Welcome back to the Healing Pain Podcast with Mike Richardson, PT, DPT, DHSC

In this episode, we are discussing perfectionism and stress in the physical therapy students. Stress and burnout in the PT profession are personal interests of mine. I have done some research and explored how to use ACT in preventing burnout and creating resiliency in physical therapists. We briefly explored this topic of perfectionism in episode 217 with physical therapist Andrea Moore. She is a PT who specializes in treating women in overcoming perfectionism, and the intersection between pain and perfectionism.

Perfectionism is often caused by having high standards or having a hypercritical evaluation of oneself. Some doctor or physical therapy students experience increased stress when they go through the rather rigorous academic coursework that we take in physical therapy schools. Yet there is limited research in understanding the intersection between stress and perfectionism in the PT students, what the successful behaviors are that these students have that help them manage this increased stress, especially those who are perfectionists coming into the program.

Here to discuss perfectionism and stress in the PT student is Professor Mike Richardson. He is a Clinical Associate Professor in the Doctor of Physical Therapy Program at Hanover College. He is a Doctor of Health Science from the University of Indianapolis. His current research interests include perfectionism and stress among physical therapy students.

You will learn all about perfectionism and its prevalence among DPT students, perfectionism’s relationship to stress, and why it is important to better understand the relationship between stress and perfectionism. Finally, what can be done? What strategies can you employ if you are a DPT student or a physical therapist yourself who is looking at the impact of stress on your physical as well as mental well-being? Let’s meet professor Mike Richardson and learn all about perfectionism and stress in physical therapy students.

—

Watch the episode here:

Listen to the podcast here:

Subscribe: iTunes | Android | RSS

Perfectionism, Stress And The Physical Therapy Student With Mike Richardson, PT, DPT, DHSC

Mike, thanks for joining us on the show.

Thanks, Joe. It is great to be here. It is nice to see you.

I’m excited to talk to you about perfectionism in physical therapists, especially physical therapy students, which is the center of our talk. Looking through the literature, there is not a whole bunch on perfectionism in DPT students or licensed professional physical therapists as well. Why was this important for you to start to investigate and study?

You do see more of this research in medical students. I was doing the Doctor in Health Science and I have always been interested in wellness, students’ well-being and stress that had been written about for a few decades now in PT literature. I was trying to find something else that I could study. I read a newspaper article about the evils of perfectionism or the negative side of it.

It almost was that light bulb moment where I’m like, “We have these students that come in and we have these very high standards for them to get here.” Some of the things I read reminded me of some students. I’m like, “There is nothing in the literature about this. Let’s see if the rates are similar in DPT students or PT students, as well as some of the samples I have already looked at.”

It was from looking at stress and burnout but taking that one level deeper and saying, “What else is there besides general stress and burnout and what could be contributing to it?” You came upon perfectionism. You already mentioned perfectionism can be dangerous to us as humans. What are the dangers of having a perfectionistic personality?

When you look at some of the research, some people will look at it in multiple categories or at least two categories. Some can be beneficial, and some can look at it as problematic or negative. Specific to maladaptive perfectionism among medical students, they have found that that was the biggest predictor of distress in that population.

Once you look at the stress literature, you have whole other bits of health problems such as cardiovascular issues, obesity issues and inappropriate coping mechanisms. It can have this cascading effect on not only our overall health and academic performance. There are so many negative things that can come about if you are on that problematic side of perfectionism.

It is interesting in the context of student physical therapists because getting into PT school can be competitive. The prerequisites can be challenging sometimes. Oftentimes universities have a certain GPA requirement, and sometimes there are limited slots. It is interesting to think back to when I was applying many decades ago. The spots were limited and there was this sense of stress that continued even when people wound up in the program and were accepted into the PT program. As people are entering into physical therapy programs, are we aware as educators on the DPT curriculum level that people may be starting a program with perfectionistic traits that may impact their performance?

I do not know what all programs are doing but I do not get the sense that they are specifically looking at that. At my current institution, Hanover College, I know we looked at emotional intelligence and we did some other things. We have not looked at that specifically but you do bring up an interesting point. We may be creating applicants and PT students that trend in that direction.

We should try to identify some of these students a little earlier because once you start the program and you get into anatomy, your time is limited. Are we going to be able to teach them coping strategies at that point? Probably not. They have to get through it. Could we identify some of the students that may trend in that direction earlier and make some suggestions prior to starting? They may be more likely to be able to incorporate some of those strategies that might mitigate some of that stress and perfectionism.

We are talking about perfectionism having a physical impact on the body, as well as a mental health impact or mental illness potentially. Is perfectionism looked upon as a mental illness, or is it more of a personality trait that one is born with or potentially develops through the environment that they are in?

