Participants
An even mix of genders was represented in the participant sample. Additionally, the cohort was well represented by experienced clinicians with over 20 years of experiences. The range of clinicians included was very broad with eight clinician professions included. The numbers of people with a compensation claim seen per week by clinicians was varied. The participant population was mainly Caucasian and as such, there was little ethnic diversity represented in the cohort (See table 1).
(Table 1 to be inserted here)
Thematic analysis
Five major themes emerged from the interviews: 1. Clinicians experience vicarious injustice when exposed to negative claimant experiences, 2. The experience of working in compensable care can lead to emotional exhaustion, 3. Working with clinical complexity can cause self doubt, 4. Helping this clinical population can be meaningful and 5. A sense of mastery in delivering care in compensable settings. Table 2 provides a brief synopsis of the content of each of the themes.
(Table 2 to be inserted here)
Theme 1: Clinicians experience vicarious injustice when exposed to negative claimant experiences
Clinicians caring for their patients under compensable systems often bear witness to this group of people experiencing distress. Some clinicians find the vicarious exposure upsetting and need to manage their own distress in response. In the process of describing how a patient under her care was experiencing stigmatisation and dehumanisation during an insurance claim, this physiotherapist is clearly upset on behalf of her patient: “That puts a lot of stress on patients… they have to tell the whole story over and over again… I even had one lady who had to, you know, do like a drug [test]… she had to do a urine sample with the door open to prove that she wasn’t a drug addict. You know, it was just awful” (Clinician #1). Another physiotherapist describes how extended delays in insurance processes impacted their patient and that this was difficult for them to observe: “We see our patients for a long time… but the length of time that it took to just get an independent medical assessment done was pretty extended… She reports, you know, increasing distress and depression... I think it has had an impact on her mental health and, you know, her relationships with her family and that's really disappointing” (Clinician #2).
Many clinicians will have an extended relationship with their patients and walk beside them throughout their often long and complicated recovery. This longer-term relationship often leads to a strong rapport. Observing the injustice experienced by these patients can be especially upsetting for clinicians given their investment in the wellbeing of these patients. One osteopath described the experience of caring for a long-term patient who had a particularly difficult time in the insurance system. He appears to be particularly attuned to, and upset by the patient’s experience of not feeling cared for by either his employer or the insurer:
“One of the fellows that I’m looking after at the moment, he's been in there [injured and under insurance claim] for two and a half years… after he was run over at work… Once he [went] back to work, no one really cared. He's never really had a case manager… You know, he’s ended up sort of floating, longer and longer and longer. But over time that breeds a little bit of resentment. And it has sort of got now to the point where this sweet gentle giant, he's very upset at the way that he's been treated and the perception that his employer doesn't care, that the insurance doesn't care and it's just him having to deal with it… He gets a little bit more ticked off… They haven't really done anything proactive for him… When he's lying there at night, thinking that you know, no one gives a shit about him and no one's there to help him and he's just having to do it all by himself” (Clinician #3).
Being exposed to many of these upsetting scenarios can be difficult for clinicians and, in describing the hardships of their patients, the empathy they feel for them is obvious. One occupational therapist, a mother herself, describes the experiences of a patient who is a single mother and having issues with getting approval for treatment in her claim:
“The experience that I've had is that the clients have found it to be a very frustrating and overwhelming experience… This lady, actually I am quite worried for her mental health as she's had roadblocks all the way through her entire claim … I actually spoke to her a few weeks ago and she was in tears.. she said, ‘I just don't know that I can do this much longer’… She's at her wits end… It’s hard for them to then participate in their other treatments as well, because they feel like they're drowning.” (Clinician #4) Similarly, this clinician describes how the frustration felt by people with a compensation claim is frequently also felt by the clinicians who are helping them: “ I find that they are frustrated. The clinicians are frustrated. Everyone in the whole clinic is frustrated just because of the [limited] access that these patients have to the treatments that they need. I find that's the hardest part of it.” (Clinician #5)
Observing the frustration and distress experienced by patients often prompts clinicians to step in to try and advocate for their patients. Where sometimes this may feel helpful, it frequently takes time away from clinical work and is not always fruitful (e.g., “I’ve had a couple of times where I’ve gone in to [advocate] for people and it’s just been a bit of a waste of time, or it’s actually been quite distressing for me” Clinician #6).
