In this episode, Physical Therapist at Pro-Activity, Dr. Daria Oller, talks about living with Long Covid. Today, Daria talks about the signs, symptoms, and causes of Long Covid, how to implement #StopRestPace, and how wearables can help guide your decisions. What are the considerations for athletes wanting to return to sport post-Covid-19 infection? Hear about the role of social media when it comes to Covid, the many mental health aspects of Covid, and get Daria’s advice, all on today’s episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways “Long Covid comes after an acute Covid-19 infection. The current definition is ‘prolonged symptoms after 4 weeks.’” “It’s multisystemic… Two people don’t present the same.” “We’re not in a lab. We can’t control for every possible thing. Just tweak one little thing and see what happens.” “Our energy is very finite.” “Learn how to pull back, do what’s really essential first, and find opportunities to rest when you can.” “Work with where you are that day.” “With any athlete who has had a Covid infection, you just need to be aware and monitoring for possible red flags… The fact that they’re able to keep going doesn’t necessarily mean that it’s safe.” “There are people who are committing suicide from Long Covid.” “There are lots of great peer support groups. Even if you’re not getting professional help, you at least have other people you can relate to.” “Looking for those little wins and victories, even if they’re small, even if they don’t seem like much, it helps.” “Do not try to push through symptoms… Stopping, resting, and pacing makes a really big difference.” “You don’t have to push so hard all the time. Things will be there. You know yourself, you know what you’re capable of doing, but resting is as important as pushing hard.”   More about Daria Oller Daria Oller is a physical therapist at Pro-Activity in Lebanon, New Jersey in both an outpatient clinic and on-site with employer clients. She specializes in working with dancers and athletes and in prevention and health promotion. She is also an athletic trainer, having worked in clinical, research, and education settings. She served as the PI for a study describing the injury and illness experience of youth campers at university-sponsored summer sport camp program. Daria contracted COVID-19 in March 2020. It continues to affect her daily life, including her ability to participate in and pursue her passions for dance and running. She is one of the founding members of Long COVID Physio, and has been sharing her lived experience on social media.   Suggested Keywords Covid, Physiotherapy, Recovery, Long Covid, Healthy, Wealthy, Smart, Symptoms, Relief, Pacing, Resting, Support, Energy, Mental Health, Sport,   To learn more, follow Daria at: Website:          https://www.pro-activity.com                         https://longcovid.physio Facebook:       @LongCOVIDPhysio                         Daria Oller Instagram:       @ontapphysio                         @proactivityus                         @longcovid.physio Twitter:            @ontapphysio2                         @LongCovidPhysio LinkedIn:         Daria Oller YouTube:        Long Covid Physio Twitter Accounts to Follow for more info on Long Covid:  @OT_Skiff @ahandvanish @PTOT4MECFS @PhysiosForME @ManeeshJuneja @itsbodypolitic @patientled @LongCovidPapers @AlyssaaErinn @ItsAngInLA @BreathewellPT @sunsopeningband @PutrinoLab @4Workwell @AHPLeader @SimonDecary @fi_lowenstein @MichelleBull4 @elisaperego78 @respphysio @Dr2NisreenAlwan @Dysautonomia @LongCovidKids   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:               https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the full transcript here:  Speaker 1 (00:03): Hey Daria. Welcome to the podcast. Happy to have you on this month, where we are talking all about long COVID symptoms and rehabilitation. So welcome. Speaker 2 (00:13): Thank you for having me. Speaker 1 (00:15): And now what's your interest in long. COVID let the, let the listeners know if they don't follow you on Speaker 2 (00:21): Twitter. It's a very public about this. I got sick with COVID last year in middle of March, 2020, and the symptoms never went away. And early on, we were told people recover in two weeks and after two weeks, I said, I'm not better yet. And I was young and healthy. I'm a distance runner, I'm a dancer, pretty fit, and I just wasn't getting better. And I didn't know anything about post viral illnesses at all. So being the good PT that I am, I just pushed exercise and pushed and pushed because that's what we do. And it made everything a lot worse. And then through Twitter some of the PTs who specialize in myalgic encephalomyelitis and chronic fatigue syndrome reached out to me when they saw my tweets and said, this is bad. You need to stop. We're gonna help you. So then it just snowballed from there. Speaker 2 (01:07): I started learning about chronic fatigue and the similarities that were coming up with long COVID. And so besides that, like just personally affects me, cause it really drastically effected my life and thinking if I wasn't aware of this and I'd been a clinician for 15 years, like how many other people don't know about this? Because it seemed like just as all the PTs with long COVID started finding each other. So many of us had no idea, and this is across all different specialties and settings, different ages. And we just didn't know, unless you somehow happened to wind up in the chronic, the peak space already. We had no idea and it seems really easy not only to make mistakes with ourselves, which many of us who got sick in the first wave did, but to then make mistakes for patients because you're going to do great at exercise. That's what we do. You're going to encourage patients to push a little bit, to push through all the symptoms and it's really dangerous. So I want to make sure, you know, that people are learning, that we're educating our colleagues and even they're trying to reach out to patients to and teach them how to advocate for themselves, teach them some of the basic information that's out. So yeah. So in addition to just affecting me personally, I've seen professionally how important it is to help educate and advocate. Speaker 1 (02:10): And can you, Darren and I spoke about this last week, but I feel like we can never say it enough. Can you define what is long COVID and what are some common signs and symptoms? Speaker 2 (02:26): Yes. So long COVID comes after an acute COVID-19 infection. So it basically, you don't clear the symptoms. You continue to have symptoms and they can change what the acute symptoms are in those first couple of weeks can be drastically different. What happens weeks and even months later, people are reporting new symptoms. So right now the current definition definition is prolonged symptoms. After four weeks, there are people who have it just for a couple of months. Many of us are on month, 15 month, 16, and some of the common signs and symptoms. Some like for me, example, seem to have carried over from the acute having shortness of breath, chest tightness, chest pain, all different kinds of chest pain. Dysautonomia is really common now. So we're seeing people who have really funky things happening with their heart rate, with their blood pressure, heat and tolerance, just a really poor tolerance to exercise. Speaker 2 (03:14): And so taking a term from chronic fatigue syndrome, there's post exertion mollies, or we've been saying post exertional symptom exacerbation. So whenever you can do not only exertion like exercise, heavy exercise, but just general physical exertion, you know, walking to the corner could have cognitive exertion, like going to work or emotional exertion that can set off a whole cascade and worsened symptoms. And that can range from just get small exacerbation to people, get fevers for me personally, like I can't get up off the couch. I can't speak really well. And it's multi-systemic so it's really interesting because two people don't present the same. Some people can have more neurological, some could be more cardio, some could be more cognitive respiratory. There can be a whole mix. We're seeing people who have mass cell activation syndrome and you're seeing allergic type things and rashes and changes in food tolerance and GI disturbances. It is really, really across the board. So there's no one set. This is what long COVID looks like. But if there are symptoms that are just continuing for weeks to months after the acute infection, terrible, terrible. Speaker 1 (04:18): And let's talk about from, so your physical therapist, athletic trainer, let's talk about the, some of the treatment parameters around people living with long COVID. So you had said, when you talked about why you're interested in long COVID it's because you are someone living with that and you said, I'm just going to exercise. I'm going to go harder. I'm going to put in a graded exercise program and that's going to get me all better because that's what we do. So tell me now, what should therapists or trainers be trying to implement into your patients or, or even you, if you are Speaker 2 (04:57): Someone living with them? Yeah. So it's, it can be such a different approach. I'll start with, there are some people that starting with the light exercise program can be appropriate, but there are things that you really need to monitor for. And nobody's like red flags. So looking at somebody has its own an again, seeing their heart rate blood pressure changes, just poor tolerance to even just moving from supine, to sitting upright, to standing poor tolerance to the heat, that trying to get that under control first so that it could be just working on breathing in their sessions, working in diaphragmatic, breathing, trying to get out of that, like very accessory breathing pattern because many of us hyperventilate and just don't even realize that we had adapted that pattern. I look at this tooth, I have one patient right now with it. I'm teaching people how to manage their symptoms, that these things are going to happen. Speaker 2 (05:45): And it tends to be very unpredictable and episodic. And that's, what's really frustrating. It's not that, oh, I just let me not do this. And then I'll be okay if I avoid this. Cause you could do something one day and be fine. And the next day it sets off a horrible crash. So teaching patients how to start recognizing those signs and symptoms and sort of like you can sort of tell sometimes and things are starting to go in a bad direction and what do you need to do if you're home, teaching them how to lie down, go through the diaphragmatic breathing. I've been sitting with my patient going through her day and like, where are there opportunities to rest? So this is very different than here's your theoretics program. It's where can you rest in your day? Where are, what are the things you absolutely need to do? Speaker 2 (06:21): Like eat, prepare food, order food, something like that. What are the things that, you know, are good you'd like to do with maybe aren't, you know, priority. And one of the stuff that like just don't even, it's not worth exertion that can set stuff off. So that's a really big part for me with the sessions is teaching people sorta how to figure out how to live with it. It's not a set plan. Like this is what you do, but here. So here's your life. Like I explained to my patient today, like we're not in a lab, we can't control for every possible thing and just tweak one little thing and see what happens. So here's your life? What do you need to do? And then how can we best set up to get you like that you're able to function that you were able to within reason control the symptoms. Like as an example, you know, right now it is incredibly hot in New Jersey, New York city. So we know that that can trigger symptoms. All right. So maybe we figure out if you have to have food shopping going early in the day, not going at noon when it's going to be really hot out. So there's not necessarily something set, but I look at it as helping people figure out how to live their lives right now while managing the symptoms. Speaker 1 (07:19): And that kind of takes me to the concept of pacing, which I think maybe a lot of people don't quite understand. So can you talk about what pacing is and how that differs from a graded exercise program? Speaker 2 (07:31): Yes. Hazing is so difficult. It sounds easy and it's not. So, and this is pacing, like say I'm a distance runner. So I understand how to pace, you know, over running, but to pace in your life is so challenging. So it might mean breaking something up. Pts will understand this. Some, some of us can sit at a computer for a few hours just to go through those notes, get them done. I can't anymore. So it's like maybe set a little chunk of time and then maybe you need to rest. Maybe you just need to get up and take a break. It might be cleaning your house that you can't do it all in one shot that you need to maybe do some in the morning and some at night, some today, some tomorrow is I look at it as like finding opportunities to slow down and opportunities to rest and something I've noticed as the world doesn't really set up for that. Speaker 2 (08:14): It is really, really challenging. You do your best and there are certain things, you know, you won't necessarily be able to pace with, but when you can just trying to spread it out because our energy is very finite and this is like literally at the cellular level, the energy is just not there. So you can't necessarily push through it. You could try, but that's going to affect you tomorrow. And then you'll be at a deficit for the next day and the next day. So it's learning how to pull back. Do what's really essential first, like really prioritize and finding opportunities to rest when you can, Speaker 1 (08:48): Yeah. Much, much different than a graded approach to activity or a graded approach to exercise is every time you do something, you increase it a lot, a little Speaker 2 (08:57): Bit more. And that's, what's interesting too, because yeah, that's just, that's what we do, but because symptoms can be unpredictable just because like, I'll use an example just because I could pick up five pounds one day doesn't mean I could do five or six pounds the next day. It might be the next day one pound. So it's really, really hard. You have to really listen to the patient and just go off of how they are feeling that day and let them know too that they're not doing worse because they can't do the same amount of whatever it is that they could do the day before. I mean, that's a hard thing. You look at it. You're like, but I just did this two days ago. Why can't I do the, why am I so tired today? It's so complicated. So yeah, it's trying to avoid that a little bit more the next day, a little bit more, a little bit more and just work with where you are that day, wherever your symptoms are at let's work from there, Speaker 1 (09:41): It's a much different mindset than what we're used to. And now, as, as we talk about that, I think that there's something important that we have to mention and that's athletes living with long COVID. So with athletes, we have to get them ready to get back onto the field, which means they have to be able to do a little bit more, a little bit more, a little bit more because they need to be able to compete. They need to be able to perform. So what are some specific considerations for athletes returning to sport post COVID infection or athletes with long COVID? Speaker 2 (10:19): Yeah. I look at this as with any athlete who has had a COVID infection and you just need to be aware and just be monitoring for possible little red flags that they might be going along COVID direction, because for anybody it's not always immediate, there are people who are doing okay in a couple months later, I had a flare up and we know with athletes in general. And I say this as one we push, you know, there are athletes who have plead while they have broken bones and concussions and all kinds of things. So the fact that they're able to keep going doesn't necessarily mean that it's safe. And an example for me, like I ran 10 and a half miles, two months after I got sick, which is insane, but I pushed and I did it. And then you could look at my heart rate and see why it was bad. Speaker 2 (10:58): So you're monitoring for, especially that post exertion L symptom exacerbation, if after they're working out, they're doing their practice, even watching film the cognitive demand for that, if it's a sport that has filmed, are they crashing? Not just the normal you know, you're a little fatigued or maybe have some dorms or something like that, but they're just completely done. It's really important to educate them and let them know because they might just think that it's just deconditioning. You need to get back in shape really important to monitor their heart rates too, because then they're going to push, especially getting back now after, after not being able to play sports from the pandemic, everyone's gonna be excited and have big adrenaline rushes and be able to push. And it's great to be able to look at some vital signs, to look at their heart rate, look at their blood pressure and see what it's doing, because they might not always be aware of what's going on to report it, but we know what you could look at as something objective like a heart rate and see, this is not the normal response from like what we would expect. Speaker 2 (11:50): So I know in the literature there's been some emphasis on clearing them for cardiac conditions, obviously super important. We see myocarditis and all kinds of things that is very important, but we're seeing many people in general on COVID whose basic lab work imaging is negative. But that doesn't mean that they're necessarily. Okay. So it was looking for the dysautonomia, particularly with sport, looking for the post exertional symptoms, symptom leaves after their playing, after their conditioning, again, after even cognitive exertion to see how they're doing monitoring for months, you know, don't assume because they were okay in the beginning because they're able to push through a couple of things that they're okay. Cause athletes will push through some pretty dangerous things to play. Speaker 1 (12:27): And can you just for the audience give a specific definition to the post-exercise malaise or post-exercise symptom exacerbation. Cause I really want people to understand that it's not just like, I'm a little tired and I just need to rest. So can you explain what that means? Speaker 2 (12:47): Yeah, it is. That looks like yes, it is actually physiologic reaction. So people will report an increase of flare up, increase in severity of their symptoms and you will actually see like physical, sick symptoms, like a fever is I think a really great example because no matter how hard you push exercising, a fever is not normally you know, response to that. And it is, it is so hard to explain when she experienced it, how crippling the fatigue is. It is something you cannot push through. Like you cannot get up. It sounds like I'm exaggerating, but I'm not. And I was talking to PT, Todd Davenport about this. And he, with his work in chronic fatigue was saying like, it's literally two energy demanding to talk like the amount of energy it takes for what we're doing right now is not there. So, and again, it can vary too. Speaker 2 (13:38): There are crashes. That's what I've kind of called them. Some other people too, that can be a little minor is not the right word, but not as severe. And some that are, people are literally bedbound and are unable to get up and it can vary to where the post exertional symptom exacerbation, those crashes can last for a few hours. They can last for days, weeks. Some of us, it takes us months to be able to bounce back from one. And even that, we're just trying to get back to that baseline of where we were when the crash happened. Not like a true, like pre-illness baseline. Got it. Yep. Speaker 1 (14:10): Thank you for that because I think it's really important to make that distinction for the listeners. Now let's talk about let's talk about the rule of social media when it comes to long COVID or COVID in general. I mean, we all know that social media is full of misinformation. As a matter of fact, I was reading an article where they said the long COVID misinformation, 80 or 80, some percent of the long COVID misinformation and misinformation on vaccine surrounding lung COVID was coming from 12 accounts. Speaker 3 (14:46): Can you imagine Speaker 1 (14:47): They just happen to have like a really, really strong presence and a really large following on social media. So what is the role of social media with long Speaker 2 (14:56): COVID? This has been fascinating. So we all people with on COVID found each other on social media pretty early. This part I didn't find initially, but body politic, they found each other really early in starting this whole launch. The patient led is another group too, but so this patient led movements. So people just coming together and saying, we're not better. We don't necessarily know what this is, but this isn't right. This isn't the two week recovery that we're hearing about. And at the same time people with chronic fatigue were jumping and they had been sounding alarms from the start of the pandemic. We didn't know about it. Cause you know, we weren't in that space. And then, so it's the people with lung COVID who named it. We gave it a name when we, you know, we weren't being heard initially because things, you know, being New York city, things were so severe that the focus was on the acute. Speaker 2 (15:40): We severely sick hospitalized people. So we on our own kind of came together and gave it a name and have gone from there. So that's social media has allowed for peer support groups and we have long COVID physio specifically for PTs, PTs, other allied health care professionals with it. I'm in a group for endurance athletes with long COVID. I'm sure there's plenty of other like specific groups where you can relate to each other because when you try to explain this to people who don't have it, they look at you like you're crazy because it just sounds so ridiculous. It doesn't sound like it's real, especially for those of us who were young and healthy and fit, you know, prior to COVID and then it's allowed us to get information out really fast where, you know, it takes a while to publish. It takes a while to do a study, but all of us, you know, we've been our little ends of one, like I'm going to report what I'm going through. Speaker 2 (16:23): You know, PT, Twitter was great. Encouraging me from the beginning, just report where you have. Cause that's, you know, that's one example we'll learn from. So we've been able to get that information out and papers have gone out very quickly. We have had some amazing webinars and just things that are, people are just producing so quickly and on their own, sometimes it was faster than having to go through a whole, you know, association and, you know, with the journal and everything. So that's been amazing and we find each other and I know which are the accounts that are going to put out like the peer reviewed articles when they're there. I know, which are the accounts that are going to have the great webinars and all the free things that are available on YouTube to watch. I know which are the counselors patient share and their stories. So you kind of find to what fits with, with what you need to know and whether you're at the, just the patient level or you're a clinician who needs information Speaker 1 (17:08): And can you, what are some of the accounts or, or if you want, you can send them to me and people listening can just that way you don't have to rattle through land accounts that no, one's not going to re no, one's going to remember anyway. So if you can send me some of the accounts of individuals and groups that people, if they're listening have long COVID, they know who to follow on where to get accurate information Speaker 2 (17:32): From. Yeah. Yeah. That's a great point that accurate that's been for better or for worse having clinicians and researchers with long COVID gives you people who know what they're talking about that you can follow them and I'll add for what you said. Cause I went, oh no, because one of the things that happens with long COVID is brain fog which is a broad term. And it sounds like not much, but the symptoms, the cognitive symptoms really, really range. And you'll see some of us just kind of get stuck finding words or trying to remember something, or I can picture people's Twitter profile photos. Couldn't tell you what the handle is on the list. Like actually see it, that's been a really challenging thing. I've been trying to kind of figure out how to work so I can send you yeah. Cause that's great. It is, it is so great to have other people to follow who are in the same boat or what we're calling, you know, allies, people who are sharing, they might not have it, but they're in a clinical space or research based to help. Speaker 1 (18:21): Yeah. Fabulous. Yes. So for all of you listening, Daria will send them to me. You can go to podcast dot healthy, wealthy, smart.com click on this episode and then you will click on whichever of those links you would like to follow. That would be much easier. Okay. So now let's talk about just this'll be well, we'll sort of finish up our conversation on a light note. Let's talk about the mental health considerations of those Speaker 2 (18:50): Living with Ms. Oh yeah. This is a whole big topic. So I'll start with it was pretty early on from when I had symptoms that somebody had first mentioned anxiety in me kind of implying that might be what the cause of my symptoms were. And I just say for me personally, I'm not an anxious person at all. So on one end, we're, you know, we're trying to say that it is virus driven. People can have mental health aspects a lot to get into, but that's not the root cause. So it's really important to tease out because people are told and I'm learning all about this from other people, chronic illness going in that direction and say, no, but psychological interventions can help, but that is not the underlying cause. But that alone, when people are telling you you're anxious, you're depressed when that's not what's driving. Speaker 2 (19:34): It is really frustrating. But because of all these symptoms, having this new chronic illness during a pandemic that has been politicized with false information is really hard because you'll talk to people who don't believe in the science of what this is, and they don't know that you have long content and you're just so that's really, really difficult. And it changes your life. You know, it's a complete change in your identity for all of us, particularly who are really active, whether it's exercise or as PTs, if physically demanding jobs. And you have to like figure out who you are now, if you can't do all the things you used to be able to do, you know, who are you? And then say for me, like running and dancing, that was my stress relief. That's my outlet. That's how I express myself, particularly with dancing. And now, you know, I'm not able to do that. Speaker 2 (20:23): Like I was before and it takes a toll and you're trying to find, well, what can I do then? What, what am I able to do to try to help cope with these symptoms is it is so frustrating. You are trying to figure out how to live with symptoms that are unpredictable and episodic. And like I mentioned before, you know, the world isn't adapting to what's going on in the world, just going on, like it was before the pandemic. So having the peer support has really, really invaluable to have other people to talk to that, understand it. And you can not only explain the symptoms, but you can be going through the symptoms and you know, they understand when you forget your word, when you stumble, when you're just too tired to sit up. So you're on a zoom, lying down. There's so many things like that. Speaker 2 (21:06): When you have people that to just, just to vent to or who, you know, they just understand what you're going through. That's been really big because the first for me, the first few months, I didn't know anybody else with it. And I obviously, there's plenty of great PTs who I was talking to, trying to help and my friends. But when you have people to talk to who understand that makes such a difference. It's just like, there's weight off of your shoulders. And like, oh, you understand you get it. I've met people. When we work with employer clients for my job who have long COVID and they start to explain the symptoms to me and I could see them kind of hesitating when they say that, it's like, no, no, I understand. I understand that you get really sweaty all the time. You're not crazy. Speaker 2 (21:41): That's a real symptom. That is a thing we can talk about that because this is something I didn't appreciate earlier. I work in orthopedics and it is, you know, there, there is a mental health aspect to it, but this is a whole other world there wasn't aware of. Yeah. As a PT, it's making sure you're listening to the patients that you're validating their experience and not say maybe if you're not familiar with this thing, well, that's weird. You know, that, that can't be right, that you're really listening to them. And that when you're, as you're listening, if you're hearing some of those red flags that maybe as a results of long COVID, or maybe they had anxiety and depression already, and this is exacerbating, it know that you're listening, you're ready to provide resources. If that's appropriate. And then now we're even taking a sad turn, but there are people who are committing suicide from long COVID. Speaker 2 (22:26): There was just a big case in the news because the woman was a writer. There's somebody who owned a chain of restaurants, it was pretty famous that had committed suicide. And there's more that are in the news, but that's really big too. And it's something that, again, I didn't necessarily appreciate until I was going through not only chronic symptoms in general, but symptoms where there's not a cure or treatment necessarily. So it's a whole new, a whole new world to learn about this. So as a PT, it's just really listening to the patients and under trying to, you know, understand, be open to what they're going through. That it's not just physical symptoms, but it's going to affect their entire being. Speaker 1 (23:02): Yeah. And you know, in Darren and I were talking about this, I said, you know, it reminds me or it makes me think of people with a headache, chronic headaches, migraines, maybe neck pain, back pain, where, you know, you're not walking with an assistive device. You don't have a limp. You're, you know, you don't have the symptoms of someone who's quote unquote sick. So it's one of those sort of silent silent diseases, if you will, or, or silent symptoms for a lot of people. And to have to explain to people why you can't meet them for dinner or why you kept it, it can just be, so how do you deal with that? Oh, Speaker 2 (23:49): This has taken a long time because I'm someone where you can look at me and assume I'm high functioning. Cause I go to work every day, you know, I, to a degree, kept up with dancing. But I'll explain to people and they're not getting it that they don't see what it takes for me to be able to do those things. The resting that I have to do, as soon as I get home from work or dance or something draining, I lie down I'm supine. That is like, if, as long as my schedule lets me do that, that's the first thing I do when I walk in the door. If I have to dry for a while, if I can I sit down when I get done or lie down even better. So there's a lot of strategies like that, that go on that you wouldn't see unless you're next to me. Speaker 2 (24:24): So I'll tell people about that. You know, I might look okay, but there are symptoms that are going on and I'll explain to a particular thing because I dance, you know, and the show must go on. I'm accustomed to ignoring symptoms and smiling and getting out on stage and spurt, you know, pretend everything's okay. So that's something that I've learned. It's not the greatest treat to have with long COVID because again, people, it just looks like, you know, we're okay. But it's, it's explaining, you know, what it takes to be able to just do basic things like food shopping. And what advice do you have for Speaker 1 (24:56): For people living with long COVID when it comes to their mental health? I think the advice that you just gave for therapists to really listen to your patients, not only listen, believe them. But what advice do you have for people living with long COVID? If they are kind of suffering their mental health is suffering. Speaker 2 (25:17): Yeah. A big thing is like, we've already talked about social media. If you can find, there are lots of great peer support groups. There are just general long COVID groups on Facebook. And then, you know, there's specific ones targeting you know, very specific populations. So at least even if it's not, you're not, you're not getting professional help you at least have other people you can relate to because I know that with long COVID clinics that are, that are starting on their wait lists. So trying to go through that referral system, you know, to try to get to somebody to help can be a little challenging. And I know for me and other people it's been having to just kind of accept that this is a thing going on and that it's, you can't push through it. You can't just kind of wish it away. Speaker 2 (25:59): You can't ignore it, it's there and you can, you can try to ignore it, but it won't let you, you're not going to get very far. And is this so much easier, seven number, just trying to accept the, how uncertain it is and just being able to kind of roll with it and know, you know, you might plan, have plans for a certain day and you wake up and say, Nope, that's not today. That's not going to happen. You know, I wanted to go to the pride parade on Sunday in the city and it was 90, whatever degrees, obviously very crowded. A lot of stimuluses Nope, this is, this is not a good idea. It would have been great to do, but not safe. So it's being able to, you know, recognize your limitations and something. I can't remember who told me this, but it's not only acknowledging the things you can't do because that is important to recognize certain things that are not right now, but something you did do that day. Speaker 2 (26:45): Like maybe I wasn't able to go food shopping, cause it was too much, but I didn't crash. I got through the day without a crash. So that's a positive thing. And it's hard again because it's not always in our control, but I that's something I've been trying to do as frustrated as I get, because there's so many things I can't do right now or I could, but I shouldn't because I've learned the things I shouldn't do. Just also recognizing there are still things that are not control maybe even on the worst day and you're not able to really get up and do much look at your heart rate and say, Hey, but I was able to keep my heart rate at a fairly low level because I understood that I was supposed to stay in bed. So looking for those little wins and victories, even if they're small and if they don't seem like much, if you're accustomed to doing a lot, it helps. It gives you just like a little bit incentive. So you can kind of look at the big picture and see that if you aren't making progress. Speaker 1 (27:30): Yeah. That's such great advice. And you know, Louis Giffords called that, looking for the pink flags. So looking for those, you know, cause we got red flags, yellow flags looking for those pink flags, which are those, those exactly what you just said those times where you're like, you know, I still have back pain, but Hey, I was able to sit through a movie, right. Or, oh, I was, I wasn't able to get out, but I was able to, to do some stretching. Right? So it's like, these are, you're really looking for those pink flags, those things that give hope that give a sense of accomplishment, however, small or big it might be. So I think that's really important. Speaker 2 (28:14): So now, so it's helpful two, because you don't know from day to day, what's going to happen. Which is just makes it so hard. That is the really frustrating part. And like you really have no idea. I can't remember. There's so many things that I've read. I always forget who, where I read what, but there was a physician who said with long COVID, it's like putting your hand in a bag of symptoms and pulling them out and say, this is me today, which is very accurate. That is a hundred percent accurate. So yeah, when you can say, all right, well today didn't turn out as planned, but I did something or at least, you know, things didn't get worse. Sometimes literally the accomplishment is that things didn't get worse and we're able to sort of manage it. It just really changes your perspective on how you look at things. But it's knowing that we don't know what's going to happen. We don't have a predictable, rough timeline on what to expect. We don't know that, oh, if you're in this age range, you're more likely to have this. Or if you were healthier, you're because we're seeing people who had no comorbidities I'm like, you know, with the severe acute infections. So just looking for those little wins can make a difference. Yeah. Speaker 1 (29:16): And, and living with that uncertainty certainly not easy. But if you have support groups, you have friends, family, peers, professional help. I'm sure that all of those things can help you kind of manage your life and manage where you are at this moment. Speaker 2 (29:37): Yes. I was explaining to my patients today that I, because she was, she was explaining friends who aren't understanding it and if it's going to happen and this, as soon as you have to, I think of the Mr. Rogers quote about finding the helpers. And in that case, you know, I had a friend who visited that hadn't seen our literally two years, but I knew she would understand. And there was a couple hours, one day I just had to lay down and I knew that would be a non-issue for her. She'd either take a nap or find something else to do. So I was looking for that, like knowing who the people are in your life that they'll understand. If you have to cancel last minute, that's fine. If you need to sit down last minute or, you know, slow down, you can do it, but that they will understand. And that's not going to be everybody not everybody's going to get it, which is fine. It's frustrating. But you know, it is what it is. But looking for those helpers who even if they can't directly help you, you know, cause they're not in healthcare, they at least will understand. They at least will listen to you. And they'll at least say, no, that's fine. This is who you are today. So we'll work with that. Speaker 1 (30:31): Yeah. That's so great. I think that does sound something like very Mr. Rogers E write something he would say. So now what would you really like for the listeners to kind of take away from Speaker 2 (30:45): This episode? A couple of things is the one is with anyone with long COVID, whether are living with it, or you have patients with it to not try to push through symptoms. I cannot stress that enough. You can use me as the example of why you should not push through symptoms. I have tons of data available from my garment and heart and crazy heart rate things. And it is just not something you can push through and it's not a failure on somebody's part. It's not that they're not trying hard enough. It's not that you're not strong enough. It's just physiologically. This is where you are right now and really doing your best to embrace. It's hashtag stop, rest pace, which is from the chronic fatigue community to really, really try to do that while there's, you know, like I said, there's no set treatment or cure. Speaker 2 (31:31): We know that that that helps it. Doesn't magically fix everything and everybody's different with how you implement it in your life. But the stopping resting and pacing makes a really, really big difference. And like as a PT, you just need to be open to the paradigm shift. It is so different than what we are taught from, you know, my mindset like so many people's it was, I gotta move. My dad's a respiratory therapist. He's retired now. But when I got sick last year in March, he said, knowing me, you know, you need to wait two weeks until you don't have symptoms before you start running is like, that's crazy. No, I got to move. And here's all the reasons why I can't be sedentary. Here's all the health reasons. And now I've had to like shift that in my brain a lot and say, okay, I know there's risks with bone health and cardiac disease and all these things, but the priority right now is trying to get the symptoms under control and really trying to prevent crashes as much as possible. So just being open to that, and yes, there are concerns about being sedentary, but right now preventing the crashes, supersedes that. Speaker 1 (32:23): Got it. Excellent advice. Now, where can people find you on social media, Speaker 2 (32:28): On Twitter? I'm on Twitter often. And I would say you can tell when I'm lying down resting, cause that's when I'm tweeting. Well, good to know it's at on tap physio two, number two, that is the best place to reach me on Instagram. I'm ONTAP physio. Excellent. It's on Twitter often. Yeah. Yes Speaker 1 (32:45): You are. And you get spread a lot of really, really good advice and, and we all appreciate your being there and being a voice of truth for people living with lung COVID and for clinicians who want to learn more. So we all thank you for that. Now last question I ask everybody this, where what advice not, where, what advice would you give to your younger self knowing where you are now in your life and Speaker 2 (33:15): In your career? I'm laughing because to not push so hard, which is crazy as a physical therapist or someone in healthcare in general, but to not push so hard. You know, I learned at my very type a all girls high school to push, like we just push you work as hard as you can. You grind got that in undergrad. And I was at the other training student, obviously I was in PT school and after that, and it has been to my detriment now that we're, you know, we look at that drive that that's such a great thing to have and look how resilient you are, look how antifragile you are looking all these great things, but we're seeing with not just lung COVID, but other post viral illnesses that can actually really harm you life in general. Yes. Yeah. And we get accustomed to not sleeping and illustrating caffeine and all that. So it sounds crazy to be saying to myself, knowing how I am, but it's to learn, like you don't have to push so hard all the time that things will be there. You know, you, you know yourself, you know what you're capable of doing, but resting actually resting, not doing things just resting is really, is as important as pushing hard and pushing hard can lead to all kinds of fun trouble. Speaker 1 (34:30): Absolutely. I think that is great advice. And one that I think any, certainly any PT should, should take and should live by. So thank you for that. And thank you for your honesty and being so candid during this conversation, because I think it will help a lot of people. So thank you so much for coming Speaker 2 (34:48): On. Well, thank you for having, like I said, finding the helpers, you are one helping to get all the information out to people on your, you have such an incredible platform where it's so important that we're reaching people wherever they are, and podcasts are definitely a way to do it. So thank you. Speaker 1 (35:03): I am happy to do it and I am learning more and more myself throughout this whole month. So thank you again and everyone. Thank you so much for listening. Have a great couple of days and stay healthy, wealthy and smart.

