Giving less and less…

Thanks Adam, to hear other clinicians share these kinds of thoughts makes me feel less guilty about the feelings I often have. When so much of the focus of our work is on outcomes, evidence, patient satisfaction, trying to be the best we can etc. etc., it is quite cathartic to reflect on our limitations both as health professionals and as human beings. Cheers.

Hi Adam,Thank you once again for sharing your insights. I listen to a lot of your podcasts and read your blog, busy and post- burnedout as I am..aged 53 and a physio for over 30 years. This comment will be therapy. My son took his own life one day when I was at work, giving my best to some-one else. That was June 2013 life does really suck. I work for money and do the best I can. That is the end. I hope things turn out better for you. I keep busy and try to be creative. Cheers ,Jane

Adam, I admire you for being so frank and brave to share what quite a few of us feel. Personally often seeing patients at the end of the road gives rise to many of the feelings you expressed, I often go home questioning my own capabilities, internalising and feeling I am turning into more of a cynical, uncaring person!! I recently set up a complex therapy clinic with my team and this has been a great educational but more importantly supportive environment for peer support and also helps patients to see their role in the process when they hear it from more than one individual. We need to keep working together and support our colleagues doing this over a large bottle of red also helps! Anju

Thanks, great article 🙂

Adam, thanks so much for sharing that. As a personal trainer I can empathise greatly – after all, we all have limited physical and emotional resources. Something that’s helped me immensely is the stimulation I get from reading your blogs and also from the thoughtful responses of your peers.
So thanks again, Jason

Adam-spot on commentary. I’d like to add that over the last 35 years that I have been practicing I have observed the profession, in a never ending effort to prove it’s worth, take on more and more. What was once a clear niche-rehabilitation-morphed in to wellness, personal training, athletic training, chiropractic, nutrition, neuropsychology, to name just a few. Is it arrogance, insecurity, hubris, market share or what? Not to mention near complete disrespect for the people who actually are trained professionals in the area in question. Trying to wear all those hats can certainly lead to burn out. It’s the rare individual who can cover all that ground, we’re mostly mortals and we get weary.

Well said Adam. I retired in April after 33 years as an MSK physio. I gave my best every working day to motivate and encourage my patients towards taking control of their symptoms and lives as many had very complex problems. It’s only looking back that I realise how much energy it took and how draining it was. I loved my job but can honestly say that I do not miss it one bit. Caring takes its toll especially when patients, as you say expect to be fixed. Expectations these days are huge and the paperwork and administration is enough to start to sink health care professionals. My daughter is a GP and the pressures they work under are unbelievable. Keep strong and ensure that you look after yourself first.

great blog thanks for this, instead of whisky I work part time this definitely helps me to stay sane, I’d
it to anyone

I agree totally with your post. I have noticed the same concerns that you highlighted in my own practice. I think clinically I am better at recognising the pre contemplative patients and I understand that we can’t help everyone because the patient is not ready. I always offer empathy to all but I am more selective in how much I invest into a patient, as my investment has to be matched by the patients investment into their own health and well being.

Another top blog !

Fantastic post!

After just returning from maternity leave and being permanently knackered I now too have less empathy but also see it as a good thing as less willing to take shit excuses from patients…. especially those lucky enough to get a full nights sleep

Excellent read! I´ve felt many times like this… being burned out and fed up with my work, lacking the ¨mojo¨ to help people. Changing work environment (and country in my case), starting from zero once again did the trick for me, and helped me get back to the basics of this work and remind me why we loved to do it in the first place…. I might try the single malt recipe nonetheless 🙂

Another honest and open view on reality in the MSK environment Adam.
Patients need to look after themselves much better with basic lifestyle principles and one of them is to exercise daily – fact!
Keep these blogs coming mate.

The last bolded paragraph, in my mind, is really the most important issue. Fantastic read Adam and makes my Monday morning a little more optimistic!

And again nice blog Adam. I quit being a physical therapist (and teacher) years ago. And this topic was an important point. I have a trainingfacility (CrossFit and strength and conditioning) with my 3 sons now. No nonsense center and I have a poster at our door. It’s already an old one, but fits your post as well.
https://orps6.files.wordpress.com/2010/10/excuses-motivated-people-only.jpg
Keep up your work on this site! It helps changing the work of many therapists in a better direction. Thanks!

