Welcome back to the Healing Pain Podcast with Ellen Zambo Anderson, PT, PhD, GCS
We are joined by Dr. Ellen Zambo Anderson, who is an Associate Professor in the Doctor of Physical Therapy Program at Rutgers University. In addition to earning a PhD in Health Sciences, she’s an Assistant Director of the Rutgers Community Participatory Physical Therapy Clinic and serves as the Special Olympics Global Advisor for Young Athletes. Dr. Anderson is the co-author of the textbook, Complementary Therapies for Physical Therapy and the Co-owner of YogiAnatomy, a company that provides continuing education on the topics related to complementary approaches for managing well-being, health and function. In this episode, we examine professional burnout in the physical therapy profession and provide suggestions for individuals and institutions to address and decrease burnout. It’s an important topic for all of us in the profession of physical therapy and other health professions as well. Make sure to share this episode with your friends and colleagues. Let’s get ready and meet Dr. Ellen Zambo Anderson.
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Why Are Physical Therapists Burned-Out? (And What To Do About It) With Ellen Zambo Anderson, PT, PhD, GCS
Ellen, thanks for joining me on the show.
Joe, it’s great to be here.
The topic of burnout in physical therapy and pain care is not something we have covered in-depth. I know it’s something you have conducted some research around. I’m excited to talk to you based on some of your research and talking with one colleague to the next in the same profession in how burnout may or may not impact us. A good place to start out is to define burnout. Most of us have felt burnout at one point or another. I thought maybe we would be heading toward burnout. How is burnout defined?
Burnout, technically speaking, has a definition that comes from Maslach. That definition has three parts. Burnout is comprised of emotional exhaustion, depersonalization and a sense of personal accomplishment. It has been typically used by healthcare providers. That’s where it originated because back early when this definition was being developed, it was observed in healthcare providers because they were working with people who had complex issues. The reserve, fortitude or skills that were necessary from the provider meant that you were constantly encountering people with very complex and almost life-altering conditions and that could be very challenging. Maslach describes burnout as not one entity but it has these various components. We now in the vernacular use of burnout, we call it with a lowercase b as interchanging it with, “I’m stressed out.” Burnout with a capital B is more of a psychological syndrome.
We can measure those three aspects that you mentioned. Is that right?
That’s right. Using the Maslach Burnout Scale, it’s not perfect as most scales aren’t perfect. Some questions are asked that get categorized according to which one of those categories. Using that scale for someone to officially have burnout, they need to be high in emotional exhaustion, depersonalization, and low in their sense of personal accomplishment.
It’s a self-rated score. I have seen it in a self-rated measure and literature quite often.
It is considered the gold standard and used in more studies than any other burnout scale.
However, when I was doing some research for this episode and starting to look through the literature, I noticed there seemed to be more studies on physicians and nurses the most. As we trickle our way down to our profession of physical therapy, I didn’t notice a lot. Would you say that’s the case?
That is the case. When I started to do this work, the burnout studies in physical therapists, we were talking a long time ago, some of them use a burnout scale and some of them didn’t. What I think we need to be aware of in the literature is that not all authors are reporting on all elements of the burnout scale and using that. The headline might be, “80% of physicians are burnt out.” When you read the paper, you realize that they only took the emotional exhaustion piece and 80% of physicians are emotionally exhausted but fewer of them hit the categorization of true burnout. What I was interested in also is, “Is there a relationship between emotional exhaustion?” because that’s maybe what people are describing when they say, “I’m burnt out,” and that relationship of that score to a stress measure. For example, using the Perceived Stress Score.
Why would someone have one component of that inventory? Is it because someone didn’t have enough time or money to contribute to the study? Are they interested in that one component specifically?
They probably did the whole burnout inventory but it’s a little bit sexier to talk about the high numbers of “burnout.” You will pick 1 or 2 components, perhaps and talk about the percentage of that. When we take a look at physical therapists, what I learned was that about 1/3 have high emotional exhaustion and about 13% have burnout. We don’t want any one of our colleagues to be burnt out. If we take a look at 1/3 having high emotional exhaustion, that is not a good place to be when it comes to our own well-being and also when it comes to patient care. What happens with high stress or high burnout is that we see that there are compromised inpatient care. There’s less reserved energy for that. In the case of burnout, if there is some depersonalization, it means that you are treating that person as a case. You are trying to initially use that as a coping strategy to not get too involved but then you completely dissociate from that person. When that happens, patient care suffers because of that.