In this episode the chair of Long Covid Physio, Darren Brown discusses the World Physiotherapy briefing paper on safe rehabilitation approaches for people living with Long COVID.  Today Darren talk about the Key messages for Safe rehabilitation from the briefing paper:  " • Post-Exertional Symptom Exacerbation: before recommending physical activity (including exercise or sport) as rehabilitation interventions for people living with Long COVID, individuals should be screened for post-exertional symptom exacerbation through careful monitoring of signs and symptoms both during and in the days following increased physical activity, with continued monitoring in response to any physical activity interventions. • Cardiac Impairment: exclude cardiac impairment before using physical activity (including exercise or sport) as rehabilitation interventions for people living with Long COVID, with continued monitoring for potential delayed development of cardiac dysfunction when physical activity interventions are commenced. • Exertional Oxygen Desaturation: exclude exertional oxygen desaturation before using physical activity (including exercise or sport) as rehabilitation interventions for people living with Long COVID, with continued monitoring for signs of reduced oxygen saturation in response to physical activity interventions. • Autonomic Dysfunction and Orthostatic Intolerances: Before recommending physical activity (including exercise or sport) as rehabilitation interventions for people living with Long COVID, individuals should be screened for autonomic nervous system dysfunction, with continued monitoring for signs and symptoms of orthostatic intolerance in response to physical activity interventions." More about Darren:  Darren Brown is a cis-gendered (pronouns he/him), gay, white man, of English and Irish heritage, living in London, UK. He is a clinical and academic Physiotherapist specialising in HIV, disability and rehabilitation. Darren leads the HIV rehabilitation service at Chelsea and Westminster Hospital NHS Foundation Trust; Europe's Largest HIV centre. He is the Vice-Chair of Rehabilitation in HIV Association(RHIVA), HIV/AIDS coordinator of World Physiotherapy subgroup IPT-HOPE, and steering committee member of Canada International HIV Rehabilitation Research Collaborative (CIHRRC). Darren was awarded an NIHR funded Masters of Clinical Research (MRes) in 2019 and continues to conduct both quantitative and qualitative research about disability and rehabilitation among people living with HIV in the U and internationally. Darren contributes to national and international programmes focusing on disability inclusion across all responses to HIV. Darren contracted COVID-19 in March 2020 and continues to live with Long COVID. He is a patient advocate for Long COVID healthcare and research, calling for the greater involvement and meaningful engagement of people living with Long COVID in all responses to COVID-19. Darren founded Long COVID Physio in November 2020, an international peer support, education and advocacy group of physiotherapists living with Long COVID. Darren is an invited expert contributing to World Health Organization Guideline Development Group on COVID-19. Suggested Keywords:  Covid, Physiotherapy, Recovery, Long Covid, Healthy, Wealthy, Smart, Symptoms, Relief, Pacing, Resting, Support, Energy, Mental Health, Sport To learn more follow Darren at:  Twitter https://www.hiv.physio/ https://longcovid.physio/ Long Covid Briefing Paper   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:                https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the full transcript here:  Speaker 1 (00:02): Hey, Darren, welcome to the podcast. I'm thrilled to have you on today. Thanks so much. Speaker 2 (00:07): Hello. And thank you for having me. My Speaker 1 (00:09): Pleasure. So this month we are talking all about long COVID. So people living with the long COVID symptoms and also what long COVID is at least what we know now, what we know at this present time. But before we get into all of that, and before we talk about the the world physio therapy briefing paper nine, which we will have a link to in the podcast notes I would love for you to let the listeners know a little bit more about you and why you are part of that paper and, and part of this world. Speaker 2 (00:48): Yeah. So thank you very much for having me today. So my name is Darren brown. I'm a, cis-gendered gay white man. I've mixed English and Irish heritage. I live in London in the UK. Hence my accent for anyone that's not where I am. I am both a clinical and an academic physiotherapist, and my background is in the area of HIV, disability, and rehabilitation, so specialized in that for a decade. So I'm kind of used to the chronic implications of viral diseases. And I also happen to be a person living with long COVID. So I contracted a coronavirus acutely in March, 2020. So as I sit here today, I'm of my 15th month after acute coronavirus and I am currently sitting here today in a really stable, good place with my long COVID I predominantly symptom free. Speaker 2 (01:45): However, it's been a 15 month journey and it's been a very episodic and up and down journey which I'll be very happy to summarize for you if you thought that was useful. So I, as I said, I contracted coronavirus last year. I went back to work pretty quickly actually, and I ended up working full time for six months, switched, included being redeployed to various sectors, including intensive care in response to the pandemic. Had some ongoing symptoms, but in September last year I crashed. And I ended up being off work for two months and the crash lasted for about six months where at my most disabled I was bed bound and flat bound and walking with a walking stick. And my symptoms were multi-dimensional episodic and unpredictable in their nature with profound exhaustion, fatigue, brain fog I've had some respiratory symptoms. Speaker 2 (02:37): I've had cardiovascular symptoms. I've had urological symptoms are neurological symptoms and I'm under all of those physicians for investigation still. I then had my vaccination, my first dose in January. I got better. I returned back to work. And then I was getting so much better. I started to do a bit more and unfortunately I had second crash. But then I had my second vaccination felt a bit better. And I've been continuing that journey since. So yeah it's been a very episodic journey but I'm also a co-founder of a group called long COVID physio. So long COVID physio was born out of the need for peer support amongst physiotherapists, living with long COVID, both in the UK and the United States, but now it's evolved, it's now a global peer support group that also provides education in the context of a long COVID disability and rehabilitation. And also acts as an on an advocacy level which kind of brings us round to where the briefing paper came in really. Because it was born out of a need for education and advocacy led by people living with long COVID. Speaker 1 (03:54): And you know, I think we spoke about this before we started recording, but your background working with HIV that has multi-system whole systemic bodily implications, you said, well, with these, the code, the symptoms of long COVID, you weren't, it wasn't like out of the blue, it wasn't a huge surprise for you, but is it safe to say it was a huge surprise to a lot of other people in healthcare and out? Speaker 2 (04:26): So in the context of HIV, we know that HIV can be controlled with medicines antiretroviral therapy. And when a person is undetectable, meaning you can't detect the virus in the blood because the medicines are working that well, people are on transmittable, meaning you can't pass it on. And when people are undetectable and they've been taking the medicines, people can live a normal life expectancy. But what we know with that is that people are growing older with HIV and the developing other complications and people living with well controlled HIV, still experience issues, including episodic disability. So when this pandemic came out, there was quite a few of us at work in the world of HIV, disability, and rehab that were kind of anticipating well, if people recover, there may be a risk that people will develop long-term consequences. So it wasn't surprising. I think what was surprising was that I was one of them and actually how severe the disability was. Speaker 2 (05:19): There are other groups of people that also were anticipating a post viral manifestation, particularly groups of people living with Emmy or my LJ can. And my lightest also known as chronic fatigue syndrome. And other people that have been living with post viral complications probably were anticipating there was going to be some form of complications after acute Corona virus. But I think mostly the world has been caught off guard by this. And maybe it hasn't been prepared for the critical mass of people globally that are going to be living with ongoing consequences after acute coronavirus, which is now commonly referred to as long COVID. Speaker 1 (06:00): Yes. And so now I think that leads us right into the briefing paper. So like I said, there'll be a link to this in the podcast notes, but when you look at this briefing paper, there are a lot of contributors to this. So before we get into the meat of the paper, can you give can you explain how you got all of these people together in order to write this paper? Speaker 2 (06:22): Yeah. So this brief briefing paper was specifically brought together communities of people from different experiences. So the idea started with myself and a few other people that had expressed some concerns that maybe there was lacking guidance and policies and standards around the utilization of physical activity, witching of all types, including exercise and sports in the rehabilitation of people who may have been recovering from coronavirus or living with long COVID. And so initial conversations were between some people that had already connected pretty much through social media. And when we got the kind of green light with world physiotherapy, that this might be something that we could work towards. We started to snowball our collective groups. It, this, this briefing paper is brought together over 50 different people from different geographical regions in the world, so that all of the five corners of the global four, four corners, but, you know, five weld, physiotherapy regions have been represented here. Speaker 2 (07:29): So we've got people from Europe, north America, south America. We've got people from Africa, Asia, and Asia specific. So we, we have huge diversity, not only in where people are from, but also in that backgrounds. We've got people living with long COVID. We've got physiotherapists, we've got physicians, doctors that specialize in a range of different things, including physical and medical rehabilitation. Also known as physiatrists. We've got occupational therapists, psychologists. We've got people living with M E the list goes on and we've got such diversity because what was needed was a consensus here. What was needed was a diversity of thought experience, both lived clinical and academic, but also geographical to come together to say non COVID is not just affecting one place in the world. And this experience is not singular to two groups of people or people in certain locations. This is actually a unifying global issue and the long-term consequences after acute coronavirus and affect people around the world. And that's why it was so important that we have that diversity, if the people that were contributing, but also diversity of experiences and thoughts, because not everybody comes from the same background with the same beliefs about all of this. And so we needed to bring that consensus together. And that's how we was able to develop the paper, though. It was not only recommending caution, but was also what can be done and also where rehabilitation is successful. Speaker 1 (09:00): Yeah. And I think, you know, for a whole systemic disease, that COVID is, and it being global, it is important to have a whole systemic group of people working on this. So I just wanted the listeners to know it's not only physical therapists or it's not only physicians, if this was a real collaborative world effort. So that being said, let's talk about what some of those key messages are, especially when it comes to safe rehabilitation of people with long COVID. So I'll hand it over to you. Speaker 2 (09:33): Yeah. So the, the way the briefing paper was written was to introduce T considerations when rehabilitation specific to physical activity in all of its forms. As I said, including exercise and sports, when those key considerations need to be taken from a safety perspective before we prescribe exercise and physical activity. And I purposeful in my terminology there because we are health professionals that do prescribe our interventions. And so therefore we do need to have safety at the core of what we do. We know that there is currently not enough evidence or any evidence on the safety and effectiveness of physical activity and exercises and intervention for people living with long COVID, but there's loads of indirect evidence. And there's also enough evidence in long COVID to give us the signals and clues as to which direction we could be traveling in. And so there was four key messages that came out in this. Speaker 2 (10:31): So the first was before recommending physical activity, as a rehabilitation intervention for people living with non COVID individuals should be screened for post exertional symptom exacerbation. Now, this is a term that's called different things. So post exertional symptom exacerbation is something that I quite like, but it's also used by other groups sometimes more commonly known as post exertional malaise, but can also be known as post exertional neuro immune exhaustion, basically, in a nutshell, when you exert yourself, whether that be physical, cognitive or social exertion, your symptoms get worse. So obviously before you get people to exercise, it would be quite useful to know whether they've got that because you can't exercise your way out of a symptom, which is made worse by exemption Speaker 1 (11:21): And, and from a physical therapy. Cause we're both physios from that physiotherapy perspective, how do we screen for that? Is it a simple questionnaire? Speaker 2 (11:33): So this is where the briefing papers really quite useful because obviously that's the first key message. And the way the briefing paper is designed is that you have the key message and the rationale for that key message. So if anyone's now going, why they brought that key message out in the briefing paper, there is an evidence based rationale for that. And then off the back of that, there's an action. So each key message has an action point where clinicians and also communities of people living with an effected by long COVID can utilize these action points. So as you rightly said, there are ways of screening for post exertion or symptom exacerbation. Now, one of the best ways of doing that is actually a narrative approach, which is having a effective communication between clinician and the person accessing the clinicians care. So one of the nice things about this briefing paper is it's also included the whole context of person centered rehabilitation and the therapeutic Alliance or relationship and how that's going to be an integral part of ensuring that safe rehabilitation is provided. Because if you can use a narrative approach to hear that people are experiencing this symptom, then it's a really good starting point. There are other tools though. Speaker 1 (12:47): So are you saying that we actually have to make the time in our evaluation to speak with our, the person in front of us to really get to know them and to ask more narrative questions, motivational interviewing, not just yes and no, and typing into a computer Speaker 2 (13:06): Now that's that's yes, that's leading, right? So, but you know, the average person probably listening to this, he's probably going, of course, I listened to my patients. Of course I communicate with my patients, but, but, but I think what it is, it's about providing space for people to feel safe, to provide the information that they can engage in. So if person centered care is going to be a key pillar of rehabilitation, we must make sure that our patients feel safe to open the engage in rehabilitation with meaningful connections that are established with the clinicians knowledge, but also the patient's belief and knowledge of their own lived experience. And I think this isn't new to many people, but I think it's a really vital skill that we can harness in terms of delivering safe rehabilitation. Speaker 1 (13:56): Yeah. And everyone deserves to be heard and acknowledged and seen and given the space to do that. So as physiotherapists, we should obviously be doing this with every patient. But when you're seeing patients who are living with long COVID, I think it behooves you to give them some extra space because I'm sure they have experienced people, not believing them. Like you said, just exercise your way out of it. You'll be fine. And because a lot of people with long COVID, unless you maybe are walking with an assistive device, they may come in and look, okay. Yeah. Speaker 2 (14:40): Th that's that's the key point, isn't it, you know, a long COVID could be classified for many people as an invisible disability. And certainly it's something that's experienced as, as not only, but also episodic in its nature and also unpredictable. So someone may look okay, one moment, but not another. And this is something that I've talked about from the lived experience of having the symptom of post exertional symptom exacerbation, which is that it's, it's wholly invisible to the majority of people because when I'm out and about, and I'm doing okay, people see that I'm doing okay, well, they don't see as the repercussions of that a day or two later where I'm laid up in bed because no, one's around me when I'm laid up in bed and no one can see that. So it is truly an invisible symptom and that's where people need to feel safe to talk about that. Speaker 2 (15:26): Because a lot of people may not understand it themselves and may be very confused by this because my experience was, I was totally confused as to what was going on with my body, when this was going on. And I was very lucky that people were able to guide me through what the symptom was and to understand it better. Yeah. And you're in the biz. So just people who aren't. Right. Yeah. I have a head, I have a level of health literacy that is probably different to the general population. And I didn't have a Scooby-Doo what was going on with my body. I thought I was doing the right things to try and rehabilitate myself by gradually increasing my activities. What I thought was dependent on my symptoms, but I had zero clue what was symptoms were doing because they were all over the show, but there are some tools to screen for this as well. Speaker 2 (16:14): And that's within the briefing paper. So there is a range of different questionnaires. And actually specifically within the, the, the briefing paper, there is a a box which actually has these 10 items that you can use. And it tells you how to score it, how it links it to the evidence-based research, which comes from Emmy and CFS. Hasn't been validated in long COVID, I'm sure that work will happen, but it's a tool that could be useful. There has been some research already that's come out of Calgary in Canada, which has used this tool specifically along COVID. And actually that was published as a pre-print literally the day after this was published. So it's not included in the briefing paper and that's a sign of how fast this research is moving, but a very high percentage of people are scoring as the threshold for experiencing post exertional symptom exacerbation when living with long COVID. Speaker 2 (17:07): So it's there, it's prevalent. It's an important consideration because what we know is that a graded exercise therapy program, which is incrementally increasing the amount of activity you do, irrespective of your symptoms has been shown to cause harm in other populations of people, particularly MEFs that experience post exertional malaise, and at our heart of what we do rehabilitation should be there to support people. It should be nourishing. It should be improving functioning, and it should not be causing harm. And that's where that narrative approach is useful because when we provide interventions, we need to provide the safe spaces for people to tell us that it might not be working and not allow people to feel that it's their fault that it's not working because they've got this symptom. Speaker 1 (17:57): Yeah. So, so, so important. We don't want to place the blame on someone for something which they have no control over. Right. And, and I think as, as physiotherapists, we have to check our biases. We have to understand that when this person comes in, I mean, we all have biases. We were, that's how we are, you know, maybe not as a four year old child, but certainly as you grow up, you acquire these biases and you have to know as the practitioner to be able to recognize that bias and push it aside, right. Speaker 2 (18:36): That's such an important point about implicit bias as well and unconscious bias. Because I think actually wholly as a profession physiotherapy has an unconscious bias, which is that the mantra exercise is medicine is within our bones. And I think as a profession, it's quite hard to hear that exercise can't cure everything Speaker 1 (18:58): Well. And, but I think you kind of said this earlier is exercise is prescribed. So we need to prescribe it just like you would prescribe a medication by dose. Right. So, and sometimes guess what that dose is zero, right? Sometimes it's zero, you're prescribing it. So again, it's that exercise is medicine. Yes, it's a thing. But you have to know enough about the person in front of you to know how to prescribe it. Exactly. Speaker 2 (19:29): And that's where physio therapists are. So ideally placed to take on board these messages, there's key message of screening for post exertional symptom exacerbation, because we all are good at prescribing physical activity and exercise interventions that are based within a rehabilitation model. And we are also good at knowing when not to prescribe. And I think that if we're given the tools to be able to identify the symptom, recognize that there might be an adapted approach that's needed that works with individuals and potentially takes a stop rest and pace approach because pacing is not easy to do. I'll say that from lived experience you know, there's, there's so much that can be done beyond the scope of just prescribing physical activity and exercise interventions. And I think that physiotherapists are so ideally placed to be working along those lines and working with our multidisciplinary team colleagues. And this is where the big shout out to the OTs go because pacing is their bread and butter. Speaker 1 (20:28): Yeah. Yeah. For sure. Absolutely. Okay. So we've got one key message is screening. Speaker 3 (20:38): Cause there were four, right? So what's number two, we Speaker 2 (20:42): Went on a topic, but it's important. Speaker 4 (20:47): [Inaudible] Speaker 1 (20:47): The most important part is to be able to screen and know the person in front of you. Yeah, Speaker 2 (20:53): Yeah, absolutely. So the second is about cardiac impairment. So what we know is that before we prescribe physical activity, interventions, including exercise or sport, we need to exclude cardiac impairments. Now there is enough evidence to demonstrate that's people that have had coronavirus and people that are living with the long-term consequences are long COVID can have cardiac impairment. And that can include things like pericarditis, myocarditis, even at mild levels. Now we know the opposite. There's a favoring for excluding exercise interventions for people that do have perio myocarditis for the safety implications. So reducing morbidity and mortality. Now, obviously this is a safety message. We don't have enough evidence yet to say what the true prevalence of cardiac impairment is amongst people living with long COVID what the safety implications are. But this key message is we must make sure that we are conscious of this because the evidence is indicating there's a risk and we need to be mindful of that risk. Speaker 1 (21:58): Right? So as a physiotherapist, if someone is coming to us with long COVID, who has not seen a physician has not seen a cardiologist has not had a cardiac workup, it would behoove us to say, Hey, listen I think your next stop should be, let's get you to a cardiologist to evaluate your cardiac function, Speaker 2 (22:18): But depending on symptoms, certainly. So, you know, people are having it disproportionate tachycardias on exertion. They are having strange cardiac symptoms, including changes to heart rate and blood pressure. They have chest pain, they have desaturations, you know, the classic cardiac symptoms that you'd expect. You're not going to try and push them through an exercise program. You're going to encourage them to see a physician first. And I think that there is going to be many people living with lung COVID that might not be going through specialist services for people designed for people living with non COVID. And there may be many that come through the doors of physical therapists and physiotherapists around the world first. And so this message is there because we need to make sure that we are aware that there is a risk. Speaker 1 (23:06): Perfect. Okay. What's number three. So Speaker 2 (23:09): We know that third one is around excluding exertional oxygen desaturation. So what we know is that COVID-19 can cause interstitial pneumonias. And so we have seen this in other diseases. So, you know, it can be things like pneumocystis, pneumonia, or PCPs. You see it in things like interstitial lung disease or idiopathic lung fibrosis with these they can cause these saturations on exertion basically, and as the most safest thing, you want to make sure that your patient is not hypoxic when you try to exert them. So it's a simple thing, but what we know is that this is often something that may have happened to people during acute COVID, but it doesn't mean that they can't have it ongoing. And we are seeing people that are having pulmonary impairments and sometimes these pulmonary impairments can manifest slightly later on as well. So it's just to be mindful of this. Speaker 2 (24:04): So the world health organization does recommend, you know, the pulse oximetry is used to measure that's and certainly in terms of long COVID services. So I'm based in England. So the long COVID services that are here do often utilize functional performance measures to determine if someone is exertion de-saturated and they might use something like a sit to stand test or a 40 step test to see if somebody is exertional desaturation, or having disproportionate successional tachycardias as well. But that needs to be finely balanced with point number one about posted exertional symptom exacerbation. Because obviously you don't want to put somebody through a test to determine if their exertion de-saturated, if it's going to cause them to end up in bed for a bit. Speaker 1 (24:49): Yeah, absolutely. Again, why point number one was so important. Let's go on to point number four. Speaker 2 (24:56): So point number four is about autonomic dysfunction and orthostatic intolerances. So many physiotherapists might not be aware of some of these conditions. So for example, there's something called pots or postural orthostatic tachycardia syndrome which is where people change posture. They go from lying to upright there, their heart rates go really, really high. And with that, they can have symptoms of presyncope or even syncope. And also other orthostatic intolerance is exists where people can have really significant drops in their blood pressure again, causing issues with precinct pain syncope. So these dysautonomia is, are actually being seen to be quite prevalent in many people post virally, potentially. When they're living with long COVID, I said potentially there, because we don't really know what's going on with long COVID. So so we are seeing there's a higher amount of that and the American autonomic association has already published some guidance on that specific to long COVID. Speaker 2 (26:00): So the key message with this is if you've got somebody who, when they change position may have a disproportionate dropping their blood pressure or a disproportionate increase in their heart rate, you probably don't want to be getting them doing a downward facing dog or sitting on an upright bike because the likelihood is they could find, or they could have a heart rate of 220. So we need to think about that. Now there are lots of existing research prior to even COVID existing about dysautonomia is including pots and there was all these protocols that existed. And actually some of the work that's come out of Mount Sinai in New York has been looking at adapting those protocols to develop something called autonomic conditioning therapy which that developed in the context of long COVID. But it's really important that we're aware of this because if we're going to be looking at whether a physical activity intervention, including exercise or sports is going to be safe and effective for our individuals sat in front of us in the absence of evidence, guidance, and policies and standards. We need to be aware that these things are happening and people are having strange symptoms including changes to their blood pressure and heart rates with changes in postures. And the, the briefing paper is really clear on what it is what can cause it, how to measure it and what to do if it's there. Speaker 1 (27:26): And so we've got those four key messages. We're not going to dissect every bit of this briefing paper, because that would be a whole weekend course, I think, but for people that are listening, what, you know, as being one of the authors of this paper contributors to this paper, what, what is that, that group's hope for people upon reading this paper? Speaker 2 (27:53): So I don't know that I can speak for everybody that was contributing to this, but I would imagine that the majority of people have the same opinion as me. It's the lead author of this which is that we hope that this supports firstly, communities of people living with an effected by long COVID when they are accessing care, which is they have a resource that they can take with them to their health care providers and have these open conversations and dialogues about what may or may not be right for me. I also think that collectively, we all really hope that this is going to support clinicians that are going to be providing care for people living with and affected by non COVID. Because we know that at the moment, a lot of people are looking for information and there's, there's a lot of information that's either direct or indirect, and sometimes it can be difficult to see the wood for the trees when there's that much information. Speaker 2 (28:48): And so we're really hoping that this has consolidated over 180 citations into one document and every single citation has got a PDF link. So you can access that literature yourself. You can do your own research around it, should you want to, but we're hoping thirdly, that this will be a starting point. We're hoping this is going to be a starting point for hopefully international collaborations to work on these messages, to develop guidelines, standards, and policies around that as the evidence continues to emerge, but also to guide the research agendas, because obviously there are going to be some people where exercise will work for them, but we need to know who they are. And we need to make sure that whilst we're doing that research, that we have the safety messages at the heart of delivering that research too. So this crosses communities, clinical practice policy and also research. Speaker 2 (29:46): So I think the hope is that this has wide reaching impact. Obviously we need to see how that is, but this isn't the end of the journey. This is going to have further interest iterations. This is a live document. This will be updated as more research comes out, but we hope as well that people will work with us as things move forward and looking at international collaborations because we know that it's interprofessional, but also multi-sectorial collaborations that meaningfully engage and increasingly include people living with an effected by the health condition that leads to much more positive responses in all of the responses to that health condition. Speaker 1 (30:25): Yeah. And, and last thing I'll, I'll touch on here. And that's, I think what you were getting at at that last little bit is really looking at the social determinants of health and of the people who are affected by long COVID. I know I can say here in the United States that we know that African-Americans and Hispanics within the United States much more effected by COVID than other other folks. And so can, might, might this also be with this international collaboration across a lot of different professions, a way to really look at our social determinants of health and what can we do as healthcare providers and researchers, and so on down the line to make sense of this and to to address this, even in, in a small way, I know it's opening a whole can Speaker 3 (31:25): Of worms, but you know what I'm saying? Yeah, I Speaker 2 (31:28): Do. And I think it's, it's a can of worms I'm prepared to go into. So so yes, we know that in different parts of the world obviously the people that are affected more by acute Corona virus has been disproportionately people of different ethnic groups. So for example, here in the UK, we are seeing it more amongst black, Asian, and minority ethnicity groups. And we're also seeing it amongst different populations of people in terms of employments, but also in terms of socioeconomic status. So we know that health workers and teachers are more likely and people that drive buses, people from black, Asian, and minority ethnicity groups and people that live in deprived areas in the UK. But what's really interesting is we're not seeing that same demographic appear in terms of who's presenting in terms of the demographics of people that we are collecting data on in terms of long COVID. Speaker 2 (32:16): So what we're seeing in the UK so with the office for national city plastics, which is probably the most representative and largest epidemiological studies on long COVID to date globally, it's actually disproportionately young white women that are have relatively different social economic. So I think the aims of maybe an unintended aim, but hopefully a positive unintended outcome is that if more people are aware of some of these key indications of awareness, maybe some greater awareness of lung, COVID the people that are probably more likely to get COVID are probably going to also be more likely to get long COVID, but we're not seeing that come out in the data or the people presenting to those services. So we need to think about health inequalities in terms of the candidacy of people to access these services, how permeable are they to access? Speaker 2 (33:19): How, how is the adjudication between the individual and the health care providers to be referred to that? What's the individual's candidacy to raise their voice, to say I deserve to access these services. And at the moment we know that structural racism exists, health inequalities exist, and people that experience structural racism often experience healthcare incredibly different to other groups such as white people. And so it's probably likely that many of these people may also be living with long COVID and not presenting to health services and not being counted. And this is a particular issue globally, which is that we're still not effectively counting on COVID. And so we don't know the proportionality of people affected by it and the need globally. So if this briefing paper has any way in contributing to more clinicians, more people being aware of some of the signs and symptoms of lung COVID and particularly those key recommendations in terms of safety, if they can say, well, maybe you do have long COVID. It might be a way of identifying people that are more at risk, but also are more vulnerable to not accessing services. Speaker 1 (34:21): Yeah. Perfectly said, I am in awe of your of your ability to succinctly and efficiently get big ideas across that allows people to understand better. So thank you very much for that. That was wonderful. Now, before we sign off here, where can people find you? They have questions. They want to know what's up. I love Speaker 2 (34:44): A bit of Twitter, so I'm on Twitter, I'm at Darren brown. Also we've got our long COVID physio group at long COVID physio on Twitter. We've also got a website long covid.physio. So they're probably the best way he's very responsible on Twitter. So yeah, I won't give out my email address, no need, Speaker 1 (35:02): No need to, no need to get that personal. But I do have one personal question before. So knowing where you are now in your life and career, what advice would you give to your younger self? Oh Speaker 2 (35:13): My God. So you warned me about this earlier, didn't you and I get to repeat what I said earlier. I was like, oh my God, this is like, RuPaul's drag race. Isn't it. There's going to be a picture of a five-year old Darren big helicopter. What would you say to baby Darren? Do you know what I would actually say? Whether I was on RuPaul's drag race or dot is the diversities of people bring out the strengths in others and I'm a man, and I know that Mo and I'm now a person living with an episodic disability. Those things have made me a better person and enabled me to have conversations with my patients and the people that come and access my care in a completely different way that because of the lens that I've seen society and life. So if I was seeing myself as a younger Damron, I would have said, be proud of who you are, be accepting of who you are and know that your diversity, your differences, your quirks, your geekiness, your diff, your things that make you unique are going to truly make you unique when you're older and give you advantages in terms of how you navigate life, society and your job. Speaker 1 (36:23): I love it. Thank you so much. That was so perfect. What a great way to end this podcast, Darren, thank you so much for coming on. Thank you for your time. I really appreciate it. Thank you for having me and everyone. Thanks so much for listening. Have a great couple of days and stay healthy, wealthy and smart.    