As a chiropractor with four years of limited experience, this is just what I needed to read right now! Adam, I feel I have learned so much more about people in the last few years and can relate to everything you’ve said. For me, the worst patients are then ones who just write “pain” on their intake form and virtually nothing else and when you ask them questions they say “just fix it”! For some reason, they often tend to be middle aged men in my experience.

I tend to emphasize the importance of “Attentiveness”; “Responsibility” and “Competence” as key values to patient centered care. Perhaps I should mark “Responsiveness” as equally an important value. 😉 https://en.wikipedia.org/wiki/Ethics_of_care#Ethics_of_Care_as_a_feminist_ethic

Thank God (or rather thank you, Mr Meakins) that someone has had the honesty and insight to say this. Yes, sometimes you will see a patient at exactly the right time, ie. when they WANT to make a change in their lives, they are ready to hear what you have to say, and you just have to point them in the right direction. But more often than not there are a lot of lazy people out there whose idea of exercise is pottering around the shops on Saturday afternoon. In a physio outpatients department, we are just scraping the surface, a much bigger change needs to come at a more fundamental level – that many people are not exercising enough, they have become lazy, and in a lot of cases they only have themselves to blame for the fact they are in pain. Instead of sitting on their fat, entitled arses they need to get up and take control of their lives and their health.

What an excellent commentary on the exhaustion i’m sure many PT’s feel in their practice. Believe it or not, i thought about quitting physio after only 2 years in. I was so frustrated and couldn’t understand why so many (the majority, sadly) would come to see me and pay good money to not take my advice and just want me to rub them, crack them, needle them, stretch them etc. I worked my ass off trying to develop my hands, even doing a fellowship in the process, only to learn that NO ONE has magic hands, despite what the gurus want us to believe. Physio became exhausting because i wanted to help everyone, more often more then they wanted to help themselves. I think guarding your emotional resources and selectively using them is what allows for longevity in this business. If you care more then your patients and your self worth is byproduct of your outcomes (like mine often are) then you are going to develop compassion fatigue. It’s inevitable

Pretty ballsy Adam and as always spot on. It’s a taboo subject but getting it out in the open is a bold move. Couldn’t agree more. We’ve all got to take it a little easy on ourselves to be able to offer the best we can. I make it a habit to tell all my new patients that I’m all out of magic fairy dust. Maybe that’s why some don’t come back…………..

It’s important to have a strong team around you. I find a multidisciplinary team hugely supportive when feeling this way. My experience of unidisciplinary teams was more professionally competitive.

Until recently I was a dentist for over 35years. When I was feeling like this I would think of the patients as people with a parcel under their arm. The parcel was their problem/s, I would do everything in my power to help and could feel very empathetic, but never pick up the parcel.

Adam,
Thanks for this blog. I can relate to all of the things that you are talking about. I have been practicing for almost 20 years (holy crap!) and became very burnt out about 10 years ago. That was after I finished my manual therapy certification. I slowly realized that this wasn’t the be all, end all. As I learned more about pain science and came into contact with different physios, I learned to take the pressure off of myself. It’s still a work in progress. I have to remind myself to watch out for the “energy vampires” during my day.
Nowadays, I can combat the stress of a difficult workday with some heavy metal, a beverage or two and knowing that other therapists are in the exact same boat. Thanks for your writing.
Aaron

Brilliant. Well said and I completely agree. I have done this for 18 years and you just said exactly how I feel. Fucking spot on. Keep up the good work and pick your battles.

Totally agree Adam.
As clinicians we have a limited energy level and is best used to direct and guide without taking on emotional burdens eg guilt, for not solving all and sundry problems. I like the ‘coach and student’ analogy. The coach can analyse the weak areas of their student, design up and teach specific drills to overcome the deficiencies, but can’t actually do the drills. No point as it isn’t the coaches problem to correct.
From AAP Education’s research with new and recent graduates, this area of clinical fatigue/burnout is one they really struggle with. We have identified 5 challenging client personas that potentially drain their energy levels and teach them through scripts and role plays how to positively deal with them.