Do you have a statistic related to that Depersonalization Scale from the work with them?
Yes. Interestingly, when it comes to depersonalization, it’s only a few percentage points. For physical therapists, it’s down around 3% or 4%. This is a personal opinion. I’m looking across the data when it comes to physicians versus physical therapists. Low depersonalization is also found in occupational therapists. There are not very many studies on that profession as well. It has a lot to do with the amount of time that we spend with our patients because we get to know them more richly and deeply. We often have connections with at least one family member. We are working on remediation and rehabilitation for them going back into their life. We have a direct effect on their lifestyle and functional well-being whereas physicians will have an understanding of their general health but they haven’t worked quite as intimately with patients in some of the areas of restoration of function.
We are low on the depersonalization and high on the emotional exhaustion part. It’s interesting for people to think about and reflect on their own experience and what they are experiencing in the clinic. You did this work a little while ago. I know you have your hands in this work. People want to know, “Why am I burnt out? What’s the reason?” Has that changed over the course as our programs and workplaces have changed from a Bachelor’s to a Master’s to a DPT? Our profession is so active, moving and changing quite frequently.
It’s vastly different. I did not ask the question about why because the study was looking at, “Do we have burnout, first of all, in our profession?” I can tell you what we know from other healthcare providers. It was consistent in some of the earlier work that was done with physical therapists. One big factor is not enough supervisory support in the workplace. I’m going to talk about the institutional factors first. Another one is the requirement to see more patients and the relationship of that with autonomy. Professionals want autonomy. When you see more patients, it’s very difficult to be able to be completely autonomous because you want to proceed with certain interventions or have time to be able to make adjustments with your plan of care. You feel as though you are restricted because another patient is coming along. It impedes your autonomy.
Another thing is the redundancy of documentation. Everyone knows that documentation has to happen. It’s the documenting for 4 different entities, in 5 different ways, doing a flowsheet, your note and the billing, that type of thing. Another big stressor in the workplace is the financial concern relative to reimbursement. Is it calls to the insurance company? Is it the communication with the patient? The influence of finances over what you think is best for your patient is another stressor in the workplace. Those are institutional stressors and reasons that contribute to therapist burnout. You can see how that’s likely consistent across all healthcare providers.
Within our profession, there are different clinical settings, pediatrics, outpatient orthopedics, geriatrics and academia. Is burnout consistent across those? Is there a place I can be less burnt out, Ellen?
Yes. There is a lesser incidence of burnout in academia. You might be able to guess that the highest is going to be in long-term care facilities, where it’s long-term care and subacute rehab. I know that a lot of outpatient therapists were working in those settings where the intensity is high because there’s a demand for many patients per day and little space for communication documentation. You might expect that they come out on top. Across the board, the two that bubble up are the worst ending at long-term care and the best is being in academia.
Long-term care makes sense to me to some level because I can see high emotional exhaustion there. Why in academia it’s the lowest?
I think in large part because there are a fair amount of autonomy and the fact that you are creating intellectual property that can be very satisfying from a sense of personal accomplishment. There may be a department or chairpeople who are terrible to work for but by and large, there’s a very supportive collegial environment because the faculty needs to work together. They need to collaborate in research but they also need to collaborate in rendering a curriculum that is important for the next generation of physical therapists. There’s a concerted commitment to that effort.
I’m surprised it’s not more on burnout because from an institutional perspective when people are burnt out, they don’t stay with the same job. If they are in the job they are in, their performance is lower. It does have a bottom-line dollar connected to it in some way, which in healthcare, we are very conscious of making the dollar go further.
That is one area of concern. Not only is burnout associated with a decreased inpatient care but we also see that it is correlated with people leaving the field. If you think about turnover and what it costs to train people, and then what it means to the profession if people are leaving because of burnout, the costs can be quite high to the profession and institution, and then think about the individual.