In this episode, Founder and CEO of Rehab 2 Perform, Dr. Josh Funk, talks about his experience with the business side of physical therapy. Today, Josh talks about how he created his business culture for employees and patients, his community outreach, and how he assembles his teams. How has Josh grown his business so quickly? Hear about the importance of a balanced dashboard and being mindful, and get Josh’s advice to his younger self, all on today’s episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways “If I think of somebody who has more autonomy, I think of somebody who’s automatically going to be more engaged.” “The first thing that you need to start with is admitting that you don’t have all the answers.” “We move fast, we break sh*t, we fix it, we move on.” “A lot of it [growth] starts with continual self-analysis.” “Me working in my business was the single biggest blockade for us moving forward.” “We’ve put equal investment on people, we’ve put equal investment into our local communities, and we’ve put equal investment into the company as a whole, and as long as we continue to feed those three different areas, and maintain lines of communication, I think we’re going to continue to be successful.” “A conscious capitalist is somebody that’s mindful of all stakeholders.” “I view the 35-50 year old female in the community as being probably the single most influential person in your local community.” “When I think of marketing, I always think of market relationships.” “When you start your company based on core values, you have people that are culture champions.” “Your balanced dashboard is most likely going to lead you to better decision-making and getting a better gage for what is actually going on behind-the-scenes in your business.” “Much of healthcare practices from a business standpoint are extremely dated, and you are better off spending time studying businesses in other industries for inspiration.” “Continue being open for inspiration in a wide variety of places. You’d be surprised, if you had an open mind, what you might be able to see in something that, maybe at one point in your life, you completely ignored.”   More about Josh Funk Dr. Josh Funk was born and raised in Montgomery County, MD and attended Poolesville High School. Josh went on to play Division 1 lacrosse and earn a B.S. degree from The Ohio State University before earning his Doctor of Physical Therapy (DPT) degree from the University of Maryland-Baltimore. It was a little over 3 years after graduating from Maryland, that Rehab 2 Perform was founded in late 2014. In addition to his physical therapy expertise, Dr. Funk has been equally, if not more committed to the growth of his role as CEO of Rehab 2 Perform. He has made sure that his personal development is not just reserved for the clinical side of things, but also to ensuring that Rehab 2 Perform is one of the most well-run and well-known health care companies in the area. Dr. Funk has immersed himself in business programs and community initiatives over the past few years in his efforts to ensure that the team and clients of Rehab 2 Perform are receiving everything they need to be at their best. It is his goal to push Rehab 2 Perform to the forefront of the community through innovation, progressive business operations, strategic growth and clinical excellence. A lifelong athlete, Josh became interested in becoming a physical therapist when going through PT as a D1 lacrosse player at Ohio State. After avoiding shoulder surgery for a torn labrum and rotator cuff, Josh has been entrenched in the world of physical therapy and sports performance. Over the years, he has continually developed his knowledge base and expertise as a physical therapist through continuing education courses and working with athletes of all ages. A Montgomery County resident, Josh is heavily involved in all areas of the community throughout the region.   Suggested Keywords Rehab, Physical Therapy, Physiotherapy, Autonomy, Community, Business, Metrics, Performance, Processes, Teams, Decision-Making, Healthy, Wealthy, Smart,   Round Table Talks: Round Table Talks   To learn more, follow Josh at: Website:          https://rehab2perform.com Email:              drfunk@rehab2perform.com Facebook:       Dr Josh Funk                         Rehab 2 Perform Instagram:       @drjoshfunk                         @Rehab2Perform                         @R2Pacademy Twitter:            @drjoshfunk                         @Rehab2Perform LinkedIn:         https://www.linkedin.com/in/joshfunk YouTube:        Rehab 2 Perform Round Table Talk: BizPT    Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:                https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the Transcript Here:  00:02 Hey, Josh, welcome to the podcast. I'm so excited to have you on today. Karen, thanks for having me. I'm just a big fan of everything you have going on and just everything you're doing for people in the profession.   00:13 Ah, thanks. That's nice to hear. And today, well, actually, this whole month, we are talking about the business side of physical therapy. And so I wanted to have you on because from what I can tell, not that I'm knee deep into your business, but from what I can tell on social media and your website is man, you are really growing, you have a budding business, it's an interesting business, it looks like your customer service is top notch. And people genuinely like your business. And they like you. So let's talk about the growth of your business and how you're able to do this in I would say a relatively short amount of time. So I'll just throw it over to you to just talk about your your business, why do you talk about your business first, so the listeners know who you are, what you do where you are, and then we'll get into how you've grown so quickly. Absolutely. So   01:09 for the listeners out there, I am the owner of rehab to perform. It's a fitness focused physical therapy company, offering, obviously physical therapy, sports rehabilitation services, concussion rehab. And then we have a couple different wellness offerings, including a golf program, golf fitness program, and our two p plus, which is kind of a discharge program, that people utilize an app receive home workouts and are able to communicate with their PT after more formalized discharge. But you know, you alluded a little bit to the growth that we've had, over the years been very fortunate past couple of years, including even during a challenging year, last year, just to continue to be able to move forward, I would if I had to break up, the time that the business has been in existence, I would say you have the first three years, and then you have the last kind of three and a half, almost four years, first three years, really just trying to figure things out, put the pieces together, do everything you can honestly to get out of debt have that minimum viable product. And when I was thinking about that minimum viable product, viable product, a lot of it surrounded creating an environment where PT was not a grudge purchase. So how do you create healthcare and physical therapy that is not a grudge purchase, it's something that has very, very minimal friction, people easily interact with it from a from a, you know, front desk customer service standpoint. And then when they actually experienced the clinical side, it is something that speaks to them, it is something that is enjoyable. And that goes for everything from just the processes and the kind of people that you have, as well as the deliverables. So, you know, these past three and a half years, we've been fortunate to, you know, heading honestly into opening our sixth location this fall. And we're very, very close to opening our seventh location. In early q1, we are based out of the DMV, and for anybody's unfamiliar with that, that is DC, Maryland and Virginia.   03:16 Awesome. I mean, it's just, it's pretty amazing. And you you hit on something that I want to talk about really quick before we go into the how you grew. But that's creating a culture that's not a grudge purchase. So let's talk about how you created your business culture, because I think this is something that is often overlooked, especially in in a lot of businesses. But how did you create that culture for your employees and for your patients?   03:52 I think if I start with the employees, I think a big part of what at least has influenced me was being in situations in which I perceived there to be too much rigidity, in terms of the how, and there was not enough autonomy given to people to just execute. Everybody executes things slightly different. And much like I would say, a good clinical framework. But if you have a very, very good cultural framework for your company, people kind of bounce back and forth between the guardrails so to speak, but you don't have this rigid playbook. Were rigid rules that are in place. There's a little bit of flexibility, adaptability, and at the end of the day, it is a shared way of doing things. It's a collective and it is not a top down style of leadership. It is more of this, what I'll call like circular leadership. So people are more familiar with, you know, an organizational chart. That's more formal, obviously, if somebody's at the top and it kind of trickles down and always whether or not it was you know, Anything from a student internship program to a specific program that I mentioned earlier, or somebody who's taking a role just on a project, or somebody who's in charge of a specific location, there is a certain a certain amount of autonomy that they are able to have. And I think that that ownership that is created really allows people to, I think, engage more when I think of somebody who has more autonomy, I think of somebody who's automatically going to be more engaged. And then if I think that I take it to the consumer, the customer, and I always like to call them clients, because at the end of the day, especially in a place like Maryland, you know, they have a choice. Direct Access is something that we have almost, you know, a, I would say, the most liberal version of it. In the United States, we have more than probably 75% to 80%, I can say definitively on a regular basis of people who come to us without having a physician tell them to come to us. So that being said, the only way that that happened was creating an environment that was enjoyable, I wanted to create chairs, a barber shop in your local bar, and deliver PT, so the more that you can make it, something that resonated with them. And for me, I always thought of a gym environment, it was very, very enjoyable, people liked being at the gym, you rarely wanted to, you know, potentially leave as well. So when you walk in, you know, it's it's open, it's friendly, there's quotes, there's gym equipment, there's a certain way of greeting people, people are going to greet you that aren't even necessarily your PT, the manner in which you're communicated to is going to be, you know, there's there's a certain amount of intent and thoughtfulness behind it. What you're going to be provided during that session is going to be something that ideally you leave with, and you go, this is personalized, individualized, and it resonated with me. So I was thought about trying to create an environment where somebody went, Oh, man, I got something small going on, I'm just going to go right into rehab to perform because I love going there, I get to go there, instead of I have to go there and that small change. And we can go down to all of the many pitfalls of your local pops, physician place that's sterile, right? It's boring, you have something that looks cookie cutter, you are doing the same thing, almost every single session, there's a lack of connectivity, right? There's not even music at some of the places in there. Everybody's wearing the same exact thing every single day, right. And we can go down that rabbit hole that people went down recently on Twitter surrounding professionalism. But I think overall just you create an environment that if I take it back to the top, you create an environment that has been shaped by so many people that have been a part of our company, too. I might be the CEO at this point. But I'm just a really good listener, just listen to people. And we make changes based on what the group wants. I'm not sitting here. And just telling everybody that I have all the answers, there was no different than advice that I gave to a young clinician the other day where he was like, Where's the first place I need to start, I was like, the first thing that you need to start with is admitting that you don't have all the answers. And the sooner you get somebody that's a cultural fit that comes in your place. And they show you a new way of doing things, the better off you'll be. But too often I think people get in a situation where they can't let go. And they can't allow other people or they think they found the special sauce. And I sit here today with a team of about 35 people. And I will tell you that I will listen to the new new front desk person that we just hired because she has new perspective and a new way of viewing things. And she can add value. And we never get to a point where ideally we're that we're that fixed project, fixed product. And then it has been that collaboration over the years that led us to both have an environment that people enjoy working in an environment that people enjoy interacting with the professional physical therapy.   09:08 Excellent. And this is gonna sound really familiar to you. But it sounds to me like your operations and processes. So if I say that to Josh, Josh and I both took while I'm still in it, he has taken the Goldman Sachs 10,000 Small Business program, we were talking about operations and processes, which is one of the modules before we came on. And the thing that resonated with me with what you just said is you you give people the process or the sub process, let's say and the details are up to them. So you're giving them autonomy. And to me that leads to innovation, it leads to better care leads to better efficiency, because you're allowing people to make the process there. own while still getting the work done, right?   10:04 Yes. And I would say that that makes me think of the number one question that we ask when something gets done wrong is not a people person, it is a proper process problem first and foremost. And we go to that person and say, hey, how can we make sure that this does not get done wrong? Again, okay, we did not provide you with enough support, we did not provide you enough clarity, we did not provide you enough, whatever. But I am asking that person who may have automatically get on the defensive because they got something wrong, quote, unquote. And instead, they're becoming a part of making sure that process is easier, it takes less steps, there's more clarity, whatever. And then there's ownership. And then they automatically feel like oh, my God, okay, now, instead of me getting yelled at, I'm in an environment where when screw ups happen, we just, we just work on it make it better, like, then they show up to work every day, you never really worried about screwing up. Because what do I tell people all the time, we move fast, we break shit, we fix it, we move on, okay. And at the end of the day, we are we're trying to move relatively quickly. We're trying to be agile, we're trying to make sure that we're doing everything we can to kind of get out in front of, you know, really the, you know, the profession in healthcare as a whole and ideally, continue to show other people that, you know, there's a different way of doing things, a different way of doing things.   11:30 Yeah, I love it. And, and that is something that I didn't really think of before until literally today. Just before we went on the air is all these like operations and processes, which I always thought were so rigid, right. But if you give people the autonomy and innovation, I can only imagine that helps you grow faster and smarter. So let's talk about your growth. How did this happen? I think we can confidently say operations and processes are a big part, what else helped you to grow your practice, because I think there are some listeners out there who might be at the stage, like I'm going to grow my practice, but I have no idea what I'm doing.   12:16 I think, you know, a lot of it starts with just continual self analysis. And I think that I finally got to a point where I recognized that me working in my business was the single biggest blockade to us moving forward. And I think part of that also was me recognizing that I, I have a little bit of a unique skill set. And that's not to say that my skill set is more important. But then from a collective standpoint, my brain works a lot more in branding, sales, and marketing. And I needed to be spending more time in that area. So let's say about three years ago, I finally stepped back. And I put myself in a position where I was spending more time than ever, on the ins and outs of the brand of our company, the brand of the profession within our company, our sales and marketing strategies, and then to be quite honest, doing a better job of making sure that we had more of a predictable rollout when opening up a new office. So at this point, you know, we have, I hate to go back to processes again, but we have a very clearly defined rollout. And it starts about six months out. And every 30 days, you're doing X, Y and Z. And there are you know, at this point it I hate to say it, but you're almost following a playbook. And much like I referenced earlier, it's not necessarily rigid. But we know that at least if we're doing these things here, and at least 90% of that we're going to put ourselves in a good place to be successful. But I think you know, the biggest thing was recognizing that I had what it took. And it was after the Goldman Sachs 10,000 small businesses program to actually operate a business because before that program, I was solely a PT, who had hired myself to deliver good PT, I wasn't necessarily doing everything that I needed to to support the team. And to put us in a position where growth was naturally happening. Now if I get back to why we're growing now, I think we've put equal investment on people, we put equal investment into our local communities, and we put equal investment into the company as a whole. And as long as we continue to feed those three different areas, maintain lines of communication. I think we're going to continue to be successful when we go in and we just opened up a new location last Monday. And I think we're going to just put ourselves in a good spot and that kind of goes to just some found Thanks for me, I know that a lot of people hear the word capitalism. And I think they there's enough stories out there and examples of, of what I would consider more of the poor version of capitalism, that crony capitalism, one that maybe is a little bit more focused on, you know, your, your, your money, right, you're just focused on bottom line. And that's pretty much it. But I think of a cop of capitalism, I always want to think about being a conscious capitalist. And a conscious capitalist is somebody that is mindful of all stakeholders, all stakeholders, being the people on your team, they all matter, the small people, the big people, whatever you want to, you know, do people that people have been with you forever, that people that are new, right, you have to make sure that you're placing value in those people. And then for us, we have five different community hubs, so to speak, that we have initiatives under just to make sure that we're making connections, we're involved or engaged, we have a pulse on the community. And then we're finding ways to meet people where they're at outside of our four walls, ideally, deliver value even without asking for anything in return. So that that conscious capitalism piece, that's one of my favorite books, I think that's always been something that's kind of been near and dear to my heart. And in putting something out there from a business product standpoint that people could look at and say, you know, what, that's a that's a big, it's a business of the future, just in terms of how it's run.   16:18 So let's talk about that foray into the community. Because that is important. So if you are setting up shop in a community, what advice do you have for budding entrepreneurs and therapists who maybe have been in practice for 10 or 15 years, but maybe they sort of stalled? You know, because that can happen? Right? So what are some examples of your community outreach or outreach? Excuse me, or how you insert rehab to perform in the community?   16:52 Yeah, I mean, I think a big part of it centers around our avatars and our avatars being like our ideal consumer, right? Who is your target audience who interacts with your business the most at the location in which you have right now or locations, and you build out the community touchpoints that that person has. So I'll be quite candid, I don't think anybody will be surprised. But I view the 35 to 50 year old female in the community as probably being the single most influential person in your local community, probably you can stretch at 35 to 55. She is in a family where she is literally dictating the decisions for the head of household, the kids, the grandparents, the in laws, etc, there is nobody who is more influential in terms of what people are doing in the family, and where they're going. So if you just appreciate that as a whole, then you start to look at a little bit more of trends. And some of the metrics surrounding where that type of demographic is interacting. And for us, we also build this into our five hubs. So, you know, from a medical standpoint, fitness standpoint, business, youth, sports, and schools, what is that particular target demographic doing? Where are they interacting? Where are they going, and then you start to have a little bit better idea of where you potentially need to develop your connectivity, but initiatives under those five umbrellas after first and foremost, creating that lead avatar is something I recommend to everybody. We do have other avatars, I would say for us, it's a competitive athlete, college athlete, high school athlete, you know, your your clubs, use sport athlete. So, you know, who are the influencers in that community, who are the influencers, providing guidance to that individual is everything from skills coaches, to strengthen conditioning coaches, to the actual sport coach, to the club director to the athletic director, and you start to build out these chains of almost influence that that these people are connected to, and you have a better idea of who you need to have that market relationship with. And when I think of marketing, I was thinking of market relationships, right? It's not necessarily creating a piece of content to put in front of somebody, it's not necessarily you know, sending somebody something and give him a hard sell. Sometimes it's just the Hey, I saw your work I'm connected with so and so they just came into the office, you know, I keep hearing more and more and I'm at least curious at this point. Can we go grab coffee or if we got on a phone call? I'd love to learn more. And the more that you're genuinely curious about people, and you're invested in learning about them, and and actually taking the time to show that you're, you're genuinely interested in in that particular relationship. I think the easier that these relationships come about their authentic people can feel them and it becomes a lot easier for you to get into what the most important is part is who you are, what you do, and, and how you solve people's problems. So once you have those three things communicated, and I should say, once you have that authentic relationship, it's much easier to clearly communicate that those three things you bring to the table once again, name, what it is that you do, and how you solve people's problems. So that's kind of a little bit of the behind the scenes just in terms of, you know, my thought process. When we go to new location, you know, we have our initiatives, you have a pretty good idea of what works, obviously, there's some uniqueness to each area. But we're starting to develop those relationships, probably a relatively early time period. I mentioned before, we have a six month clock that we function off of. And really, you're just trying to find a way to almost solve their problems before they even necessarily need to send somebody into your office.   20:55 Yeah, amazing. I love everything about what you just said. And I really hope it gives people listening who are maybe thinking of starting their own practice or expanding like this is work. Yes, right. It's not like I'm gonna open up a practice, just because I feel like it is like you have to do this is done before you open your doors, you need to know who your avatars are your ideal clients, your ideal customers, whatever you want to call them, and you have to build them out. And there's more than one. And for every single one of those, there is a separate marketing plan. There is a separate communication plan for each and every one of those avatars, you do not use the same marketing plan for Well, the 35 to 50 year old woman who Yes, the women are the users and the decision makers. We all know that they run the show. There's no secret anybody out there says no, you're sorry, sorry, wrong. But you know, you're going to market and communicate with them differently than maybe the local college athlete.   22:06 Yes, right. 100%. They have different needs, different interests, different places that they're frequently interacting in the community. 100%   22:15 I love I love everything you just said. I think that is just a wealth of advice for anyone listening to this podcast, who I can't wait to we do our roundtable next week. Awesome. Or I shouldn't say next week. We're recording this a little earlier. Tomorrow, tomorrow. All right. So now everybody, the jig is up. It's not live. But yeah, no, I love that. All right. And then last thing about growth and movement within a business is really assembling a good team. Yes. So talk to me about how you assemble your team or teams within your business.   22:56 Here's the part that I'll be at least honest about the early part of the business and say some of it was just damn good luck. The first person that I had a part of my team probably could not have been more of a culture fit than if maybe he was a part of my own family. So we went to PT school together. We didn't grow up very far at all. From a high school standpoint. family values were all very, very similar. We had very similar outlooks on the world similar ideas when it comes to came to leadership. And when you asked us in general, what your principles and values were, that governs your life, they were very, very similar. So I was fortunate to actually and I'll probably get a couple chuckles here, I convinced him to quit his job. Right after his wife had delivered their first child, I think that their first child was four at the time. And I gave him three months of paper checks. And I said, hey, there's enough money here for you to quit your job and give it a go. But nonetheless, he helped me kind of shaped the culture of the company. Our next hire was a female was more compliance oriented, somebody that we definitely, definitely needed. And then the fourth person, some people might be familiar with Dr. Jared Boyd. He's now an NBA PT for the Memphis Grizzlies. And his commitment to I'd say, research, and the clinical side of things was kind of what Zack and I needed. And what we needed was contrast. So we overlapped on a lot. And we were able to find contrast in terms of areas in which we didn't have a natural affinity to we're really have that much interest in diving into and then moving forward. We hired people predominantly off of, once again, a collective decision making process. It was, Hey, is everybody comfortable with hiring this person? There was no one person in charge of the hiring process. And a lot of what we did was make sure that there are multiple touch points for that person to interact with our business. So whether it was an early exploratory phone interview, that then would follow into a formal phone interview, obviously, that things like a background check references, etc. And then you would actually have them come into the office and spend some time Hey, Shadow, people spend time with the front desk. And you start to get multiple touch points where every single person at the office had at least interacted with them enough to go Yes, or we've had more than our fair share of knows where somebody's got a wrong vibe, or something was said or something was picked up on. But making sure that you know, hires especially at this stage of the game, where we do have five locations, me hiring for a location, and me being the sole decision maker is silly, I do not work at an office with these, right, these people for 30 to 40 hours, I'm spending a much smaller block of time. So at the end of the day, the people that need to have the most influence are the people that actually are the leaders at that office that are at that office every single day that to be quite honest, probably have more control over what's going on in the culture and in the environment at that particular office than I do. So I once again, I think it goes a little bit more to like your decentralized leadership style. And your you have more of this flattened approach to leadership where a lot of people are involved. But if we talk about just central pieces to team, what are your values? What are your principles, those have to be the early conversational points, that that drive the conversation about whether or not this person is a fit, we have our core values literally on the wall, every single office is transparent, so much even that the clients can see them. You know, so when when you start your company based on core values and principles, everything from I mean, a couple like just basic things, obviously, you know, education, empowerment community, for us to be talking about principles on offense at all times, right? solutions instead of problems. Or we say thumb first, instead of pointing a finger, right? What can you do to potentially change something than then pointing a finger in another direction. So I think when the foundation of the company is just so grounded in in those core principles and values, you have people that are culture champions, and at the end of the day, people understand that, that the sole reason why we've been able to do that we've been what we've been able to do is attracting people for the right reasons. It's not people that necessarily are championing solely their GPA or their clinical knowledge and expertise and kind of beating their chests about how smart they are. It's first and foremost, foremost, like, how does this person align with us on a foundational level, we know that at the end of the day, that person will become the best version of themselves within the company, because they value with the rest of the collective value. So I know when a bunch of different directions there, but I think, yeah, I mean, we've been very just purposeful. And there's been a lot of evolution, I'd say there over the years and knock on wood. And I never like to honestly say this without just just being aware that it's not just me, it's our whole team. But we have only had three pts in almost seven years decide to leave the company, one was for the MBA, one was for home health, because she wanted to spend more time with their kids and another one would took a military job. So we've not had a single person yet that's had a parallel move to somewhere else in the local community. They've either completely moved in are on a base somewhere or in a professional sports organization, or in home health, spending more time, you know, raising their family things that we can't compete with as a company.   28:55 Right, amazing. And, and I really like that your approach to hiring, I guess it's the hiring funnel. You know, we talk about sales funnels and marketing funnels, you have a hiring funnel, where it starts with some exploratory calls to more formal, and then you keep going down. So you may have 100 exploratory calls. But as you funnel down into how many ideal candidates are for the job, maybe it's two. Yep. Right. 100%. So I think it's a nice visual for people to see that.   29:27 I am involved in exploratory. And that's literally about it. At this point, I will get resumes and stuff will catch my eye or somebody will connect with me on social media. And there'll be something that I'm at least like, hey, let's explore this. And I'm often handling an exploratory call on looping in people, most likely the site directors at potential offices that could hire this person. And then they actually start to incorporate the other members of their team for calls as well. So it really becomes a point where this person goes, Oh my gosh, I could be a part of this team. I bet make an impression, or different times or five different times because all of these people are important. And if any one single person says no, then we move in a different direction. And that has happened before.   30:10 Hmm. Amazing. I love it. Okay, so we touched upon your company culture, we touched upon your avatars, your team, how you've been growing? I mean, we can go on and on and on? Or is there any other major point that you wanted to hit about the growth of your company that we didn't touch upon that you're like, Man, this is super important. I really want people to know this. I think a balanced   30:39 dashboard is very, very important. And I think that in a world where people do focus a lot on productivity and utilization, right units, or how many slots you have filled, and I'm not here to say that that's not important, because at the end of the day, you need to have a business that is delivering a service for a certain amount of time, and having an individual which you're providing a salary benefits, etc, PTO, whatever, some some benefit, that certain things are also, you know, reciprocated. So it's not to d value those but to paint a better picture of business health and metrics that would support at least for us, when I think of smart growth, it's like, Alright, how do I know that we're just not adding locations, and the quality is rapidly diminishing? Okay, that stuff over there good. We get people in the doors, okay, yes, in terms of just keeping the lights on, we need to be able to have a certain amount of billable units. And if we hire somebody, they need to have a certain amount of slots allocated. Beyond that, what else is meaningful for us to continually be looking at. So net promoter score and churn rate are two big metrics that I'd say we've looked at more and more, especially over the past two years, for people are unfamiliar with Net Promoter Score, it's considered a gold standard with regards to brand loyalty, and the creating the kind of word of mouth referral generating, I think all of us are looking for. So I say this, once again, just to provide perspective, but we add locations, we have to make sure that the company stays above 90, which is considered world class. And when we don't, or something pops up, or somebody is saved below 90 for a given quarter. You know, there's certain just conversations that are had, in addition to the fact that when we have a seven or eight, or a six or below, there are certain things that are happening internally to make sure that we're being mindful that somebody is either potentially a little bit passive on what we have to offer. And they've communicated that or they potentially might be somebody who's going to drop off. And then when you think about churn rate, just think about somebody interacting with your business and having a negative experience and not even really giving it a chance for you to work with them. To get towards ideal outcomes. At the end of the day, we're trying to drive outcomes. So when you get somebody in, and you've put time and energy behind communicating what it is, who you are, what you do, and how you solve their problems, and they get so turned off after a visit two visits or three visits, that they've gone somewhere else, or they just altogether potentially left the profession. That's not necessarily a positive thing. There is metrics out there to support that, say, if they get to four visits, they are X amount more likely to actually go through a plan of care and be able to see some of those ideal outcomes that I think all business owners would think that their business can, can provide. And then, you know, outside of that, I mean, obviously online reputation, being mindful of Facebook reviews, Google reviews, those are some some big ones for us. And then not to completely discredit your functional outcome measures, right. And then there are certain things in web PT we have afforded where you're able to track pain from IE to DC are able to track satisfaction goals met, in addition to some of your outcomes measures that are a little bit more formal. And yeah, the insurance companies telling you to do them, but doesn't mean you should automatically dismiss them. Right? There's, there's often some tangible and objective data out there that a lot of other people are valuing. So take it with a grain of salt, you're not putting much like your evaluation, right and your return to sport testing, because that's the world we live in where everybody likes to argue about that all the time. You're not putting any more value on any one given thing, the more that you have this aggregation of data, the better off you're able to look at that and maybe potentially come up with certain trends or or certain things that in terms of painting this more broad picture better define your your business health So figure out your balance dashboard, your balance dashboard can be applied to a lot of different things obviously could go behind the scenes with regards to finances and stuff like that, but all other conversation 100% but you know, your your balanced dashboard is most likely going to lead you to better decision making. And giving you a better gauge for what actually is going on behind the scenes in your business. And it really, it's, it's, and I always look at that, and I go, Well, this is telling us whether or not a process actually works. And if I'm not getting what I want to hear, we need to go back to process,   35:14 I was just you took it took the words out of my mouth, I was gonna say having that balanced dashboard allows you to make better shared decision making 100 better, better shared, better shared decisions. Yes, just like just like we would do with a return to sport after an ACL. It's a shared decision making between the therapists, the coach, the parent, the the patient, whoever it is, everybody's got some input. So when you look at a good balanced dashboard, and just for people who aren't familiar when we're talking about what a dashboard is, it's where you have, what metrics you're using to evaluate your business. And those metrics can be your net promoter score, it could be your net profit, it can be patient satisfaction, it can be whatever it is for your business you want to have on that dashboard. And it's different for everyone and should be, right, yes.   36:13 and dare I say after 10k, SD, my dashboard looks a lot more like an Excel spreadsheet at this point. And I know you can relate.   36:20 I can't go into Excel spreadsheets right now. But yeah, so just so people know, like your dashboard is anything that you're using to measure something, a process in your business. So it can be a whole boatload of different things. But just like we do with patients to look at that dashboard, and be able to to look at it with your team employees, whomever, and be able to make informed shared decisions on how you're going to move that business forward. how you're going to make changes in your process, like you said earlier. So perfect. Perfect. All right. Now, last question are actually no, where can people find you? Let's talk about that first.   37:03 For sure. Instagram and Twitter is probably where I interact with the most I try to keep Facebook honestly just a community connection. So if you friend me on Facebook, don't take it the wrong way. I just try to keep the PT side of things off of Facebook. But from a professional connectivity standpoint, at Dr. Josh funk on Twitter, and Instagram, my email is also Dr. Funk at rehab to perform calm. If you really want to get a hold of me, DM me on social media, get my phone number, text me your availability, that's the best way to get things done. Email right now is very chaotic. We just opened up a new location. I'm also getting married in about three weeks. So my life is not necessarily all that organized. And just because there's a lot of moving parts right now. So email, not the best place. But I'm very happy to interact, always happy to make time for a call, especially when I'm driving sometimes I like to just honestly plan out a call for when I'm driving between locations or something like that.   38:00 Excellent. Well, thank you so much for giving people all that info. And last question, knowing where you are now in your life and in your career. What advice would you give to your younger self, let's say a young grad out of PT school,   38:13 I think I would have focused more on expanding my horizons outside of healthcare and physical therapy sooner. I think the more that I started to look at what was going on in other industries, other professions. It made me better at PT and especially made me better at running a business, I can safely say that much of healthcare practices from a business standpoint are extremely dated, and that you are better off spending time studying businesses and other industries for inspiration. It's not to say that there's not some people that are doing amazing work in our profession and healthcare as a as a whole. But I would say the collective is still I almost at this point. I wonder if it's decades behind, just with regards to just how they're operating. So continuing being open for inspiration in a wide variety of from places, you'd be surprised if you just had an open mind. What you might be able to see in something that maybe at one point your life you may be just glanced past or completely ignored.   39:16 Love it. Excellent advice. Josh, thank you so much for coming on. And again for the listeners tomorrow at 730. Yeah, right. No eight. Oh my gosh, where's my head tomorrow? The 27th at 8pm we're going to have our roundtable with Josh, Eric mellow Michelle Callie and shantay Cofield. So if you haven't signed up yet, definitely sign up because we're gonna be talking like this but probably more in depth and we need your questions. This is a this is your chance to ask people like Josh and Shantae and Erica and, Michelle, any question you want to have these four people together on one sort Stage, it's not going to happen anywhere else. So now's your chance, ask those questions. You ask those burning questions to four amazingly successful entrepreneurs in the physical therapy space. So I encourage you all to sign up. You could do that at podcast at healthy, wealthy, smart, calm, click on the tab that says round table talks. So Josh, thanks so much. And again, looking forward to tomorrow. So thanks.