Hi Adam,
Thanks for writing this, I needed to read it. I get myself physically ill (and presently am) from giving too much of a fuck in the treatment room, trying so hard to convey how important it is for clients to just get moving and then stressing about how I could (or in a lot of cases could’ve ) done more.
Once I’m back at work I will begin to try and actively decide if this client gives enough of a fuck for me to as well. Though everyone will get the same care and listening ear I will not try to make rocks go uphill on my own, the client must push with me.
Cheers again.

Hi Adam
As a recently qualified sports rehabber I am really enthusiastic at the moment but this is definitely something I have noticed in others and wondered how long it would take for me to feel like this!
For me it’s all about empowering patients to take responsibility for their own body and health and giving them the tools to do this. Where they go from there is down to them.

Adam , I love it!! Thanks Samuel !!!
Samuel Welter Ireland
>

now then, once again, good points, all well made! a lot of the comments make sense as well, we have become a nanny state. I have noticed more and more people are being referred with pains that they’ve had for DAYS, sometimes self referring with pains for HOURS! its extraordinary. People just will not accept pain, they want rid and still believe we have magic hands. If I had a quid for everytime ive heard someone say “I want you to fix it, take my pain away, heal me!”
im not sure where this all ends though, to me, the public are becoming more dependant, despite evidence, despite folk like us screaming at them, ive no idea why.
just gotta keep fighting the good fight.
and drinking whiskey
or beer
or both.

Well Adam , I am sure you didn’t expect this blog to resonate with so many ? The fact that it has struck a cord suggests to me that we are inadequately educated and are ill informed for the task in hand. I think we are deluded and perhaps seduced initially to think that most people want to ‘get better’ , I know I was . Many enter physiotherapy with the trajectory of the ‘common sense’ approach to injury/ pain resolution -perhaps based on their own experiences in the sporting world or recovery from injury perhaps . In reality, particularly in MSK settings we are faced with the complexity of pain behaviour , ill defined suffering and chronic inter related stress disorders. Working with a medical education welded to a dualistic model we are often ill prepared for what is an increasing reality which education should prepare students to better cope with. I studied Maitland when in fact its more useful to study Ekman https://www.paulekman.com/wp-content/uploads/2013/07/Facial-Expression-Of-Emotion1.pdf or look at the work of this guy ..https://www.amazon.co.uk/Whiplash-Useful-Illnesses-Andrew-Malleson/dp/0773529942….
General outpatients is often a respite centre for GP patients who get the half hour to 45 minutes of attention rather than the 5minutes at the initial visit and the problem with being an open caring soul is that people off load and it happens all the time ! Managers in NHS settings should support staff and recognise the toll this takes and education should recognise and discuss topics such as somatisation disorders and the like rather than suggest that we can understand people via neurophysiology (which I used to think was the case…..) . Explaining pain to people doesn’t cut it either as many are just not on the page…pre contemplative would the jargonistic term perhaps…Its obviously not like this all the time otherwise I wouldn’t do the job but burnout is seldom a result of not knowing enough, its not knowing enough about the effects interacting with others has when you are not on top form yourself ….
Do you cover this kind of stuff on your shoulder courses as even Cyriax mentions the shoulder as an emotional area ?!

whisky certainly not sure about the other stuff…

I found your blog quite confusing. Again, what is the source of pain? Do people attend therapy to “get healthy?” It would not appear that you know what the motivations of most people are, if they are not yours.

Fantastic. On so many levels. I think we should start all evaluation visits with “What are the odds of you taking to heart what you will learn today and making positive changes?” Anything above 50% gets a return visit.
Steve – 22 years into it….and hanging on for dear life.

Thank you Adam for this post, it’s such an important area to be highlighted. I can definitely identity with having burnout at different points in my career. Physiotherapy managers do need to be aware of the pressures on staff and the mental and physical health implications this can have. We spend all day advising patients about this but can often neglect ourselves!
I would certainly advise exercise/walks/music or whatever people enjoy to switch off and unwind. Personally I make time for non Physio related activity and love when I don’t have that particular hat on! As time has gone on, I’ve realised (despite some horrified looks from certain colleagues) that it’s nothing to be ashamed of!!
Keep up the great work Adam.