Replacing an employee is very expensive. It’s also a time-consuming process for human resources. What would your recommendations be? Let’s say a hospital administrator said, “We noticed that our turnout is high in our PT staff. We did this little study and they were burnt out, but we don’t know how to help and support them.”
I would do a two-pronged approach. I would look at institutional factors that contribute to burnout, and then I would do some assessment regarding the personal factors. The Maslach Burnout Inventory can give you insights into those domains but it’s not giving you a lot of information about how to get better, how to fix the emotional exhaustion or depersonalization. In thinking about the relationship between emotional exhaustion and stress, you can look at perceived stress in your staff. Note that the stress might be high and then, “What strategies can an individual or administrator take to help individuals become more resilient to help them manage stress?” What is speculated is that you have people who can be two people in the same institution. One, Burns out with a capital B. They were gone. Somebody else stays, “What’s the difference between those two?”
That difference is the same institutional factors. It comes down to the person. What kind of coping strategies and mechanisms does that person who stays put into place? What my research showed and this is consistent in other papers, is that there tends to be less burnout in older therapists who have been practicing 25 years or longer than younger therapists. The hypothesis is that they figured out how to deal with it. You found a way to be able to cope. Good news for our therapy profession. It wasn’t a coping strategy that was dysfunctional because if it was dysfunctional, then you would depersonalize and go through the motions.
We found that in our profession, we have low depersonalization. We found a way to be able to deal with all of those stressors, the stressors that the patient gives us and from the institution. If I was advising an administrator, I would say, “You need to take a close, hard look at the role that your supervisor is playing in support. Do you have efficient systems in place? What kinds of rewards and spaces are you giving? What kinds of benefits are you providing for people to find their way to navigate their stress to improve their health and well-being?”
There’s a part there where there’s a responsibility of the practice of the institution. It sounds like there’s also a little part of self-reflection on the clinician, the individual and to look at what type of coping strategies they have to deal with. We are talking about mental health in many ways.
As we have all experienced, we could be humming through life dealing with various stressors. Something catastrophic comes along and we are unable to regroup. What does the institution do to help an individual in that situation? We also know that there are times when people are going along and it takes one more straw to break the camel’s back. With the supervisor, the institution is not going to know that, but the individual might with appropriate reflection on being able to get a sense of where they are from a mental health standpoint.
About the person who has maladaptive coping, I have two questions for it that are coming up for me. One is the supervisor plays an important role. That’s interesting to me because I provide a lot of peer review and support for professionals. It’s always interesting to me to see how much peer review and peer support people need if you have any idea concerning that. What can an individual do who’s recognizing, “I think I fall into that emotional exhaustion category. What can I do to rev up my own personal coping mechanisms so that I can buffer some of this burnout?” About supervision, is there frequency intensity? It was like several hours per week spread out over time. I think research has been done in that area.
I don’t know about dose. The idea of having time to meet with a supervisor and your employee to talk about exactly what we were describing. What are the stressors? How do you see yourself in this workplace? Are there areas where you would like to grow and develop? Tell me what’s happening as far as frustration. On your most frustrating day, what do you think the triggers are about for that? The supervisor shouldn’t feel as though they have the answers because if you think about what a coaching session is all about, you ask those questions. The person, you give them space to respond to that. They hopefully find their own way. I think supervisors are often hesitant to go into that conversation because they feel as though they have to have the answers and fix them.
The recipient, the worker, wants to be heard. More often than not, they are not looking for a fix. Sometimes if they are boiled over anger, they want to fix it but most of the time, they just want to be heard. The research supports that as well. The challenge to the supervisor also is that you don’t make a promise that you can’t keep. Don’t offer anything. Don’t try to fix something and then not be able to come through with it. It takes reflection on both entities, the worker and the supervisor, to do that. The second question was about, “What can you do for yourself?”
It’s that internal process that so many people struggle with, especially in pain care because we know the burnout is high amongst all pain professionals.
