PMC Phase 2 is Officially Underway

Back into the office today after a successful couple of presentations of preliminary data analysis and results from the summer project. I was quite honoured to be invited to present this information at both the PTAlberta Connect+Learn conference in Kannaskis last weekend and the CPA Leadership Forum in Ottawa this past weekend. While the messaging isn't always as upbeat and positive as what I usually like to deliver, it is realistic. The messages seemed to be met with generally positive reaction (at least to my face), and it seems that there is now mounting interest in seeing these results get out to into the wild as soon as possible so we can leverage the momentum and work collectively towards creative solutions. The end game here is that PT be positioned to not only survive the coming 10-20 years (and beyond), but thrive, yet in order to do so we probably need to ask some difficult and at times uncomfortable questions.

To be clear, I have no intention of preaching my own opinions on solutions. Whatever happens from here needs to come from the PT community. This is in fact the nature of the Physio Moves Canada project itself - I could have sat in my office writing about potential threats and opportunities, but I needed to hear it from the profession, and now it is the profession that needs to be engaged. 

So now that the data have been all but collected, the real work starts in terms of conducting rigorous and trustworthy analyses and disseminating meaningful information to those who can best use it. This is no small task; there is a mountain of data to be poured through. I will of course be writing scientific manuscripts for publication as part of my role here at Western University, but I am well aware that such publications rarely translate into real world impact without additional mechanisms of dissemination. Further, there is far more information than can logically be included in a scientific manuscript or even a series of manuscripts, and it will likely take a couple of years before it is all published. By then my fear is that the information may be getting a little long in the tooth.

So, after reflecting and talking with a number of my own mentors, I've decided that there is a book here, or perhaps a manifesto of some kind, in which we can describe not only the threats, opportunities, research priorities and training reforms I heard about over the summer, but even opine on how some of these may start to be addressed. However, going back to my earlier comments, I do NOT want this to be all about me and my beliefs. I'm only one person, and there is a full community of clinicians, academics, educators, administrators, and entrepreneurs who have their own views on these issues. We need a mechanisms to allow this level of exchange to occur.

To be fair, I won't sit here and say I have the answer to this, it's a challenge. But, I feel compelled to try something. So, to that end, my first attempt at creating and growing our community is to harness the collective through the new world of crowd-sourcing. This past weekend I officially launched a campaign on the Patreon crowd-sourcing website. At this point, the campaign is focused on helping me find the time and space to get the information disseminated through a book by replacing some of the income I would normally make through my weekend teaching / workshops. What I like about the Patreon model is that it offers the potential for more sustainable funding (pledges are collected monthly), that no single person or entity is relied upon for a large part of the funding (pledges can be as little as $1/month), that there is no commitment (if you don't feel like the outputs are worth your pledge, pull the plug with no questions asked), and it is an easier path towards engaging a community. I have created 'tiers' of pledge amounts, with the highest being $20/month (again, I don't want anyone to be investing too much here) at which level I am offering the chance to provide feedback in real time as the different sections are completed, so that it can truly become a community effort. That's my vision, perhaps it's overly romantic, but I think it's time for us to try something new. After a year my hope is to leverage the traction and engagement into something bigger and more sustainable (podcasts, town halls, think tanks, seed grants, etc...) such that this becomes an entity on its own that helps our other professional associations move us forward. A formal not-for-profit seems like a reasonable goal, but let's not get too far ahead of ourselves just yet.

And to that end, one final comment - while I am NOT a CPA staffer, nor member of the board, I will say that I DO NOT want your contribution to the PMC project to take higher priority than any contribution you might be considering to the Physiotherapy Foundation of Canada or other such charitable group. Make those contributions FIRST, and if after doing so you feel you have the available resources to contribute something to this initiative, then I welcome you on board. I would much rather have 400 people contribute $5/month, than any single entity contribute $2,000/month, and hope that leaves plenty of room for those other important initiatives.

