So this guest blog is a little different from the others we have had on ‘The Sports Physio’ in that it’s from an anonymous writer who despite being open and honest with me via email wishes to remain incognito due to some fears that they can not trust you lot not to go running to their employeers and tell tales. Now I would not normally allow an anonymous blogger onto my website, but due to the subject and content they cover, I think this needs to be published and discussed.

In this blog we get to hear the unreserved thoughts of a very newly qualified physio working in the private sector and their experiences. There are many things in this blog that I can relate too having worked in the private sector for many years, and think the points raised are important for other physios and their employers to hear and learn from. So with out further ado, here is ‘anon’ with what new physios can expect from working in the private sector.

Thoughts of a new physiotherapist in the private sector: Manual therapy, madness, whiplash and more…

I am a recent physiotherapy graduate working in the private musculoskeletal sector and Adam has kindly let me write a guest post here today anonymously so I can share my thoughts on what it’s been like so far, and hopefully provide some insight for current students and other recent graduates who are still trying to decide if this route is for them. I’m also hoping that it might be a good read for private physio employers, as more and more of them are taking on physios straight from uni. Obviously, these are just my experiences and I am working right in the centre of London, so may not be representative of the sector as a whole throughout the country.

What’s it like to go straight into the private sector?

First of all you should be prepared for 90% of the NHS physios you meet to tell you that you need to do your rotations and that you won’t be an effective/safe physio without doing two years of band 5 inpatient and community work. This is bollocks – they are mostly saying this because it’s what they did.

They will also cast aspersions on your moral character, suggesting that you are an awful profiteer for wanting to go into the private sector. This is also bollocks as the salaries aren’t massively more at this level and some even less than the NHS – if you really are after the big bucks at the expense of all else, you’re in the wrong profession and you should retrain as a chiropractor (apologies to Greg Lehman)

If you go into the private sector expecting to treat a range of fascinating conditions and to work with lots of elite athletes, then you will probably be disappointed too. Since the rise of the medico-legal industry, numerous companies have expanded greatly or been set up entirely because of the influx of whiplash patients. This means that in many companies you’ll be seeing a lot of neck complaints, as well as a few crash-for-cash fakers (although not as many as I was expecting). With that in mind, here are some bits of advice.

1) Research different companies and ask tough questions

Private physiotherapy companies vary considerably, from the small sole-trader to the much larger national and regional businesses with dozens of clinics. Based on my experience and those of others I have spoken to, the larger companies can offer a bit more structure and resources in terms of things like CPD and HR, but they will tend to hammer you with pretty punishing schedules. I have heard of numerous cases of people working for some companies where they can see up to 20 patients in a day with no admin breaks to do the medico-legal paperwork and with minimal support. NHS outpatient clinics are getting more and more pressurised as well, but at least there are other people around and you will have a Band 6 to keep an eye on you if you need it. There are also some large-ish companies that run NHS contracts which seem to have an ethos which is a mixture between private and public.

Smaller physio companies tend to be a bit more relaxed with their schedules and might offer the benefit of a more intimate clinic environment where there are a couple of senior physios around in the clinic that you can bounce ideas off. However, a lot of the smaller ones can’t afford to pay a particularly good salary and might offer to hire you on a self-employed basis where you get a cut of each patient you see (typically 50%). If you’re really motivated then this can be quite lucrative but when you’re first starting out you might want to think twice about it.

A good way to get a feel for things is to approach various companies that you like the look of and ask if you can do some shadowing – a lot of places are quite flexible with this, especially if you’re still a student. This can also be a good way of getting an interview or an even an outright job offer; I actually got my job off the back of some shadowing that I arranged through a uni friend in the year above, so networking does pay.

Some good questions to ask at interview are:

• What will my caseload be like in terms of appointments per week?

• What is the make-up of patients in terms of the medico-legal : private ratio?

• Will I be given time to do admin?

• Will I be given time to do my own CPD?

• Is there a CPD budget for courses etc?

• Will I be expected to work autonomously?

• Will there be onsite/remote support in the form of a mentor/senior physio?

• Do you have a lone-working policy? (often a concern for female physios but potentially everyone)

• How much clinical autonomy will I have

• Are there particular methods or approaches I would need to adhere to?

