up for a couple of years and now people are like, OOH, I want to travel. And flights have gotten awfully expensive. But if I'm a salesperson, I could probably travel on the company dime and make some real good cheese while I'm at it. So that's another appeal of sales. And yeah, it's that upward mobility, unlimited income cap. 

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[28:22] Richard: Situation moving on a little bit, we mentioned Reimbursement challenges. Pretty much every episode I'm kind of talking about Reimbursement Challenges. I'm getting tired of it in a way. But everything's going away. Continued wager inflation, PT practices really are having no choice to continue to optimize, and one can say that that is reducing waste. But to be honest with you, what I've seen. In a lot of practices, there isn't a great deal of waste, and time is well optimized. When you look at the state of rehab, average visits for twelve and an eight-hour day, I think for outpatient therapy. And given the administrative burden associated with seeing those patients, I don't think that's necessarily bad. I don't think they're necessarily sat round if they're seeing twelve patients and giving great care. So, we've got this situation, I think, where essentially therapists are working fairly hard and reimbursement is going down and we're optimizing the business as best we can, but costs of doing business are going up as well. So, we've kind of got this continued structural problem. And then on top of that, as we've talked about, is a shortage of therapists as well. And hospitals, for instance, they operate on a very thin margin. So, between one and 5% 3% is probably relatively normal for a hospital. So very tight. And where do you see this going? Do you think that payers will wake up and say, you know what, we've squeezed you so tight, we've asked too much of an administrative burden. We're asking you to do excessive administrative tasks. Given the fact that we're reimbursing you at actually below what it costs to provide the care USPH. And their last quarterly earnings report, I think they averaged, I think it was about 85 of cost per visit. And we know there's a lot of big payers out there that are paying much less than 85, 80. I don't mean to get kind of on my high horse, but that is just outrageous that a payer thinks it's acceptable to reimburse at a level that's 15, $20 less than actually what it costs to provide the care. So kind of roundabout way, what do you see happening? Are you seeing more clinicians? Just saying, you know what, I've had it, okay, I'm done. Or do you see people coming back in, setting certain parameters for themselves, doing better job at setting their boundaries? Or do you see the profession fighting back against the other stakeholders to try and improve clinician or employee engagement and supporting them better, or trying to make changes to support them better? Or do you see a whole array of those things? 