In this episode, CEO of Performance Physical Therapy, Michelle Collie, talks about the business of physical therapy. Today, Michelle talks about the lack of business knowledge of physical therapy graduates, the belief that marketing and sales are bad, and the importance of encouraging entrepreneurship. How do we change the public’s understanding of our roles in health care teams? Hear about the challenges Michelle has faced, how she maintains her company culture, and get some great advice, all on today’s episode of The Healthy, Wealthy & Smart Podcast. Key Takeaways “I do think that it’s our responsibility for the well-being of our profession that we do include some basic business information.” “People don’t know what we do. We don’t do a good job of explaining the value.” “Any way we can support small businesses is going to be helpful for the future of our profession.” “You definitely have to work on yourself a lot, and be very mindful of what you need as a person if you want to be a leader in an organisation.” “How you act at a holiday party or social event, is going to have a big impact on what your organisation is like.” “Get comfortable with the word ‘money’. It’s not a bad word. Just think of money as one of the things that helps us be able to evolve as a profession and serve more people in our communities.” “Be curious about learning more about business.” “Believe in yourself earlier, and address the fears that you have of your lack of knowledge and your inability to do things. Make your mistakes earlier.” More about Michelle Collie [caption id="attachment_9677" align="alignleft" width="150"] headshot of Michelle Collie[/caption] Michelle Collie PT, DPT, MS is the CEO of Performance Physical Therapy, a privately held practice with clinics in Rhode Island and Massachusetts. Celebrating 21 years since it was founded, Performance employs over 230 people, with ongoing growth plans, including 2 new clinics opening this month. Performance PT has celebrated many accolades including being the recipient of the APTA-PPS Jane L. Snyder Practice of the Year, and 7 times, Rhode Island best places to work award. Michelle currently serves as the president of the RI chapter of the APTA and chair of the PPS PR and Marketing Committee. She was a member of the PPS Covid Advisory board and is a two- time recipient of the PPS board service award. Michelle is a board certified orthopedic clinical specialist. Suggested Keywords Well-being, Knowledge, Business, Physiotherapy, Culture, Marketing, Sales, Money, Entrepreneurship, Leadership, Healthy, Wealthy, Smart, APTA, PPS, Therapy, Recommended Resources August 20th Graham Sessions: https://ppsapta.org/events/graham-sessions Marketing Resources: https://ppsapta.org/practice-management/marketing-resources.cfm To learn more, follow Michelle at: Website:          https://performanceptri.com Facebook:       Performance Physical Therapy Instagram:       @performanceptri Twitter:            @performanceptri LinkedIn:         Performance Physical Therapy RI YouTube:        Performance Physical Therapy BizPT Round Table Talk Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:               https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the Full Transcript Here:  Speaker 1 (00:03): Hey, Michelle. Welcome back to the podcast. I am so happy to have you here for this month, where we are talking all about the business of physical therapy. So welcome. Speaker 2 (00:13): Thank you, Karen. It's great to be here. Speaker 1 (00:15): And I mean, you and I have talked business in the past, like I said, in your intro, you have several offices within your business and you've really grown your business into a really great place to work. And I think that that's so important. It seems like your employees are happy. You're happy, and that is not an easy thing to do these days. So kudos to you for that. And that's one of the reasons why I wanted you to come and be part of this discussion this month, because you are a physical therapist with multiple locations. You're not just a solo preneur, right? So how many people before you go on, how many people do you employ, just so that people can get an idea of, you know, the, the breadth and width of your practice. Speaker 2 (01:04): We currently have approximately 230 employees. Now we've got openings case. Anyone's looking for a job, but as I know, everyone else is looking for employees as well. This is a common problem throughout the nation at the moment, but yes, 230, but still growing. Speaker 1 (01:21): Yeah. Which is amazing. I mean, that's, so I always think about that as they're in, like you're helping 230 people grow their wealth, improve their families, keep their lives going. I mean, it's a big deal. It's a lot of responsibility. Speaker 2 (01:37): It's a great point. And I kind of guess I love that opportunity to do that because people often say to me, oh, do you miss treating patients? And I am like, well, I do. But now I feel like I get to somehow have a larger impact on a whole lot more people. And I, yes, I love to treat patients. I love the care that we provide as physical therapists, but I do love knowing that I'm helping to provide a place for an employment for lots of people to work. And I especially felt that through COVID and the way that we were actually able to keep all of our stuff on, we did have to furlough for some of our administrative staff, but then ultimately we're able to bring everyone back. And and that was something that helped me get through the pandemic actually, knowing that I was able to have a positive impact on the fiscal sanity of all, for lack of a better term for many of the people in our community. Speaker 1 (02:32): Yeah. Which is amazing. And now, you know, this month we're talking all about business, you have a growing thriving business. So how much of the business of this business knowledge did you get when you graduated as a physical therapist? How much did you learn in PT school? Well, Speaker 2 (02:48): Probably about the same amount that every PT that's graduating these days you know, and to be fully transparent and clear, I took over performance. I actually purchased from the original founder. I was a clinic director there. It was a smaller practice with 16 employees and I was very pregnant, eight months pregnant. So I thought I was invincible. And through a seller finance note and an SBA loan, I somehow ended up with this practice and a lot of debt. And the first day that I officially owned it, which was I think three weeks before I had my first son, I walked into the office manager and said to them, don't tell anyone this, but people keep talking about financial statements, but I don't really know what they're talking about. So I prided myself on being a good PC and really loved that the value of physical therapy and what it provided to our community and patients. But when it came to actual business knowledge, especially those off to do with the financial management of an organization, and even thinking about things such as marketing and human resources, I would say I was completely ignorant and didn't have one scrap of knowledge. Speaker 1 (04:04): Right. And so this is obviously a huge deal challenge for our profession, right. So what can we do should, should these topics be included in school? Speaker 2 (04:16): I mean, I, of course I'm a proponent of it for a number of reasons. And I do, and I really respect those folks had in academia and I bought them, challenged them. You know, why don't you include some more business information and the curriculum. And the response is usually I revolve around time. We don't have enough time. And the other one is, is that always students don't want to learn that they want to learn physical therapy things. However, I do think that it's Sarah, truly a responsibility for the wellbeing of our profession, that we do include some basic business information. And that's not just because some people will want to go and start a business or be part of the business. So yeah, it will help those folks. But I do think for, let's say the staff PT, if a staff PT has a little bit more understanding of, let's say what marketing is, then they suddenly are better at advocating and speaking to their patients about the value of what we do. Speaker 2 (05:17): If someone is able to understand some of the communication skills that align with marketing and even sales, then we will suddenly see word of mouth referrals go up. When someone understands financial management a little bit more, they have a better understanding of how to code, how to negotiate your salary, the meaning of different kinds of salaries and what they mean in the longterm. So I think having some basic business information seats up every individual, no matter what setting they're working in to be a better manager and better, better more knowledgeable for the career and the longterm. We hear so often PTs talking about burnout. We hear them talking about lack of reimbursement and not getting paid enough and obviously student loans. But I think with empowering our graduate San UPTs with some bitter understanding of business and how it works, it actually gives them some foundational knowledge. So they actually can do something and make a difference rather than just this overall overwhelming complaints we hear, oh, we're not paid enough. Reimbursement keeps going down. Student loans are too high. We have at least problems with their proficient, but we need to empower our next generation to have some business knowledge. So they can ultimately help do something about this crisis that we're headed into. Speaker 1 (06:44): Yeah. And, and I think even being able to make a financial statement for yourself, it doesn't have to be a business. You don't have to own a business, but you should know, well, how much money are you bringing in? What are your costs after that money comes in? What are your debts and your liabilities? And you can look at that and, and make a budget. It may help you be able to better budget yourself to be able to pay off those student loans or, you know, do the things that you want to do. I mean, I find, I found that learning all of that has just been so eyeopening for me. Speaker 2 (07:19): Yeah. I couldn't agree more. And especially these days, we, you see different compensation packages coming out, different kinds of variable salaries. Oh, you know, if you work per diem versus full time, or maybe I do wanna, you know, have a side hustle, but understanding the long-term financial implications of those decisions can be really important and again, and how you to make the decisions that are best for your career. So you can actually work in the seating and provide the kind of care that you truly want to, and being out of balance out the money side of it and in the clinical side of it. Yeah. Speaker 1 (07:55): I couldn't agree more, I think, and I, you know, I do hope that at the very least when it comes to teaching business courses, I mean, at least help therapists understand the financial aspects of a business, whether that be a hospital, a skilled nursing facility, an inpatient facility and outpatient facility. I just think understanding that will give them a better idea. Like you said, of salaries negotiations, how much are you getting paid? Whether it be per code per patient, like you said before, you started a little, a little tweak and what you code and how much you code can compound exponentially. Speaker 2 (08:35): Exactly, exactly. Very small changes in your coding changes of business. But I also think speaking to that, having a knowledge of the kinds of employers that are out there, and that's a side of businesses as well, understanding the difference between for profit nonprofit, understanding the difference about PE and corporate owned and public on versus privately owned. There is not one that is better than the other at all. There a great PTs who are in corporate practices. There's also crappy PTs and corporate practices, same thing for private practice. It's all over the place. However, if individual PTs have a basic understanding of the, those different businesses and how they're set up, it gives them a more well-rounded approach to being part of that team, no matter who they decide to work for, or at least they want to go out in the business on their own. Speaker 1 (09:30): And, and I don't know if you have the answer to this, but do you have, can you think of off the top of your head, any resources that may be practicing PTs or new graduates can utilize to help them understand? Let's say to be more financially fluent in the physical therapy world. So let's say you didn't get it in school, which odds are you probably didn't. Where do you have any resources that people can learn more? Well, Speaker 2 (09:57): The one that's out there, which we don't actually do, I don't think a good enough job of messaging and marketing and here's, I can do that right now, but obviously the private practice section or, you know, and maybe it should be called the business section because it does have all the resources there for, for business. And again, that doesn't matter if you're a pediatric or orthopedic or in a hospital or in home care, the business of PT is everywhere. And I think the private practice section has tremendous amounts of resources for that they have, for instance, a whole series called finance 1 0 1, which is multiple videos, just on finance marketing 1 0 1. So educational opportunities, webinars, all of those, there's a huge amount of resources through the private practice section, their annual conference, and many, many people who work in all kinds of different settings come to get a through that chapter of the AP TA. So I would say for anyone with any business interests, it is a very non-threatening welcoming chapter for peoples that people at all different times in their career and all different kinds of practices to come to. Speaker 1 (11:09): Yeah. Excellent. All right. Thank you for that. So now you've said it a couple of times marketing and sales, and I know you're on the marketing committee, so we are going to dive into that. So what about the belief that marketing and sales is bad? Like it's icky. It's like people should know what we do. Why do we have to go out and market ourselves and be like, quote unquote used salesman, used car salesman, not use salesman. Speaker 2 (11:38): So incredible. I tried to flip it and say that to me, marketing and sales, we should call it advocacy because what it is is actually advocating for who we are and what we do. I was speaking to a student the other day, actually. And I love speaking to students because it's really interesting to hear when and how they learn their sort of opinions and biases. And this student was telling me about their clinical affiliation and that he couldn't understand why all doctors weren't telling their patients about direct access and we have direct access, but doctors don't tell their patients. And I see this, I say to the student, I see, did you, did you, does your mother know what [inaudible] is? And he goes, no, I had to explain it. And I see it. So let's first of all, stop using this word direct access because no one understands what it is we like to use it. Speaker 2 (12:36): But first of all, we have to be able to communicate and let people know. And then I said, do you think that the average doctor healthcare professional knows that you could see us without a referral? I don't know that because we never tell them how are they supposed to know that? So I think what it is is when we're marketing is really about advocating or educating people don't know who we are and what we do Magento here's my random guests is that 40% of PTs. And I just made that number up. But I asked a lot of people, 40% of PTs got into the field of PT because they were injured as teenagers. And they learned about the field and I was one of them. And I, I would love to know what percentage of PTs out there had ACL tears, because there is every second PTI made is like, yeah, I told my ACL when I was like 15 and I fell in love with my PTs. Speaker 2 (13:28): And I realized what a difference it made to my life. And then I decided I want to be a PT. Like, why do we have to be, you know, we experienced it. That's how we found out about it. But yet we don't want to tell other people about it. We think it's icky for some reason. So I just always try and push people. People don't know what we do. We don't do a good job of explaining the value. People have biases and think, oh, you just helped someone after they've had a stroke to walk things like that. But I think it's time that we don't just say, yes, we take care of all different kinds of people. Get them back to their life and doing what they want to love. We actually have to take it a step further and say, no, no, we're actually a major solution. When it comes to the issues with MSK, MSK ailments are a huge problem in our society. And we have the ability to keep people moving so we can decrease those downstream costs, such as knee replacements, hip replacements, chronic illnesses, your diabetes, your obesity, your hypertension. So the value in Walt we can do and create is way, way more than even what we message on a day-to-day basis at this stage. And we have to do a bit, your job of it. Speaker 1 (14:40): How do we do a better job? That's the question, the million dollar question, great. Speaker 2 (14:46): How do we do a better job? You know, I've worked at PPS and we've tried to pull PR committees and PR companies to help us with it. But I think at the end of the day, what we've found most useful is is doing grassroots advocacy work, ensuring that every student comes out and understands how to describe and how to talk about and the meaning of it. Yeah. Yeah. Speaker 1 (15:14): And, and I, like, I always tell people, if you want people to know what you do, what we do as physical therapists and you have to put yourself out there to do it. So it's not just talking to each other within the profession. We know what we do. You know, I always encourage people like you know, pitch yourself to your local newspaper, get a column, right. Like I said, this too, like in my PPS talk that was online last year. I went step-by-step and taught people how to do that. And then a couple of weeks later, I got an email from a woman who watched it and she said, I, I, I was able to get a column with my local newspaper Speaker 2 (15:59): Colson. Exactly. You put yourself out there and don't think I just have to be a PT in the clinics. I like you do a podcast. Mine's very different. My podcasts I do with different healthcare providers in our community, including PTs. And we discuss things such as how to stop running or picking your right running shoes, or what do you do if you've got back pain or how did you manage through COVID, but putting out information so that people in the community see, you see you as experts in movement and health and wellbeing and not just the clinician that your primary care doc seems to you once they don't know what to do with you because of your ongoing back pain. We're a whole lot more. Speaker 1 (16:44): Yeah. Yeah. And I think physical therapists in general, this is just my opinion, but they really need to get off the sidelines and start taking control because a lot of this, like, is it up to the AP TA to do all of this? No. You know, as an individual physical therapist, you have to put yourself out there as well. Speaker 2 (17:03): You really do. And I, I do get a little frustrated when I see people on social media bashing the, a PTA about all the things that a PTA should be doing. I think what we've seen in the year, we've seen changes in our profession such as, Hey, we're all now doctors, a PT thinking that this label would suddenly change how the public and how healthcare providers perceived us a new title, a new label, or a fancy ed doesn't change who we are. It's how we behave. So we have to behave like professionals. We have to stop being on the sidelines and actually get in and play the game. When it comes to health care, sit at the right board tables, be confident and comfortable calling out local docs, countable care organizations, insurers, and letting them know the role and the value that we provide. Speaker 1 (17:57): Yeah. Perfect. Couldn't have said it better. Excellent. Now, you know, this whole month is all about small business or not small business, but about businesses, entrepreneurship. And, you know, in speaking, before we went on the air, we were saying how important small businesses and entrepreneurship is to I think bringing back this country after hopefully as COVID starts to recede. So can you talk a little bit more about that? Speaker 2 (18:27): Yeah. I mean, you see it in every industry, that's entrepreneurship, these are where the new ideas, the crazy ideas and small businesses have the opportunity, the luxury to be savvy and make quick changes in what they do. COVID sore that, I mean, who were the first folks to suddenly provide telehealth services? It wasn't the big corporate or hospital run facilities. It was the savvy small businesses who were able to flip their operations overnight and suddenly implement telehealth. And of course that led the way for everyone else being able to follow. So I think COVID helped to prove it and show that that is the way that the world works. Entrepreneurship, small businesses seems to drive innovation. I think now in the world of physical therapy, we are seeing major challenges with reimbursement and payment. I personally, and a big fan of my moving towards value-based payment. Speaker 2 (19:24): I really despise the whole, you know, the more you do, the more you get paid, I would much rather the, we are paid to keep or get our patients healthy and have good outcomes and just find the journey to get there. But I think it's small businesses that had the opportunity to, to take on risk and try different ways, whether it's with employers or whether it's with healthcare insurance, healthcare insurance companies like go to these different organizations and pitch, then pitch different ideas. Now you're going to get turned down probably 90% of the time. That's okay. But then you're going to find little pilots and you're going to find opportunities. And even when I look around the country, now I hear from colleagues and peers who are like, oh, I'm in this kind of financial model where we're doing health screenings and we're just taking care of the lives. And someone else says, oh, we've got a subscription paced program to keep people moving. So there's different pilots going on. And it's small business that has the ability to be innovative and do those that then we can ultimately model after. So I think any way we can small support small businesses is going to be helpful for the future of their proficiency. Speaker 1 (20:39): Yeah. And I love that. You said they could be more innovative and nimble and, and that's true. That's true. Most entrepreneurs because they don't have to go through a million different boards and get approval from XYZ. They could say, well, this is what I'm seeing in the market. This is what our clients want. So let's try it. Speaker 2 (20:59): Exactly, exactly. And you can do it at a clinic level. You can do it at company level. You can do it with, oh, let's try this program at this clinic and see if it works. And yeah, you can be very savvy and very timing and get these things done quickly. It's small business might not have all the resources and may not have whether that's financial or brains like people power, but usually entrepreneurs are pretty savvy about finding solutions to some of those challenges and problems. And that's where the likes of PPS and a PTA can be really helpful because it's pretty easy to find other people with that business or entrepreneurial ship desires that can come together and help each other. Yeah, Speaker 1 (21:41): I agree. And now, you know, as we're talking about business and you have a thriving business at this point, but what were the challenges of your business and a view as an entrepreneur now, I think you mentioned one of them earlier being, having no idea what financial statements were, I'd say that's a challenge. But for people listening for who might be maybe wanting to dip their feet into the entrepreneurial pond, so to speak, what are some challenges that came up for you and what did you do to overcome them? Speaker 2 (22:21): As you said, that I started writing out a list of challenges because I've made a lot of mistakes. I've had many challenges. I heard an interesting quote. I read an interesting quote today, actually. If I could have my time again, what would I make? All the mistakes, same mistakes. Yeah, I would, I would've just done them a lot sooner. So I could've got the mistakes out of the way earlier, but I think some of the challenges, a lot of the challenges were with delegation and leading things go, it's very hard to step away from patient care when that's something that you're very comfortable with and you think you're good at so managing time and I hear that coming up a lot with business owners, how much, you know, should I treat patients or not, not, there's no right answer there. You know, it depends what makes you happy. Speaker 2 (23:06): And it depends what you enjoy doing. So delegation was a big pot. Someone else told me the other day, I liked this quote as well. You know, you're delegating enough. If you want to have a growing business that if three times a day, you cringe now you cringe because you had given something, a project or a task or something to do at work to someone else so that they have the opportunity to grow and evolve. But you cringe because you look at them doing it and thinking, oh, I could do it a little bit faster. I could do it a little bit better, or I might do it a different way, but that's okay. And you have to get to that stage of going like, you know, you could call it 80 20 rule, but that rule of going like it's, it's actually a gift to be out on power and allow other people to grow and evolve. Speaker 2 (23:53): So learning how to manage that can be had the culture things interesting. When you've got a very small practice, the culture just happens automatically and you have this amazing culture as a practice grows and evolves. You have to become much more disciplined and diligent about how to actually execute on maintaining and having a great culture. So something you have to be aware of putting the systems in place as you grow and evolve, the more systems you have in the place in place, the smoother things can run. And it creates actually a structure, a structure that actually allows innovation and allows people to be creative, but they've got the walls and the guidelines of how to do that in a safe way. So I don't know, those are the key things that came to mind for me. You know, it really comes back to managing your time, how you delegate, how you let go of things. Speaker 2 (24:47): You got to keep becoming more and more humble that every year I realized how much I don't know. And it just seems to be almost, it's like my list of things I don't know, actually is increasing. So I'm not sure if I'm just getting older and losing my memory, or if I'm just becoming more aware of how clueless I am, but I guess I'm comfortable owning that at the stage. So I think, and being comfortable with who you are and your own skin, you definitely have to work on yourself a lot, take care of yourself a lot and and be very mindful of what you need as a person, if you want to be a leader in an organization. Speaker 1 (25:20): And what is your advice to maintain culture as your company grows? Because that's like you said, I'm really glad you brought that up because people join your company because of the culture. And if you grow and you let it go, or something happens, then people are going to leave. So how did, how did you do that? How did, what is your company culture and how did you maintain it? Speaker 2 (25:44): I liked the question. What is your company culture? Because I mean, I think of our culture is a very much like work hard, play hard, definitely a lot of fundraising up a lot of philanthropy, a lot of giving back to the community. Now, maybe what would happen 15 years ago, it would have been like, Hey, let's all dress down this month for this great organization and get together and do a 5k for them. And they will go out to her via what's. The net would stay the same for a great culture and getting to know people as individuals now, as with a larger organization, we have to be much more diligent about or more mindful about hearing from all of our people who should we dress down for and choose carefully based on the feedback and then communicated appropriately, have some PR involved the social media, making sure everything's much more streamlined. Speaker 2 (26:38): So all of the good happens, but it just takes a lot more work. It just doesn't happen quite so easily. So you just have to put the work into it determining what kind of feel you want it, social events, what kind of behavior expect again, you know, speaking your late leadership, how you act at a holiday party or at a social event is going to have a big impact on what your organization is like. And if you want to dress up like a pirate and dance around, which is what I do then yeah. You're going to create a different kind of culture to someone who's going to come across in a different way. So you just gotta be really mindful that as you grow, people are watching you and how you behave and that's going to drive it a lot of the culture. Speaker 1 (27:20): Yeah. I think that's thanks for elaborating on that because I feel like that's a piece of the entrepreneurial pie that often doesn't get addressed. Speaker 2 (27:30): I agree. I think especially if you have a smaller company as that grows, you think you can, it's easy to forget about culture because it almost seems fun and that is fun. And it almost seems like, is it silly that we're talking about what events or what we're going to do to build culture, what team building things, but it's really, really important because your people are everything. And if we're, I always just say to my stuff, sometimes people say to me, what do you actually do? And I'm like, really my job is to keep you all happy. That's really all it comes down to because when you're happy, you'll give good care. If you're miserable, the care you give sucks. If you're happy, you give good care. And if you happy you'll stay. So my job is to keep everyone here simply saying Speaker 1 (28:16): You're the C H O chief happiness officer officer. Exactly. Pretty much. Yeah. Well, that's a great title. Actually. You should put that on your cards. Bring that up to PPS. Ask how, asked how many businesses in PPS have a chief happiness officer. Yeah. And see, see what we can see what shakes out on that one. But yeah, I, thanks for elaborating on that. I just really wanted the listeners to understand that your business is more than dollars and cents Speaker 2 (28:48): Completely, completely. And if it was just business dollars and saints, it would be kind of boring. I do think it's wonderful. Seeing the PTs, who own practices, they do it with no matter what the size you do. It, we all love people and making people happy and better. And whether you're their employer or their physical therapist, it's not that much different. Speaker 1 (29:09): Right. Absolutely. And now before we wrap things up, what are the key takeaways you want the listeners to come away with with R D from our discussion today? Speaker 2 (29:19): I would say that get comfortable with the word money. I know I'm going to go straight to business. It's not a bad word. It's not a bad word. And as PTs, we don't like talking about it. Oh, I don't want to talk about my salary or I don't want to do this, or I think I should get paid more, but I don't really want to understand it. Like, it's just, just think of money is just one of the things that helps us actually actually be able to evolve as a profession and serve more people in our communities. I don't know if that came across very professionally or not, but I do think people should be comfortable with it. Be proud of what you do. And when someone at the local bub you're a barbecue, or when you're grilling with friends, complaints to you about your back, their back pain, help them and tell them what you do and make sure they get the care they need. And don't sit back and, and let them have to try to figure it out on their own. And and just be curious about learning more about business. It's not scary and it will help. The more you understand, you'll have more control over the decisions you make. And I actually think you become a better clinician because you're more mindful of the value of the services that you're providing. Speaker 1 (30:32): Excellent. And where can people find you if they want to get in touch? Do they have questions? They want to learn more about your business? Speaker 2 (30:39): Pretty easy to find live up in little road, mighty Rhode Island. We like to call it. So email's the easiest way. You've I, and through my practice, performance PT, R i.com. You'll find me on Facebook and on Twitter as well. I'm not as savvy on social media, some of you, but I love getting emails from people and helping other PT students, practice owners, different kinds of business owners out there. Speaker 1 (31:06): Great. And we'll have the link to your website at our website at podcast at healthy, wealthy, smart.com in the show notes for this show. So people can one click and get straight to your website to see what your business is all about. And if they have any questions, like Michelle said, highly encourage you reaching out to her and emailing her to ask questions. That's what we are here for. And Michelle before. Last question is knowing where you are now in your life and career. What advice would you give yourself as a new grad? Speaker 2 (31:39): Well, that's a good question. What advice would I give myself as a new grad who as a new grad, I would just as a new grad, I would say, believe in yourself earlier and address the fears that you have of your lack of knowledge and your inability to do things. So, yeah. Maybe make your mistakes earlier. Michelle is what I want to say. Speaker 1 (32:06): Excellent advice. Well, thank you so much for coming on for our month of business. And of course, we'll see you in a couple of weeks at our business round table, which will be on the 27th of July. Think at 8:00 PM Eastern standard time where it will be you and Eric and mellow and Josh funk and Shantay Cofield AKA the movement. Maestro people probably know her better with her Twitter, with her Instagram handle than her actual name. But I'm really looking forward to that. I think we'll a really robust conversation because we've got just like PPS, we've got those four different personas, totally nailed down. We've got your solo preneur, we've got your more traditional PT practice, which is Michelle's. We've got a newer grad with an, a growing practice in Josh and we've got a non traditional PT. So working as a physical therapist, but not with patients in Shantay. So and that was total coincidence. I didn't even know that when I plan this out. Perfect. So I'm really looking forward to it. Speaker 2 (33:15): So, and I just think it's really cool when you get these different kinds of business owners who are PTs and all different kinds of businesses. It's awesome. Yeah. Speaker 1 (33:24): Yeah. We'll have a nice, a nice step meeting of the minds. So everybody definitely sign up for that. And the link for that is also in the show notes for our round table. So Michelle, thank you so much for coming on and I hope to see you hope to see you soon. I hope to see you too. Speaker 2 (33:41): Karen. Thank you so much. Of Speaker 1 (33:43): Course. And everyone, thanks for listening. Have a great couple of days and stay healthy, wealthy and smart.  

In this episode, Co-Founder and CCO of WebPT, Heidi Jannenga, talks about the trends that were revealed in the State of Rehab Therapy Report done by WebPT. Today, Heidi gives an overview of the Rehab Therapy Report, and she talks about how technology has benefitted the industry, business continuity and growth, and the reality of burnout. How has the pandemic impacted business revenue, budget, and employment. Hear about the lack of diversity in the industry, the disparities in advocacy and associations, and the tech adoption boom of 2020, all on today’s episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways Survey results show that 77.4% of rehab professionals identify as white, 6% as Asian, 5.5% as Hispanic/Latino, 2.8% as Black/African American, and smaller percentages as American Indian, Alaskan Native, Native Hawaiian, and other Pacific Islander. “There are huge gaps in terms of not reflecting who our patients really are in every area of the nation.” “40% of the [women] respondents said that they now hold C-Level executive positions. That’s a 10% improvement.” “Almost every clinic leader I talk to today are at pre-Covid numbers, and most of them are above pre-Covid numbers.” 50% of therapists, and 42% of therapy assistants reported feeling more burntout now than they did prior to the pandemic. “60% of rehab professionals said that they didn’t participate in any of the numerous advocacy efforts from last year.” “Even if you disagree with some of the decisions or directions of APTA, that’s all the more reason to be involved.” “It takes a lot of vulnerability and confidence to say ‘I don’t know.’” “As a leader, you shouldn’t have all the answers. You become a crutch to those that work with you if you’re the only one who has all the answers.”   More about Heidi Jannenga Dr. Heidi Jannenga is a physical therapist and the co-founder and Chief Clinical Officer of WebPT, an eight-time Inc. 5000 honoree, and the leading software solution for physical, occupational, and speech therapists. As a member of the board and senior management team, Heidi advises on WebPT’s product vision, company culture, branding efforts and internal operations, while advocating for rehab therapists, women leaders, and entrepreneurs on a national and international scale. Heidi has guided WebPT through several milestones, including three funding rounds: an angel round with Canal Partners, a venture capital round with Battery Ventures, and a private equity round with Warburg Pincus; five acquisitions; and numerous national corporate and industry awards. In 2017, Heidi was honored by Health Data Management as one of the most powerful women in IT, and she was a finalist for EY’s Entrepreneur of the Year. In 2018, she was named the Ed Denison Business Leader of the Year at the Arizona Technology Council’s Governor’s Celebration of Innovation. She also is a proud member of the YPO Scottsdale Chapter and Charter 100 as well as an investor with Golden Seeds, which focuses on women-founded or led organizations. Her latest venture is called Rizing Tide, which is a foundation dedicated to fostering diversity and inclusiveness in the physical therapy workforce. Heidi is a mother to her 9-year-old daughter Ava, and she enjoys traveling, hiking, mountain biking, and practicing yoga in her spare time.   