For the individual, it does come down to finding a way for you to be able to identify your stressors and what your resources are. Where are your strengths to be able to effectively deal with the stressors? For some of us, it may take us to go to a counselor. It may take talking with someone else to be able to explore that. Most of us could sit down. I like to use the phrase, “I became irrationally irritated.” I’m like, “That’s irrational. It was just a little thing. What’s happening in my space? What’s happening in my mental health now that that little thing triggered me? I overreacted to that.”
Certainly, the work that you promote and teach that I also teach is taking that moment to the ground, take a deep breath, stop what you are doing, reflect what you are doing and practice that because you never know when you are going to need it. That’s the whole thing. You have to have a practice because then in the middle of the gym when things are going crazy and you want to explode, you don’t. You don’t allow that, “I’m going to explode energy,” take you to another place. You contain it right away. The practice is to be able to do that.
You teach some continuing education courses on yoga through a company that you have called YogiAnatomy.com, which everyone can check out. Is there research supporting yoga for health professionals about burnout? Have you seen that in your own participants where they thought they were coming in to learn about yoga and wound up learning a whole lot about themselves, started to take some of those skills and bring it back to their practice?
There is no literature per se on healthcare providers taking yoga in whatever dose you want. They are better for it. The yoga literature is looking at healthy individuals. There have been some studies with teachers doing yoga or meditation practice. However, the answer to the second part of your question about, “Have healthcare providers come to the course and realize that they end up learning strategies and techniques for themselves?” Absolutely. What we see is that you might come to a continuing education course on how to apply yoga principles into therapy and want something different for your patients. Some people will come because they just want to know what our awesome is about. My patients are asking me about yoga and I want to know if I can refer them. Maybe I can have better adherence if I incorporate some yoga into my plan of care.
The other piece about it is, there’s attention in a yoga practice paid to mindfulness. All movement is with breath and mindfulness in yoga. How can we take what we do in therapy, where it might be ten straight leg raises? How do we make that mindful? How do we incorporate the breath into that? Is that yoga? People come to the course in that way and they realize that they can do things slightly differently. When they practice in our continuing education course, they realize how beneficial it is for them as well. The courses are very experiential so that you are not just hearing about the technique and the science of pranayama or meditation but you are practicing that and then trying to think of ways to be able to get a little bit into that therapy session.
As they say, the movement can be the meditation, right?
Absolutely. If you are knocking off ten straight leg raises, how mindful is that? You were like, “Ten, done.” If it’s, “Inhale and exhale. Inhale and tighten up your quad muscle. Where are you feeling that? Fantastic. Lower that down. Did you exhale that time? Let’s do it on an inhale.” Those kinds of cues are so ever-present when you go to a yoga class, shouldn’t we be doing that in rehab?
Yes. What you are talking about, as you mentioned, is cueing. Cueing happens in yoga classes and a traditional mindfulness class and it is the most important part. That’s the skill of the practitioner, instructor or teacher helping you.
In class, we were doing squats as a precursor to plyometrics and skills or agility. Students who are learning the cueing are practicing looking. They were missing a whole lot of stuff. They were missing the drift of the knee, landing of the foot and where the hips are going. Once you pointed out to them and they see it, then there’s a whole other skillset by how to cue it. They don’t know what to do. Along comes a skilled lab TA who says, “Push your thigh into my hand right here. Perfect, now leave it there. Great. Now, go ahead and do your squat.” They think it’s a miracle because all of a sudden, everything has changed.
That cueing was all that that person needed. The students were stymied by it. That master clinician came in and did the right cue at the right time. In this case, the student learned how to do that. I sometimes think in rehab, when we let things go, when we are talking about how many sets and reps and what the next end game is, it’s not the what. It’s the how. The how can be so powerful, particularly when it comes to motor control but also when it comes to managing pain or exploration of other movement patterns. That can be helpful for people who need to find new ways to move.
The cueing is the unspoken science. It’s not a separate class on this, at least to my knowledge in school. Maybe there needs to be a whole section of a class. Even I think of continuing education courses, cueing is something we almost take for granted. It’s a skill we develop and some people may not develop it so well. Tied into some of the more contemplative practices, cueing is very important.