That is a little bit beyond the scope of what I have looked at. I do not know if it has been categorized on the psychology side of things. I know they have looked at this among adolescents. I’m not sure how young they have looked at this. It can go into different dimensions in your life. What I do remember from some of the literature reviews is you typically do not have perfectionism in every single dimension of your life. It might be where you pull in your most self-identification. If you are an athlete, it may be in your sport. If you view yourself as more of a student, it might be with your grades. Mental illness, I can’t speak to that.

There is a beneficial side to perfectionism for some people as well. Is that right?

Yes. It comes down to acceptance and tolerance. Having high standards is important, but if you start to have extreme, unrealistic or excessive-high standards, that becomes the issue. It is always important to be self-critical and self-reflective, but when you start to become hypercritical, that is when it becomes a problem. If you are doing some practical or competency skills check and you get off right off the bat, that spirals you into making more mistakes versus being able to accept that like, “I did not do this perfectly. It is okay. I’m going to move on.” That is when we end up with some of the issues of that maladaptive or unhealthy perfectionism.

Helping students identify with self-reflection and self-evaluation is part of being a student, as well as a professional, but if it starts to go off the rails, then being able to reflect upon that and say, “I may need some help. I may need to pay attention to this part of my personality or my life a little bit more at this time.” What has your research found with regard to the incidents of perfectionism in DPT students?

Specific to the sample we looked at, we had about 40% that we identified as that adaptive healthy perfectionism. We had about a quarter of them that we identified as having maladaptive tendencies. That put us at almost 2/3 of our class falling on that perfectionism spectrum. We talked about it earlier. You expect that we are going to have high performers in our PT programs. You do expect higher numbers of perfectionists in this population.

It is similar to a group of medical students. They were about a quarter as well for maladaptive perfectionists. The closest I could find with PT students was a pre-occupational therapy group. They found higher rates in that group for perfectionists, in general, as well as maladaptive perfectionists. They’ve found that little over 40% is maladaptive.

Is it consistent as students graduate and become licensed professionals or we do not know that yet about DPTs?

We do not know about DPT students. Most of the literature has been done on undergraduate and some high school. You are starting to see a little more in health professions. I have not specifically looked at once you become professional. However, I have not stumbled across it either. I do not think it is out there too much from a professional standpoint.

It is new because there has a whole area of research where people can delve into and see what is happening with DPTs as they graduate. They move on into clinical practice. What can we start to do either potentially before we enter a DPT program or maybe in a DPT program to help mitigate? What are the strategies that we can look at or look toward?

When it comes to strategies, we can look at them from a personal level as well as a program level. There has been a fair bit of research on stress management strategies and mindfulness, mindfulness with movement. You do a lot of work with Acceptance and Commitment Therapy. We have some individual levels and those have been successful. We still need to teach students that and talk about that. Some will set a canary in the coal mine. We are doing some things to address the canary. Is it time to start looking at the coal mine or the PT programs, maybe healthcare in general? What can we do to make it less stressful while we still maintain the rigor?

We want those high standards and that rigor. Is it a sequencing thing? Is it how we set up our examinations or assignments? A strategy might be trying to identify on a program level where these stressors are. Typically, you can figure out over the course of going through different cohorts, and perhaps you can build in a stress management curriculum that goes throughout the whole curriculum versus a one-time shot. Maybe it can proceed to an area where you know it is a stress for the students.

Sometimes it’s disclosing to the students like, “This is going to be a hard semester for you or this is going to be a hard two weeks. It is coming up. What can you do to prepare yourself and make that a little easier?” It is almost like disclosing that information ahead of time. If you have parts of your program that are a little slower, maybe you can do something a little more involved with stress management. Those are some of the ideas that are out there and some of the things that we can consider.

It’s a throughline within the DPT program that includes stress management.

That is great. Maybe even emotional intelligence. There are some options out there for sure like resiliency training that I have read about. We have some interests options. We have a lot of stress information on health professions, student side of things and professional side of things. It would be nice to be able to teach some of these students while they may be more open to learning some of these stress management so they get some of these habits before they matriculate and become professionals. Hopefully, we can address some of the healthcare provider wellness out there.

That’s interesting to consider. Let’s say there was a mindfulness-based stress reduction class that ran for eight weeks every year. What is interesting to me is learning that is good for your own stress reduction and stress management, but then we have tools that we could use with our patients as well. We are helping ourselves as well as learning an evidence-based approach to potentially helping a patient with pain or with anxiety that may be interfering with their recovery. I have seen some published papers where they talked about components of DPT curricula or even potentially some of the CAPD standards that start to look at things like mindfulness and stress with regards to the patient populations that we are seeing and treating.

You are spot on with that comment. I do not think I could say it any better.