Suggested Keywords Covid, Survey, APTA, Rehab Therapy, Report, Data, WebPT, Diversity, Physiotherapy, Advocacy, Technology, Burnout, Business, Healthy, Wealthy, Smart,   Recommended Resources The State of Rehab Therapy 2021: https://www.webpt.com/downloads/state-of-rehab-therapy-2021 The State of Rehab Therapy Webinar: https://www.webpt.com/webinars/the-state-of-rehab-therapy-in-2021   To learn more, follow Heidi at: Website:          https://www.webpt.com Instagram:       @heidi_jannenga Twitter:            @HeidiJannenga LinkedIn:         Heidi Jannenga   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:               https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the Full Transcript Here:  Speaker 1 (00:03): Hey, Heidi, welcome to the show podcast. I'm so excited to have you on today. Speaker 2 (00:08): Thanks Karen. So excited myself to be here. So thanks for the invite. I really appreciate it. Of course. Speaker 1 (00:14): And today we're going to talk all about the key trends that were revealed in the state of rehab therapy report powered by web PT. But before we get to those trends, can you tell the listeners how all of this information was compiled? Speaker 2 (00:32): Sure. So we actually started conducting this industry-wide survey of the rehab therapy industry and what we consider rehab therapy is PT, OT, and speech back in 2017 that was the first time we released the state of rehab therapy report. And essentially we were trying, we had a lot of questions about the industry that we just honestly couldn't find the answers. And so we decided, well, we're just going to put out a survey to ask the questions we want answered topics ranged from business financials, operational structure, patient volumes, job satisfaction, technology trends, demographics, like we just really wanted to dive into sort of slice and dice the industry a little bit more as far as data goes. And we took a little bit of a pause in 2020, obviously due to COVID. But we did actually launch the survey at the end of the year. And so that's what we're talking about now. As far as the results go and we collected, I think over 6,700 responses, the majority of, of whom treat patients directly. So either as therapist or assistance, and 60% of them were from outpatient private practice. So the other 40% were from other therapists who work in other areas of the industry. So we feel like the findings really you know, give a good sort of breakdown of what's going on in the profession as a whole. Speaker 1 (02:10): Let's just dive in, then let's talk about some of those trends. So I will just kind of throw it over to you and we'll go through the major trends that you found. So let's, let's start. Speaker 2 (02:22): Yeah, let's just kick it off with something that's top of mind. I know for a lot of businesses and not just in the PT world, based on some of the occurrences within 2020, and that's really focusing on diversity. I think we've talked about it a lot that we, we all sort of know that there's this issue of lack of diversity within our profession as a whole. We're pretty much racially, very homogeneous. Our survey results showed that 77.4% of rehab professionals identify as white. Our results showed 6% identify as Asian five and a half to identify as Hispanic or Latino 2.8% identify as black or African-American. And then smaller percentages of the American Indian or Alaska native and native Hawaiian and other Pacific Islander. And so if you sort of then contrast that right with the overall society of, of the U S I mean, there's just huge gaps in terms of not reflecting who our patients really are and in every area of the nation. Speaker 2 (03:42): So, you know, we, we asked a little bit of why some of the factors that are leading to that, and, and I, I think that, you know, we can sort of hypothesize a lot on, you know, the flood student recruitment. Like we're just not getting them in. We're not, for whatever reason. They don't know how cool it is to be a physical therapist. They're not attracted to it. So the recruitment is kind of broken. And so from there you just have a limited hiring pool. And so of course, you know, I think what a lot of people are sort of now attacking also is just, do we have some unconscious bias, like, do we need more training of our, our teams and recruiting processes within our own organizations to sort of eliminate and hopefully put a little more attention on trying to, to become more diverse in our employee base. Speaker 1 (04:33): Yeah. And you know, like you said, that this is not unexpected to continue to show this lack of diversity and, and yeah. Where, where does this start? Does this start with recruiting teenagers out of high school, into undergrad and then recruiting from undergrad into grad school? Is it exposing more you know, people of color just to the profession in general? You know, there are some people doing great job with that, like Jasmine tools in Southern New Jersey. I don't know if you know Jasmine, but she created a girl scout badge, a physical therapy girl scout badge. And she works mainly with girl scout troops in inner cities in Philadelphia. So you've got all these young girls who now know what physical therapy is because they're getting their physical therapy badge. Speaker 2 (05:25): That's awesome. I love that. Yeah. And we need more of that obviously happening at an earlier age to just, I mean, we've talked a lot about it. I knew you've talked about it on this podcast about sort of the brand problem of actually attracting patients in, but that also is reflected in attracting amazing people of all, you know races, color, everything like, you know, into our profession as a whole. Now I will say Karen, that we did see something positive you know, we, you and I have talked a lot about sort of the misrepresentation of women in leadership within our profession. And we did see a pretty good uptick. We we've also always talked about it in terms of you know, 70% of therapists are women and yet only 30% of them hold any kind of leadership position whether it's clinic, director or above manager. But we did see that number go up from where it was. And so 40% of the respondents said that they now hold a C level executive positions, which I thought was mean that's a 10% improvement. So huge. That was awesome to see. Speaker 1 (06:45): Yeah. I love hearing that. That's a huge, that's a huge jump. 10%. Excellent. Well, that's a, that's definitely a positive. Okay. So let's go to another trend that came out of this report and it has to do with technology. So can you expand on that? Speaker 2 (07:04): Yeah. So I'm sure that a lot of your listeners can relate. Telehealth was an explosion that had to happen during COVID. We were all stuck at home and people were in the midst of rehab, some hurt themselves doing, you know, working out at home using their, their Peloton or whatever it was, and they still needed therapy. It wasn't like people stopped needing PT, right. Or rehab therapy. And so tele-health exploded. So the use of, of platform tele-health technology platforms spiked significantly over the last year, although we saw about 75% of clinics that actually implemented tele-health during this time, we've now seen that number completely plummet down to two pretty low numbers. So people are going back to status quo. Now that most cities and states are, have opened back up. So it's going to be interesting to see how this trend continues. Speaker 2 (08:14): I do a whole tangent, we could do a whole nother podcast, I'm sure on how do you, how can we put, how can tell a health be you lies a, from a patient experience perspective, but also from a reimbursement payment perspective, like how do we make sure that is there, is there a hybrid potential in the future to, in, in my assessment, reach more people like we, you know, we always talk about the 90% problem, right? If 90% of patients who have a diagnosis that could be beneficial in rehab therapy, aren't getting to us. So how do we expand that opportunity? Tele-Health has it, has it, has the potential to be a of that? Yeah. I experienced Speaker 1 (08:57): That over. COVID that exact thing now I still am. I am still using tele-health because I'm in New York city as a lot of people know, and there are still people who are like, not, not just not comfortable, you know? Right. So I'm still using it. But what I found was that, so I have a cash based practice. And so some people were like, Ooh, it's a little pricey. Do you have a way around this? And I said, well, why don't we do one session in person? And then we can move to tele-health and maybe do half hour sessions on tele-health, which will be less expensive. Right. And it was a great mix. I do that. I did that a lot with kids. I mean, you can't keep a kid's attention for more than a half an hour in person or on telehealth and teenager, forget it. Right. So I found, oh, this is a perfect use of tele-health. So it's, it's still allows me to create the revenue I need for my business. And it's certainly a less expensive option. And I would argue a very very convenient and, and maybe just the perfect option for that subset of people. Speaker 2 (10:04): Yeah. I agree. I'm, I'm very much in favor of understanding the patient experience and the flexibility that telehealth can allow patients. Right. I think that there's just a lot of discussion right now on how do we get paid for that? Right. And whether or not does it tele-health is, should we be paid the same amount as an in-person in-person visit versus a tele-health visit? And I think it's still up in the air. Like, I, I, I fully can see it from both sides. Right. but to your point, the expense side of what your, your cost as a individual business owner on tele-health is significantly less. Right. And you could, the volume of people that you can kind of stack up to be able to see is significantly more. Right. And so, I guess also the, there's still a lot to be known about the outcome, right. Speaker 2 (11:03): Is it truly beneficial for the patient experience? Because, you know, there's, there's data now coming out that telehealth is actually expanding the utilization of care of in-person. So people aren't getting Nessus it's, it's increasing the number of visits in a episode of care because it's not taking the place of in-person it's adding to in person. Right. So we still need to understand and pull the data 2020 to understand how it fully impacted. Cause you know, insurances are always leery about adding more visits and paying out a little bit more for treatment, but if the outcomes are better, that to me always speaks volumes as Speaker 1 (11:48): Well. Yeah, absolutely. Now, was there any other technology aside from tele-health that reported being used more like, were there any apps or any, you know, other types of, of tech or was tele-health really the, the main thing? Speaker 2 (12:04): Well, telehealth was the big one. But I think there were a lot more folks that decided to ramp up their direct access marketing efforts. So I thought that was really interesting, like in order to, to keep in contact with your patients, right. And also keep some volume coming in. Again, we, it, it sort of pushed people in areas that they knew they should be doing, but now had the opportunity to do during this sort of time. You know, we, we were talking a lot about it at web PT. This is the time to work on your business when maybe you can't work in your business. Right. And so we saw, you know, marketing significantly ramp up for a lot of clinics, whether it was, you know, working on their website to their digital marketing strategy things like that. Speaker 2 (12:59): And then figuring out some different ways to offer more non-traditional services, whether that's, you know, like you cash-based services, ride share you know, nutritional counseling, like additives sort of things to their repertoire of services that they could add add on additionally to the clinic, which, you know, all great things. So I think it's just expanding the opportunity for more revenue streams through the use of technology mainly via their site or zoom or, you know, other things where they can have a larger audience all at one time versus having to only have a few that you had to physically come into the practice. So that's really cool to see. Speaker 1 (13:49): Yeah. I think it COVID sort of forced people to think outside the box. So instead of just sticking with, well, it's been working and then all of a sudden, wait a second, this literally can't work at the moment. So what do we have to do? So it may be, it, it sparks some more creative thinking from people. Absolutely. Yeah. That's a good thing. Speaker 2 (14:10): That's a good thing right. Out of your, out of your proverbial Speaker 1 (14:14): Box. Yeah. Yeah. And, and oftentimes you'll have business growth from that, which leads us to our next point. Let's talk about what a great segue let's talk about. Business continuity and growth, which when I read this, I was like a little boy. So go ahead. Let's talk about that. Speaker 2 (14:35): Okay. Well, as you can imagine, it was a bit of a mixed bag, right? I mean, there were quite a few unfortunate closed doors that happened at practices. It was also a huge opportunity for some of our larger organizations, enterprise organizations in the profession to continue with their consolidation and bringing more clinics into the fold. But we did find, you know, we, we've been doing a lot of education over the years on the business side and really have talks about how important it is to have that rainy day fund of, you know, at least three months of expenses. Now we all know that COVID happened longer than that. We've been under this COVID umbrella for longer than that, but truly having to close your doors probably did not have to happen for more than 90 days, depending on what state you were in, but essential, we were essential workers. Speaker 2 (15:32): Right. So, you know, the bright side of that was that I think 38% of leaders that took the survey said they did have that. So 40% of respondents said, yep, we had what we needed to do. We hunker down, we did some of that. There's other things that we could outside of the box during that time. Right. and we survived. Right. And so that, to me, it was just really heartwarming to see, like you hear horror stories and other industries, restaurant, and other things where man, they just suffered big time. Right. And so it was good to see that from the private practice sector there were still significant amount of businesses that were remained viable during this time found ways to continue on with some other revenue streams. And as a matter of fact, 34% of our clinic leaders said they were already starting to open more practices and locations within the next five years. Speaker 2 (16:37): So they're not, you know, struggling right now. And as you know even though our visits completely plummeted for a few months, like they quickly ramped back up and almost every clinic leader that I talked to today are at cope pre COVID numbers. And most of them are above COVID numbers. They can't keep up with the volume right now for the most part, so good problems to have. I'm just excited that, you know, again, we we were at the forefront of, of essential workers helping people in need, whether it was specifically in orthopedic you know, rehab, but also there's so many great stories of how clinics, you know, were out there helping folks. And now we have the post COVID long haulers that we're now getting into our practices. So the value of PT did not dwindle during this time, which is, which is great to see. Yeah, Speaker 1 (17:38): Absolutely. And now, as we talk about these clinics ramping up and more patients coming in and more work for the PTs, well, oftentimes you can kind of see where I'm going here that can lead to burnout. So talk about the, the topic of burnout that you found within this report. Speaker 2 (17:59): Well, this was a problem pre COVID, so it's not even anything super new. We we've continued to report on this. It can, you know, the, the slope is on the RA is going in the wrong direction. Based on our, our, our survey 50% of therapist and 42% of therapy assistants reported feeling more burned out now than they did prior to the pandemic. Most of them cited reasons for that burnout or fear of contracting COVID and just reminder, you know, this survey was taken at early this year, end of last year. So we were still sort of in the thick of things changes in their work hours and sort of change in the whole overall clinic morale. Speaker 2 (18:51): We're all experiencing some, you know, mental health sort of pieces fall out great word fallout from all of this. Right. And so, as you can imagine, that was reflected in the survey. So, you know, at the, at the same time, even though they reported this, this burnout most of them have said that they obviously still love our industry. They don't have any necessarily thoughts of, of potentially leaving. Although we do, we are seeing some, a little bit of that. I think just like every other industry, when you couldn't work, people picked up their heads and said, Hmm, what else is out there? And we are seeing, you know, a few, a few more percentages of people looking outside of clinical care, which I I'm, I don't think is necessarily a bad thing to, to continue, you know, projecting a, an awesome brand for PT professionals. But outside or doing things now in nonclinical care nonclinical work. Speaker 1 (20:00): Yeah. And I've definitely seen a lot. I've seen that sort of trend as well as moving away from patient care and going into nonclinical roles, which, like you said, there's nothing wrong with that. You have to do what feels good for you. What, what advice would you give to a PT who is maybe they are one of those 50% who are feeling burnout or feeling like we hope it's not feeling apathetic towards the profession and their patients, but that is part of, of the burnout feeling burned out. Is that real, like apathy for just doing the job? So what advice would you have? Speaker 2 (20:48): Yeah. You know, most of the time and I'll speak to myself and when I feel burned out, I have to get back to the root of passionate around why I'm doing it. Why, why do I love, why, why did I get into this in the first place? What is my purpose sort of in being a PT and you know, and figure out, you know, what's causing, what are the root causes of, of, of these feelings of burnout? Is it the current position I'm in? Do I just not like who I'm working for? Do my values, not line up with my employer. Like some of these things like people, you just, you still feel so lucky to have a job sometimes during time. And then, and then now that, you know, things are kind of opening back up. I think a lot of people are coming out of COVID experiencing like, holy crap. Speaker 2 (21:38): Like, what am I doing with my life? They they've lost their family members. They've lost friends. Like it's, it's kind of this wake up call for a lot of people to say, holy crap, what am I doing with my life? Like, is this really what I want to do and love to do? And so you see a lot of people struggling with that and maybe not perhaps loving what, where they are and what they're doing. And so they're kind of in this burnout phase and I, again, this was taken in like December, January, right? You've been hunkered down for a whole year with not a positive end in sight, even at that point. Right. I mean, it's starting to come out of it. So things were kind of doom and gloom in the country. We're just transitioning out of, you know, a present presidential race. Speaker 2 (22:27): There was a lot of change and a lot of turmoil going on in the, in the country at that point in time. So I think that's also reflected here, Karen. I would say this is probably similar to what you might ask any average American during this time. Right. So I would just take that into consideration as we look at these numbers, but you know, one of the things we didn't talk about here with regard to demographics is also just the, the student debt that is still a, such a huge problem in our profession. And it's just, it's not getting any better necessarily. And so again, compounding your student debt on top of, oh my gosh, do I really love my job? Like, there's an COVID and everything else, like, there's just you just, you feel kind of in despair. Right. And so I think that's, what's really reflected here again. What would I tell people I'm like, again, go back to the roots. Like what, what do you, why do you love what you do? Or why, why do, what did you get into this profession to do and find a path to be able to make that happen? Speaker 1 (23:40): Yeah. It's like you said, it's sort of stress upon stress upon stress with uncertainty. Yes. And that's really difficult for people, especially when you have a boatload of student loans and wait, no, one's hiring now. Right. When this was taken, when the survey was taken, we weren't at those pre COVID levels yet because the vaccine hadn't been widespread yet. And so yeah, I can understand why a lot of people felt burnout and, and quite honestly, I agree with you, I would say 50% plus of Americans felt burned out at that time as well. Speaker 2 (24:20): Yeah. And, and going back to some of the COVID impacts, like when the survey was taken, you know, our survey results showed that a lot of clinics were in that uncertainty phase of not exactly knowing when they were going to actually meet or exceed or even get close to their budget that they had projected for 20, 21. Right. And so there were cutbacks being made perhaps, you know raises were on hold. Right. There's just a lot of factors as an employee or as a therapist that you're kind of like that uncertainty really does not make you feel good. Right. So I think all of that is reflected. I mean, there's so many facets that that can be reflected in that burnout number, especially after the year we just had. Speaker 1 (25:07): Yeah. Yeah. It's not just one thing. It's a lot. Yeah. It's a lot. Okay. Is there, what were, are there any other sort of major trends from the report that we didn't hit on yet that you want to make sure the listeners get? Speaker 2 (25:22): Well, you know, I'm a huge advocate on advocacy as you are. And you know, we always kind of want to know, like where, and how are people doing advocacy? How do they get involved with the profession? How did they get involved to, to stand up for where the profession and no, no difference in, in years past, you know, the, unfortunately the PTA and the OTA and even ashes to some point, Ashleigh actually has done a fabulous job as far as galvanizing their SLP base. But AP TA and, and almost 50% of those responded to our, our survey said that they were either not members or had no intention of being members. Cause they didn't feel like it added value for the cost of, of being a member. And so, you know, from an advocacy perspective I, it was also a dismal number to sit to show that 60% of rehab professionals said that they didn't participate in any of the numerous advocacy efforts from last year, Speaker 3 (26:43): Which was Speaker 2 (26:45): Again to my heart. I will say though, that that is a significantly yeah. Lower number, which is still sad because we did rally a lot of people last year around the 9% cuts and all of that. I think more people than ever, I guess, if you look at the, you know, the positive side of this, more people than ever did get involved whether it was, you know, to provide tele-health to have an avenue for more for revenue, the 9% cuts, you know, all of those things definitely rallied folks to become more involved, but we still have, you know, to your words earlier, some apathetic PTs that just don't understand, maybe it's just don't even understand how advocacy works. They don't feel like they have time. It doesn't make a difference, like all the excuses that people want to give. So it's always a point of contention for me, whether it's, you know, if you want to be a member, I believe everybody should be a member of the PTA. Speaker 2 (27:45): It's your association. They represent all everyone in, in the profession as a whole. I know they struggle because it's just, there's so many opportunities for PT and, and specializations within our profession that everybody wants to raise their hand and say, you need to represent me. But at the end of the day, we're all physical therapists and that's what we need to, I feel like we must come back to and so, and also with the PT pack, you know, and, and having been a previous trustee, I know how hard it is to in the small, small percentages of people that do contribute to this hugely important effort of how advocacy has to be done in meetings and people knowing who you are as an association and as a group, and why it's so important to, to not have cuts to our profession. Right. I mean, they are just ignorant to, to essentially what we do on a regular basis and how much we get paid for it, or lack thereof. Speaker 1 (28:56): Yeah. And, and what I would say to people listening, even if you disagree with some of the decisions or directions of a PTA, that's all the more reason to be involved so that your vote, your voice can be heard. And, and maybe you can change some of those things that you don't like. I mean, I understand it's a slow ship to steer. It's a big organization. Like, you know, it's not like a nimble small private practice owner who can change things on a dime, you know, but it is a big ship to steer, but the more and more people, especially younger therapists that can get involved and have their voices heard. I think that there's a good to make a difference Speaker 2 (29:43): For sure. And I, I think just understanding how you can get involved, whether it's, there's lots of ways to be involved, even if it's financial for now, or maybe a kind of, maybe it's just time, like there's lots of different ways to, to add your voice and your voice does matter. And I think that more than ever is important to, for people to understand. I think we had the most it's not just even therapist's voices, but patient voices. We had the most number of patients that was something we, we rallied so well with this year is to get the patient voice heard with regards to the 9% cut, especially on the Medicare side. And so I think that was pretty impressive and made a huge, huge impact with the legislators, with regard to the effect and why we've had some significant progress in, in mitigating those cuts. Speaker 1 (30:40): Yeah. And oftentimes, like you can be involved in like the easiest way possible by just like going onto a website and putting in your zip code, finding the people and pressing a button and it sends it up. Like to me, it sends it off to like Chuck Schumer and, and Kiersten Gillibrand. And I don't know. Yeah. Speaker 2 (31:01): It's so easy. Even if you don't know who your legislators are, the apt [inaudible] like, there's so many sites now that are help making this so much easier to become involved to, to, to lend your voice right. In a way that is super impactful and only takes a couple minutes. Yeah. Speaker 1 (31:24): If that, and you don't have to be a member to do that yes. Nor do your parents or your friends tune in seconds and it's free. And if you have a smartphone, it literally takes two seconds and a LA it's all pre-written. So, yeah, I agree. I think positive advocacy efforts are so needed and like you said, they, they make a difference, you know? So, okay. I think we talked about a lot. We talked about diversity technology, COVID advocacy business growth. Anything else that really jumps out at you from this report? Speaker 2 (32:09): No. I think those are the big highlights. You know, we look forward to, to now be able to compare this is a a great sort of slice in time, immediately post kind of post COVID bef just immediately prior to the, you know, getting back to quote unquote normal as far as visit numbers and things like that. So we definitely look forward to doing this again next year. So I, your listeners to participate in the future again, to get your voice heard and to, to really be able to reflect more of what's going on in the industry. Speaker 1 (32:53): Yeah. I think it's great. And where can people find this report if they wanted to read the whole thing? Speaker 2 (33:00): Yeah. If you go to web pt.com/state of rehab therapy or if you just go to our blog page you'll find it and it's a free to download. It's actually a 60 page report full of graphics. And like, if you're a data nerd, like dive in, because they're there, we have sliced and diced it and made this beautiful. Our team is just awesome. And did a lot of work to, to make this digestible from anyone, even if you're not a data nerd to bring out the highlights. And then also Karen, we're going to be doing a webinar coming up in just a couple of weeks. So you'll find that on our website as well. You can sign up for the webinar. We'll, we'll go in much deeper depth as far as the details of, of more of these topics that you and I have talked about today. Speaker 1 (33:57): Excellent. Excellent. And they can, all that can be found on the web PT website. Yep. Perfect. And where can people find you on social media, things like that if they want to follow you or get in touch or ask you questions? Yeah, Speaker 2 (34:12): I'm on LinkedIn. I'm also on Instagram at hydrogen Nanga. So it's J a N N E N GA. And yeah, happy to engage on social, do it quite a bit, especially on via LinkedIn. So love to connect with any of your listeners. Speaker 1 (34:31): Excellent. And then finally, last question. What advice knowing where you are now in your life and career, what advice would you give to your younger self? Maybe you're that PT right out of PT school. Speaker 2 (34:47): Yeah. it's a great question, man. I have to reflect back quite a few years when I was a young TT now. But I think that the biggest piece of advice I would give is really around not thinking that you have to have all the answers. So I had a hard time when I first came out of the, I felt like, okay, I'm a, I'm a physical therapist. Now I'm in front of my patient. That credibility of any question they have are going to ask me, I have to know the answer. And that's not always, that's not true, actually the, the ability to say, I'm not sure that gets, let me get back to you and truly providing research, great response versus an off the cuff, maybe not perfect response. I think sometimes it can be so much more valuable in your overall long-term credibility with that, that particular patient or other therapist or leader. Speaker 2 (35:59): It takes a lot of vulnerability to say, I don't know. And a lot of confidence to say, I don't know, but I wish I would have been able to do that maybe a little bit more on the beginning and not felt the pressure of having to feel like I needed to know all the answers because Lord knows, I didn't know all the answers back in the day. I still don't know them today. Right. And you know, one of the other interesting things, just from a, as my growth, as a leader in this same sort of vein is what I've learned over time is that as a leader, you shouldn't have all the answers, right? It's my people come to me now and they've learned over time, like you become a crutch to those that work with you or for you. If you're the only one who has all the answers, right. Versus putting it back on to them to say, well, what do you think? Like, what do you think the answer is? Coming to me with solutions, not just a problem. And so to me, that's training and bringing in new leaders. I learned that from, from a leader who was a mentor to me quite a few years ago. And so that's another sort of way that now I've shifted that same response from a leadership perspective. Speaker 1 (37:24): Oh my gosh. I could talk all day on this from a leadership perspective who may have to do another podcast on it. So I think people would love it. Well this was Heidi, this was great. Thank you so much such good, good information for anyone in any of the rehab therapies, PT, OT speech to download this report, dive in and, and use this report for your own business or your own practice, you know, that's what these reports are for, right. To kind of not just look at it and say, oh, that was cool report, but to actually use the report and use it to be a guide maybe to your business or to your practice. Yes. Speaker 2 (38:04): Yeah. That's exactly right. Like how, how in your business decision trends that you're seeing in industry that you can validate some of your decision-making on is exactly why we've, we've put this out there to the public with no cost to you. Like it's, it's really just to, to benefit and give back to this industry that we love so much and want to see flourish. So Karen, thank you so much for having me. I really appreciate the opportunity. Congratulations on all your, can't say enough, how awesome you are with your advocacy and as an influencer and, and true thought leader in our industry. So thanks for everything you're doing with this podcast and, and, and all of your other ventures. It's, it's awesome to watch you and see how much of an impact you've been able to have in our profession. Speaker 1 (38:57): Thank you. That's so nice making me blush aside from the large scratch for my cat on my cheek, where it's already red. Thank you so much. I really appreciate that. And everyone, thank you so much for listening to this episode, go download the report today. We'll have all the links to it at the podcast at podcast on healthy, wealthy, smart.com under this episode. Thanks for tuning in, have a great couple of days and stay healthy, wealthy, and smart.  

In this episode, Owner and Founder of Velocity Physiotherapy, Erica Meloe, talks about the business of physical therapy. Today, Erica talks about her previous career, how to foster motivation and commitment in patients, and addressing company culture. What does it mean to be out-of-network? Hear about the biggest lessons Erica has learned in her career, the importance of mentorship, and get some valuable advice, all on today’s episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways “Being an entrepreneur, you need to be able to know what your strengths are, and really work with those strengths.” “I learned over the years to delegate out what I don’t like to do or what’s not in my strengths.” “Practice makes permanent. It does not make perfect.” “If you put a computer between you and your patient, you decrease the outcome by 50%.” Some important definitions Co-pay. This is a fixed amount that’s generally used for an in-network model. Co-insurance. This is based on a percentage of the bill. Balance-billing. This is balancing the bill up to what you typically charge. “Lately, a lot of plans are being reimbursed as a percentage of Medicare.” “A lot of being an entrepreneur is mindset.” “Why reinvent the wheel when someone else has done that?” “Be unapologetically yourself.” “We need to find joy in our life, and whatever that is, we need to do more of that.”   More about Erica Meloe Erica Meloe is a board certified physiotherapist in private practice in NYC. After a decade solving financial puzzles on Wall Street, Erica took her MBA and her problem solving skills into the clinic. She specializes in treating patients with unsolved pain and her mission is to raise awareness of the physical therapy profession to a level like no other. Erica is co-host of the podcast “Tough To Treat. A physiotherapist’s guide to managing those complex patients.” She is also a thought leader in the profession and helps her patients as well as her colleagues empower themselves to lead and live with purpose. Erica’s book “Why Do I Hurt? Discover the Surprising Connections That Cause Physical Pain and What To Do About Them” was released in June of 2018. She has also been featured in Forbes, BBC, Women’s Day, Better Homes and Gardens, Muscle and Fitness Hers and Health Magazine. Erica is also fluent in Spanish and loves traveling!   Suggested Keywords Physiotherapy, Therapy, Health, Motivation, Commitment, Consistency, Practice, Entrepreneurship, Culture, Mentorship, Business, Mindset, Healthy, Wealthy, Smart   To learn more, follow Erica at: Website:          https://ericameloe.com                         https://toughtotreat.com                         https://www.velocityphysiony.com Facebook:       Erica Meloe PT                         Velocity Physio NYC                         Tough To Treat (Podcast) Twitter:            @EricaMeloe                         @VelocityPTNYC Instagram:       @toughtotreatpodcast Pinterest:         @emeloe LinkedIn:         Erica Meloe                         Velocity Physio YouTube:        Tough To Treat Business Round Table on July 27, 2021 at 8:00 PM EST  Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:               https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the Full Transcript Here:  Speaker 1 (00:04): Hey, Erica. Welcome back to the podcast. It is always a pleasure to have you on, so thank you for coming back. Speaker 2 (00:11): Thanks. Thank you Karen, for asking me, I can't believe it it's been, I remember our first podcast was probably 10 or 11 yeah. Years ago. Speaker 1 (00:19): So yes. So long ago, like way way, the beginning of healthy, Speaker 3 (00:23): Wealthy and smart. You were Speaker 2 (00:27): On the second street. I was just, so I remember taking a car going up in the elevator and sitting there in the office. Oh my God. Yes. It's a pleasure to be back on again. Thank you so long Speaker 1 (00:37): Ago. Gosh. Yeah, that was a long time. It was like 10 years ago. And now this month we are talking all about the business of physical therapy. So I thought who else to have on who better to have on than you, who is a successful physical therapy entrepreneur business owner here in New York city. So before we get into your, what your business structure is like and how you run your business, I would love for you to remind the listeners a little bit of your background. So just so people know, Erica had a career before she became a physical therapist. So talk about that and how that career prepared you for your role as an entrepreneur. Speaker 2 (01:24): Yeah, that's a great question. I, it's funny, I've gotten much more involved during this time being at home a bit more during COVID with the whole wall street and and, and the whole, the financial markets, cause I've had more time to look at it, but I graduated just in brief. I have an MBA from stern school of business at the NYU stern school. And after graduation, I ended up working for an investment bank, a global investment bank and international foreign owned bank, literally starting in Karen, when I tell you and I'm dating myself, but I started like just before the market crashed. Okay. Like the 87 crash, Speaker 3 (02:05): I was going to say, you have to, you have to be more specific. There's been a few. So, Speaker 2 (02:12): So that was, and I started off in research and, and that was all great, but I ended up going on to a trading floor and it's, it's a, you know, like a huge trading floor with a lot of seats and it's an open, open area and mostly selling and trading international bonds, futures and options. And I, I really, I loved it. I loved, I really enjoyed working on wall street and I think that it was a different time back then, way different than it is now. And, you know, somebody asked me recently, why did you leave? And I was like, I didn't want to retire on a trading floor, which was the truth. You think God. Right. But I, I, I often think about why did I like it so much and how can I take that, that part of the business into anything else that I do. Speaker 2 (02:58): Right. And I liked it for many reasons. And one of it was, I was part of a team, you know, and I think the team of people, you know, we talk about collaborating in our, in our, in our world. I do very well with people, with a team, people who are team players. And I think for me, that's why I think in physical therapy land, I've been, you know, in the profession going on. Yeah. Committee's trying to run for different positions because I like being part of that team. It's just an, and we all have a lot in common too, I think as well. So it, and that's, you know, I got to talk to people on the phone a lot. I was, it was very much, it was back in the old days where we actually had to pick up the phone and call people and not, and it wasn't all computers. Speaker 2 (03:42): So that's the point. I think for me, I enjoyed the most and, and also figuring things out and problem solving. And as an entrepreneur, I mean, we have to figure things out all day long. Right. I think for me, it's, it was being a team player was definitely the main thing why I miss it. But I also liked the, the fast pace and, and, you know, yes, we're in New York, we all liked the fast paced and certainly not as fast as it used to be. That's for sure. But I enjoyed making those quick decisions and, and, and talking to clients and analyzing with them to solve their problems. So it's similar to physical therapy, right? I mean, we deal, we see patients, we try to, we talk to them, we try to figure out, you know, what, what's going on, what's going wrong with them or what their problem is. Speaker 2 (04:33): And, you know, I did recently a a paper for I'm doing part-time some courses and I did something on the therapeutic Alliance and the therapeutic Alliance, the quality that is the most important is really being, being a good listener and like listening to your patients, listening to your clients. So that's how I'm when I was on wall street. I, I really, this is when we had great expense accounts. Peter I've waited, you know, I flew to Mexico city for, for lunch one day with, for the central bank and came back. I exploited, I mean, that's the life I loved and I, to this day, I do miss it. I'll be, be honest, you know? And I, I was able to fly. I didn't, I didn't, I only covered a few international clients was mostly of domestic, but it was establishing those relationships, maintaining those contacts. Speaker 2 (05:25): I know you talk about like the concierge I read your article actually in an impact magazine. It was excellent. And it's about, you know, it's that extra service it's that, it's that developing that relationship. It's going that for mile. And, you know, I was one of the top sellers on the desk. And when I left people, some of my top clients were like, we liked you, or, you know, the, what if they use the word like, but they were like, you never shoved anything down our throats. I never shoved the deal down their throat. I never shoved anything down their throats. It was a, and I think that's, what's, I've taken a lot from that, you know, in a nutshell that, that whole experience, you know, Speaker 1 (06:05): And as an entrepreneur, where, where does that sort of plug in? Where does that fit? How did that help you grow your practice? Because you have a thriving practice in New York city. It doesn't happen overnight. Speaker 2 (06:20): Oh no. Oh no, no, no, no. And to be honest with you, I think as entrepreneurs, we are lucky in the sense that, you know, since we don't work for somebody, we work for ourselves, right. We have a little bit more leeway to discover things about ourself and what we want to do to grow the business. Right. and I think that what has from taking from the wall street experience the ability to that, what's the word I want to use. It's almost like being an entrepreneur. You need to be able to know what your strengths are and really work with those strengths. So when I first started out, I knew that my strength was I did the strength finders 2.0, you know, everybody should do that. It's, you know, and I'm like a learner achiever. You have to be a connector. I swear you have to be a connector. Speaker 2 (07:14): Right. You must, right. I'm a learner achiever like maximizer input and responsibility for those of you who have done that. So for me, the way I work best is when I play to my strengths. And I learned over the years to delegate out what I don't like to do, or what's not in my strength. Like, I it's just, why would you, do you, you know, we have the ability to do that. So playing to your strengths is that one of the first things I learned early on, because, you know, people say, oh, you can be a generalist physical therapist. You can treat everything, but what makes you different from the person down the street? Right. And for me, it's like, and I'm still, I still hone this to this day. This is all a work in progress. But you know, it's the problem solving. I love to figure stuff out. Speaker 2 (08:06): That's just basic. I love to figure stuff. I look to look at a trade when I was on wall street to figure it out, how can you make money? How can I make you money? Because if you make money, I make money. Right. And you know, if you feel better, if I can make the patient feel better, I do make more money. Cause they'll refer their friends and family. So it's very similar mindset. I think that was the hope. That was the answer you wanted, but it's, for me, it was really honing on, on what I did best. And then more recently, Karen, I looked at patients who I really like to treat. And what was the common thread, right. Wow. Speaker 1 (08:45): You knew what was it? What was the common thread? Speaker 2 (08:49): The, honestly it was being motivated and coming in consistently and being committed to going the full pro the full, raw, the full round. Don't come for two visits and don't come back. You want to, you're, you're literally, you are committed to having someone look at your entire body from the brain to the foot and looking at the connections in the body and be willing to commit some time to getting yourself better. That was the commonality, Speaker 1 (09:15): But, and they were athletic. But here I have, I have something to say about that. So was that the common thread they innately had or was that something that you helped to foster in them when you first see them, those first one or two visits? Speaker 2 (09:34): Yes. I helped to foster that. How Speaker 1 (09:37): Do you do that? How do you do that? How do you help to foster that? So, Speaker 2 (09:41): So when people phone initially, I'll backtrack a second. When people like this recently I had someone come in to sit, you know, she said, I'm seeing a well-known therapist in New York, blah, blah, blah, et cetera. What makes you different? And I was like, this is what makes me different. And I start off and I say, everybody says, they treat the whole body. You know, it's everybody treats differently. But what I do is I look at the connections in the body of the relationships of the regions, of the body, to each other. And I don't just treat your symptom. I look at your impairment and I look at their relationship with the head to the PIP, the need of the foot. And I tell them a story. I say, I have a patient recently. She had a pet issue in her pelvis, low back pain. Speaker 2 (10:18): And her driver was her foot. And I explain a little bit about why I do that. And I do that with patients when they first come in, this is what I say. I say, look, I don't want say, look, I basically tell them it's w I try. I listened for quite a bit. And then I basically tell them that it's, this is a relationship. And we're trying to change your movement patterns. If learning is very important, and I need to know how you learn best practice makes permanent. It does not make perfect. So you need to be able to come in and I'll say this to them. I need you to come in consistently at the beginning, once a week, I generally don't treat twice or three times and they start a surgical. But I'll treat for the hour. And I'll say, you know, minimally once a week for, let's say three weeks, I need to front load the visits because I'm trying to change strategies and trying to train your change, your brain. Speaker 2 (11:11): And I need to do that with a lot of input at the beginning of the treatments of the treatments. And if you want to space those out after I'm fine with that. And if patients can't do that, I basically say for whatever reason, if it's financial or Trey or vacation, I tell them that that's okay, but you won't get the same results. It will take longer. And the people who come in at the beginning, who front-load them get results quicker, and those are the people. And I looked at that list and that very true. They were coming in consistently and front-loaded, but I tell them that, but you know, it's based on the assessment and if I can give them, like, I don't want to say a wow, but if I, if they get what I'm trying to say, I can make a change in the first visit. Speaker 2 (11:55): Then they are more convinced of coming in more frequently. And I think because I do a lot of listening and I ask questions that not many people ask. I mean, we're similar. You and I, but I think that they don't get a lot of that outside of, of medicine, traditional medicine. And I think that when I explained to them, I'm trying to change your movement pattern. I'm trying to change your strategy. You're, I'm trying to work with you. You know, I'm trying to change how you move about your nervous system, your neuromuscular recruitment, things like that. And I, I, I work with them. I'll have the move and I can see I can. And I take P ever since COVID started, I've been with that Darla health. I've been taking more pictures in the office because I can really, I mark them up on my apple preview. And I'm seeing things that I never saw in the clinic before. And then when I show them this, they're like, oh my gosh. Wow. And I think their brain starts to change immediately when they in the first visit. And I think that that's important to get that buy-in at the beginning a little bit to help them come more consistently. Speaker 1 (13:00): Yeah, absolutely. If you don't have buy-in in the beginning, then they're not gonna, they're not going to be that patient who you said this common thread is they're motivated and committed. But I think that yes, if people are coming to see if they're seeking out a physical therapist, they're somewhat motivated, maybe committed, but it's, you who's educating them and listening and going that extra mile, making them feel comfortable, making them feel heard. And that's why you have motivated and committed patients. Correct. So it's a combination of the patient and what you do. So don't say, oh, it's just these motivated people. Speaker 3 (13:43): Good point [inaudible] I Speaker 2 (13:47): Know. And it's so funny because the, the, because we spend so much time listening, that is the form of communication, the best therapist or the best communicators. I mean, when I was doing this paper for therapeutic Alliance, you look at the, there's a like different pieces of the puzzle, listening and communication where like 70% of the outcome. I mean, maxi, Missy acts, she's a researcher at a McMaster, right? She says, you know, you walk into a treatment room, I'd say for somebody who's, you're, you're the fifth person you walk in there, hypervigilance, you know, distracted, you've exerted a no cebo effect on your patient before you even sat down. And they're not coming back after that. Right. So it's so important. And to, to know that, and I think that that'll help them make, make changes. You, if you go in there, you can be the best therapist ever and, and try to get them to be more motivated and committed. But if you're distracted, that doesn't work. Speaker 1 (14:43): Yeah. I mean, just put yourself in their shoes. That's all you need is, is like just a smidge of empathy, you know? Cause we all, you don't have to be like an empath. You just need a smidge because like, we all know what it's like, like when you go to the doctor and, and you're trying to like spill your guts to them. And they're like on their commute computer. Aha. And