That’s a piece that we don’t do well in PT school. There are no contemplative type of approach to working with patients or clients.
I’m very happy that you have said that because some of my work focuses on some of those areas. Let’s touch base on that for a moment. We are in this world now of biopsychosocial care. PT programs are three years long. When you go into the CAPTE Accreditation standards, behavioral approaches to patient care are present. Although in CAPTE standards, there are guidelines. There are no specific bullet points of what we should be teaching. If you had a magic wand, Ellen, knowing that you have some expertise in contemplative yoga, mindfulness and you may be doing some of these, how would you ideally like to see those principles worked into a PT program, course or curricula?
I think that a way to start is to have students learn those practices personally. Have them begin to understand and practice mindfulness and meditation because the change that occurs in an individual can be profound. I don’t know where you put that into a PT program but I do think that it is important for that step to be taken. I then think that there needs to be not just an acknowledgment of the biopsychosocial model from a model standpoint but that it needs to be incorporated into every patient case that is presented. I find that to be extraordinarily challenging myself. That is because the courses that I teach are part of a large, a couple of year curriculum.
I acknowledge and accept the fact that students need to learn terminology first. They are still deciphering even into the 2nd and 3rd semesters. They are still trying to figure out, “What’s the difference between active assist range of motion and range of motion?” There’s that, “Never mind the more complex terminology.” They are trying to learn some hands-on skills. They are very much like, “Where do I put my hands? How do I move? How do I guard? How do I do gait training?” There are so much skill. Now, you are asking them to do it in an informed and mindful kind of way. It’s a big ask. I’m optimistic that we can get to some students and inform curricula in that way but I don’t know whether we get to 100% of the students, 100% of the time to be thinking about that. The one thing that I have been talking to a lot of different groups, committees and things about the biopsychosocial model, it has been around for many years.
I know it’s not new. Everyone talks about it like that’s a new thing. I’m like, “It has been around a long time, people.”
I’m on committees with medicine, dentistry, nursing and things like that. It befuddles me how we are still talking about that. If we put the patient in the center and we are talking about how many different professionals need to be in access of care, then why do we still have MDs being the gatekeeper? Why is that? It is because of how things get reimbursed. It is because of how, here in the United States, we interpret what healthcare is. We interpret what healthcare is based on insurance. When you go to other countries and you don’t have that kind of hierarchy per se, people with mental health concerns get referred to physical therapy as quickly as they get referred to a counselor or a psychologist because it has accepted that movement and mindfulness, which are taught by physical therapists in other countries is going to be helpful for the patient. We don’t do that here.
I love that you said that because there’s this perception, “We have the biopsychosocial model. We are identifying that there are psychosocial factors that are a part of this person’s pain experience or their overall health but if it’s a psychosocial problem or they have a mental health condition, more specifically, then they get referred out. I have been doing this for a while now. My strong stance toward physical medicine professionals of all sorts, including PTs, is that while you may need a mental health professional to be part of your team, collaborate.
Realize a lot of what you do. The somatic experience that someone has with you can have a profound impact on their pain, health, stress, etc. That’s not spoken about anywhere in PT. I graduated in 1996. With my memory of school, it wasn’t spoken about that. Although, there’s a professor in my program, Terry Miller, who studied Feldenkrais. It is a very mindful movement somatic approach. She was pretty much the lone wolf at that time. Coming from some of the backgrounds I had with moving things to that, I was like, “What’s she saying makes perfect sense.”
Try to do a Feldenkrais class in PT school.
She did it and it was not taken well.
Speak to someone who has tried. What happens in particularly the Scandinavian countries and Australia is that psychosomatic is a fact. It is where the mind and the bodywork together. If you say psychosomatic here in the United States, people respond to you as though, “You think it’s all in my head. I don’t have anything wrong.” What psychosomatic means is there’s a connection between the mind and the body. The nervous system is what connects the mind and the body. We can find ways through different practices to affect the mind, which will help the body and also the body, which will help the mind. Here, it has such a negative connotation that people will put up a barrier. “You don’t believe I have pain and problem because you think it’s all in my head.” That’s not the intention. The intention is to accept the fact that these are tightly wound together. When you take a rehab or a therapy approach, that blends the physical with the emotional. That’s where you are going to get a lot of success.