The link to the Patreon page is: www.patreon.com/PhysioMovesCanada

A Quick Round of Professional Compare-sy's

Today (Sept. 30th) is the final day to renew your CPA membership before late fees start to kick in. While I have no interest in being a CPA shill, I will say that I've become acutely aware of the power and value of a strong unifying voice and advocacy group at both the national and provincial levels, and when you join CPA (and automatically your respective provincial association), you are contributing to our professional ability to advocate on important issues that affect us all. Advocacy and leadership was a dominant theme during a lot of my clinician conversations during the Physio Moves Canada project this summer and fall, being raised literally across the country, so it's clearly an important issue to many. More interestingly are the conversations that go something like this: I am not a member of CPA/provincial branch because I don't find they do enough for me, and then later on: we need more people to be members of the CPA/provincial branches so they can do more for us. There's a bit of a weird chicken-egg proposition there - should we wait to join until we see stronger leadership and advocacy? Or should we join to provide the resources needed for stronger leadership and advocacy? For what it's worth, I tend to be in the latter camp but ultimately it's a personal decision and I respect arguments on both sides. But in the interest of ensuring informed decisions, I figure today is maybe a good opportunity to do a bit of a comparison exercise against some relevant other professional groups for those who are still on the fence.

First, I've managed to get membership number for CPA (PT), CAOT (OT), CCA (Chiropractors), CNA (Nursing), and CMA (medicine), and in addition I've tracked down the available data on how many total full active practitioners there are of each group in Canada. So to start, how do we compare in terms of percent engagement?

From this table we can see that CPA has achieved about 55% engagement (the numbers aren't likely precise) out of all eligible full-practicing PTs in Canada. While that pales in comparison to Medicine at 70% and Chiropractic at a whopping 92%, it is better than our colleagues in OT at 46% (who, when we look back at my prior post on attrition, appear to be in worse shape than we are on a number of metrics), and nursing at 45%. That said, but absolute numbers nurses still easily take this case by virtue of sheer numbers.

From what I've learned of PTs over the years, I know that the Chiropractic comparison tends to strike a nerve, and from this table we can already see that almost every DC in Canada is also a member of the CCA, which is quite impressive. But, in absolute numbers, they're still a smaller group so how do they appear to be such a powerful advocacy voice? For that, I did a bit more sleuthing and tracked down the cost of membership for CCA and have compared that to CPA. For this I'm going to use the Ontario numbers (since that's the context I know) but it's likely safe to assume the numbers are similar across the country. And before anyone accuses me of giving away any insider secrets, rest assured that both of the numbers I'm about to show are openly available to the public.  Here are the ones for CCA. And here are the ones for CPA.

So, what did I find?

Yes, you're reading that right. Including HST, our Chiropractic colleagues pay over 350% more in annual dues here in Ontario than do we. And these costs do not include the cost of malpractice insurance, which is not publicly available for the chiros through their Canadian Chiropractic Protective Association, but I'd bet dollars to donuts it's also considerably higher for DCs than it is for PTs. You can do the math, but compared to PT, the Chiropractic association has far higher engagement, a smaller overall membership to manage (so presumably lower operational overhead), and at least through dues they have higher annual revenues.

Again, my intention in showing this is to give my PT colleagues a sense of, frankly, how good we've got it. Again, I'm not trying to push membership, I get exactly zero kickback, I'm not on the CPA payroll, I'm an independent academic who also happens to be a passionate physio that harbours a mild concern that if we don't increase our engagement we risk continuing to lose our share of what we still have in the great pantheon of healthcare. Maybe these numbers speak to you, and maybe they don't. Maybe you disagree with the direction CPA is heading, or maybe you're simply ambivalent or on the fence. Regardless, these decisions are your own and I make no judgment on the validity thereof. But if you were wondering, if you are perhaps one of those on the fence, maybe this information will help you make a more informed decision about CPA membership.

How Does PT Attrition Compare to Other Professions?

A quick follow-up to my previous post, it's hard to make meaning out of a single set of numbers. So, I've gone back to CIHI and pulled some additional attrition indicators (age group, years since graduation) for the other regulated health professions for which the data are available: Occupational Therapists, Registered Nurses, and Physicians. These data are mostly 2015 numbers with the exception of RNs for which 2016 data are also available so I used that. In both of the following graphs, PT numbers are highlighted in bold blue with diamonds, RNs are light orange with triangles, OTs are light grey with circles, and MDs are light yellow with squares. 

Here's the graph by age group:

Figure 1: 2015 CIHI data showing percent of current workforce by 5-year age groups.

Figure 1: 2015 CIHI data showing percent of current workforce by 5-year age groups.

And here's the graph for years since graduation:

Figure 2: 2015 CIHI data showing years since graduation

Figure 2: 2015 CIHI data showing years since graduation

A couple of things we can pull from these graphs. First, you'll notice the MD data look a bit wonky. Interestingly the CIHI data for MDs provides less granularity for age ranges for MDs (10 year rather than 5 year blocks) yet more granularity for years in practice. To get a smooth line I've split each 10 year block for the MD age ranges in half, but still the beginning (since there are very few practicing MDs <30 years old) and end (MD age ranges are reported all the way up to 80+!) look a bit funny as a result.