you're like, well, nevermind. I don't feel like telling you anything. Speaker 2 (15:10): I know. I know. And you literally, if you put a computer between you and your patient, you've decreased the outcome by 50%. Wow. That was an interesting statistic I found. And so now people are looking at me and this is extra work for me. And it's something I'm working through, but I literally barely write in the first part of the interview. I'm just listening to them and looking them in the eye. And I'm like, I'm trying to remember, and I have a good memory, but I'll write a few things down, but I'm listening to them. And I'm just passive, to be honest, if they don't give, I don't get what I want. I will ask other questions. But I think that that writing that paper on the therapeutic Alliance, even as an entrepreneur, because yes, we have the, we have the ability to make it, make our own schedule. Speaker 2 (15:54): Right. Have the freedom to do that. We have the, we have the freedom to tell people we don't want to see them. You know, I literally someone said to me recently, I don't know what you think about this is that you should have an application process to have them become your patient. I was like, Ooh, that's interesting. I'm not sure I'm there yet, but that's an interesting concept. You know, how business coaches do that a lot, you can apply for the program, right? I'm not sure I'm there yet. I can, you know, I can talk to somebody on the phone and get an idea of who, if they're right for me or if they're not, I'll say maybe there's somebody else, but I don't like, like a formal application process to do that. Speaker 1 (16:32): Qualifying people. I mean, I guess you can, but I, I mean, I think that you're doing that in that first visit by saying, you know, I, I really want you to be committed to this process. Is that something you think you can do? Yes. Right. how do you learn best? Because I want to make sure that my teaching style matches your learning style depending on who you are and how you do things. And, you know, what's interesting is you know, there's StrengthFinders, there's all these different things. In the Goldman Sachs class that I'm taking now, we used one called people styles at work, by Bolton, Bolton and Bolton second edition. And it basically it's 18 questions and it splits you up into four different kinds of learning styles or leader, sorry, leadership styles. But you can use that even with your clients and with, if you're an entrepreneur, let's say you have multiple people working for you. Speaker 1 (17:31): You can have them take these take this test or quiz if you will. And if someone is more analytical, maybe you want them doing this kind of work. If someone is more, there's four different kinds, there's analytical, which I think you are which would be less assertive. But some of these, I, I don't agree with that. I mean, it's, they're not all perfect, but less responsive to others, task oriented, precise, and attentive to detail, prefers to work with procedures and symptoms motivated by the right way to do things I, and, you know, we sort of fall into things that might be a little analytical, a little expressive, but there's our analytical, your exp you could be an expressive and amiable or a driver. Speaker 1 (18:22): And it's, it was very interesting to look at that, even from a client standpoint. So as you're talking, you can kind of guess like what the, what maybe your client is and how you can. So if they're more analytical, maybe you're going to want to hit them with your facts, your figures, your numbers. If they're more expressive, maybe you're going to want to hit them with the things that sort of tug at the heartstrings. If you're more amiable, if you think they're more amiable, then you're gonna maybe want to challenge them a little bit. So they're not always just yessing you all the time. You know what I mean? Yeah, Speaker 2 (18:58): Yeah, yeah, absolutely. That's, that's a great that's a, that's a great tool. I have to look into that. It's funny because I sent out some questionnaires ahead of time as well. I do the CSI questionnaire and the DAS questionnaire, and I get a good idea of, of just what their personalities are by looking at those. And some people I see them and I look at them, their questionnaires and they're like completely different people, you know, honestly. Right. But that gives me an idea of just their, just their overall persona. And then I explained to them, you know, I explain how I assess and I just say, and they're like, well, why are, you know, why are your hands in my armpits type thing? And I'll cause I'm well on the thorax, the head had the feet and I'll say, well, I'm, I explained the rules of the game. Speaker 2 (19:39): I said, I'm just gonna explain the rules of the game. Cause we don't know the rules we can't play and they all laugh and it's fun, you know? Cause I think it's just a way to make people feel at home. And I think it's funny because when I weirs ago and when I was working for other people as like a staff PT, yes, I'm older now, but I, I feel that as an entrepreneur, you can, you can express yourself differently and you have more freedom than if you were to be with, you know, sort of in the confines of a culture, like a corporate culture, like on wall street. For me, I wasn't confined in the sense because it was all about getting the deal done, making the money is pretty driven by money, right. So there were kind of no limits at that point back then. Speaker 2 (20:18): So you did what you felt, whatever you, whatever you do, you get the deal done. And we didn't really have, it was just, we had limits obviously, but it was very different. We weren't reigned in so much, you know, and then we were able to sort of be ourselves a little bit. And I, I always believe that things happen for a reason. I believe that I was meant to cover central banks are meant, I was meant to cover other banks at other different hedge funds because of the analytical style that these people have. You know, I think, you know, people say you find patients, I think patients find us, you know? Speaker 1 (20:54): Absolutely. Yeah, absolutely. And that's where, you know, your website, your wording, your copy, all of that can reflect that. And you hit on something that I want to touch on quickly too. And that's company culture. So how did you, and you have a partner and he gal, how did you guys address your company culture, the culture of your clinic, where you sort of very what's the word I'm looking for? Speaker 2 (21:31): Like, did we have like something Speaker 1 (21:33): Like, was it purposeful, did you sort of purposefully, like this is going to be our culture, this is, these are our values and what we want to reflect on our business. Yeah. Speaker 2 (21:45): I mean, we didn't do that formally. But we certainly, if it evolves over time, because it naturally the types of patients that would, that would come into the office would be those ones who sort of have been elsewhere or have, you know, really wants I don't even want to say hands on approach anymore, but more of a, of a, of a whole person approach and that it naturally evolved that way. And that sort of like when we did at one point when we were gosh, I think this was when we first started, we actually had to go up to Columbia university to speak to the student center up there. And, you know, we did a little PowerPoint and in that PowerPoint, it was, we talked about, you know, why the, you know, the hip is related to the foot. And, and so it evolved over time that, that whole, that whole culture and, and, and we were out of network from the get-go all right, because we knew that in order to treat this way and certainly New York rents, you know, you know, they're changed now, but back then, it was you, you could not at least in New York state, cause we're like, like the lowest reimbursed state in the country, right. Speaker 2 (22:55): I mean, you cannot maintain a business in New York city on an network network, unless you see, you know, five patients an hour, which is unacceptable to me. So that is not the way I'm I treat. And even, you know, it's funny when I graduated PT school, I called up a lot of places that I was going to interview at and see how many patients they saw an hour. And if it was four, I didn't go for the interview. And I had, I was lucky I had a career change. I had some savings, so I could be a little bit choosy, but I, I, it's very stressful working in that kind of an environment. Speaker 1 (23:25): Yeah, absolutely. So let's talk about the structure of your business. So you said you've been out of network from the beginning. So what does that mean? Can you explain to the listeners what that means? Speaker 2 (23:34): Yeah, so we don't contract. So basically we don't contract with an insurance company. So we have, we take Medicare. We are what we call par for Medicare. So that's con that's a contracted in New York city rate. And, but other than Medicare, we are out of network, which means that if your client has out of network benefits, we can do one of two things. You either build the insurance company directly. We charge them the co-insurance and then we get paid. So we get paid or the patient pays us directly. And then they submit the claim themselves, or we can submit the claim for them. So the majority of patients now have no out of network benefits. So what we end up doing is just billing the patient directly. And there are some insurances that we don't take it all. And so even out of network, so what we'll do is we'll just, the patient will pay us directly and then they'll submit on their own. We just give them a receipt, but out of network. So long-time patients of ours. We will bill the insurance company for them and wait for the insurance company to pay them, pay us, excuse me. And we'll charge them the co-insurance and that's gotten much less lately. Speaker 1 (24:51): Yeah. And can you explain what a co-insurance is? Speaker 2 (24:55): Yeah. So there's the co-pay and the co-insurance, the co-pay is a fixed amount. That's generally used for an in network model. So you have a 60 per dollar copay when you see a specialist. So co-insurance is based on a percentage. So for example, I work for, you know, large company, a here in New York, I have Cigna, my benefits are 70%, 30% Cigna will pay 70% of what's reasonable and customer in 30% is the co-insurance that 30% of the co the co-insurance is based on what you bill out of network. So you bill $400, the co-insurance can be 120 bucks, or it could be lower. We generally drop it lower. Okay. But we're because we're not contracted with, with any insurance companies. So a lot of people lot of lately, a lot of insurance companies have been sending patients letters like you, just so you know, you're seeing an out of network, I'm using this in air quotes, out of network, physical therapist, just so you know, they can balance bill you. So they're doing a lot of these sort of nefarious practices to get the patients saying, well, I don't know if I want to do an out of network practice, and they've been doing this for a while now, but in my patients know better. But recently someone brought in a piece of paper and it was not, was not a bill. It was just a statement of fact we've received charges, you're out of network, just, just FYI. They may balance bill you, which is, you know, they never did that before. Speaker 1 (26:21): Yeah. And balanced billing is Speaker 2 (26:24): They're going to build. So I'll use a simple example. Let's say $300. We charge, for example, let's say that's the number the patient's covered at 70%. Assuming. So let's say that it's, that would be two 10. That's usually not what they pay. Let's say they pay one 50. The co-insurance we charge was 50 bucks. That's $200. We can bill them to a hundred. That's a balanced bill means you balance you balance bill up to what you've charged. Speaker 1 (26:48): Got it. Got it. Yep. Just so people understand what all the well, because we're throwing out a lot of terms here. I want to make sure people understand, because this is all about the business of physical therapy, right. This whole month. So this is, this is literally the business, right. Speaker 2 (27:04): And I will, and I will. Yes. And I will tell you lately, a lot of plans just for anybody who's wants to do an out of network and bill and accept what they pay. A lot of plans are being, being reimbursed as a percentage of Medicare, which as we know is not great. So more often than not, you do not know that upfront. Sometimes they'll tell you, we do mostly electronic right now. And they won't, if there's nothing on the site that says patient is reimbursed at a certain rate, so you'll get paid. And then you realize, oh no, this is not enough. And so, you know, and that happens a lot of times after the fact. And so we have to, we have to you know, make the different part of the difference up in the co-insurance. So it has to, it's just, we have to, because of the, you need, we deserve caring. Speaker 2 (27:51): We deserve to get paid. This is what I say every night or every morning I write in my journal, my work is of high value and worthy of massive compensation because it is yes, we deserve to get paid. And and patients accept that now a lot more than they used to, a lot of patients now do not have out of network benefits at all. So they just pay and that's that, and that also comes down to your ideal client, right? Who, you know, you want, do you want somebody who's just going to like, you know, ask you to drop your rate or cause they, they will do that. They will ask you to drop your rate. And I generally don't do that anymore. You know, it's a special situation of course, but because those people are not sort of going to stick around, right? Speaker 2 (28:36): You want a lot of people who have no problem paying and it, depending on what your rates are, they will stick around and they will have no questions asked. And that, you know, as, as an entrepreneur, you will hone that ideal customer avatar over time. But speaking from experience, it is very frustrating when you, you, you treat an hour an hour and 15 minutes sometimes with people in any insurance company, out of network reimburses you at a percentage of Medicare, that's a joke. So you and I would get angry over it. And so at a certain point, you know, I, you know, a lot of I'm happy that we don't have out of network benefits a lot of the times, because it will save me that frustration and anger and the patient can just get reimbursed themselves, you know, pay me directly. But once again, as a new PA, if, if we have people who are just starting out or they're five years in the business and they want to start their practice, they may have to do that. And you're going to learn over time that the reimbursement changes from between insurance companies in between dates of service. I mean their insurance companies who we bill out of network will pay different rates for the same codes. It's just ridiculous. It's ridiculousness. And, you know, we have a small practice, someone who has a large practice like that, who's getting hurt like that. You need to almost hire us, hire like an advocate or somebody who can negotiate for you, you know, because that that's, that's a full-time job. Speaker 1 (29:57): Yeah, absolutely. And, and I think that it was really important to go through all of that, because that can be really confusing, especially for a new physical therapy entrepreneurs who want to start their own practice, who are on the fence. Should I take insurance? Should I not take insurance? I always tell people, call insurance companies and find out what they reimburse in your area. Yeah. Because it may be worth it to take an insurance, take one insurance and not take the others because there are insurance companies that may reimburse 120, 150 a visit. Hey, that's not bad. Speaker 2 (30:33): I will tell you there's a couple of patients. And if it's planned dependent, because there's far and few between, like I can count on one hand, the amount of patients I have who have like the platinum insurance plan. Right. And you will get paid more than your direct rate, which that number is dwindling. I've had people therapist asked me recently, should I? Because of COVID because of the financial stresses people are under, should they start billing out of network for their patients? And I basically tell them what I just told you. It's, it's, it's a great service you can offer. But if you don't have an assistant, you will be on the phone way too much than you want to be on the phone. Okay. so it just misses out your priorities. Yeah. Yeah. Speaker 1 (31:16): And actually my next, that was going to be my next question for you is if let's say a, a budding physical therapy entrepreneur comes to you and says, gosh, what, what was one of the biggest lessons you learned when in the course of either starting or now continuing to run your business? What would that be? Hmm. I think Speaker 2 (31:47): With regards to, I would say being willing, being open and being open to collaboration, being open to like expecting the patient to do the right thing. Because a lot of times we can say, oh, their patients never got going to pay. They're not going to do this. They're not going to do that. And I think that a lot of about being an entrepreneur, and this is one of the biggest lessons is, is your mindset. It's the vibration that you have. And it may sound woo woo. But trust me, it works. You know, 80% of this is mindset. 20% is execution. You know, you can sign up with an insurance company, you can do the billing, you can put the codes and you can do the evil, right. It's about minds. If you expect people not to pay you, or if you expect people to, you know, B B be difficult with, with regards to where, if you expect with insurance, we expect to have a difficult time. Speaker 2 (32:44): You will have a difficult time. And a lot of it is mindset. That's the biggest lesson I think because the technical stuff can be, can be taught, you know? And when I first started out opening the practice, I was looking for a mentor in our profession and, you know, Karen, I still, I couldn't find one. And it was very frustrating because I was I was, you know, did have an MBA, but the school of entrepreneurship didn't was not open at stern. And when I was there, right. So I was coming from a corporate culture, transitioning to an entrepreneur, an easy transition in terms of mindset, but not an easy one in terms of logistics of, you know, what does it take to be an entrepreneur versus working for a corporation or corporate it's very different. You have to really advocate for yourself. Speaker 2 (33:32): You have to know who you have to know who you are treating. Your marketing is huge. You have to really learn a lot about that even before way before you even, I mean, I w I wouldn't say learn that before you start your business, because most people, if we did that, we would still not have a business. You know, I would just start and go and you'll learn, you know, but, but the mentorship is huge. I think because why reinvent the wheel when someone else has done that? So talking about the 80% strategy, why, why reinvent the wheel, find somebody in our profession who can mentor you, right. That can help you do that. And the 20, the mindset is stuff is, is, is you, you can learn with mentors or finding somebody outside of our field to help you with that. But that's, that is important. Speaker 2 (34:17): And I believe that the, the, I know we've got a lot of business groups out in our field right now who charge very large sums of money to, to, you know, to up to, you know, and they're great programs, but I will throw out an option. You know, there are a lot of great physical therapists out here, you know, who have business backgrounds, who are entrepreneurs, who have successful businesses like you and me, we, we could all easily help out people, you know from a mentor program. And, you know, we need to grow the profession. We need to grow our physical therapists. And I think it's important that we give back and, and it being, and, and learning one of the main things I've learned as side's, the mindset is learning to be a mentor and learning the importance of mentorship. Because I didn't have one when I first came on and I still don't have one yet. I'm still looking, but, you know, that's why I have a team and collaborate with people like yourself, you know, cause we learn. But I do think that people should like you and I are like on the front lines, so to speak, right. We're, we're, we're, we're seeing patients, we're, we're actually doing it, we're running a business. And I do think that is important when people look for programs out there. Right. Because I think it's, it's, you know, we've done all the hard work. Why reinvent the wheel? Yeah, Speaker 1 (35:41): Absolutely. I couldn't agree more. And I think that's great advice for any upcoming entrepreneur in the physical therapy space. And before we jump off, where can people find you, if they want to ask you questions, if they want to know how you do things, where's the best places for people to reach Speaker 2 (36:00): You? A couple of things, we have a podcast with the wonderful Susan Clinton and myself it's called tough to treat. Yes. we've got our a hundred, our hundredth episode was last week kind of Speaker 5 (36:11): Crazy. Right. I was so proud my God. Speaker 2 (36:14): So there's our website, tough to treat.com and I've got a bunch of website, our business, the website, but I'll give you like the way to reach me is all my handles on social media are at Erica mellow. And my email is erica@ericamellow.com. Speaker 1 (36:31): Perfect. And your website, Eric Speaker 3 (36:33): And mellow.com. Yes, yes, yes. Speaker 2 (36:37): Yeah, no, I'm thinking more philosophy. Physio. One is being redone right now. So that Erica mellow.com is a, Speaker 1 (36:42): It's a good one. Perfect. And we'll have the links to all of that at podcast dot healthy, wealthy, smart.com and the notes for this site for this podcast. And I know that you've answered this question before, but I'll ask it again because you know, more advice from you is not a bad thing. And that's, what advice would you give to your younger self? Maybe like fresh, forget, forget you your first job out on wall street, or even your MBA. How about like fresh out of undergrad? Speaker 2 (37:18): That's a good question. And you asked this of everybody, right? I, I know this, I know you do. I think that, and, and I'm saying this now because I've experienced so much throughout the life, I've lost loved ones and things like that, but be unapologetically yourself. You know, Speaker 1 (37:39): I know don't we waste too much time being somebody else. Yep. Speaker 2 (37:44): Yep. It's at it is. Yes, we have. We do. And I think that if we are Susan always calls me my podcast. CO's a confronter, I'm like, I'm not really a confront her, but I do, you know, have opinions. And I think that we that's the advice just, you know, open your mouth basically and be up, be yourself. Speaker 1 (38:09): Excellent advice. Because like, like you said, we waste so much time trying to be somebody else and trying to conform to what people think we should be instead of just being who we are. Speaker 2 (38:19): Yes. And I, and I think that if I were to give an like other advice, because there's so much burnout in our profession now is that, you know, we need to find joy in our life and whatever that is, it varies for everybody need to do more of that. And this is a practice that I've done. So I recently went to a polo match gesture day. And so I have every year I have a thing called magical moments. And if I have a magical moment like that, I write it down. So it can be like, you know, spinning at soul cycle and Hudson yards during a pandemic, you know, or, or, you know, going to the, met with my niece or going to a polo match or Disney when I, and so at the end of each year or new year's Eve, I'll look at that. And I'm like, oh, I actually did have a nice year because I think we don't write those things down, you know? And I, and I think that's good for, for, for us to do. Speaker 1 (39:10): I love that. I love it yet. Another great piece of advice. Well, thank you so much for coming on the podcast and we will see you again at the end of the month on Tuesday, the 27th of July for our business of physical therapy round table talks, I'm really excited. And for all the people listening, you can find that out in the show notes as well, how to get more information on that round table. So I'm looking forward to that. So thank you so much, Erica, for coming on Speaker 2 (39:45): Again. You're welcome, Karen. Thank you. And, and to all Speaker 1 (39:48): Of you guys listening, thanks so much, have a great couple of days and stay healthy, wealthy and smart.  

In this episode, Co-Owners of Kornetti & Krafft Health Care Solutions, Dee Kornetti and Cindy Krafft, talk about all things maintenance therapy and care. Today, they talk about maintenance therapy in the home, diversifying revenue, and they bust a few maintenance therapy myths. How can maintenance patients have a goal statement if they’re never going to get better? Hear about home-based therapy, teaching patients to self-manage, Medicare part B, and their book The Guide to Delivery of Home-Based Maintenance Therapy, all on today’s episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways “It’s never been that if you don’t improve, then services aren’t covered.” “Rehab potential is the responsiveness to care.” “The myth of coverage has some roots in the denial issue.” “If there’s room for improvement, a restorative or improvement course of care is what your skills would be indispensable for. That’s what would make your care medically necessary under the Medicare benefit.” “If someone else can do it just as well as I can then this is no longer considered skill.” “We are helping patients be accountable for their chronic disease management.” “There are times that we are indispensable to help people improve and recover function back to a prior level or maybe beyond, and then there’s times we are needed to preserve and stabilise their exiting function so that their quality of life can continue on in the fashion that it currently is.” “Be a bit more open-minded with how physical therapy really works in reality. Don’t assume that what your path at the moment is THE path and can’t vary and can’t change. There are many other ways you can utilise your skill to benefit those around you.” “Don’t be afraid to ask questions, and don’t think you have to know it all.” “If you’ve got a great idea, or you have something that is a passion, and you’ve got that intersection of your passion and your skill set, go for it. Start to explore that. The possibilities are endless.”   More about Dee Kornetti Dee, a physical therapist for 35 years, is a past administrator and co-owner of a Medicare-certified home health agency. Dee now provides training and education to home health industry providers as Owner/Founder of a consulting business, Kornetti & Krafft Health Care Solutions, with her business partners Cindy Krafft and Sherry Teague. Dee is nationally recognized as a speaker in the areas of home care, standardized tests and measures in the field of physical therapy, therapy training and staff development, including OASIS, coding, and documentation, in the home health arena. Dee is the current President of the American Physical Therapy Association’s Home Health Section and serves on the APTA’s national Post-Acute Work Group. She serves as the President of the Association of Homecare Coding and Compliance, and a member of the Association of Home Care Coders Advisory Board and Panel of Experts.  She has served as a content expert for standard setting for Decision Health’s Board of Medical Specialty Coding (BSMC) home care coding (HCS-D) and OASIS (HCS-O) credentialed exams. She holds current credentials in Home Health Coding (HCS-D) and Compliance (HCS-C) from this trade association.  Dee is also on Medbridge’s Advisory Board for development of educational content on its  home health platform, and has authored several courses related to OASIS, Conditions of Participation (CoPs) and therapy. Dee is a published researcher. on the Berg Balance Scale, and has co-authored APTA’s Home Health Section resources related to OASIS, goal writing and defensible documentation for the practicing therapist. Dee has contributed chapter updates to the Handbook of Home Health Care Administration 6th edition, and co-authored a book, The Post-Acute Care Guide to Maintenance Therapy published in 2015, along with an update in 2020 titled, The Guide to Delivery of Home-Based Maintenance Therapy that includes a companion electronic workbook. Dee received her B.S. in Physical Therapy from Boston University’s Sargent College of Allied Health Professions, and her M.A. from Rider University in Lawrenceville, NJ. Her clinical focus has been in the area of gerontology and neurological disease rehabilitation.   More about Cindy Krafft Cindy Krafft PT, MS, HCS-O is an owner of Kornetti & Krafft Health Care Solutions based in Florida. She brings more than 25 years of home health expertise that ranges from direct patient care to operational / management issues as well as a passion for understanding regulations. For the past 15 years, Cindy has been a nationally recognized educator in the areas of documentation, regulation, therapy utilization and OASIS. She has and currently serves on multiple Technical Expert Panels with CMS Contractors working on clinical and payment reforms and bundled payment care initiatives. Cindy is an active member of the National Association of Home Care and Hospice (NAHC) and currently serves on multiple committees. She has written 3 books – The How-to Guide to Therapy Documentation, An Interdisciplinary Approach to Home Care and the Handbook to Home Health Therapy Documentation – and co-authored her fourth, The Post-Acute Care Guide to Maintenance Therapy with her business partner Diana Kornetti PT, MA, HCS-D.   Suggested Keywords Maintenance, Therapy, PT, Physiotherapy, Improvement, Assessment, Goals, Home Care, Rehabilitation, Accountability, Medicare, Myths, Health, Healthcare, Sustainability,   Book Discount Code (10% OFF): KK2021 The Guide to Delivery of Home-Based Maintenance Therapy   To learn more, follow Dee and Cindy at: Email:              kornetti@valuebeyondthevisit.com Website:          https://www.valuebeyondthevisit.com Facebook:       Kornetti Krafft HealthCare Solutions Twitter:            @Dkornetti                         @KornettiKrafft LinkedIn:         Kornetti Krafft HealthCare Solutions   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:               https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the Full Transcript Here:  Speaker 1 (00:01): Hi, D N Cindy. Welcome to the podcast. I'm happy to have you guys on. Welcome. Welcome. Thanks for having us happy to be here. Glad to be here. Excellent. So today we are going to be talking about maintenance therapy. So when a lot of physical therapists think about maintenance therapy, they often think that, well, this is something that's not reimbursed. This is something that maybe the patient doesn't quote unquote need. So today we're going to talk about what it is, some of the myths and a lot of other stuff surrounding maintenance care. So my first question is, can you define what maintenance care is or maintenance therapy? Speaker 2 (00:47): Okay. Karen, this is Cindy. I'll take that one. I think, you know, just as you were saying, the word maintenance, I'm sure at least one listener twitched, a little, the eye Twitch, the uncomfortable many times when you say the word maintenance, it looks like, you know, people react like you swore in church to like, oh, I don't do that. Or I, you know, somebody does that and get in trouble. And, and I think even the word has become a barrier. So Dee and I have tried to reframe the conversation by getting to the heart of what it is by referring to it as stabilization of function. So putting aside that baggage and the history of the word, the approach to care is saying I'm utilizing all the wonderful things I know as a therapist, my ability to assess and all of those great things and develop a care plan. But the end result that I'm going for is a stabilization or preservation of their functional level or slowing of decline. I think maintain can get people tied up in knots and miss the point or think that we have to do all kinds of different things, which we'll talk about in a moment with the myths. But I really think it helps to, to approach it as we're talking about stabilizing someone's function. Speaker 1 (01:58): That makes a lot more sense. And I really like that word. And you're right. I feel like maintenance care does kind of give people that, oh, I don't know if that's quite my lane, but when you say stabilization of function, preservation, decreased speed of decline. I think physical therapists are like, yeah, of course that's what we do. We'll think about it. We, we, we treat patients that have these chronic diseases right there. We don't share them. They go to doctors, numerous doctors, you know, cardiologists primary care, right. With their, with our heart conditions, they see nursing, right. They see all kinds of disciplines and all kinds of professionals. But they're never getting cured. They're it's management of their symptoms, right? So, so it's to like Cindy said, we are, we're going to preserve function. We're going to, you know, optimize their ability. Speaker 1 (02:50): We're gonna re hopefully use our skills, knowledge, and ability to reduce their demand or their requirement, higher cost centers of care. What happens when you have poorly managed symptoms of chronic disease, like COPD or CHF or diabetes, these people use urgent, emergent care. These people go in the hospital. This is extremely costly to our, to our medical system. And it's, it's not sustainable as an aging pie, you know, as we age as the population. And so this idea that there's things we can do to have people function optimally, no matter what phase or stage of this chronic condition they're in too, so that they're not as dependent or on higher cost centers of care, or they don't realize the kind of sequella, you know, think about a diabetic with poorly managed blood sugar, you know, that starts to develop retinopathy Neff, prophecy, peripheral neuropathy, right? All these other problems that happen. You know, that's all very manageable. If we can get an early and often and preserve an optimized, I even say optimize function. So we're not improving people necessarily because sometimes they haven't already experienced a decline. A lot of times we're just going in there to share what we know so that they can be accountable and manage these chronic diseases themselves. Yeah. That makes so much Speaker 2 (04:16): Karen. I would add to that, you know, for your listeners, cause some folks, you know, D and I have been talking about this for years. Some folks have a difficult time with this conversation, not just the word, but the concept. It sounds good. It sounds valuable. But I think we have to take a moment and acknowledge how deeply as therapists. We have defined ourselves by that word improvement. You can see it in our documentation. If you're going to get physical therapy, you're going to walk five feet more or 10 feet more, every time I get near you because that's, that's what I have to do. And that if I'm not improving you, we've all been told that if, you know, after a certain number of visits or certain number of treatments, if you don't see improvement, you're obligated to discharge people. When you start finding out that, that isn't really true and it hasn't really ever been true. Speaker 2 (05:06): I think we've got to give ourselves a little bit of grace here and realize that this can be quite the seismic shift internally about how we value ourselves as therapist, how we define ourselves and how we're defining ourselves to our patient populations. I think to the patients, to the potential patients, to our other members of the interdisciplinary team, we've done such a bang up job, talking about improvement, that when they don't feel that they're going to improve as, as the beneficiary or other members of the team say, well, that's patient, isn't going to get better. They don't even refer them to us. They don't even come to us because we've created this wall of you have to be able to get better, or you can't come to physical therapy. Speaker 1 (05:47): Yeah. Oh, I'm sorry. I was going to say, Cindy, what's your favorite line? When you talk about how we are addicted, like we, we are ingrained with improvement. What is your favorite line to say? Speaker 2 (05:57): Oh, well, I created a little, self-assessment like you answer these questions to get these points about how addicted are you. Because it, I feel very comfortable using that word because this challenge is a lot of those core beliefs. And we have identified ourselves by this. So tightly that it's like, okay, we, we have to step outside of our comfort zone a bit. And then as we see therapists start to do that, then we get the questions. Then we get the, okay. I kind of understand it, but what about this? And what about that? And what about this other thing? And that's when the myths all start to bubble up to the surface with where did that even come from? Speaker 1 (06:40): Yeah. So let's talk about some of those myths and see if we can bust them. So I will, I'll take, I'll throw it over to you guys. Either one of you can start, but let's talk about a couple of myths of maintenance therapy for me. One big one is, well, it's not covered. Speaker 3 (06:58): It's not covered by insurance. Speaker 1 (07:00): I'll take that one. This is thing. Yeah. Well you know, maintenance has been part of the Medicare benefit under any Medicare beneficiary part a or part B, since you can find it in the Medicare benefit policy manual, as far back as the, as the 1980s. So it's been around forever. This is not new, that Jimmo V Sebelius case that was brought forward. Just kinda shine the light on it, but it's never been that if you don't improve and services aren't covered or you don't have no, this idea that rehab potential is the ability to improve no rehab potential that we all typically document at some point is the responsiveness to care, right? That's what rehab potential is. Whether the care is going to allow you to improve from where you are at the baseline of assessment or to maintain or stabilize your function from where you are now without any unforeseen event in the next three, six, nine, 12 months, two years, are you going to be able to manage this condition and not decline, right? Speaker 1 (08:13): Or if you're in a progressive type of disease process, are you functioning optimally? And are we slowing that deterioration or decline? That is a normal part of the condition. So Cindy, I can pop a punch it over to you. And since we talk about it being paid, I think we busted that Karen. Right? We busted that pretty good. Okay. So, so other payers, I don't know, but anybody that is a Medicare provider, so under part a or part B, it, it is part of the benefit. Okay. So Cindy, talk to me about what are the type of conditions that are covered by maintenance as if the diagnosis determines it? What do we know about that? Speaker 2 (09:00): Well, very often what we hear is, okay, I understand maintenance therapy. I know what it's for. It's for people who have progressive neurological conditions. So it would make sense for Parkinson's. It makes sense for Ms. It makes sense for ALS. So it must be those three patient populations that are maintenance. Okay. We got to step back for a minute. There are patients with those three conditions that benefit and have the ability to improve with therapy. So it's not Parkinson's is synonymous with maintenance. And there's nothing in the coverage criteria that is diagnosis specific. Diagnosis is only one piece of the conversation. It is where are they functionally? What are the, what is the impact of this diagnosis and their resorted comorbidities on their functional ability? And what does a therapist know? What does that skill that you bring to the table that is unique to that discipline that is indispensable to this patient? Speaker 2 (09:56): But I think the myth of coverage has some roots in the denial issue. We, we can't go past this point without acknowledging that therapists have seen denials for providing maintenance therapy, that you did not show improvement in wham. They took away payment for part of this care, which is what drove the Jim versus civilians conversation that led to the court settlement with CMS to basically say, you know, Hey, we've looked at this benefit. It doesn't say you have to improve to get services. And, and we're, we're good friends with Judah Stein who was the lead attorney in that case, and still has the ability to call CMS back on the carpet and the legal sense about how that settlement has played out since, because CMS basically approached it with a oops, you're right. It doesn't say that shame on us, but it's like, wait a second. Speaker 2 (10:48): You've been denying coverage of services for a long time. And so it's very hard to say, yes, it's in there. And we understand it's in there. And D and I've explained the fundamental pieces of that, but there's still that I got denied, or I know somebody who got denied this can't possibly be true and it's unfortunate. And my personal opinion is I have a really hard time with CMS, just kind of Oop, seeing it versus, you know, ownership. And we saw a subsequent event to the initial Jimmo case that compelled CMS to put on their resources, particularly on their website, where they had to quote disavowal the improvement standard. So not just say oopsies, but say you have to flat out say that does not exist. And if beneficiaries qualify for these services, they absolutely should get them. Speaker 1 (11:36): Yeah. The, the, the woopsies sees that my bad defense never, ever seems to go over well, does it? No, no, no. Okay. So we talked about, is it covered? We talked about diagnoses covered. What other big myths are there surrounding maintenance therapy? All right. I Speaker 2 (11:59): Got one for you. D I got, you know, where I'm going. We very often hear they say, okay, so if it's not about their diagnosis, I need to assess the patient. Right. Figure this out. So now looking at what I typically do in an assessment, oh, test and measures. Well, those must not apply. Then I wouldn't be using tests and measures on a maintenance patient. And we would say, well, why not? Well, why would I measure something if I measure it again later? And it's the same, then why did I measure it to begin with? So any thoughts on those tests and measures in the maintenance patient D Speaker 1 (12:32): Yeah. Well, and, and I'm going to tie it to goal statements too, from there, right? So, so this idea, why do we take objective measurements of patients to establish a baseline, right? And we need to do that regard, you know, based on the presentation of the patient, regardless of their diagnoses and comorbidities, because we want to see if they're functioning at, or near where we would expect them think of a class three heart failure patient, are they functioning where you would expect, you know, a class three heart failure patient to function, or are they functioning like end stage, right. Class four, are they functioning below where you would expect them to function? And so obviously if there's room for improvement, a restorative or an improvement course of care is what your skills would be indispensable for. That's what would make your care medically necessary under the Medicare benefit part a part B that's what it would do so that the tests and measures, establish that baseline. Speaker 1 (13:30): And you compare, this is how the patient's functioning. This is how we'd expect them to function. Now, when you get a patient who is functioning at, or near where you would expect them to function with, with their PR their presentation, the question you have to ask yourself, as you don't just jump right to maintenance, right? You can't just say, okay, this a maintenance patient. They need me. Yeah. Basket. What do they need me for? You know, is there something I can teach them, train them, provide them so that they continue to stay, be stabilized, maintain, be accountable for their care over longer period of time. Right? And if the answer is yes, then you absolutely should pick them up on, on, on a maintenance course of care, because there's some sort of skills, your knowledge, your expertise, that which makes you, you, what I like to call the magic, that is me as a PT, right. Speaker 1 (14:21): And we've all had those magic. That is me moments. When you ever, whenever you walk or, or you, you readjust a, an assisted device to properly fit a patient and people look at you like, oh my gosh, why didn't we think of that? And it's just like, because you're not the magic. That is me. I mean, I, and we take it for granted. So the idea is that tests and measures absolutely help you establish a baseline and determine if there's room for improvement or they're functioning at, or near where you would expect them to function based on the severity, the course, the interplay of these disease processes. And then that helps you pick which course of care restorative or improvement, stabilization, or maintenance. And then you