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