You said looking at the canary in the coal mine and the coal mine itself. The coal mine of a DPT program exists. The program itself could be a coal mine, but the university setting dictates some of that as well. That is an even bigger coal mine. Have you been able to make any connections either through the literature or personally looking at the stress of the faculty?

I know a lot of faculty members are interested in stress management and vicarious trauma that has happened over the past couple of years with regards to COVID-19, and all the changes they have encountered in the DPT program. Is there any balance or play that is happening between the traits and personalities of the professors that impact the traits and personality of the students?

I have not specifically come across any of that. We all know that how we role model to our students is so important. You bring up the last couple of years now with COVID-19. When I started this project, we were not in COVID-19 yet. We were collecting stress data as well. We were able to look at stress levels prior to COVID-19 and during COVID-19.

Unsurprisingly, we found that they went up in our students. We also are starting to try to look at things beyond that typical White population. We looked at Hispanic versus non-Hispanic students. What we found was prior to the pandemic, the stress levels between Hispanic and non-Hispanic students were the same. Both groups increased when we took the measures again 10 to 12 months later, but our Hispanic students dramatically were more stressed than our non-Hispanic students. There was a lot of stuff that was going on at that time, COVID, immigration issues, Black Lives Matter, the digital divide, and many other factors. We need to start considering race, ethnicity and origin when we are looking at some stress management even perfectionism as well.

The trauma that we bring with us into the program potentially and how that waxes and wanes as we encounter stress in the program, going into clinical affiliations, and moving into the professional sphere are important. You have talked about some of these topics at the ELC conference. I know they are being spoken about more and more at CSM, which are all important topics for us to be discussing. On the topic of students, have they read your research? What are some of their responses when they read it? Are they surprised by it or are they like, “Dr. Richardson, now you have the data, what can we do?”

The students that were going through it at the time and agreed to participate were aware of it. Some of them did come and talk to me. Because we have the article in the press, we have not had a chance to roll it out to them very much. I have talked to them along the lines of stress and perfectionism more individually versus as a whole. We have not had a chance to talk to them about that.

I will have students that almost will self-identify as, “I’m a perfectionist.” That student that you know is conscientious, studying hard, working hard, and they bomb a couple of practicals. You are talking to them and you find out they made that small little mistake at the beginning of it and could not recover from it. That is a great opportunity to have that conversation with that student at that time.

I know you spoke about this at the ELC conference in Atlanta. What were your peers in the educational setting? How were they reacting to your data, and what were the conversations that were happening around that topic at the time?

We had a great response to that education session. It was a very enjoyable one to do the conversation after it was very robust. A lot of them were appreciative of the talk. I did have the question of like, “I always viewed perfectionism as negative, and you are saying there is a positive side.” That is what the researchers are talking about now, but there are a group of researchers that say, “There is no healthy perfectionism that you are seeking excellence at that point.”

That person did have a valid point about that. It’s like what you just asked. We know that our students have stressful times and can be stressed, which has been going on for a few decades. What is next for us? What can we do? We have identified a student who may be a maladaptive perfectionist. What can we do? Part of it is knowing what our scope is. Is it to the point where you need to refer out and connect them to student services? Is it a conversation that you can have with them and hopefully, they can start reframing things a little bit?

I was reading about a Japanese concept called wabi-sabi, and it is the beauty in imperfection. I’m like, “What a great reframing of something.” Perhaps it is this discussion we can have with some of our students and colleagues on that because although I have not studied it yet, I do feel like it would be quite interesting to start collecting perfectionism data on faculty, clinical instructors and practicing PT. There are a lot of data out there that we could look at and collect.

As you mentioned before, there are adaptive and maladaptive but the word perfectionism is a construct that potentially is unattainable. That is the whole underlying thought of there is no healthy perfectionism.

I grew up playing sports. It was the “Practice makes perfect,” and it evolved to, “A perfect practice makes perfect.” When I first started teaching, I brought that mantra into the students. Now it is evolved over the last few years doing this research and it is, “Practice how you want to practice.” This is a safe space to make a mistake. This is where you want to make a mistake and we can coach you up. It is talking to students about identifying the things that need to have high standards, but also identifying things that perhaps good enough is good enough. You can get it done and move on to some things that are a little bit more important that do need to have those high standards.

Do you have the next step in mind for your line of research in this area?

We only did it at a single Institute. Trying to broaden that out would be very interesting to learn about. I would like to do something or perhaps the next sample might be clinical instructors because our students are good connectors with that. That might work out fairly well also. At that point, you have identified the incidence and prevalence. What intervention can we do to make a difference? That is further down the line but that is the direction that we are looking at.

Is there an intervention that costs you the most? Exercise and physical activity are coping mechanisms for a lot of PTs but I wonder if that goes deep enough with regard to this topic.