have to say, this is what my skills are going to be medically necessary for. So, so I'm going to tie that now to the next thing that comes, because if we get people this far down the myth-busting trail, Karen, the next thing they say is, well, how am I going to write a goal for that? I mean, if I'm not going to write something to improve, I mean, our, our documentation is called progress notes. I mean, you want to see how addicted we are. That's Cindy's line, right? We write on progress notes you know, Cindy, talk to us about goal statements. How can, how can maintenance patients actually have a goal statement if they're never going to get better? Speaker 2 (15:43): Well, I think, you know, we talked, we talked about coverage criteria, and then the documentation piece goes with that because I can't, and I'm going to kind of work backwards because what we'll see at times is therapists kind of go, okay, I understand it. And then you go to the goal statements and every one of them says, maintain this to maintain that I'm maintaining strength to maintain ADL's. And it's kind of like, okay, let's, let's take maintenance out of it for a minute. That that doesn't measure anything. What ADL's are you talking about? You didn't give any sort of quantifiable way to say what you're trying to maintain. So the goal solution is not to stick the word maintain in there as many times as humanly possible. It's still looking at it as we should be looking at it is what is that quantifiable element? Speaker 2 (16:29): How am I measuring something so that I can demonstrate whether or not we've improved it or stabilized it or slow the decline. And then the end piece is how was this functionally relevant to the patient? So I think what happens at times when D and I work with agencies about writing goal statements for maintenance, the by-product is actually their goal writing overall gets better. Because I think we've lost focus. We think, oh my gosh, I have to have an HCP goal, right? Because that's another addiction, you know, patient will have, you know, visual be independent with Hep. Well, it doesn't say what it's for. Why do you tend for them to do it forever? We don't know, but you have to have that goal. Then you have to have a strength goal. So, oh gosh, this has maintenance. I'm going to put, you know, increase a quarter grade. And yes, Karen, I have seen that documentation, the plan to increase one quarter grade, it's like, can you just go to maintenance and stop trying to improve in minuscule, teeny tiny amounts? Speaker 1 (17:27): How, how is that measured? I Speaker 2 (17:30): Have no idea. I thought half a grade was bad, but then we get into quarter grades. We see assessments that contain the terminology of severely poor. I thought poor was like the basement. I didn't know there was a tunnel under the basement. So this goal writing is really a good place to say, am I focusing in on, what am I quantifying? Why is this functionally relevant to this individual? Then we're setting the stage as to why therapy is in fact necessary for this person. I think the, I will maintain this to maintain that. Doesn't really speak to that. And then we'll go see, I got a denial. That means this whole thing is, is self fulfilling prophecy. They don't pay for maintenance. I will never do this again. And it's like, yeah, but did you really cover what you needed to cover and speak to why the therapy was important and why they needed to have it now? Yeah. Oh God, Speaker 1 (18:24): No. I was going to say, that's great. Thank you for that. Speaker 2 (18:29): But I think the extension of that, and I guess my way to push the ball back to D here as it were, is okay. So I've assessed them. I did my test and measures that wrote some goals. Now the issue becomes, I got to establish a care plan. So how often am I going to see them? And this is where at times, you know, when we had the ability to see folks in person, I swear people's heads are going to start spinning around in confusion because we start talking about things like you don't necessarily see these folks every week. You may see them once a month. And then D what about PRN visits? Can, can therapy use visit frequency? I mean, don't, we have to go or see them or interact with them at least once a week or else this won't be paid for. Speaker 1 (19:14): So talking about service utilization, you know, it's my answer is it depends. What does the, what does the beneficiary, what does the patient need, right? And so do I have to go three times a week for them to stabilize function? Do I have to go once every three weeks? What does it take? What is it that I'm doing that is indispensable for them that only can be provided by a therapist? You know, they can't go to the local you know, green, orange theory and have somebody work out with them in the gym and get the same benefit. What, why, why do you know, why does it have to be me? And so we, so we have to have an understanding of what's it going to take? How often do I have to go? And so when Cindy's talking about PRN visits, that's like a big no-no in home care for therapists, right? Speaker 1 (20:04): Under the Medicare part, a benefit in reality, it's not nurses do it all the time. You know, when they have to adjust Coumadin levels, right? For, or blood thinners, when they have to, if people still even on Coumadin, when they have to do sliding scale insulin adjustments, when they have to run labs, when they update or they're changing wound care orders, they write PRN visits all the time, but supposedly therapists can't do that. Well, that's not true because think about it. I think in, when I'm making this care plan, I'm not writing everybody for three weeks for I'm writing this person in five times a week, because they just got out of the hospital for an elective surgery. And I'm going to go every day, because if they went to an ER for SNIF, rather than home, they'd probably get daily therapy. Right. Okay. And this person was referred from maybe from their physician. Speaker 1 (20:54): And, and we're in the second episode of care, if you will, the second certification period. And there were still as ensuring that they are being, that they're stabilizing function. They're still teaching training oversight, checking, following up on 30 day reassessments to confirm that our interventions are actually working well, if I'm waiting on a piece of equipment, maybe that I decided, okay, we're going to get them a splint or something to meet, or we're going to get them this, this device. And we have to go through all the machinations with DME. I could write that I'm going to go out one time a week for four weeks. But what if that device doesn't come in for two weeks, what am I going to do? Just go, yada, yada yada. And the second week of that 30 day period, or do I just write like a PRN visit that says, you know, when the device comes, if it's not a, you know, when I would normally go out, if it's not going to be there, when I'm planning to go out, I'm not going to let it sit in my office or the back of my, you know, the boot of my car for another week. Speaker 1 (21:52): Or I'm not going to write an add on order. I'm going to have this PRN, but well, it's come in. I wasn't planning on seeing you for a week. I'll bring it out there, fit, adjust it, set it up, teach you how to put it on Don and doff it, you know, check your skin, how to wear it, everything you need to do. It's the same thing. Think about when you think about Karen, when you tell your patients, oh, Hey, if you have a problem with this exercise program, give me a call. How many calls do you get? I don't get that many calls. And then I go back out there and they're doing like rhythmic gymnastics with the Sarah band. And I'm like, that's not what we taught you. Right. That's not the correct exercise. So, so this is a way this, this kind of go out as often as you need to, and not one visit more is appropriate, not just for maintenance, right? Speaker 1 (22:37): So, so writing, writing utilization is really hard for people to understand, because they're used to seeing their patients every week and that doesn't sometimes have to happen. How long do you have to wait to see if the exercise program was efficacious two weeks, three weeks, four weeks, how long, you know, you've got to base it on what, you know, what the evidence shows us? What, what, what our, you know, our, our scientific literature says that's important. So, so I have one more myth to kind of finally push the ball back to Cindy since utilization depends. So now we've got people test to measure some kind of goals that aren't just written, maintain. We have utilization. That seems to be very beneficiary specific, Cindy now, cause they're on maintenance. I got to see them for the rest of their life, right? Speaker 2 (23:29): Yeah. That that's, that's very common and, and it kind of splits into different ways. Karen, sometimes it's the, I made a lifelong commitment because they could decline at any point in time. So by that standard, this is forever or there's the gleeful hot maintenance, a great way to go for patients that don't want to be discharged. So as opposed to them crying, when I talk about discharge or the daughter runs back to the doctor and keeps getting orders, I'll just put them on maintenance and then everybody's happy. Okay. You can't do either one of those things you still are accountable to skilled, reasonable, unnecessary. So the benefit is clear. You can't just keep going or having them come to see you at the clinic, just because you're nice. This does need to require the skills of a therapist. We're still accountable to all of those criteria. Speaker 2 (24:19): And as di said earlier, if there's nothing left to teach, train, or do I can't just do it because you either don't want to, unless I stand here or the caregiver doesn't want to have someone else can do it just as well as I can, that this is no longer considered skilled. And that's what drives the decision to discharge as well is when I have taught you what I, everything that I can the program I've given you is effective. It is in fact stabilizing function. There are no more adjustments to make. There are no things that need to be changed, then you really don't need me anymore. And that's where I think that it comes back to again, how are we finding our value that I think we've gotten very used to. They come to see us X number of times per week for this number of weeks in a row. Speaker 2 (25:07): Then we say, okay, you're done. The order is done. If anything goes wrong, then come back again. Where maintenance really makes us think about a term we use very often is how are we dosing ourselves? So thinking about ourselves, like a medication, when do they actually need that encounter with a therapist? And when we've reached a point where you don't need it, there's nothing I'm doing that is uniquely therapy, then we need to stop. But I think the hard part in that, Karen is some of our skill and touched on one, oh, I had just a piece of equipment in the family looks amazed because that is a skill. You, you know how to do that because of your training. I think sometimes the decision to discharge, we jumped the gun too fast, whether it's a maintenance approach to care or restorative by this. Oh yeah. Speaker 2 (25:53): They got it. They understand it. I don't really, you know, they're just doing the same thing, but are you still contributing something? Are you still making any sort of adjustments? Are you convinced? Because on the restorative side, I've never understood these, you know, lofty strength and improvement goals for a two week care plan that suddenly, you know, the, the they've gained a whole muscle grade in two weeks. I don't know what literature I missed, but this, this, this will be great because I'm going to go join a gym for two weeks when it's safe for me to do so. And then I will be fixed in two weeks. It's all done. So I think it, again, challenges us to think about, have we done everything that we can, are we confident as do? You've said more than once. I mean, we've taken care of mitigating concerns. Speaker 2 (26:37): I mean, if they may have a completely unexpected stroke next week, I'm not expected to be telepathic, but I have looked at your condition, given you the tools and resources. And in fact, whether there is nothing left for me to adjust to do, I am going to discharge. So there is active discharge, planning and maintenance care. We are, we are not saying because of this decline risk, then I'm here forever. And we also have to be careful because a lot of beneficiary advocacy groups have done a great job, educating our patients about this, who will then come at us with the resource. You can't discharge grandma because I've got this GMO thing. And it says, you have to, that's where I think some therapists have gotten caught and been like, oh, okay. That looks like an official document. I'm going to keep having you come to the clinic. I'm going to keep seeing you in the home. And it's like, wait a minute. That's why you have to know what the rules really are because yes, beneficiaries should be educated, but they don't necessarily understand the coverage criteria very well, just because they want this to continue. Doesn't mean it's automatic because of that, Jim. Okay. Speaker 1 (27:43): Yeah. And I think that that is where your judgment as a physical therapist and as the authority figure in that situation, you really have to come down from on that and, and be able to explain exactly why you're making that decision instead of just being like, oh, okay. I guess I'll just keep seeing the men, even though it's at this point, not medically necessary. So what, what advice do you have for the physical therapist who might be in that situation? How do they then speak to the caregiver, the patient, et cetera. So that's, that's happened to me cause I've been providing maintenance therapy. When I had my Medicare certified agency in central Florida, way back 2008, 2009, been doing it a long time because we get tired of people. We get them better and then they'd go off and then they decline and then they come back on. Speaker 1 (28:41): I'm like, we're missing something. We have to be able to monitor these people. I watched nurses do it all the time with the monthly catheter changes, right? Because most people are not good at self cathing and preventing infection and doing it accurately. So they'd end up in the hospital, you know, with some sort of puncture or something or an infection. So, you know, monthly catheter changes can happen for years and years with nurses. So what were we missing here? Here is the bottom line for clinicians. I, when I have taught and trained everything and my skills are no longer necessary. You ask yourself, is there somebody that could oversee that could carry this out with you? Because it really just requires sometimes the assistance of another person or a cheerleader or somebody to motivate you or supervise you. What we have a lot of patients that might have cognitive and limitations. Speaker 1 (29:31): And even if that person isn't available, just imagine, just ask yourself the question. If that person holographically appeared in the room, right, and said, teach me train. And they were capable. Would you give it to them? And if the answer is yes, then you should no longer be going anymore. So what I tell patients is I will say to them, I understand that you want me to come, but as a licensed physical therapist, I have a fiduciary responsibility to the payer and the payer has requirements. And one of them is medical necessity. And at this point you need to do this, but you don't need me as a physical therapist to do this. So I can teach and train you, your spouse, your family member, a paid caregiver, or you can pay me to come, right. But I cannot bill your insurance for this because I would be in essence, fraudulently saying, it's still required. Speaker 1 (30:27): My skills, knowledge and ability when I'm telling you it doesn't, it just requires another pair of hands or somebody that could be shown a lay person, how to do this. And so they're like, oh, well you calm. And then I'll tell them, this is what it costs to privately to pay for a physical therapist. And some people take me up on it. And some people say, oh no, I'll get my grandson to come over. Can you show him how to do it? And I'm like, that's great. So, so I think we have to, like Cindy was saying, we have to understand the regs. We have to understand this. Doesn't go on forever. We have to understand that when we are going to sign our name with our credentials, so hard earned right through through education and practice that we are basically signing an affidavit. If you will. Speaker 1 (31:13): That says, I attest that this meets the requirement of this third-party payer. If Benny therapists stopped, many clinicians heck stopped and thought about that. They might not provide some of the services that they're told they have to provide or do the things they have to do, but it's really comes down to our license. So when I sign that and say, this is medically necessary, I I'm going to make sure that I show that my skills and my contribution to that visit is a billable visit. If I no longer have needed for that, then I can teach and train someone else, or I can discharge them from the third-party payer and they can pay me privately. They could, it can be a cash based service. And that has happened. Speaker 3 (31:56): Yeah. Yeah. That Speaker 1 (31:57): Makes so much sense, guys. This was so good. I just know that therapists are going to have a much better idea of what stabilization care is versus maintenance care. We won't use that term anymore. Maybe we can, we can change that preservation of function, care stabilization of function, carrot just, it sounds it's. I think it sounds better for the therapist and quite honestly, like more humane, more human for the person that we're caring for. Instead of just maintaining someone, you know, we're preserving their function, we're their ability to do the things that they want to do. Just sounds so much more, I don't know, human than maintenance care. It sounds so cold and sterile. I don't know. Maybe it's just me. No, I think, you know, for me, when you say that, it makes me think that we are helping patients be accountable for their chronic disease management. Speaker 1 (33:01): Right. We are teaching them what we know and how important it is for people with aerobic impairments that they have to maintain that lung capacity you know, within the confines or the constraints of that disease process so that they can continue to do their self care, which is metabolically demanding. Right. So, so it, it really, it really shifts responsibility. I think maintenance is a very passive sort of thing that, you know, we're, we're maintaining range. You know, I, I think you know, people that were doing stuff to versus where we're in we're we're arming people with the ability to manage and be accountable for their chronic disease and to, and to function optimally within the constraints of those, that disease or those diseases through a stabilization or preservation of function. Yeah. Speaker 2 (33:55): And I think it's important to, to just kind of circle back a minute that we don't want the visual now to always be maintenance patients or stabilization patients are very debilitated, have to have a caregiver, very ill individuals. These, we can teach these types of programs to the patients themselves, for them to self manage. I think sometimes, you know, okay, I'll give it up. It's not Parkinson's ALS and Ms. I got that point, but these must be like really sick, bad off people. They might be, but they might not be, they might be the heart failure patient that's functioning pretty well right now, but has a history of pushing themselves too hard. So the now kicks in the fluid overload. It ends up back in the hospital because they're overdoing. How do you better task plan? How do you help someone understand when their disease process gives them good days and bad days? Speaker 2 (34:45): What, what do we want them to do on a good day? What do we want them to do on a bad day? Because we know many of our folks that are receiving therapy. Cause they basically think that we're gym instructors, we're gonna, you know, show up for the treatment, wearing spandex and tell them to drop and give us 20 anyway. So we're trying to get past that, but on a bad day, too many of our patients, regardless of diagnosis, sit and wait until they feel better, maybe, you know, with a recent orthopedic surgery, a little bit arrest, okay. We encourage some rest. That's not a problem. And some of these chronic diseases, you're one day turns to two days, turns to a week, you haven't done much of anything and now you've compounded the problem. So I think you're right. It does feel like we're utilizing our skills in a more person focused way meeting them where they are. Speaker 2 (35:34): But I think, you know, very often just briefly we'll get the, well, what are the treatment interventions for maintenance you didn't in this whole conversation, give us any treatment strategies because it's not about the treatment. It's not about the assessment. We do what we do. We have the tools in the toolbox, but what, what are we trying to get to? What is the end vision for this individual? And then I'm going to utilize what I know how to do best in that context. I just think for a lot of us, we felt that door was never open. That you were not supposed to do that. That if you could not show significant improvement that you had to discharge and Dee and I have seen therapists, when you see the wheels turning, I've said a couple of times we need to develop like a stages of grief equivalent for the discussion of maintenance, because we'll have people get mad. Speaker 2 (36:21): Like I can't believe nobody told me this. And then you'll see guilt, you know, oh my gosh, I've had patients and I discharged them. I thought I was doing the right thing. I'm a horrible therapist. What am I going to do now? And it's like, okay, let's just start looking at the information and change what we do going forward and not go backward and be all upset and think we're horrible or mad about who lied to me. It didn't tell me about this before, but we do need to start making a difference. Cause D and I heard far too often, you know what? That was interesting ladies, but we don't do that here in this clinic. We're not going to do maintenance therapy. And it's like, wow, you just get to unilaterally, decide you're out. If you want to be out, that's fine. But then you want to direct them to a clinic that does do it because if they need it and they qualify for it, then find them a provider who will, but this kind of, oh, I never heard of it. I'm not participating thing is, is very frustrating in the current environment. Speaker 1 (37:14): It's, it's not correct. I mean, we have to understand beneficiaries have paid into this benefit. They are entitled to it. And if their presentation is such, that stabilization of function is the appropriate course of care. They are entitled to it. It is part of their benefit package. You don't have a right to say, oh, we'll take you on care. But you know, you're not going to get that. That that's that's you, you can't do that. I mean, you either provide the care that is within the insurance. Right? I mean, think about it. If you went to Jiffy lube for your 32 point checkup and they charged you 90, 95 and, and you only got 10 of them because that, oh, we don't do those other 22. Would you be paying for, I wouldn't as like, listen, I'm entitled to this. This is what I'm appropriate for. Speaker 1 (38:07): It's part of my benefit. Maybe you don't do it, but you can't determine that I don't get it if it's part of my benefit package. So it really comes back to the beneficiary. If they're entitled to it, we, as professionals are not ones to say, we can recommend and say, I don't think that's the appropriate course of care. But to literally say, we're, you're not getting that component of your benefit. I don't think that would go over very well. Do you care? Do you not? No, not at all. Not at all. Especially with, you know, like you said, people have been paying into this, their whole working lives. If it is part of the benefit you should offer it. For sure. And if you're a physical therapist who says, I don't know how to do that, well, you better get educated and learn how to do it. Speaker 1 (38:56): Exactly. The things that I am not the most gifted at as a therapist. So I'm not just going to start dabbling in dry needling. Okay. That's that's not my area. Oh yeah. Just give me some, you know, go into the pin cushion and let me start working on you. It's a skill set and it's something that you have to understand the rules and regs. You have to understand what the payer source requirement is, but we as clinicians don't need any other evaluation skills. We don't need any other tests and measures. We don't need special interventions. What we need to understand is that there are times that we are indispensable to help people improve and recover function back to a prior level or maybe beyond. And then there's times we are, we are needed. We are indispensable to preserve and stabilize their existing function so that their quality of life can continue on in the fashion that it currently is perfect. I was going to say, do you want to button it up? But I feel like that did it, but now listen, before we wrap things up, let's talk about the book, the guide to the two delivery of home-based maintenance therapy. So talk about the book, where can people find it? And what will they get out of the book? If people go and purchase this book, what are they getting? Speaker 1 (40:16): Well, they're going to get DNA, Cindy. That's what I'm going to start with. They're going to get us, they're going to get us. They're going to get an updated version. I think it's the only book. And actually it's our second edition and really focused on community-based care part a and part B for Medicare, right? Whether it's part B in a clinic or part B in the patient's home. And we really focus on the rules and the regs. And we and, and literally walk you through common case scenarios. We try to myth bust, and we try to give you a how to like how to start to think about this, because I think theoretically or conceptually when, Cindy and I talk about this and we've been talking about this for eight or nine years now. And teaching on this, people don't disagree with this. They fundamentally understand, they just don't know how to operationalize it. They don't know how to, if they see it. Okay. Well, I understand what you're saying. I understand. I, I agree with you. That would be, I could see where that would happen, but then how do I do these things we've talked about? So Cindy, what does this second edition really afford them? This time around that, you know, it was kind of like a value. Speaker 2 (41:30): Well, I think part of it came from, we were folks, as you just said, understand the concept, but then struggling to say, I got chew on this for awhile. This is really going to change my core, that I am not just defining myself by improvement. I got to work through some stuff and figure out how to do that. And so our first edition started out. We have a consistent scenario throughout to really talk about assessment and goal writing and detail and all of those pieces. But then as we looked at the second edition, we said that that's a good place to go. You got a nice, consistent scenario. It builds throughout the entire book. So you have opportunity to do that. But then this time around you know, I think you got the sense. I tend to be more in the regulatory nitpicky, wheelhouse, and D tends to go toward the operationalization side. Speaker 2 (42:18): And so she brought up, why don't we put a workbook with it? Why don't we add to that idea of a consistent scenario and say, what are some additional knowledge application activities? How do you comment that same thing about assessment or goal writing a little bit differently than one scenario to really get the juices flowing about how to do this. Now, the challenge is, is there a right answer? Like, do I just go to the answer key? And there was only one way that could have been done while listening to this conversation. There was quite a few, it depends. How often would I go? What would I focus on? So the answers give you some context, some suggestions, some validation, but it was not meant to be, there's only one way to do this. And in a scenario, you know, five sentences long, you better figure out exactly what you would do all the way through this only one path, but it's really to help kind of put those guard rails on and say, well, did you think about this? Speaker 2 (43:14): Or what about that element to, to be able to say, okay, I am understanding this. So I could use that as an individual to go through that process, or I could use it in an organization and do it as a group activity, but to really help people continue to process what sounds like. Yeah, I got it. But now I have a patient in front of me and, and I'm still stuck. Old habits die hard. I still struggle with the goal. I still think I can fix this. I, I still feel that voice in my head. That's telling me if they're not getting better, you're not supposed to be here. So people need that opportunity. So we wanted to provide that in a tangible way that, you know, doesn't really lend itself to an educational event unless the thing was days and days long, and people camped out with us, which nobody wants to do. But gives them that opportunity to come to step away, think about and come back to it at their own pace. Speaker 1 (44:07): Awesome. And just so everyone, all the listeners out there the book, the guide to delivery of home-based maintenance therapy, it's on the Kornetti and craft website, but we will have a link that takes you directly to the book and, and listeners. If you use the coupon code KK 2021, you'll save percent on your purchase. We will have all of that at the show notes at podcasts on healthy, wealthy, smart.com under this episodes, you don't have to remember it. You don't have to send everybody DMS and things like that. Just go to podcast at healthy, wealthy, smart.com click on this episode, it'll be under the resource section in the show notes. So we will make it very, very easy. That's all you got to do is one click, and it'll take you right there. So now before we wrap things up, the question I ask everyone on the podcast is knowing where you are now in your life and in your career. What advice would you give to your younger self? Speaker 2 (45:19): Come on Cindy? I would say, well, I, I would say to my younger self to be a bit more open-minded with how physical therapy really works in reality. I think career-wise would come out. I came out very, this is what I'm going to do. And, and briefly my goal is I'm going to work in a traumatic brain injury unit. I loved working with that population as a student, I'm going to be a famous therapist in a big old rehab facility. And now I'm going on nearly 30 years in home health and have never actually worked in a, in a fancy schmancy rehab clinic. I started this kind of on the side, fell in love with it and never went back. I tell, I tell students all the time, don't assume that what your path is at the moment is the path and can't vary and can't change whether you go into teaching, whether you go into other avenues there's a lot more possibilities and it took me a little while to process that piece to say there, there are many other ways you can utilize your skill to benefit those around you. Speaker 1 (46:28): Excellent. D I would say to my younger self I may not come across that way now 30 going into my 36 years a PT, but I would say don't be afraid to ask questions and don't think you have to know it. All right. So I, I think that I kind of stayed in my box a little bit more and got really, really good at what I did. Some of that time, Cindy was in a traumatic brain injury a locked unit and I got very good at what I did, but I had a lot of questions about, but what if, but why not? Right. And I think sometimes I kind of just that maybe I shouldn't ask that question. I was a little bit too con you know, self-conscious about it. And so I, I think the idea is ask those questions, be fearless. Speaker 1 (47:18): And, and instead of asking, why would I do that? You know, look around. Why not? You know, I'm a big, why not, if you've got a great idea, you have something that is like a passion, and you've got that intersection of your passion and your skillset go for it. Right. A good friend of Cindy and mine Dr. Tanya Miller started event camp for kids. Like when she was like a new grad PT. It's like in it's what, 27th year. And she's written grants for it. And, you know, they take these kids on ventilators out in kayak. I mean, you can do it, you can do it. So be fearless and don't be afraid to ask questions. Don't don't, don't think, oh, well, I don't know as much as Karen Litzy or I don't know as much as Cindy craft, you know, start to explore that the possibilities are endless. That's what I would have told myself when I was younger, fabulous advice from both of you. And I couldn't agree more. Thank you so much for coming on for sharing all of this great information and your book, and it's just sounds great. So thank you so much, Dee, and thank you so much, Cindy, for coming in. Thanks for having us, Karen. It's always nice talking to you. Pleasure. We had a great time. Excellent. All right. And everyone who's listening. Have a great couple of days and stay healthy, wealthy and smart.  

In this episode, Circus Medicine Specialist, Emily Scherb, talks about all things circus. Today, Emily talks about recreational circus, how physical therapy comes into play, common circus injuries, and the things physical therapists should be aware of. How is “circus” defined? Hear about important lingo, one of Emily’s favourite circus stories, and get some valuable advice, all on today’s episode of The Healthy, Wealthy & Smart Podcast.     Key Takeaways   •       “Circus is everything that can happen in a performance environment that would be defined as ‘circus.’” •       “Ask questions. It’s okay to not know. With these artists, they’re expecting you to not know.” •       “Figuring out the demands of the sport can be really challenging if you don’t speak the language.” •       “Every circus artist has a video of them training on their phone.” •       “Use the knowledge you have, and then seek more information.” •       “Circus really is for everyone.” •       “Be brave enough and take the time to listen more. It really does take bravery to admit you don’t know everything.”     More about Emily Scherb   Dr. Emily Scherb is a physical therapist specializing in circus and performing arts medicine. Through her 30 years of training and working in the circus arts she has gained deep insight on how circus bodies work in the air and on the ground. Emily now teaches workshops for circus artists, instructors, and healthcare providers with the mission of improving health and safety in circus training and performance. Her bestselling book Applied Anatomy of Aerial Arts was published in 2018.     Suggested Keywords   Circus, Physiotherapy, Medicine, Artists, Safety, Injuries, Lingo, Performance, Healthy, Wealthy, Smart, Healthcare, Training, Fitness,     Get 80% OFF Emily’s Course: Learning The Ropes Course 12 Weeks of Circus-Based Knowledge and Content: Circus Fusion   Circus Vocabulary List: Circus Vocabulary   Get Emily’s Book: Applied Anatomy of Aerial Arts       To learn more, contact Emily at:   Email:              Emily@thecircusdoc.com Website:  https://www.thecircusdoc.com Facebook:                        The Circus Doc Instagram: @thecircusdoc Twitter:    @thecircusdoc LinkedIn: Emily Scherb   Subscribe to Healthy, Wealthy & Smart:   Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy- smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:                                    https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:               https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the Full Transcript Here:  Hi, Emily. Welcome to the podcast. I'm happy to have you here. Speaker 2 (00:06): Hi, thank you so much for having me. It's really exciting to get, to spend some time talking about circus with you. Speaker 1 (00:11): Yes, and I'm excited because as we were talking before we went on the air it was, it sort of changed my outlook on what circus is and what circus quote unquote performers are. So we're going to get into all of that, which I think the audience will really love. But before we do that, can you talk a little bit about your journey into this niche, into working with circus performers or circus athletes? Speaker 2 (00:40): Absolutely. I started off as a kid who loved gymnastics love to flip and fly and just be in my body and move through space. And I stumbled on circus as a hobby at a summer camp when I was a kid. So I started doing circus and I was really young and realized that I loved to perform way more than I love to compete. So the competition aspect Gnostics was fun for me, but I really just liked being out there in front of the judges and smiling and doing my thing. And I realized I could do that with circus. And it was a really collaborative collaborative environment and very challenging and very similar ways. And so I started circus as a kid went through high school, continuing to expand my knowledge about spickets and my own body. When I could, there was not a lot of resources for learning circus at the time. Speaker 2 (01:27): And after high school, I moved out to the West coast and joined some aerial dance companies to continue to pursue professionally knowing I'd go back to school eventually. And I did. So I went, I went to undergrad every summer, either working at a summer camp teaching circus, cause that was a popular place for circus schools to be, or wherever I could get a job teaching circus doing circus during the summers after college, once again, much, much to my parents' chagrin. I took more time off to go back and do more circus. And I moved to New York to your neck of the woods, spent some time there working with a dance company called strep and with trapeze school, New York while I was there and teaching circus, doing circus and professionally using my body through space as a performing artist before going back to grad school. And then even in grad school, I may have taken residencies and done my clinical rotations where there were circus schools. So captain was part of my life for sure. Speaker 1 (02:29): That's amazing. And now before we go on, can you define what circus is? So you're teaching circus and people think, wait, circus is, I thought circus was a show or an event. So I'm a little confused. So can you define what that is? Speaker 2 (02:47): Really great question. When I say circus, it's also going to be slightly different than when someone else says circus circus is everything that can happen in a performance environment that would be defined as circus, which is debatable even in the circus community. So circus is acrobatics. It's aerial artists, it's juggling, it's clowning, it's acting, it's dancing, it's communicating through movement, it's performing arts and what qualifies a circus is kind of the definition of the individual company members that are involved in the, in the creation. When I say I'm teaching circus for me, I'm primarily teaching aerial arts, I'm teaching flying trapeze or I'm teaching aerial silks. It's like that fabric that hangs down or I'm teaching a static trapeze or rope or web there's lots of different apparatus and lots of different challenges for the body. I just prefer my challenges to be off the ground and in the air. So when I say teaching circus, I personally mean Ariel. Generally I have taught tumbling as well. But circus is a huge, huge arena for challenges to the body and performance challenges in space. Speaker 1 (04:09): Awesome. And now when, when we're talking circus and when people think of circus, they might think of Ringling brothers, Cirque de Solei, these, you know, grand extravagant performance artists. But I know what you want to talk about is the growth of what we would call recreational circus, recreational circus athletes, let's say. So I want you to talk a little bit more about that. I'm just going to throw the mic over to you to let the listeners know what the heck is that and where does a physical therapist come into play? Speaker 2 (04:47): Absolutely. so circus in the U S has grown exponentially in the last 15 or so years. We went from having maybe 10 schools for all levels. But like I said, I started a summer camp. That was an opportunity. A couple of the universities around the country have had circus schools. So like Florida state university has one. There's some youth circuses in, in like circus Ventas in Minneapolis, Minnesota when actually youth circus out here in Washington where I am, those have been around for a really long time, but then there's this phenomena of circus rapid rapid growth in this last 10 years. We've gone from those 10 or so schools to having over 800 schools in the U S that I know about, and that's counting circus schools. That's not including aerial yoga. And that's not including pole-dancing studios that might have an apparatus or gymnastics gym that might have an apparatus or two in their space. Speaker 2 (05:46): So circus has not only grown for recreational use of it's not only grown for recreational artists across the country to, to try to do after work or on the weekends. It's also growing in these other niches and, and kind of just keeps expanding. So there's things that we can all do after work or on the weekends to keep our bodies healthy. This can be our, you know, our soccer game instead of soccer game, I'm going to go take a class and I'm going to stay fit and stay strong and build my community through the circus world. The other thing that's really happening in, in an interesting way in circus is the development of what's called social circus, which is using social using, just using, Speaker 3 (06:35): There we go Speaker 2 (06:38): Social circus, which is using circus to do outreach and community building through specific groups often involving a social worker or using trainings that have a lot of which have been developed by search delay through a program, they call sick demo to do outreach in schools and in different settings that make people grow and increase physical literacy to also increase health literacy. There's a urban youth circus in St. Louis called circus harmony. That's been around for decades. I should know when, but it's been around for decades and they have youth classes and they also have these youth performers performing every weekend at a, at a museum. And they perform every weekend. They have the social responsibility of showing up, getting their work done. They, they really have that community building element. There's also been studies all over the world, but the one I'm thinking of in Canada in the fiscal education system that uses circus is as PE class to have an equal growth of both boys and girls. Speaker 2 (07:47): And they find that that does not have a gender differentiation. Everyone has an increase in physical literacy in those, in those groups. So it's a great way of reaching out that way. Here in Seattle, we have a women's group, a women's circus group. That's run by a social worker here which is a really great resource for, for these women. We also have a boys and girls club group that comes in and we have on the other side of things on the more medical side of things, we have circus it's been adopted for anyone to participate. There are juggling tools that don't actually involve throwing and catching. They involve rolling in gliding so that they can be a little more accessible. We can take our aerial apparatuses and lower them down to the ground. So we can use it like the aerial silks, more like a sling or a hammock where you can tie the bottom together. Speaker 2 (08:36): And you can use that for compression. You don't need to have quite as much balance or grip strength. So we've been able to do work with kids with cerebral palsy and had great work with them on the trampoline, kind of getting some, some input with them there and then taking them to the air and they get to do things that are cooler than their friends. They have to go back into and tell stories. And on the other side of that, we have adults with Parkinson's and we have a Parkinson circus group and using the novel learning novel movement, learning of circus with Parkinson's to make improvements and give them more comfort moving in their bodies as well. So circus has just really expanded into the recreational world and into every aspect of movement, which has been incredible boon to, to see, and, and to be on the sideline of, as a physical therapist, my personal interests tend to be more on the orthopedic side, but if there's someone out there who really loves working with pediatrics, and you want to get involved with circus, how cool, you know, someone, someone comes in your door and they have difficulty with dorsiflexion, but what if the goal is to hook their foot on something instead of just trying to make their ankle move, you know, and it gives different goals and different levels of excitement for all sorts of artists of all ages and abilities. Speaker 1 (09:53): I mean, this is so much more than I