Another thing we can pull is that after an initial drop, RNs seem to be fairly stable, suggesting they stay in their profession deep into their careers. Not surprisingly MDs are also quite stable, and one wonders if this stability gives RNs and MDs as a group better institutional memory and a greater ability to leverage the wisdom of experience which may explain their overall better public branding (maybe). On the other hand, it looks like our OT colleagues are in fact in worse shape than we are in terms of attrition. A full 37% of them are <35 years old and it drops consistently from there, and compared to at least 15.6% of practicing PTs with over 30 years of experience, only 9.5% of OTs can boast the same number.

So, perhaps some thinking to be done. The stability in MDs across the age range and years of practice is not surprising and there may not be a whole lot of insight to be gained there. But what about the RN findings? Why are nurses more likely to remain in their profession all the way to retirement while PT and OT seem to drop off considerably after age 40? What can we learn from what nurses have done successfully and apply it to the medical rehabilitation professions?

Are we Alienating our Mid- to Late-Career Clinicians?

Can a profession thrive without engaging the collective wisdom of those who have done the hard yards and lived to tell about it? In (very) broad strokes, as a profession, globally I think, we have skewed towards prioritizing early-career clinicians in terms of mentoring, development, and establishing career trajectories. And for good reason in many ways, we need young clinicians to keep the profession fresh and evolving. But have we done so while ignoring those clinicians 15-30 years into their careers? It seems to me that these should be the people we are tapping most for their wisdom and vision and experience gained to ensure the next generation of clinicians are prepared for the realities of what lies ahead.

A few blog posts ago I posed a question of whether we have a broad engagement problem, and I'll necessarily focus my lens on Canada because that's what I know best but suspect the issues I'm about to raise are not limited to the great white north. The general response I got to that earlier question can be summed up as 'yes, yes we do' but of course the reasons for that will be multifactor and highly complex. One of the groups I heard a lot from, and continue to hear from, are our mid- to late-career clinicians who are feeling somewhat alienated by the profession to which they've dedicated so much of themselves. And now having viewed the profession from many different angles across the country, I get it. And let's be clear, I would also be in that group having graduated with my BScPT degree in 1999 (18 years ago). 

Let's start with looking at any evidence that we are in fact alienating our more mature clinicians. If I look at the Canadian Institutes for Health Information (CIHI) data that are available here up to 2015, I can start to see evidence of a problem. And because I like graphing things, I made a couple:

age trend.jpg

2015 CIHI data showing percent of Canadian physiotherapy workforce stratified by age

years trend.jpg

2015 CIHI data showing percent of Canadian physiotherapy workforce stratified by years since graduation

 

So at least statistically it seems that about half of the Canadian PT workforce is under 40 years old, and over a third has been working for less than 10 years. More alarming however are the trends, the drop offs after those two modal peaks. Shouldn't those remain a bit more stable at least until clinicians start reaching retirement age, assuming they're remaining in the profession? Of course it's hard to interpret epidemiological information with any kind of fine comb so perhaps I'm overthinking this. But I recall seeing a post within the past couple of months showing the average career span of a clinical physiotherapist being about 130 months - I wish I could find that post again but I'm struggling to do so, I'll update this post if I do. However, the numbers on the years since graduation graph would generally support that, it looks like the 50th percentile would fall somewhere in the first half of the 11-20 year range, so 11-13 years of an average clinician career sounds about right (remember that the percentages above include everyone who identifies as a PT including administrators, educators and researchers, all of which tend to have longer career spans than clinicians). Then we can look at this handy report from Australia, again with data from 2015, showing the average career span of a clinical physio to be about 12-13 years, and it seems we're all in the right ballpark.

So let's assume the average career span of a clinician is in fact in the 11-13 year range. That doesn't seem good. For comparison purposes, and I haven't fine-toothed this literature AT ALL so take it with a grain of salt, but here's a news article suggesting the average work life of a physician was about 35 years in 2004. So the question becomes: why are we losing our most experienced and arguably most valuable clinicians early, and where are they going?

I don't know if I can answer the last part of that question because I don't think the data exist. It is safe to say that PT continues to be a female-dominant profession, and epidemiologic data from many sources indicate that females tend to have shorter work lives than males, so that may partly explain the numbers, but that still doesn't tell us where people are going or why. However, I'll say the 'why' may be easier to answer, and I'm going to provide some examples that I heard during the Physio Moves Canada project that may shed some light, and may suggest some ways to mitigate what I see as a critical problem.