PT students, in general, are a little more active on campus than most. A lot of them do get their exercise, and we know that there are a lot of good benefits with stress reduction with exercise, mindfulness, yoga, and all of those good mindfulness approaches. When it comes to some of this, it is that reframing. Part of it is when you think about stress, it can be very individual for a student. For some students, you need to teach them how to say, “No.”

They have signed up for way too many things, and they have spread themselves too thin. It probably comes from identifying the students and what they might benefit from the most. Is it saying no more? Is it reframing things? Is it accepting, tolerating, coming up a little short, and that is okay? You learn from it and move on.

It’s the skills part of it. There must be some skills that we can teach new students coming into the programs, and awareness around the topic as you come into that. As you come into a DPT program, you are encountering other students like yourself who have been highly successful in the academic realm. Some of them have had a time stood out as being the top of the class but then they wind up in a program where they are now on the same playing field. No one stands out at the moment when they start the program. You are a big fish in a small pond.

They are probably in the top 10% or so in their class coming in, and now you have a whole other ball game. It is almost like going from playing high school sports to college sports. At each level, it is more competitive, and you may no longer be at the top.

I always remember starting at PT school. On the first day, I had met one of my classmates. She had graduated from an Ivy League school. I did not graduate from Ivy League. I remember feeling intimidated around that area. I wonder how much of those interactions can breed perfectionism versus doing the right nurturing types of relationships, help calm some of that perfectionism, and make it adaptive as you mentioned.

I have not come across too much of what does it take to bring someone from a maladaptive side to adaptive side. There are some suggestions out there. It gets more onto the psychology side of things with Cognitive Behavioral Therapy and some of those things.

That is what I was thinking about before as you mentioned, there is a physical and emotional cognitive side to this. As we move into psychologically informed care in our profession, which we are well on our way to, it started with pain management. Can we now take those skills and apply them to other areas of our practice or in PT school? If there is a PT professor that has some cognitive behavioral training for chronic pain, are they able to generalize those skills to their students now and help them with perfectionism, stress or sleep management, which can be a big part of this? Things like that all pop up in every area. 

It goes back to the modeling that we talked about earlier and takes away almost that stigma of self-care. Who knows? If it is your yoga practice, you talk about it. If you are feeling stressed, you talk about it to the students. You create a vulnerability in yourself but you humanize yourself to your students, patients or whatever your population is. There is a lot on the therapeutic alliance, but there has got to be that same relationship building with students as well.

How has your research changed your relationship with your students?

The empathy has increased. Going through my Doctor of Health Science program, I got back into seeing the student’s point of view of things. There are a lot of factors there. I don’t want to come across like I did not have empathy there, but I always felt like I had compassion and empathy. I will better understand their point of view when it comes to certain things.

I still have those high expectations but I still feel like I’m able to communicate and listen to them a little bit better. I still keep a patient practice going. It occurs there as well. You do not know what some of these students and patients have gone through or going through. You have to be open that they have a different journey than you, and you need to be aware of that.

Perfectionism may be showing up in your patient as well. It could be a factor in their overall health pain function and how much time they devote to their care or not. They devote themselves to their care. It is all-important.

I know your practice is a lot more with pain. That would be a very interesting population to study to see what type of perfectionist tendencies that population may have.

I have looked into it a little bit and there is not a whole bunch on it. There is some information on perfectionism and chronic pain, more along the lines of the anxiety trait and how that relates to pain but ripe for someone to do some research into, additional PhD work, some papers and books like that. There is a physical therapist I know who has been on the show. Her name is Andrea Moore who is a physical therapist. She is very interested in that area and has done some continuing education work in that area because she has seen it show up in the women that she treats. She sees it as a component.

What I love about this work is it calls to us as DPT students that could carry over into our professional relationship. We also see perfectionism could be showing up in our patient populations, so three important areas. Mike, it has been great speaking with you. Let people know how they can learn more about you and stay connected to your work.

We do have an article in the press through the Journal of PT Education coming out. I’m also on the faculty at Hanover College. I can be found on their Faculty page at Hanover College.

I want to thank Mike again for being here and talking about perfectionism in DPT students. Make sure to share this with your friends and colleagues, especially in the world of physical therapy education and physical therapy, in general.

Thank you, Joe. I appreciate it.

Important Links:

• Episode 217 – Past Episode
• Doctor of Physical Therapy Program at Hanover College
• Journal of PT Education
• Faculty page at Hanover College

About Mike Richardson, PT, DPT, DHSC

Mike Richardson, PT, DPT, DHSc is a Board-Certified Geriatric Clinical Specialist and Certified Orthopedic Manual Therapist. He is a Clinical Associate Professor in the Doctor of Physical Therapy Program at Hanover College. He earned his Doctor of Health Science from University of Indianapolis. His current research interests include perfectionism and stress among physical therapy students.