[31:36] Meredith: Yeah, it's interesting because as you were asking and sharing that and I love that you get on the high horse, please do, because I think it's an important topic and you're absolutely right. It feels like we are fighting a losing battle. And I think before I go any further with this, I think people are tired because you get out of school and want to go out there and change the world and start treating patients, and you hit a brick wall of reality of this is your pay, even though you might have read online that it was going to be this, it's this. Because guess what? Reimbursements have dropped since that article came out a year ago and, oh, you have all these loans. Sorry, you should have chosen a cheaper PT school. Oh, you can't afford to pay your rent here. Maybe you better go live somewhere cheaper. And so that leads to the point I was going to make of I think different people are going to have different reactions to all of this based on where they live. I know reimbursement tends to be different state by state, but we can still admit that there's a nationwide problem where it's not high enough anywhere. And so in the past I remember when I graduated probably 13 years ago now. Oh, my gosh, 13 years ago. I just remember they said, we'll go work in a state that has good Reimbursement. And it was pretty jarring to hear that, because not everybody can just pick up and leave. In fact, I went to PT school this is funny, where my boyfriend was, where we lived. I didn't want to leave the area because he lived there. And then we broke up during PT school, but I didn't want to leave the area. My life was there, my friends were there. I had a place to live there, even though it was an apartment. I had my rent set and everything. So it was just one of those situations of, oh, okay, so that's how we got to play this game. You got to shift your life around this career to make it work. And I guess that's how my parents generation did it. My dad, we ended up growing up where I did because my dad's job took us there. My parents didn't like it. It was far from their families, but that was what we did. And I think with PT, we were kind of sold this idea of you can work wherever you want. And for me, that was a really attractive aspect of the profession. And so now that no longer is applicable for a lot of people because, yeah, maybe if you live in a really expensive area and your family's there, and you have all of this generational wealth in the housing situation, that's going on there, then, sure, you can stay because your parents can pull some equity out of one of their free houses because they've been there since the 50s or seventy s and help you get a house and it's fine. But I think that's what's really starting to become a problem is that this isn't a profession that someone can go into and have a better life than their parents did. It used to be something where it's like picking physical therapy, especially back when it was a bachelor's degree. Picking physical therapy is a really smart move financially because it's a low barrier to entry. It's a bachelor's degree. And then you get out there and you earn a pretty good income, and it's pretty low stress. You don't have to see that many patients in a day. You can really give them your all, you can feel super accomplished at the end of the day and just none of that's the case anymore. You were saying the average is 13 people or twelve people a day. That's pretty reasonable. I love that. That would be wonderful. That's not what most people I know are reporting. They're reporting like 20, and that's 20. Oh, if we get a couple of cancellations because I'm expected to see 24, and that's the norm in outpatient. And so you just combine all of this with low salaries and then saying, well, okay, you should pick a cheaper place to live. Okay, maybe that's off the table because whatever, your parents are local and you have free childcare, whatever it is. So then they're going, well, go get a second job. Okay, I'll go get a second PRN job on the weekend. Do you really think those same people are going to want to then spend the money they just earned at their PRN job to go join an organization or go spend a day on the hill to fight things that, from their perspective, this is views are not my own, I should say here, but this is what I'm hearing from people. An organization that fights and fights and fights and the Reimbursement cuts keep happening. And so I think that's what's happening is people are getting learned helplessness, the psychology term. And so if you start to feel helpless and you're like, okay, I pay several hundred dollars a year to this organization and I know they're working hard. I can't volunteer my own time because I'm working two jobs already and just trying to afford a house, which is unaffordable because we all know what happened to real estate the last few years and this just isn't working. I'm not going to spend now hundreds of dollars to support