Vicarious exposure to claimant distress was usually related to issues with dealing with the insurer, the claims process, and the delays that are often reported by people with a compensation claim. The flow on effects of these issues observed by clinicians were patient disengagement from treatment and poorer clinical outcomes, which were upsetting for both patients and their clinicians (e.g., “They feel quite upset and vulnerable and angry, because they haven't been treated well in the compensable system, then they're assuming the worst of the rest of their treating team as well. They're assuming that because the (insurer) hasn't provided them with timely care… then you won’t either. That can be challenging to build rapport,” Clinician #7). The distress that clinicians feel from being exposed to these scenarios in patients who they care for undoubtedly contributes to the sense of emotional exhaustion described in the next theme.
Theme 2: The experience of working in compensable care can lead to emotional exhaustion
Clinicians working with patients under compensable care face many additional tasks compared with their work with private patients. Additionally, the patient population tends to present with much greater distress and unmet needs, frequently caused by insurance-related delays to care or other communication issues. The combination of the both the additional administrative load and dealing with high patient distress frequently leads clinicians to contrast their experiences between treating private and people with a compensation claim. A sense of emotional exhaustion was frequently reported by clinicians when describing their response to the complexity of treating people with a compensation claim. For example, one physiotherapist described: “I would just often have this really profound sense of exhaustion, like at the end of my day, or like on my days off. I just feel like I was just sapped… I think that feeling of exhaustion is definitely something I hear from a lot of other people… who are working in similar sort of settings to me ”(Clinician #8). Similarly, this physiotherapist reports: “I'm certainly drained to a degree, and more so as I've got older. You just don’t bounce back quickly” (Clinician #9). Another experienced female physiotherapist described being “exhausted, and probably dreading going back next day” (Clinician #10) after treating many compensable patients in a day.
The consequences of these feelings of exhaustion varied for clinicians and was influenced by many factors. For some clinicians and their teams, the additional emotional and administrative burden meant that some clinicians would refuse to see compensable patients or meant that there was a sense of stigma associated with those patients in the workplace. For example:
“We don’t like treating people who are being covered by interstate work covers, or some of the insurance companies who are really difficult to deal with.” (Clinician #11)
“The clinic that I’m working at here isn't as supportive of [compensable] patients as some places I’ve worked over the years. They typically don't bulk bill or encourage any third-party payers and so I take on board all of that risk for my clients… the amount of time required to get paid slightly less by the [insurer] just made it untenable and we just couldn't deal with them any longer… we made the decision together that we weren't going to waste more time dealing with [the insurer] and that we would work with her GP and look at the Medicare plan to support her.” (Clincian #12)
“The culture at the clinic that I worked at was to share [compensable patients] around …The patients were treated as if they were a burden, which was really sad... [The clinic would] book them in on a rotating roster to prevent the practitioners themselves from being burnt out.” (Clinician #7)
Coping with being exposed to claimant distress and the exhaustion it brings was a variable experience. Some clinicians felt that not getting too emotionally involved in the patient’s story helped to maintain their own emotional balance (e.g., “I don’t… have a strong emotional… response. In fact, I tend to feel that’s a little unhelpful. I tend to look at… these really complex sort of problems… with a degree of objectivity,” Clinician #13). Others found that allowing enough time to deal with the complex nature of the presentations, as well as knowing when to refer to other clinicians helped (e.g., “If you have that type of particular patient, we need a little bit more time to listen to them, to really listen to what's going on in their lives and what's causing their stresses. And then, is it something that we can handle or something that we need to put a referral into the G.P?” Clinician #14). One physiotherapist reported that his religious faith brought a reassuring perspective which helped in managing his response to claimant distress (“I think there's a religious perspective… I hold a Christian view, a Christian perspective on the world. I think that's relevant for me,” Clinician #15). Reducing the number of compensable or otherwise complex patients was reported by several clinicians as a strategy to reduce exhaustion (e.g., “If you have too… many complex patients in one day, I couldn't manage that myself… From a very early stage of my private practice career… I needed to diversify,” Clinician #9).