The two areas that I believe will change that for us as PTs and I know physical therapists are working in this area and sharing the same belief and perception that we are talking about. Chronic pain is one and then PTSD, which when you look at a lot of the research around it, there’s pretty good research that top-down mechanisms are not enough to help people with PTSD. They need more of the body somatic work, which we fit well into. We have tremendous skills in that area.
I think that you can go and become a yoga therapist or Feldenkrais practitioner. Name another one, Trager. Name a complementary therapy approach that is a mind-body approach. There are, by and large, very good outcomes for some of those approaches. What do they do? It is movement linked with intention. We already, as physical therapists, can do the movement well. We can analyze movement. We can fix movement, tap here and say this. Isn’t the next step for us is to be mindful about it for us to get people to engage cognitively and mindfully in that movement? That’s the missing piece, in my opinion.
Maybe one day, we will revolutionize the PT curricula in another dramatic way and bring it through another revolution or a wave of change, which sounds like you and I are both on the same page with that. It has been great chatting with you. As I mentioned, everyone can find more information about it on your website. It’s called YogiAnatomy.com. There are lots of great continuing education courses there. Tell people how they can learn more about you and some of the new things you have set up as you move into 2021.
2021 is not 2020. That’s a very good thing. There have been opportunities to do some online teaching. I have had an opportunity to collaborate with physical therapists in Mexico and South America because there’s a big movement in increasing the awareness of the role of physical therapy in people with mental health concerns as well as mental illness as a primary diagnosis so schizophrenia and bipolar disorder. I collaborate a fair amount with the Department of Psychiatric Rehab at Rutgers and work with clinicians there so that we are able to work with clients with serious mental illness in a way that’s informed and includes some movement.
What we are working on is developing a series of videos that will be available to clients but also another set of videos that will be developed to help healthcare providers in mental health. There is a big concern about those healthcare providers in mental health and their state of mind, level of stress and level of burnout. We have already done some focus groups and got some feedback on some preliminary things that we have done. We would like to put together a series of those kinds of videos to make it available through a network of healthcare providers in mental health.
Everyone can learn about that work at YogiAnatomy.com. Make sure you take this episode and share it with your friends, colleagues and anyone interested in burnout, yoga, chronic pain, PT school and all the things we have been talking about on this episode. Share it with your friends and family on Facebook, LinkedIn, Twitter or in a group such as a Facebook group, where people are talking about these topics. As always, it’s an honor to be with you. I will see you in the next episode.
Thank you, Joe. It has been a pleasure.
Important Links:
- YogiAnatomy
- Rutgers University
- Complementary Therapies for Physical Therapy
- CAPTE
- Terry Miller
- Facebook – Yogi Anatomy
- Twitter – Yogi Anatomy
About Ellen Zambo Anderson, PT, PhD, GCS
Ellen Zambo Anderson, PT, PhD, GCS is an Associate Professor in the Doctoral Program of Physical Therapy at Rutgers, The State University of New Jersey where her primary teaching responsibilities are in Therapeutic Exercise, Development Across the Lifespan and Clinical Inquiry. Dr. Anderson, a Board Certified Geriatric Clinical Specialist, earned a BS in Physical Therapy from West Virginia University, an MA in Motor Learning and Control from Columbia University and a PhD in Health Sciences from Rutgers University.
She is the Assistant Director of the Rutgers Community Participatory Physical Therapy Clinic, a student-run, pro-bono clinic in Newark, NJ, and serves as the Special Olympics Global Advisor for Young Athletes. Dr. Anderson is the co-author of the textbook, Complementary Therapies for Physical Therapy: A Clinical Decision-Making Approach and has spoken internationally on physical activity, mental health, and complementary health practices.
She is also co-owner of YogiAnatomy, a company that provides continuing education for rehabilitation professions on topics related to complementary approaches for managing well-being, health and function.
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