this organization that's doing this great work. And I'm definitely not going to use a day to go and lobby on the hill and it's not working anyway. And so I think there's just a lot of defeatist learned helplessness, which I understand and totally get. And I'm not trying to be like, oh, those little whiners, because it's not like that. This is a real situation these people are in. And if I were still treating patients, I would probably feel very despondent by this point. I guess the point of all of this being I don't know that fighting for higher reimbursements is going to ever be a winning strategy at this point. I think we have to kind of rethink the profession. And one thing I did want to bring up, if you're open to me kind of sharing this unconventional idea. But one thing I really think we have to offer as physical therapists that I should say as a profession, and this goes for OT and SLP, too. And this is really not applicable to many other kind of doctorate and advanced level professions. We have a unique situation where someone can work, and if they need to go out on leave or want to go out on leave for a month, say, someone else can somewhat easily step in and provide equal care. It might be different, but it will be equal quality care. And I was talking to my husband who has an engineering background and saying, is that the case in engineering? Could you just work for six months, step away for six months, go travel the world or do whatever you want and then come back and actually feel like your job is no different than it was? And he said, absolutely not. And I don't think a teacher could do that, just walk away. Well, I guess they could walk away for the summer, obviously, but they couldn't just walk away from October through January and expect their kids to be the same. And so I think we have this really unique position and that's kind of a value added benefit of our profession, that if we really want to retain clinicians this is my feeling if we really want to retain clinicians, we have to say the one thing we can really offer you that you can't get anywhere else. It might not be the highest pay, it might not be the greatest reimbursement, but boy, howdy we can offer you flexibility. And that way if you, say, run a clinic, you could hire someone going, this is a six-month position. I'll benefit you the whole year. You might not get paid as much, but you will get benefits the whole year. You only have to work six months out of the year, and then you can go do whatever you want. If you want to go bartend and make a bunch of money, if you want to go be a substitute teacher just to try something else. And I think there's going to be a section sector of people, whatever the word is, who will be super drawn to that and say, I might feel real burned out by the idea of doing this forever and ever. And ever. But if I can do six months on and six months off or four months on and one month off, whatever schedule that is, that is the one thing that I don't think can be taken from us. Like, they're taking our reimbursements, these insurance companies, they're taking away earning powers. We're removing a lot of these things that are appealing about the profession. But one thing that really can't be taken from us if employers, I should say, are willing to be flexible with benefits and things like that. And some people might not even need the benefits if they get it through a partner or spouse or a parent if they're young, but just that flexibility. I think that's what's going to take to retain people and keep them working in this workforce is the idea of, like, sure, it's not the highest paying thing, but I go and I work on a cruise ship for a couple of months out of the year, hang out, get a tan, maybe work as a bartender, make some great tips. And then I come back and I treat patients. And in fact, one of my friends I've been talking with who is married to other said friend, we've been exploring that idea as a way to make more money for him is, oh, maybe you go back to doing some bartending. And I think in some senses it's a little sad. But I also think it's kind of cool because PT is one of the very few careers where you can pick up a couple of PRN jobs and as long as you figure out the insurance part, which that's a whole nother conversation for another time. I can see we're on the same page there, but if you could figure out the insurance part, then how fun is that? As a variety seeker, which I happen to be and he happens to be, that sounds super appealing. It's not going to sound appealing to the achiever because you're not really going anywhere in your career. But for someone who wants a lot of variety and excitement and they want to be able to travel and see the world or maybe take their kids traveling during the summer when they're off school and take three months off, I think it's going to really appeal to certain people. And that's just something that we can really offer as a profession that nobody else can. 