For those clinicians who worked with large numbers of compensable patients, some reported the need for dedicated self-care strategies. For example:
“Being able to walk away, turn off your computer, and [recognise] you can only control what you can control. You need to switch off … If you're not switching off it does impact the quality of care.” (Clinician #16)
“Sometimes it might take a minute of just laying back in my chair and… take a few deep breaths or something.” (Clinician #2),
Exercise and relaxation and talking to colleagues, peer mentoring.” (Clinician #17)
“I will go for a big walk after work, or to a Pilates work out… something to try and just de-stress.” (Clinician # 5)
Some clinicians reported that dealing with high claimant distress, such as in the case of patients presenting with suicidal ideation, was difficult to cope with after leaving work. Some described ruminating about the patients at home (“Taking that home. Have I said the right thing, did I say something wrong, which may contribute to this [suicidality?]” Clinician #18; “When you go home, thinking about what happened to that patient. Are they okay? It plays on your mind a bit, I guess, after work,” Clinician #5), Other clinicians described different responses such as "being quite emotionally distant from my family and just, you know, wanting a bit of solitude and space myself” (Clinician #17) or feeling “I need a beer after that day” (Clinician #19). Many clinicians mentioned burnout in the context of these discussions. One clinician observed of other colleagues: “Sometimes people have a lot of sick leave… people do just call in sick because they can't be bothered. They can't deal with it. They don't want to have to go back and do it all again another day. … I know that some people just change careers” (Clinician #5).
This theme explored the commonly reported experience of feeling exhausted or drained when working with inured people with a compensation claim. Most clinicians reported that the interactions with distressed people with a compensation claim was a reason for this response. Many of the responses described could be seen as coping strategies for dealing with the clinician’s own distress.
Theme 3: Working with clinical complexity can lead to self-doubt
In the process of describing their work in these complex clinical settings, many clinicians expressed a sense of self-doubt in their abilities. At times, they would describe feeling overwhelmed by the nature of the situations they were presented with and a subsequent sense of helplessness in not being able to provide solutions. Some clinicians would describe feeling out of their depth, under prepared, un-supported or a sense that they were working outside of their scope of practice. For example:
“As a clinician, that’s really challenging to manage because we don’t really get that training right? We get trained to manage the biological factors… But when you’re then trying to do those things in the context of someone who’s really distressed… that can become really challenging for the clinician. I don’t think we get the support and the training to know how to start to unpack that and help someone to navigate that distress so that they can actually engage in the things that we think would be beneficial.” (Clinician #8)
When attempting to navigate insurance processes such as getting approval for treatment on behalf of a patient, clinicians described that the difficulties or failures that they experienced with these processes was upsetting. They would frequently question if it was their lack of knowledge of skills that had brought about the situations or let the patient down. For example: “You feel helpless… Is it my application? What am I doing wrong?... You start to doubt yourself” (Clinician #19). A physiotherapist similarly described: “Often I’m second guessing if I am doing the right things. Is it a failure on my part? Am I missing certain elements?” (Clinician #18).
This sense of feeling underprepared was particularly evident for some clinicians who were regularly dealing with people with a compensation claim who were expressing suicidal ideation. For example: “Sometimes they are… threatening to end their life, which is quite challenging when you’ve had no formal training… in that area... That's quite stressful as a clinician [and] takes up a lot of time and resources... I feel like [clinicians] maybe need more training in that area” (Clinician #5). The life and death nature of these situations were often described as being the most stressful clinical experiences, with clinicians frequently feeling frightened and out of their depth (e.g., “Those high levels of distress are always the most challenging. High levels of depression or suicidal ideation which really raise the stakes of the appointments and the interactions that you have…. It just feels very scary” Clinician #17).
For a large number of the clinician participants in this study, the sense of feeling out of their depth encouraged them to pursue further education to fill these gaps. For example, an osteopath described: “Because they had a lot of extra psychosocial components and they weren’t strictly musculoskeletal cases, I felt like I needed to know more. I needed to be more specialised to be able to help them” (Clinician #7). When asked about the consequences of working in complex settings, a physiotherapist described: “The consequences have been life changing. It has sent me down a pathway of wanting to know more. It has directed me into more of a psychologically informed physiotherapy approach” (Clinician #8). Another physiotherapist described further education as a buffer for dealing with the complexities of the work: “I do think experience and further education has helped my process” (Clinician #13). He explained that it helped him to define his scope of practice and to identify when he was not responsible for certain issues and needed to refer or seek additional support (“There are issues here that I can’t deal with. So then [I did further training] and found out about the psychosocial issues as well. I feel much more confident having the background knowledge to say these issues here are beyond my control,” Clinician #13).