• What is your plan to grow the business over the next few years?

Key message: Know what you’re getting yourself into and don’t rush. Now is a good time to be going into the physio profession and you don’t have to go with the first company that makes you an offer.

2) Don’t throw away all the skills from your NHS experience

At uni I was a bit sceptical about the biopsychosocial model, placing a lot more emphasis on the bio bit. If you try and treat patients like this all the time then you will definitely fail. It’s actually very useful to have an understanding of the yellow flags and keeping a person-centred approach in mind.

A good example of this is all of the discharge planning you will have had to do as a student on inpatient placements. As you may recall, it’s often the physios and occupational therapists who act as key workers and make sure that the patient’s package of care is sorted out, that they will have some food to eat when they get home, that relatives are kept informed and so on.

Well, MSK outpatients can be a bit like that. Very often, patients have been batted back and forth between their GP, consultants, insurance companies, other physios etc. They are frequently unclear of their diagnosis or have been carrying around a piece of misinformation about their condition which is having a considerable impact of their quality of life. You often end up being the person who sorts out the mess.

Many patients still expect to receive an 80s-style neck collar for their neck symptoms but are not prepared to grow the accompanying mullet.

A lot of the whiplash patients I mentioned present with psychosocial complications which are very much integrated into their physical symptoms, and there is a lot of similarity to the sort of persistent pain patients you see in the NHS. Looking into the work of people like Mick Thacker and Mike Stewart is a good place to start.

Key message: read round the areas of chronic pain, yellow flags and talking therapies – when you’re looking at CPD courses then don’t just leap for the hardcore manual therapy options, like a weekend learning how to do “deep fascial realignment” (I’ve just made that up but it sounds good). Which leads me to my next point…

3) Don’t neglect exercise by getting bogged down in manual therapy

Even though I had my doubts during uni, for most of my studies I was a bit of a manual therapy fanatic – I loved the idea of all the different approaches and how we as therapists could push and poke things around and get tissues to function better with impressive hands-on techniques.

I was encouraged by some of my private colleagues who did a lot more hands-on stuff than in the NHS and who took a very biomechanical approach to their clinical reasoning. Manual therapy is, after all, one of the “four pillars” of our profession and partly the reason behind the pair of hands that feature on the CSP lozenge we all wear so proudly every day.

It didn’t take long for this enthusiasm to wear off once I started having a go myself. Within a couple of months I realised that many of the effects of manual therapy were temporary and that a fair few patients actually responded quite poorly to any sort of hands-on intervention. As I looked into the evidence for various conditions, I became increasingly disoriented and disillusioned as it seemed that so many things that I had held in high esteem were actually dressed up in a lot of nonsense.

Thankfully, as I read around I came across different points of view online and came back to one of the other pillars of physio: exercise (which Adam loves to bang on about). Of course I was always aware that exercises are a key part of virtually every treatment, but I think I had placed them below the manual interventions because hands-on stuff made me feel important and in charge. Probably there’ll be some of you reading this who will think this is all obvious, but if you go straight into private practice you will be under a lot pressure to do manual techniques. In some places it is actually a company policy to use it – especially for the private paying patients – and you can even be disciplined for not using it.

I do still use manual treatments every day but my reasoning behind it has changed – I’m not expecting it to fix the problem, but if it helps with patient buy-in and gets them to engage in their exercises more then this is surely a good thing. I’ve become much more enthusiastic for strengthening and find that this will very often play a big part in fixing things.

Key message: It’s important to challenge your beliefs right from the start of your career and to embrace the confusion. Don’t be afraid to limit your manual therapy to the minimal amount needed and spend whole sessions going over exercises or taking your patient into any gym facilities you have (which do tend to be more available in the private sector).