Adam,
I’ve followed along on Facebook and here. I think you’ve opened a discussion and highlighting an important issue in healthcare generally and of course physical/physiotherapy specifically.
This is a complicated and emotionally charged issue. I think it’s a pseudo tabu subject. It’s hard for us as professionals to admit, even if we know it, that we only have so much to give, that we have implicit bias, that we can’t help everyone. Further, we don’t talk about it with students nor teach and train them to cope. Others would chastise some for saying they don’t care, or can’t care. We burn out, or become cynical. Educators, researchers, society, administrators ignore (or don’t know). Providers are too involved or too distant. I’ve reflected on whether you need care to be caring: http://ptthinktank.com/do-you-need-to-care-to-be-caring-sympathy-empathy-compassion-and-caring-in-healthcare/. And, these are cognitive and emotional issues.
And, it spans care settings. I practice in an acute care hospital in a medical ICU (mortality rate of about 15% IN the unit), so these issues are in the forefront (although still at times ignored). ICU nurses have a higher rate of PTSD than Iraqi war veterans:
https://www.uchealth.org/news/cu-researchers-take-aim-at-ptsd-burnout-in-the-icu
https://www.ncbi.nlm.nih.gov/pubmed/25362680
Now, I don’t bring this up to stay one setting is better or harder than another. They are just different. And, they are all challenging. The idealism of helping people who are excited and eager to learn and change their beliefs, as Adam highlighted quite nicely, wears off quite quickly. And, this is regardless of setting. Why? You realize that regardless of setting you are treating people who are distressed, coping with physical limitations and symptoms, and come in with all of their baseline issues or ability to deal with their new circumstances. Whether a high level athlete or a hospitalized, chronically ill individual, their identity, their function, their life has been altered.
My sense is that often times we underestimate the profound nature of these situations, especially in outpatient orthopaedics. Relatively, it’s not that bad (you just have pain, you can still do X, you’re not in the hospital, etc, not as bad as Bill over there who blew his knee out, etc). It can be easy, maybe too easy, to assume the profound nature of a critical illness or stroke or amputation. The paradox here is that we may underestimate the person’s resilience or ability to cope. But, the paradox at the level of the provider is the habituation to these situations, and the automatic relative comparisons are brains make. “I’ve seen patients like this do better.” OR “It’s not as bad as so so.”
To regress back on course here, we see people in horrible situations. And we stumble into to these situations as young, novice clinicians without perspective or skills to appropriate conceptualize and cope. And, maybe how we cope, deal, and conceptualize over time, the skills we develop are not ideal. Do we navigate appropriately?
This can affect us, our life, and our connections. I ponder aloud if such under recognized effects (burn out, cynicism, relative comparisons, etc) are one of the contributions to patients dissatisfaction with the healthcare system and experience. It’s undoubtedly one of the factors contributing to the struggles of healthcare professionals. And, that contributes to our ability, especially as therapists, to provide high level care. This may affect outcomes. It’s like a dark, sick feedback loop.
Sorry for the diatribe, but thank you sincerely for your contribution and being willing to discuss difficult, complicated issues.

Another great read Adam and a topic every single HCP will be able to relate to. You are right, we need to be realistic and comfortable with the fact that we aren’t going to be able to help everyone due to many of the factors you raised. The sooner we could realise that in an episode of care the better as these pts are the one’s who can drain every ounce of energy from us. BUT, we care, and mostly know we can ‘help’ them and it’s why we all put our hearts and souls into every consultation. We know a great day can quickly turn into your worst day just by that 1 pt. We feel their distress and it can be exhausting. Like you say, impt we take care of ourselves and I hope employers read this blog and ensure they look after their staff. Paula.

Thanks for this great article on an often neglected topic. Awhile back i heard a fellow clinician say “Never do for your clients more than they are willing to do for themselves” which I think is more eloquent way of saying “give as much of fuck as your clients do”. It’s a philosophy I’ve adopted to help mitigate professional burnout.

Hi Adam – just wondering who you’ve written this post for – your patients, other heath professionals or the general public??

Thanks for your post Adam. As always, I have enjoyed reading it even if I don’t always agree 100%!! After 18 years of practicing, for me its not a case of caring less, but of being much more realistic in my own ability to help people and, more importantly, not taking it personally when I don’t!! Sometimes its biology limiting improvement, but more often than not its the clients motivation and adherence limiting them, so no reflection on me!!!