[41:05] Richard: I think to finish off, I totally agree with you with regards to one thing that employers can do is offer more flexibility. And I think that has occurred. The dichotomy we have as a provider is as a consumers want that kind of a 711 mentality of that service. The employees themselves struggle with being able to provide that time frame parameters or amount or quantity or whatever. But certainly I think there's a realization of employers that they have to be flexible because it's a fight for labor. Have you found or have you seen or have you heard of employers implementing processes, policies, initiatives, tactics that are trying to at least counteract address anxiety, stress, potential, burnout in the last year or two, have you thought that employers are at least trying to tackle this? 

[42:09] Meredith: I think so, but to be honest, I don't think it's going very well. And in the last year or two, I'm not going to say I can see a huge difference from when I was treating so going in the time machine back to say like 2000 and maybe 13 ish when I was in the hospital, I remember every hospital employee except for me. I was PRN, so I didn't count. But this was this particular job I had. But I remember every full time hospital employee got I think it was six massages per year and visits with the mental health professional and all of these great perks and I remember I was deciding whether to go PRN or full time. And I ultimately went PRN just because the hourly rate was higher. And they said I could mostly get full time work. And I had my husband's insurance, so I was like, I lose the six massages a year. But the thing is, I remember talking with the people who worked there and they were like, I've only ever used one because the minute your schedule has a hole, it gets filled with another patient. You don't get to go use those chair massages or whatever they were offering. And the people who were using those massages, they weren't the nurses or the therapists. It was like the bean counters or the people at the desk jobs. Oh my gosh, I could step away from my desk for 3 hours. I don't have a meeting, I can get lunch, and then I'll get my massage, and then I'll have a cup of coffee to wake back up, and then I'll finish my job. And so I think that's what's really making people want to leave the profession, too, is just seeing things like that, seeing this isn't your daddy's physical therapy where you went and got a bachelor's degree. And I used to hear stories at my first job about one of my coworkers would this is a little crass, but he would go in, use the restroom for like, 30 minutes, read the newspaper, all on the clock. And sit down and leisurely, have a cup of coffee, read his chart notes for the day, get a really good idea about the patients he was going to see, talk with a few other clinicians to really sort through. A few cases, go out, see his three or four patients, come back, chart, talk through the cases with the other clinicians, see if anybody had any other ideas, and then take a lunch with his coworkers. Go out to eat at the restaurant, come back and then sit back down, do a little more chart review, and then go see his three or four more patients. And I just think none of us younger. I mean, I'm not even young. I'm middle aged. But none of us of that kind of younger generation, especially the people really graduating now, can even fathom that. I mean, that's just so wildly unfathomable to me. And the only reason I believe it is that my coworkers weren't liars. And I know that they were telling the truth. And I can totally see this coworker of mine doing that because he was awesome. And I can totally see him taking his newspaper in and just having a leisurely morning constitutional. But all of that to say, this is not happening anymore. And so I don't really know how much mental health attention companies are giving to their patients I'm sorry, to their employees, because what people really need, in my opinion, to stay mentally balanced is just a little breathing room during the day. You can't cram that many people into somebody's schedule and say you can't even go out to eat because you have a time box. Even if you have an hour break by the time you get to the restaurant, sit down and get back, that's over an hour no matter what, unless that restaurant is the hospital cafeteria. And so I just think there are these quality of life factors that are soft factors that aren't being considered, and comparison is a big thing in America. That's really huge. Keeping up with the Joneses, that is huge. And if you're watching your engineer friend or husband or wife go off and have lunch with her coworkers, a two hour lunch, and then get paid double what you're making to sit in front of a computer and drink, coffee all day and go to the bathroom when you feel like it instead of cramming it in between patients and hoping they don't notice that you were a little bit two minutes late. I mean, there's just so much to unpack with this that I don't know how we can compete as a profession with some of those things. Unless, again, coming back to that whole flexibility thing, we have to figure out the ways that we can make our employees happy, that are super unconventional, but will make people happy enough that they choose clinical care. And I think we also have to admit to ourselves that we've been marketing this profession as a growth oriented, top of line. It's more competitive to get into PT school than med school. Whatever these things, we're telling people to attract them to go into PT school. We're attracting a certain type of person, and that person wants growth and upward mobility. And if that's what we're marketing our entire marketing scheme to get students in, we're not marketing to people who are like, it's all about the patients, and we just want to help the patients because, yeah, we all do want to help the patients. But if you're attracting people who are top of their class and they have this drive and this type A, type three enneagram driven personality, I mean, trying to appeal to them with guilt and saying, oh, but the patient care is suffering. It's not going to work very well. There's a reason why I can tell you, almost everybody who takes my course or goes through my program and takes this enneagram test, the people who choose to stay in patient care are almost exclusively type two. That's the helper. So we need to be thinking, okay, if the helpers are staying and they're the ones who want to stay or maybe the Type Seven variety seekers like me who the idea of getting paid not as much, but being able to do something else six months out of the year because we get bored so easily, maybe that's what we appeal to. Or we find out what type of person is going to thrive in the future of PT. And then we got to market to those people and they need to be aware of what they're getting into. And maybe I think we just really need to rethink the entire profession. But this is getting way out there. And I recognize this is probably most people would be like, you crazy, girl, and I get it. But this is just I found myself really trying to think unconventionally. Like, what else can we do to keep people from looking at their engineer wife and going, she's making twice what I do. Why am I here? I'm going to go get a coding boot camp certificate and I'm going to go make what she makes and then we can actually get a house and maybe afford to have a baby. 

[48:26] Richard: Wise words. It's great to chat with you with regards to trying to perhaps solve some of the ills of the profession. I don't think we got very far, but at least we had fun talking about it. Thank you so much for being a guest on this podcast, Meredith. If people want to reach out to you, how can they go about that? 

[48:45] Meredith: Sure. I'd say go to the nonclinicalpt.com. It's all one word. No dashes or anything thenonclinicalpt.com. And we've got a number of ways to connect. We've got a great networking group that's totally free. It's huge. People are having really good a lot of these conversations that you and I are having are based on the conversations that we're already having in that group. So it's interesting. I think there are a lot of people who want to solve a lot of these problems and share some unconventional ideas yeah. And just kind of get involved. And if you have questions about anything you find on our site too, you can hit support at Nonclinicalpt.com and we are happy to answer any questions. Sometimes people are looking for a specific thing on the website and can't find it. We've got a Start Here page that makes it a lot easier to navigate, but I'd say just explore what's out there, but think about also, for anyone who's listening, don't always jump to leaving the profession. If you're the type who has these kind of wild, unconventional ideas, don't be scared to share them, because right now, I feel like the profession is in a situation where we need all the ideas we can get and you just never know if your idea could be the one that kind of saves us. 

[49:52] Richard: Absolutely. Well, thanks very much. I've enjoyed the conversation. 

[49:56] Meredith: Me too. Thank you. 

[49:59] AD: This podcast was brought to you by Alliance Physical Therapy Partners. Want more expertise and information? Visit our website at alliantptp.com and follow us on social media. You can find links below in the description. As always, thank you for listening.