4) Avalanche on Bullshit Mountain – beware of private sector nonsense

The public sector is certainly not without its share of crazy ideas, but they seem to flourish in the private world where there is a bit more money floating around, or at least the prospect of it. Here are some examples of some of the stupid crap I have heard from private physios:

* Telling patients to do trans abdominal activation work to enhance “energy signals” to the VMO

* Claiming that you can relocate a meniscal flap tear

* Using dangerously high levels of ultrasound on chronic tendinopathies to “cook” the affected areas

* Doing cervical mobilisations to treat knee pain

* Recommending homeopathic “remedies”

* Telling patients with calf pain to avoid carbs and eat more red meat

* Advising patients against vaccinating their children

So, don’t be afraid to speak up when your nose gets a whiff of excrement that has a distinctly bovine flavour. I’m not suggesting that you launch into a full scale Richard Dawkins-style assault on your boss, but the best method I have found is to ask pointed questions about the evidence behind a given technique, or even asking for a basic anatomical/physiological justification. Remember, your anatomy knowledge is often better fresh out of uni than someone who’s been practising for years.

It’s important to remember that once you are qualified you are an autonomous practitioner. This is an attribute that good educators would have helped you to develop as a student; as long as you didn’t look like you were about to do something dangerous like try to massage a tumour then they hopefully gave you the freedom to reason for yourself.

Now you’re qualified you need to take this to the next level and be prepared to defend your reasoning all the more – don’t let someone play the age/experience card. If their reasoning and evidence trumps yours, then it’s only right to consider your position. But if you find yourself surrounded by Pilates purists who are horrified at the idea of a patient breaking a sweat during their HEP then don’t feel you need to water down your treatment accordingly.

Key message: Private physios are often more dogmatic than their NHS counterparts and might try and mould you into something resembling themselves. Maintain a healthy scepticism and try to read at least one journal article a monthand check out some of the excellent physio podcasts now available. Many universities will let you access papers via your alumni account, or you can always access the journal Physiotherapy for free via your CSP membership.

5) Keep really good notes

During your NHS placements you probably had educators busting your balls/ovaries every other day about keeping really good, detailed notes. In the private sector this often goes out of the window. There are certainly some companies that are hotter on it and perform regular audits, but at one place where I did some shadowing they often looked like this:

Subjective: Doing well
Objective: Good ROM
Treatment: Soft tissue and mobs
Plan: Continue

This is not an exaggeration. It should go without saying that this doesn’t fulfil our HCPC requirements and is basically illegal. But more to the point, it’s making your own job harder as there’s no way you can manage a caseload of 80-90 active patients and remember everything about them. Also, if you have a busy schedule it’s not uncommon for one of your patients to have to see a colleague for a session or two during the course of their treatment, so you’re best leaving a really clear plan – otherwise, when they come back to you, you might find that they’ve been told to rub homeopathic creams on their trigger points while activating trans abs.

Adam has rustled a few jimmies lately by saying that most physios are “thick as shit”. Judging by the quality of some of the documentation I’ve seen, maybe he has a point… or maybe they’re just lazy. Either way, at least make an effort!

Key message: Don’t pick up the bad documentation habits which are rife in the private sector. Think back to one of your best educators and imagine they’re reading your notes over your shoulder, ready to beat you with a reflex hammer if it’s not all not up to scratch.

Concluding Thoughts

A few months into my career I did get quite disheartened and was wondering if there was really any point in the MSK bit of our profession. Certainly, reading through the above might put you off going straight into MSK. With further time and reflection, I’ve been able to reconcile some of this and with any luck I can leave you with some more general advice that I’m trying to follow in my daily practice:

1. If you are already set on MSK, then I think the private sector can’t be beaten just in terms of the experience you’ll get. With many NHS trusts now looking to extend Band 5 rotations to three years, you can get a massive head start. Also, the interviews are much easier than the gruelling NHS ones.

2. Don’t give yourself the burden of trying to fix everybody and everything 100% – patients with difficult problems aren’t like puzzles to solve with a fixed solution that you can find if you just look hard enough. Recognise the limits of your profession and do what you can within it. This probably applies to physio anywhere but the pressure arguably feels higher in the private sector when there’s money involved.

3. Trying to use a strictly evidence-based approach is daunting and restricting to many private physios, possibly because some of the wacky, pseudo-scientific methodologies are more funand/or marketable. I like to see the fun and challenge coming from how I can creatively apply the evidence – devising and modifying exercises to fit in with each patient’s lifestyle and needs in a bespoke fashion.

I hope this has been useful – I look forward to reading the comments.

Anon!