As well as seeking further education as a buffer to helplessness, some clinicians sought the support of their team (e.g., “I feel protected by the team around me here. The specialists and other allied health team are there to speak to immediately after, which is wonderful, because… it is quite a threatening situation,” Clinician #17). Similarly, an experienced physiotherapist described the importance of “surrounding yourself with other practitioners who you can spin things off. You need to that… In a practice where there are other physios and you can either have a corridor chat about this difficult patient or hopefully you can have case presentations where you can problem solve and brainstorm” (Clinician #10).
In this theme, clinicians described feeling unsure of their abilities, uncertain about how to proceed, and in some cases that they may have been letting down their patients. Clinician responses to these feelings included upskilling and seeking support from peers. For a great deal of the clinicians interviewed, these experiences contributed to steps in a career that led them to develop a sense of mastery in how they delivery care in these complex settings, described further in Theme 5.
Theme 4: Helping this clinical population can be meaningful
In the process of describing the complex and often emotionally draining experiences involved in working in compensable care settings, clinicians would often contrast this by describing the factors that made the work meaningful. These explanations were perhaps provided to justify their decision to continue working in this setting despite some negative experiences (e.g., “You do have some days when you walk out and think, yes, I’ve made a real difference to people’s lives and some days when it’s the complete opposite,” Clinician #19). Some clinicians described a curiosity about the individuals they were treating and a desire to help. They would often then go on to explain how helping others made them feel fulfilled. For example:
“I really care about people. I’m interested in their emotions and feelings… I think it is like my inner being is, in a way, dancing with theirs a bit... I still love exactly what I do. It’s still very privileged to be doing that. It’s a bit of a joy, and even though it’s taxing, it’s something that I’ll do as long as I feel like I’m doing a good job.” (Clinician #9)
“I think deep down I like to help and be useful. I think facilitating people to recover, to reclaim themselves would probably be the thing I enjoy the most.” (Clinician #13)
One physiotherapist reported that taking time to engage with and educate insurance staff, such as claims managers, was meaningful to him as it meant that future people with a compensation claim may benefit. As such, he felt this was a good investment of his time to help improve the claimant experience (“One of the things I do see as a responsibility is to educate insurers. So, I’ll frequently find myself, as I’m discussing a particular patient with the insurer, particularly if I go in with a conciliatory tone… I have a good knowledge in this area, and I can be informative… I see that as a good way of… doing my part to educate people in the system,” Clinician #15). A doctor explained that the work was meaningful because they were able to learn clinical tips during interactions with the doctors from the clinical panels of the insurance body. He felt that in reviewing complex cases with the insurance doctors, the suggestions that were provided for medication review were sometimes helpful in a practice setting where such case conference options are not easily available (“They might suggest this or that instead as an alternative. Sometimes they might even contact you out of the blue and ask ‘have you thought about this?’ It’s helpful. It depends on the skills and experience of the person calling… but it can be a more collegial sort of experience which can be very helpful” (Clinician #20).
In being asked about working in compensable care settings, clinicians had often spent time describing the flaws of the system that impacted both themselves and their patients. However, being in a position to provide assistance to this vulnerable population also provided opportunities for fulfilment on a personal and professional level and a reason to get up for work in the morning.
Theme 5: A sense of mastery in delivering care within compensable settings
As well as describing that the work is meaningful, clinicians frequently expressed a sense of professional accomplishment in being able to engage with the complexity of the work. They found the challenge of being able to unpack the complexity and find creative solutions to help their patients to be rewarding and satisfying. At other times, however, clinicians would find that system factors might prevent them from being able to engage with the work on this higher level, leaving them frustrated and professionally unsatisfied.