1. They feel alienated. I heard a fair number of strong opinions while out in BC regarding the BC College's recent introduction of their new quality assurance strategy that consists of a multiple choice exam that clinicians need to successfully complete to maintain their independent practice license. The mid- and late-career clinicians I spoke with at different events expressed their frustration that the test, having a similar flavour to the Physiotherapy Competency Exam that new entrants to the profession must complete, unfairly disadvantages them as over the years that have (justifiably I'd say) lost some of the foundational knowledge in fields of practice outside of the one they've focused in for the past 10-30 years. Some even went so far as to say they've opted for early retirement rather than write the test out of fear that they'd be deemed incompetent. Now I am hesitant to provide opinion on this as I don't fully understand the context and I'm sure there are strong arguments in favour of this approach as well, but from a purely subjective standpoint these are the concerns I've heard and may explain some of the attrition we continue to see. This is just one example however, another thought has to do with advancement opportunities.

2. They have few opportunities for advancement. Remember we're talking about clinicians, many of which work in the private sector, but even in the public sector the problems seem to persist. It's fairly clear for those in the private sector especially small business owners - there are really no opportunities for advancement when you own the place. Larger corporate models offer more opportunity, and I wonder if we'd see differences in attrition between sole ownership clinics and large corporate clinics. In the public sector physios have traditionally not been the ones pegged for leadership roles with the possible exception of profession-specific practice leaders. For whatever reasons, even middle management in hospitals tend to go to nurses or other professionals, PT is rarely in the running. Not never, but rarely.

3. Professional development for PTs needs more variety. I found this one myself - as with MANY young PTs I quickly jumped onto the manual and manipulative therapy path here in Canada. And by and large I'll say I enjoyed the journey until the end and even today Canada's Orthopedic Division syllabus is regarded as one of the best in the world and for good reason. Across the PT PD landscape there are few programs that are as rigorously-designed, accredited, and have standards for ongoing quality assurance as the OD syllabus system. But also as with many PTs, upon my completion of that program in 2004 and having achieved the hallowed FCAMPT designation, I wasn't actually the Level 90 wizard PT I thought I would be. And to be fair that should never be the expectation of any PD, but after that then, what else is there? I could have started down another technical path, dry needling or McKenzie method or something, but at the end of the day I'm not really changing my practice by large leaps. I'm iterating, and for mid- to late-career PTs who have gone down those traditional paths and come out the other end and still realized that they're continuing to work in the same environment largely the same way they did before starting those paths, at some point they must ask themselves the question 'what else is there?'. For me, this was the time I began working towards what would eventually become the Pain Science Division of CPA, allowing me to build something new that kept me adequately intellectually stimulated for the time until I finally entered back into academia a few years later. But for many, the PD landscape and opportunities for professional advancement are simply not easy to find.

4. We do not let them take on leadership roles in our training programs. Now this one may be more Canada-centric, but starting around the early 2000's entry-level PT programs switched from the undergraduate BScPT to the graduate level MPT degree (DPT in the US). This shift has had what I suspect is a few unexpected consequences, but one major one being that as most programs now fall under their university's graduate and post-doctoral studies oversight and regulations. One of the things that means is that those without a graduate degree are ineligible to manage a graduate-level course or to take on a full-time faculty position. I was reminded of this recently during our school's search for a new academic coordinator of clinical education. Many mid- to late-career clinicians would be outstanding in that role, being able to leverage their existing relationships with the clinical community and their exceptional organizational skills developed after a long career in patient care, but they are ineligible. I'm referring to those of my vintage, 10-20 years out who currently 'only' hold a BSc. So when we should be tapping these people for their expertise and mentorship for the next generation of clinicians, we are instead excluding them from entering the halls of academia in any role greater than lab assistant or tutor. If there's ever been a sound argument against going to a DPT in Canada, this may be it.

I'm sure there are other reasons that we lose our best people after 10-20 years. It may be due to fatigue after spending so many years fighting for respect from other health professionals. Surely in some cases a fair number will take a maternity leave and decide not to return, or any number of other personal reasons. But at the end of the day I can't help but feel like we are losing a massive accumulation of experience, wisdom, and institutional memory to attrition by not adequately respecting one of our greatest assets.

Do you know someone who has left the profession? I'd love to hear from them, ask them to come hear and leave a comment to tell us why. Or perhaps you are a mid- to late-career clinician, I'd love to hear from you what's keeping you in? How could the profession overall support you and make it more attractive to remain a PT?