You’re def digging into the annals of most busy therapists minds with this one, but its a tough one to admit due to our reliance on empathy and compassion as an intervention and a business tool!
I think we become very good at ‘turning it on’ even when our cups are severely depleted! I suppose that makes your post more reassuring because the more I practice the more I just want to tell patients to man the f–k up!
I recall reading some research somewhere suggesting the more empathy shown to a person, the worse they percieve their symptoms to be!
When it comes to the passive patient that expects to lay dormant on a plinth and be fixed, I blame the antiquated education of therapists such as osteo’s and chiro’s. As a practicing osteo (def not in the classical sense) I spend half my time convincing patients that their joints don’t just slip out of line and need putting back and that their own volitional movement is far more effective than my theatrical, pulling, prodding and pressing. However, this culture is perpetuated by the self proclaimed body mechanics who convince patients that they regularly need ‘re aligning’ or ‘fixing’ Somehow an audible crunch makes everything ok and at the same time deepens this viscous circle of patient reliance and lack of self autonomy. I don’t think there’s anything wrong with well directed and controlled shots of empathy and compassion for the active participant who endevours to take control of their health but finds it difficult. However, for the deluded passive recipients of musculoskeletal healthcare who outsource their bodies to the biggest blaggers, I think a stiff dose of candid education is the way forward and ironically as much as it may not be what the patient wants to here, it will keep our cups full and help to debunk the archaic crap still spouted by so many therapists out there. great stuff sir!

Great post Adam and timely, having just ticked over 25 years in private practice. Increasingly I find it difficult to motivate myself to cajole non-compliant patients into doing anything outside their weekly appointment with me in terms of exercises, stress relief, lifestyle changes and have finally let go of the guilt I felt when they didn’t get better.
A smart mentor told me 15 years ago that you can’t help everybody, wish I’d really understood that back then. I’m making sure my new grad team members are getting that message quickly. Invest your time and emotional energy on the right patients and less on the time-wasters.
I can recommend Mark Manson’s “The Subtle Art of Not Giving a Fuck” as a useful read in this area as well.

Hi Adam !
Thank you so much for your post , I have been working in the physio field for few years though definitely not as long as you , however I can totally feel what you have written on this post. And that has totally described all my frustration in the recent period and that explains it !! I’m glad that from reading your post I have understand where’s and why’s and how’s my confusion of unhappiness with my job stemming from ! Thank you again !

Thank you so much for this article, it helped me to understand what I was going through.

Hi Adam,
I enjoyed your blog as it does certainly seem to resonate with current practice.
My undergraduate project looked at burnout in physio students and physical activity and I found that even spending short periods of time in clinical practice can increase your risk of burning out.
One of the main risk factors is (maybe obviously ) organisational stressors which I think are all too common in health care settings. Certainly I’ve found in my short time in the NHS that little is being done to protect staff.
Work out at work is a great concept because as, you’ve described physical activity can be a great buffer for negative health states such as burn out, but is often a limp showing of physios making a token effort. Maybe more could be done to help staff be more physically active or maybe that issue is much bigger than just health care?
I feel that another big factor in health care is that the culture is not condusive to health for the staff. How many wards are chocka with sweets and chocolate, how many of the staff are overweight and ‘on a diet’ and how many staff drive into work? I get looks of shock if I decline a slab of triple chocolate cake on cake day because this is the born. These are the same staff that are supposed to offer ‘healthy’ advice to their patients….
I do fear that as services and staff feel the ever tightening squeeze in the health service, these negative health states will be more and more prominent. Blogs like this one are key to highlighting issues such as burnout, so keep up the good work mate!
Thanks

Reblogged this on PhysioM and commented:
Reading this blog a bit late since it was posted but Adam Meakins always seems to hit the nail on the head. As he rightfully said we physios can only do so much to help our patients who want to be helped into healthy bodies and minds. Sometimes we forget to look after our own wellbeing. Thanks for discussing Adam

Halleluja and amen! Thanks for putting into words what a lot of practitioners are experiencing!

So true and some employers don’t seem to get it (even experienced physios). One practice principal bases performance reviews on the average number of times you see a client and you get criticised if people don’t come back. Often it’s because they didn’t like the message given or just want some massage etc. Can be very frustrating personally and professionally!