As described previously, clinicians often feel a sense of self-doubt that might prompt further education to move them to a place where they feel more comfortable working in this setting. Combined with experience, further education was often pursued to build confidence to move a clinician to a place of mastery in their field. For example:
“My initial upskilling sort of came from this feeling of oh, my God! What do I do for these people? I need to equip myself in some way to know how I can actually help them because what I'm doing is not working… These days I feel a lot more equipped to deal with it. I enjoy the challenge of being able to help people who really need it.” (Clinician #7)
“I've gone through postgraduate then specialisation training, more for my development and self-interest… I gravitated towards [this type of work] because it's more of a challenge.” (Clinician #13)
Another clinician described how the complexity of the work kept her feeling professionally challenged and allowed her to use all of her skills and experience to unpack difficult scenarios:
“ I found personally, my brain doesn't do well with very simple or linear sort of tasks. I very much enjoy that sort of complexity and situations where there's lots of factors interacting. It sort of almost requires that bit more of an abstract approach to seeing those interactions and those interplays and, you know, sort of almost coming up with…creative solutions.” (Clinician #8)
This clinician (#8) went on to describe that this brought personal and professional satisfaction that offset the negatives of working in this space (“It's almost like a bit of an art process… It's that really collaborative approach to what is actually going to be workable for you, and that's the bit I think that really draws me in. I really enjoy and love it,” Clinician #8). A physiotherapist also described the joy that he experienced from using his skills and experience to get a good outcome in his work:
“The enjoyable bits, the discovery, and particularly the discovery for them… The detective part of that. The linking and building a sense of confidence is really huge and rewarding. Because wow! I think I've really done something here, you know, facilitated something here for this [person] to really get back and be really happy again… I love that. I love that. What could be nicer than that?” (Clinician #9)
As well as gaining skills and experience to help patients presenting with complex psychosocial factors, clinicians explained that knowing how to navigate the insurance system brought with it a sense of confidence in being able to assist patients to do well within the system. One clinician described this as “knowing how to play the game” (Clinician #6). Another element of mastery described by clinicians was being comfortable with ambiguity, whether it was for patient factors such as diagnosis or prognosis, treatment planning, or navigation of insurance processes such as challenging denied treatment requests. An acceptance of the flaws of the system also seemed to help clinicians to roll with difficulties and buffer against feelings of helplessness. For example:
“That's changed across [my] career. I think I've got to a pretty comfortable place where I’m comfortable with ambiguity. I don't expect that I need to know everything because I don't think that's plausible. And so, I think I feel more satisfied… You've done what you think you can do. You've put your effort into it. You're not going to get much more if you invest much emotionally or professionally. I can let it go.” (Clinician #13)
In supporting the development of mastery, working in a supportive team and having good mentors was reported to be important. One physiotherapist explained that her workplace placed a great deal of emphasis on mentoring, knowing that without helping junior clinicians to understand the nuances of working in complex care settings, they may leave or experience burnout symptoms:
“We do a lot of training for communication and framing of tricky conversations… Trying to make sure that they understand where each of those key stakeholders is coming from and their perspectives. We do a lot of modelling, and so, we call them doubles in the clinic. Observe that behaviour that we perceive to be really good… those kinds of things help.” (Clinician #6)
Other clinicians described how mentoring helped them to place a different emphasis on what they saw as a successful clinical outcome in complex settings, which helped to improve professional satisfaction. For example:
“A lot of younger clinicians ride the outcome of your patient. And so, when [a treatment] went well, I [felt like] the best physiotherapist ever. If it went badly, [I felt] like the worst clinician and that impostor syndrome really started to rear its head. So, riding the outcome was something that I did early, and wasn't great… In mentoring with more experienced clinicians, you know, they started to reframe what a good outcome looks like… it helps you to reframe what your role is. Reframing the expectation that you're always aiming to get someone one hundred percent… But for some people that isn't going to be possible. You know, they have life-changing, life-altering injuries.” (Clinician #11)
At times, the drawbacks of working with insurance systems, particularly those that led to delays to care, interfered with clinicians being able to achieve a sense of mastery in their work. For example:
“It’s demoralising because, you know, you're getting into healthcare, hoping that you're going to make a difference and then you've got clients in front of you and you've got all your wealth of experience, and you feel like you can offer a lot to these clients lives, and yet you’ve got your hands tied behind your back because it is pending feedback communication [slow communication from the insurer is delaying approvals for treatment].“ (Clinician #19)
Similarly, other clinicians explained that the constraints of the system meant that they were unable to deliver care in a way they felt was best practice. As such, they felt they were put in a situation where they were delivering substandard care. This often created internal conflict for the clinician. For example:
“It’s a bit of an ethical thing for the clinician because you then go well, how much do I bend the rules of the system under which this person is being funded in order to deliver what I think is person-centred care? Versus, do I compromise on that person-centred care in order to make the requirements for me practicing and delivering a service under that model? So, I think there's some really sort of challenging ethical and moral things happening there.” (Clinician #8)
Clinicians, particularly those with further education and many years of experience, were easily able to describe a sense of mastery and confidence in their work that made dealing with these complex clinical scenarios challenging and rewarding. On the other hand, where the systems that create the complexity in the first place became too complex and intrusive, clinicians frequently described finding themselves hamstrung and unable to use these high-level skills to benefit their patients.