was thinking. I was literally thinking that what you do within circus medicine is just working with like Cirque de Solei or professional. Like I had no idea, the large umbrella that is sort of circus and that is circus performing and yeah, so much more fun, Speaker 2 (10:19): So fun and so cool. And it's incredible because all these schools have popped up that most of us can within a couple mile radius find a circus school to take a class in on the weekends if we want, or are likely to, as healthcare practitioners have a client will walk in the door, who's taken a class and wants to get back to doing it as their physical activity. Speaker 1 (10:39): Okay. Well, let, now let's talk about that. So, because let's say you're a physical therapist and maybe this is not your specialty, but like you said, if there's this huge rise in recreational circus, we may be seeing people who are coming in for an injury that maybe they got well doing circus. So let's talk about what are some, and if there are common injuries that one may see understanding to all the listeners understanding, like we said, this is a huge umbrella, so we're not going to go over every single injury, but let's talk about some common ones that maybe the everyday PT might see from one of their recreational circus athletes. Speaker 2 (11:23): Probably the most common one that I see in my practice is chronic overuse of the shoulder. And when I say overuse, I mean under preparedness for the activity that they're undertaking and that's because most of us live our day-to-day life, especially right now in front of our computers, typing away with their arms in front of us and reaching out to our laptops. And then when we go into the circus world and we're all of a sudden asked to bring our arms all the way up, overhead stabilize our entire body weight, without relationship to the ground, or only in relationship to the ground, if our legs are over our heads and we're in a handstand, our shoulders just aren't necessarily prepared for that level of load. And so there's definitely a pattern of different shoulder problems that crop up. So there's, there's a lot of chronic shoulder pain. Speaker 2 (12:13): And some of my job is also go into the circus schools and educate these artists that, that chronic shoulder pain is not normal and that they can get rid of it. So that's also a huge, huge thing is there's a, a saying in circus that is pretty pervasive, which is circus hurts and circus does hurt in that you're pushing your body in new ways. You may be having pressure against an apparatus. Maybe you get a bruise and that's okay, but circus shouldn't hurt like an injury hurt like deepen the joint hurts. So that's one of those things I try to get out there and, and explain to people there's of course, more acute injuries both of the shoulder and the rest of the body, but that, that's one of the biggest ones, especially in my aerialists and a little bit in my hand balancers. Speaker 2 (13:01): And even my recreational contortionists, that is a thing we have recreational contortionists now, which is incredible. The other really big injury is hamstring strains, proximal, hamstring strains are a huge one. I can. Same thing. Yeah. So we're getting to end range possibly with dynamic motion. So maybe if there are tumbling and working in the ground and they go to do a Cartwheel for the first time as an adult, or the first time in a very long time as an adult, and you're kicking your leg approaching end range rapidly without necessarily the preparation, strength and control at that end range. So that's, that's another one that's really common. And then, Oh, go ahead. Oh, say one of the, the third, probably most common injuries are ankle sprains, either from landings or falling off mats. So often protective equipment can also be in an interesting challenge as well. Speaker 1 (13:55): Oh yeah. That makes a lot of sense. I was a gymnast for many years when I was younger and I always had an ankle sprain. So I would feel like I remember being on crutches at least once a year, once every other year from an ankle sprain. So I can definitely see that now let's say you're a physical therapist like me or others who do not don't have like this vast knowledge on circus and what is involved. And someone's coming in to see me with chronic shoulder pain. I don't expect you to go through a whole eval here, but what are some things, maybe some questions we want to ask some things that we should be aware of and then maybe even some resources you can send us to, to look at, Hey, what are these people doing? Speaker 2 (14:45): Yeah. So great question, because I think it really will be a challenge that we will face soon. I hoping circus keeps growing beyond the pandemic. And as, as circus schools keep keep expanding. And I hope that you will get to see eventually a circus status walk into your clinic. So the first thing is, ask questions, ask questions, ask a lot of questions. It is okay to not know with these artists, they're expecting you to not know. They, they probably learned relatively recently, all the things that they're learning about circus. So ask questions, ask them what their discipline or their apparatus is. Ask them if they're an aerialist or a ground Acrobat. Are they doing handstands on the ground? Are they doing handstands on another person holding them up? Are they hanging from a bar or a horizontal apparatus grabbing kind of like with normal shoulder flection or are they holding a vertical apparatus? Speaker 2 (15:43): Like those aerial silks where they might be grabbing one hand up stacked on top of each other. Let's just give you, gives you an idea of what kind of shoulder range of motion they're going to need. And what they need to do with their body is also asking what level they are. Because as recreational circus grows, circus artists people are defining themselves as circus artists in different ways. So the recreational artists may still say, I'm a circus artist. And so might your professional. And so really diving down, what does their training look like and who are they? And then specifically to the shoulder, I just want to reassure everyone that circuit shoulders aren't that different. They are just functioning at, at end range. So you just need to make sure that all the things you normally look at are working and are working at and range. So if they need to get into field reflection, making sure those last 10 to 15 degrees, if their mechanics look perfect and I do a lot off the ground sorry, I do a lot on the ground without them being in the air. And you can learn a lot just by watching their movement through everyday activities. Even if they're not having pain with those, they may only have pain with their circus activity, but there's still things you can see with your professional life that really can be helpful. Speaker 1 (16:57): Awesome. And then obviously when you ask those questions, you look at that end range being so important, and then you get into the treatment. And again, this is where, you know, as a physical therapist, you're looking at, what are the demands of the sport? What does this person have to do? And how can you create a plan around that? Is that about right? Speaker 2 (17:17): Yeah. And so figuring out the demand to the sport can be really challenging if you don't speak the language or you don't know what the apparatus, the discipline is that they're doing. And here's the cool thing. Every single circus artist has a video of them training on their phone. Speaker 1 (17:31): Oh, that's so smart. Of course. Right? Speaker 2 (17:33): So everyone's like setting their phone up in the corner and watching themselves trained. If they have a move that's painful, they usually have a video of that too. If you didn't ask them in advance to take one, if you have that opportunity, that's fantastic. And if not, just ask them, Hey, you have a video of you doing that and you can get a general idea of what they're doing. If you, and, and that's interacting with your patient as well, in a way that's kind of building that trust trust with them, that that level of interest, if you have advanced knowledge and you kind of know what's going on, Google it, it's amazing. There's so many beautiful performers out there and you can Google almost any apparatus and see how they interact and what they need to do. Again, it's going to depend on their level, but it gives you an idea or even better. If you do have access to a circus school, taking a class, if you have the have the ability to do it, or just go out and observe and see kind of what's going on with their bodies it can be really fun and educational and the, both the students and the coaches usually love it. They love knowing that healthcare providers are interested and want to get involved with their bodies and help them perform better. Speaker 1 (18:41): Awesome. That's all great tips and great advice because I just don't want PTs to walk away from our conversation and be like, well, that was really cool, but what am I supposed to do? Well now, you know what to do. Speaker 2 (18:53): Absolutely. Yeah, yeah. There's plenty of resources out there. There's not plenty of resources out there. There are, there are resources out there to seek knowledge in how to work specifically with circus artists, but there's so much you can do with the knowledge that you already have. And that's the real key is use the knowledge you have and then seek more information. The artists are great resource themselves, and they really want to get the most out of the treatment and that interaction. I have learned so much from my artists. I give them an exercise, they come back making it three times more relevant, and I've taught me so much over the years, which is just absolutely incredible. Speaker 1 (19:35): Yeah. That's pretty amazing. And is there like lingo or jargon that if you're going to be working with this population that you should really know, Speaker 2 (19:46): There is some lingo, some jargon I can happily get you a link to a vocabulary list that I have. And I'll, I'll get that over to you. So that there's a little bit of a little bit of lingo that, that helps. There's some things that just having a few words mean so much to these artists to just feel welcome. So taking the time to look over and things like that is great. Some of the lingo you should know is Ariel is anything off the ground. A bass or a Porter is a person who throws someone else or move somebody off. And they place them in space, either from the ground or from hanging the flyer is the person who's being manipulated. Right. And then some other things that are really helpful, kind of coming from the domestics world, the idea of opening or closing a joint is kind of a similar to flection or extension opening in the shoulder cases. Speaker 2 (20:47): And closing would be extension hips. Closing the joint would be fluxion opening extension. So like when they're artists are saying things like that inversions are hand balancers are doing inversions when they are turning upside down. Our air lists are inverting when they turn upside down as well, but they're hanging from their hands. So that's another really common place that there's pain is as we're changing through all those planes of motion. That's another really helpful term to note as well. And then that, that vocab sheet just has some of the common ones on it. Of course the circus being so broad, it doesn't cover everything, but it gives it a good starting point, at least a starting point for us. Speaker 1 (21:29): Yeah, absolutely. And, and I'll have that in the show notes at on the website under this episode so that people can, can click and download that. And, you know, as you're saying all of this, gosh, it does sound a lot like the competitive cheerleaders, the flyers, the base. So, you know, learning about the rehab, learning about rehab within the circus space can really translate out to a lot of other areas of, of athletics, I suppose, Speaker 2 (22:03): And the other way around. So if you are working with St gymnast or park core artists or climbers or cheerleaders there's, there's so much inter relatedness of the movement, other, so there's so many connections in, in how there's so many connections and how these artists move to other things, because circus is so broad, it comes from a tumbling background, it comes from a climbing background. It comes from all these things that have been pulled into what is now currently circus either in a contemporary or a more traditional sense. Speaker 1 (22:38): Yes, yes. I think that's great. And, and for me, this cleared up a whole heck of a lot because I had no, I mean, I had an idea of maybe what a physical therapist can do, but boy, it's so much more, it's just so much more, so it was great. So much more than I thought. Like, I, would've never thought of working with children's cerebral palsy or adults with Parkinson's or the recreational, the growth of recreational circus didn't even come into my head and I'm in New York city. I see that trapeze on the Hudson, you know, like I know it exists and I know it's not professionals using it. Know, we all saw that sex in the city episode when Sarah Jessica Parker was flying on that trap piece. Right. Speaker 2 (23:27): Absolutely. I was happy to be involved with that school at the time. And it was a blast to be there. Speaker 1 (23:33): Yeah. Oh, I bet it was. Yeah, I bet. So I, so when people, when therapists say, Oh, I'll probably never see anyone that works in the circus, ah, you don't have to be a professional. So you might, Speaker 2 (23:48): I don't have to be a professional and those recreational artists need help. And if I have a moment to tell a story, I would love to, one of my favorite stories is I had the pleasure of talking to someone, not a patient actually. She's 72 year old woman. And she was telling me her story, which is she went golfing and she hurt her shoulder, playing golf for club into the ground, hurt her shoulder. And she was fine doing everything she does except for pole dancing because she was also a recreational pole dancer. And so she went to go see her doctor. And she said, doctor, my shoulder hurts my pole dance, but I'm fine. Otherwise I heard it playing golf. And he said, well, you shouldn't pull down. That's dangerous stick to golf. And it's like, it's just so interesting. Our preconceived notions of what our normal activities for our body. She's 72, she's spinning in space. She's holding her body weight up. She's doing proprioceptive training, strength, training full body movement, mobility work. How much better could it be than that? And, but golf is the normal activity. So the more we normalize recreational circus and make it more part of our practice, the more helpful we can be to keep our patients healthy and active in doing the things they love. Speaker 1 (25:01): Amazing. And now I have to tell you, after watching the super bowl halftime show, not this year, but last year with Jayla and Shakira, I was like, okay, I think I, I need to do some pole dancing here because, Oh my gosh, like J lo is out of this world, you know, Speaker 2 (25:20): It's an amazing fitness tool. It really is. Yeah. It's on so many aspects. Speaker 1 (25:25): Yeah. Oh, and I never thought of that as being in circus again, under that circus umbrella, but of course it is. It's just your apparatus is the pole versus the silks. Speaker 2 (25:35): Exactly. Exactly. And again, it'll depend on the person and how they want to define circus because it keeps changing. But there are many circuses now that do include pole and there's even something called swinging pole or hanging pole that moves in space instead of just staying. Speaker 1 (25:50): Oh my gosh. No, thank you. Oh my gosh. That's crazy. Well, is there anything, do we gloss over things? Is there anything that we didn't hit that you're like, Ooh, I really want the listeners to take home this. Speaker 2 (26:06): I just really want the listeners to understand that circus really is for everyone that you can go take a class right now and that you might have a client in your waiting room at any moment that has at least some experience with it. And being able to speak that language or having a little understanding of what they do can really go a long way. Speaker 1 (26:23): Excellent. I love it. Now, where can people find you? Where what's your website? Where are you on social media? If they have questions, they just want to say, wow, this was awesome. Where can they find you? Speaker 2 (26:34): They can find me on social media at the circus doc on Instagram, on Facebook, on Twitter. I'm on most of the things I was going to say, all the things that I'm on Tik TOK yet. But I am out there on at the circus doc and my website is the circus doc.com. And through there you can find the courses I teach and lots of information lists of physical therapists that like to work with circus artists and other resources to help improve your knowledge about circus bodies. Speaker 1 (27:04): Amazing. Well, thank you so much. And before we sign off, I have one last question and that's knowing where you are now in your life and your career. What advice would you give to your younger self let's say right out of, right out of PT school? Speaker 2 (27:18): I think the biggest thing is taking the time to you. The biggest thing is to be brave enough to take the time to listen more. I think it really does take bravery to admit you don't know everything and to do more listening and do more and better question asking both of my patients and of mentors and of just the resources around me. I think in the last couple of years, I've just done such a better job of connecting with humans like yourself and, and taking the time to ask questions because you just never know what you're going to learn and where you can help each other on this great journey that we're not in competition and having the bravery to collaborate. Speaker 1 (27:58): Amazing. What great advice, Emily, thank you so much for coming on. This was great. I'm like so excited because I feel I learned now and like, I was like, I want to go take a class. So next time I'm in New York, we'll go together. Perfect deal. I will hold you to that. Thank you so much for coming on. Speaker 2 (28:15): Thank you so much, guys. This was a bunch of fun, Speaker 1 (28:17): Everyone. Thanks so much for listening. Have a great week and stay healthy, wealthy and smart.  

In this episode, author of The Full Spirit Workout, Kate Eckman, talks about achieving success and fulfillment. Today, Kate talks about the 5 P’s of Confidence, the story behind the Full Spirit Workout, and how we can find personal fulfillment and success. How can we boost our mental metabolism? How can we achieve our goals? Hear about coaching programs, how to handle perfectionism-itis, and get some valuable advice, all on today’s episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways “Coaching isn’t consulting. It’s not therapy. It’s not problem-solving.” “Remember to stay in your own lane, think about the impact that you want to make, and the work that you’re here to do.” “So many people see the end result and they just want that, but what they dont see is all the work that we have put into it.” The Five P’s of Confidence (and 2 Bonus P’s): Presence. Being fully present where you are, in the moment. But also, showing up like you mean it. Patience. “Hold on loosely.” Put in your work, take those action steps, and then take your hands off the wheel, gently lean into trust, detaching from those outcomes, release expectations, and trust in the process. Purpose. This is your ‘why’. It’s important to have a strong ‘why’ that will keep you going, even when it doesn’t feel like anything is working out for you. Preparation. Build habits that lead to better behaviours that lead to better results. Practice. Your talent warrants investment. Pause. Take a moment of mindfulness. Person. Be a person. Lean into not only the person you present to the world, but the messy person behind-the-scenes. “We don’t often give ourself the grace to expand our inner selves.” “You can do whatever you decide is important enough.” “Everyone is struggling with something.” “Even if you don’t tell someone else, tell yourself the truth.” “It’s all happening. Keep going. Keep trusting. You’re doing a great job. I’m so proud of you. Just go relax and have some fun. You’re doing great.”   More about Kate Eckman Kate Eckman empowers high-achieving individuals to actualize their full potential. She leverages her experience as a well-known communications, performance and mindfulness expert; accomplished entrepreneur; and former elite athlete to equip leaders with the tools, methodology, and energetic boost they need to compete and win at the game of life. With a results-driven approach rooted in neuroscience, positive psychology, and whole-person coaching techniques, Kate helps her clients succeed in and out of the boardroom and on and off the field. She guides them to identify who they are beneath their titles and labels, clarity their priorities and values, and then co-create a game plan to get them from where they are now to where they most want to be … adding in some fun and humor along the way. Kate incorporates a mind-body-spirit approach into her coaching engagements, recognizing that when we take care of our inner world, our outer world takes care of itself. Clients report that working with Kate leads to greater focus, energy and presence; increased performance and resilience; more meaningful relationships and newfound confidence; and greater overall well-being and fulfillment. As someone who is known to thousands as a broadcast journalist and an international TV personality, Kate understands the pressures and demands to be always “on,” perform at a high level and be an exceptional team player. She brings that high-level presence, professionalism, and infectious enthusiasm to each coaching engagement. Kate recently led and organized the team behind the launch of QVC’s first and only proprietary beauty brand, which made more than four million dollars in sales the first day alone. Known for her incomparable salesmanship, she helps global beauty brands shape their vision, strategy and innovation to inspire the achievement of breakthrough results. Kate earned her B.A. in communications from Penn State University, where she was an Academic All-American swimmer. She received her master’s degree in broadcast journalism from Northwestern University’s Medill School of Journalism. She graduated at the highest level from Columbia University’s executive and organizational coaching program. Kate is also a certified International Coaching Federation coach (ACC) and a licensed NBI consultant. Kate is the author of, The Full Spirit Workout: A 10-Step System to Shed Your Self-Doubt, Strengthen Your Spiritual Core, and Create a Fun & Fulfilling Life, which helps readers excel at the game of life with research-backed strategies (New World Library, April 27th, 2021). Passionate about mindfulness practices for both brain and body health, Kate is a meditation teacher and course creator for Insight Timer, the world’s number-one ranked free meditation app.   Suggested Keywords Coaching, Spiritual, Perfectionism, Mental Health, Workout, Community, Confidence, Goals, Support, Presence, Patience, Purpose, Preparation, Practice, Pause, Person, Health, Truth, Fulfilment, Success, Impact,   Pre-order the book for FREE gifts: https://www.thefullspiritworkout.com   To learn more, follow Kate at: Website:          https://www.kateeckman.tv Facebook:       Kate Eckman Instagram:       @kateeckman Twitter:            @kateeckman Pinterest:         @kateeckman LinkedIn:         Kate Eckman YouTube:        Kate Eckman   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:                https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the full transcript here:  Speaker 1 (00:01): Hi, Kate, welcome to the podcast. I'm really excited to have you here. Thank Speaker 2 (00:06): You so much for having me. It's my joy to be here. And now, Speaker 1 (00:08): As I said, in your bio, you are the author of the full spirit workout. And we will talk about the book in a little bit, but what I'd love to talk about first? Well, a couple of things. So one I, one thing I'm actually quite curious about, I noticed on your website that one of the coaching programs you went through was the Columbia three CP program. And I know a lot of listeners are always wondering what, what is a coaching program? How can I get into that? So can you talk just briefly about that before we get going? Just so listeners have a better idea of where you're coming from? Sure. Speaker 2 (00:48): So it was a very, very rigorous intense program. It was about a year, a little over a year, and it was, it was deeper and harder than master's degrees. And I had colleagues who went to Columbia business school. They said it was harder than that. I mean, it was really intense and hardcore, but it was such thorough training. And we learned whole person coaching techniques and neuroscience and positive psychology. And it was just so much peer coaching and, and really going through a really detailed process and going through the guiding principles of coaching and going through just so many programs and processes that they had developed. And that main man named Terry [inaudible], who started the program, who is a genius. So I was just working alongside so many top notch people and minds, and the faculty was incredible and, you know, coaching right now is I feel like everyone in their mother is calling themselves a coach. Speaker 2 (01:48): And it, it, it kind of disheartens me a bit because it is a serious role where you're holding someone's well-being and in your hands. And it needs to be, I think, a bit more regulated and taken a bit more seriously. And that's why I chose this program. And I wanted to have this knowledge and, and taking the profession very seriously and not to sound like a total nerd, but I also loved that they required us to write a massive research paper that was almost like writing a thesis and, and really dive into the art and the practice of coaching. That's Speaker 1 (02:19): Amazing. I have to, I didn't think that it was going to be that rigorous year because oftentimes I hear, you know, kind of coaching programs might be a couple of months, three or four months. So that is much, much more than I thought. It sounds incredible. Speaker 2 (02:33): It was, was probably the best investment I've ever done. And I, I have gotten another graduate degree at Northwestern years ago and journalism, and I was about to say, I love that program. I liked it. It was it, that was another superintendent. Was it a year intensive program that I took an accelerated program and nearly killed me. It was, it was so much work. So between undergrad and grad and then this program, the Columbia was I think my favorite and just rewarding and just to be able to help people and an impactful way. And so much of it is, is, is underneath the surface level though, you know, it's listening to what people aren't saying and, and really reading and feeling body language and just opening up this space and container for people to come to their own conclusions. I think that's another misconception about coaching, coaching. Speaker 2 (03:22): Isn't consulting. It's not therapy, it's not problem solving. You know, when I first got into coaching, that's what I thought it was like, if you were my client and you came to me for example, and said, I want to make more money. I thought it was my job to come up with this business plan or to come up with the solutions. But really it's, we're focusing on the client's agenda and you have all the answers. It's my job to ask the questions that will make you reflect so deeply questions. You've never been asked before to take you into the depths of yourself where you actually have the answers. And of course, I can say some things I can ask for permission to add here and there, but really it's about bringing out your own wisdom. That is way more powerful than anything I could say to you or tell you to do. Does that mean makes sense? Speaker 1 (04:08): Yes, absolutely. And, and I thank you for that because I agree the word coaches all over the place these days. And I think that was a really succinct way of saying, Hey, this is what coaching is, and this is how I learned how to be a good coach. And I think that that makes a big difference. Speaker 2 (04:29): And it, it really is a partnership. I like to say, I'm your thought partner and, and we are co-creating together. And it does become about that, that container. So, you know, I, everyone who's in the field obviously wants to help someone. I just invite and encourage people, whatever your field is. And you know this from your profession too. I think this, I come from a family of doctors. So I come from a family where you go to school for years and years and years, and you have to have the medical school and the fellowship and the residency and all the things before you can, no one can just call themselves a doctor on Instagram, you know, or a physician. And so I see, I see I've seen what my brother has gone through, for example. So I think I wanted to, I want it to be there and, and, and have longevity and just the type of people that I wanted to coach who quite frankly, are not going to put up with any nonsense, know the high achievers are professional athletes. Speaker 2 (05:23): They expect you to come in and be on top of your game. And that takes training. And that takes research. And that takes working on, on yourself. And then as I like to say, you have to fine tune your instrument before you can play it for the world. And there's no escaping that. And you know, when you're in the midst of the hard work and you're paying a lot of money to work really hard, and you see people around you who have no credentials and are making 50 K whatever on Instagram to sell something, that's when you have to just remember to stay in your own lane, think about the impact that you want to make and the work that you're here to do, because it wouldn't be tempting. I can see why people like I would never go back to school or I would never pay money or do some intensive program. That's too much work, but I just, I just have to ask what kind of impact do you want to make? And I can even feel some eyes rolling or, you know, a lot of people, I think don't want to hear what I'm saying, but for me, this is, was the right decision. Speaker 1 (06:21): Yeah. Well, I think I can say with confidence that I feel like my audience does want to hear what you're saying, because you know, as physical therapists who go to school for seven years, Speaker 2 (06:31): You know, my mom's a PT, so I Speaker 3 (06:33): Love you already. Yes. Yeah. Speaker 2 (06:36): So I, I, I, okay, so your audience gets it because I, you do a lot of the Instagram crowd. They, and I'm not saying that that's your audience, but they kind of think I see it, that culture thinks the opposite. And it is kind of frustrating because same with writing a book, for example, I think so many people see the end result, whatever it is, and they just want that. But what they don't see is all the work that we have put into it. And this, this reminds me of even a story that just came to mind that comes to me often, which is interesting because it literally happened 20 years ago. But in 2001 country singer Shelby, Lynne won best new artist. And when she accepted her award, this is the only acceptance speech I have ever remembered at the Grammys ever 20 years ago. And she was gracious. And she said, thank you. But also kind of mocked the award and said, best new artist. It only took me 13 years and six albums to get here. I just thought, yeah, because people think you just show up and no, you have to put in the work. And I don't know why people aren't wanting to hear this or understand this. And so all everyone listening who has been through your seven year program, I honor you, and you will have a much greater impact and you will have the longevity. And, and if I was your patient, I would feel so held in your care. So thank you. Speaker 1 (08:05): Yeah. Yeah. That's great. And you know, I, as I mentioned, I said, I could say with good confidence that my audience would agree with you and that this is a nice segue to talk about. One of the things that that you coach and that's confidence. So what are the five PS, the letter P just for people know of confidence? Speaker 2 (08:28): Sure. So it's presence, patience, purpose, preparation, and practice, because I love you and your audience. I'll give you two bonus piece. And that is pause and person as in be a person, and I'm happy to quickly go through them. And it's something that we can all discuss later, even offline or online somewhere, but presence. So presence obviously is being fully present where you are with whomever you're with, even if it's just yourself. So the phones and the TV and all of it is off. And you are just there in the moment, focusing on your breath, focusing on the task at hand right now, I am locked into you. Nothing else. There's a million other things that could be going on, but being present. And then with that comes, bringing your presence. So showing up like, you mean it. So many people tell me, oh, I'm not getting a school. Speaker 2 (09:25): This isn't happening. And I'm like, I don't think that you care, you're showing up. Like you don't care. So I think bringing that energy, bringing that enthusiasm to everyone, you meet and to everything that you do, patients, oh man, I think of that 38 special song that says, hold on loosely. So I think sometimes we're all guilty of gripping. So tightly to our goals, we want this relationship. We want this job. We want this money. And when we grip so tight, we actually repel it. So putting in your work, taking those action steps and then taking your hands off the wheel and gently leaning into trust and detaching from those outcomes, releasing expectations and Shelby Lynn, the story I just told what a perfect example of patience, right? And trusting in the process and confidence stems from the words to trust, to do something with trust, which is great because you can build on that. Speaker 2 (10:18): And it's something that comes from within purpose is your why. So it's so important to have a strong why that will keep you going. Even when it's hard, when you want to throw in the towel, when it doesn't feel like anything is working out for you, that's what this book. I had a really strong why. My two friends who are no longer with us and they kept me going when it was really challenging. And I think a lot of people, this is where they get tripped up because I'll ask them, well, why do you want to do this? And they often don't have a good answer. Or the answer is impressing other people or just money is the only goal. Things like that. It's like the people who say, well, I want to be a parent because when I post pictures of my kids on Instagram, I'll get more likes. Speaker 2 (11:01): Ooh, probably going to hate parenthood. And your kid's probably not going to go over well. Yeah, yeah. Not a good reason to be a parent. Yeah. So I, I, yeah. And, and if you are a parent, you are my personal hero. I don't know how parents get anything done. I, I bow down to them every day. Preparation of course is about, you know, building habits that lead to better behaviors that lead to better results. So that boosts your confidence when you're prepared and practice, there's this misconception that we don't have to put in that much work. It's like what I was saying about school and the credentials. And I think of Tom Brady, because we're the same age. We're both big 10 athletes. He's still winning super bowls. And my knees hurt when I go to Pilates. So Tom Brady are an inspiration, but Tom Brady is the best because he practices harder than anyone. Speaker 2 (11:52): You know, people think, oh, well, if you need that much work, you must be the worst. No, you, you P he practices that much. Cause he's the best, not the worst and your talent merits investment. So practice pause is really what the, this inner fitness program is about. It's, it's taking that moment before you respond to the upsetting email, before you tell the jerk what a jerk they are. It's taking that moment of mindfulness and thinking, okay, I'm really upset, but I'm willing not to be. And who do I want to be instead? So it is about non-reactivity again, I got to practice this a lot. And, and the last one is, is, I mean, they're all my favorites, but this one makes me laugh, be a person. My speaking coach, Eduardo, plusser always says this to me because I'm someone who has struggled with perfectionism and performance and obsession with performance. Speaker 2 (12:39): And he always says, just be a freaking person. And this is really about our humanity and just leaning into not just the person we present to the world who has put together, but that really messy person behind the scenes, just trying to keep it all together. He or she is awesome to let let's embrace that and just be a person. Cause that's where that's, what's really beautiful about us, right? Our humanity, and just being willing to show up, even when it's hard. And, and that's, that's another, a key building block of confidence is, is our willingness to show up and not be great first or ever that's to be in dance class, never going to be a great dancer, but you show up, I build confidence because I dare to put myself out there and not be good and a room full of dancers and feel like a complete, but it's fun. And, and it's, it's that one activity I can do where I it's such a rebellion against my inner perfectionist. Cause there's, there's never going to be a perfect performance dance class. It's, I'm just there to show up and, and, and move around and, and release some energy. Speaker 1 (13:40): Absolutely. You're speaking my language. Totally. I, cause I took, when I was at Equinox, I always took this dance class. It was like six 30 in the evenings. And it was with this guy, Johnny, and some days it would be like jazz hands. Some days it was hip hop. So I'm not a dancer, but I would show up and I would have the best time. And I mean, there are women in there who were clearly dancers in their early years. I mean, they're like in their sixties and seventies and they're splitting and high kicking and doing all this stuff. And I'm like, I can't even touch my toes when I'm sitting. And these women have like, their, their stomachs are on the ground, you know, but it's true. You go out there, you put yourself out there. And the more I did it, the more confident I was as a dancer, not that I'm a good dancer, but I was confident in what I was doing because I practiced. And the more I did it, the more, and I also think the more I really enjoyed it. Speaker 2 (14:34): Yeah. And, and those moments, then we become a dancer and I had this woman in class who was a gorgeous dancer and I had to perform in front of these people. Let me restate that. I got to be a person in front of these people. And they, they wrote the one woman wrote me a note after class. And she said, you are a dancer. And I thought, yeah, I am. Cause I'm here dancing. It's not about being ushered J lo or you know, whomever it's I'm yeah. I'm here dancing and I'm a dancer. Speaker 1 (15:04): Yeah. That's great. And you know, and it brings me to that concept of perfectionism and performance, which a lot of high achievers have they have perfectionism itis or performance itis. I don't know that those are words, but you know what I'm talking about. So what do you say to those high achievers where it's all about high performance and perfection? Yeah. I first Speaker 2 (15:32): Would want to work with people like I had to do with myself and just ask, where does this come from? Where does this thought process come, where you even think you have to perform or achieve at this high level to even be worthy or valuable or loved. And it really is about feeling safe in the world and not feeling so alone. And that's the story I tell in the book about being the four year old at the swim club and being in swim lessons that I didn't really like and overhearing my instructor, tell my mom that I'm not a very good swimmer and how heartbreaking it is for me as an adult to think of my sweet little innocent. Four-Year-Old thinking like, oh gosh, I, I love my mom and dad. I want them to be proud of me. I don't want them to have a daughter who's a bad swimmer, especially since they're so athletic and then going on to break every record at that swim club, because my mentality was I have to perform at a really high level to be safe and not just when the love of mom and dad, but I guess I need to impress strangers. Speaker 2 (16:34): So they say nice things about me and I can feel worthy. And, and then people will love me because I'm good at something. And they can be wowed by my quote unquote performance and what a trap that is. So I think it is about taking ourselves back to where we even come up with this mentality. But I think when we are in that place of obsession, it's like I said, you have to go back to being a person, but you have to also go back to why do I even, why am I even doing this? And, and I think when you are more clear, even I have a client who's extremely wealthy, extremely high achieving, and he's coming to that point in his life. He's about to turn 50 where he thinks, what does all of this even mean? What is my cause? He had a health scare and what if I pass away, what is my legacy that I made a bunch of money? Speaker 2 (17:22): And, and so he's starting to think of what impact he wants to make, or, you know, like many of us, we experience external success, but then we feel unfulfilled on the inside or insecure full of self doubt, full of anxiety. And so I think it's just coming back to what, what really matters to us and who are we underneath all of the titles and the labels and the achievements and the accolades and awards, all of that stuff, and really clear on that. And then your desire to be perfectionistic or to always have to perform at a high level goes away because you know who you are without all this stuff. And then spoiler alerts, you actually end up achieving more and less time and attracting the people, experiences relationships, because you've become the person who just gets to have that or gets to be that rather than striving and forcing and controlling. Does that make sense? Speaker 1 (18:19): It does. Yeah, absolutely. And it has me going back in my head, like, is that why I did that? Is that why I did this? Was it for, you know, to have your parents feel proud of you or to have people tell you, wow, that was so good. Or for, yeah. I need to do a lot of inner work thinking about this right now, Speaker 2 (18:43): But what a great practice that I invite you and everyone listening to do is go back and think of that limiting thought or think of, wow, I am so anxious and it's because I feel like I have to impress people or earn someone's approval and try to go back. And it's always in childhood something. And it's something that we don't even think of. I hadn't thought of that swim club moment until I was doing heavy thought around this book when I was writing it and doing a lot of meditation and reflection, and that story came I'm like, where did this come from? This obsession and how crazy right. And that we hold onto, and then also inviting everyone to, instead of the criticisms or the society that tells us how we don't add up ever, especially as women. So really think of the compliments or think about your strengths and, and, and making that the root of your core belief system instead of all that other crap. Yeah. Speaker 1 (19:36): Oh, it's so good. And now let's talk a little bit more about the book. So the full spirit workout. So what is, what was your why for writing the book, talking about purpose, right? So let's tie it together. What is your why? Speaker 2 (19:52): Oh, you're so good. My, why is salmon Roth? There are two dear friends. They were both two of the loves of my life and they both decided to leave us. They both took their own lives almost a year to the day of one another. So I lost both of them in one year. And this project, I call it a divine assignment. It's the most challenging life assignment I've ever had, certainly the most rewarding, but I did it for them. And for everyone who has felt like them in a place of hopelessness or despair who didn't have the tools who didn't feel confident or secure or safe to reach out for help, who thought they had to do it all on their own or hold it all in. And the, the name of being a man or looking cool to the outside or not wanting to show their dark side for lack of better term, and also wanting it to be a celebration of life for everyone. Speaker 2 (20:47): And, you know, I talk about society and, and it's really sick right now. And it bombards us with all these messages about how we aren't enough and it doesn't give us the tools to, to be healthy and happy. It's just, it's the constant negative. And so, you know, I was a competitive swimmer for 17 years and knew how hard I had to train my physical muscles to compete at a high level. And after losing them and finding myself at the Dwayne Reed on eighth avenue and 34th street contemplating taking a bottle of pills, I knew that my life depended on answering this wake up call and shifting the way that I was choosing to live my life. Like everybody, I will say everybody is guilty of placing their worth outside of themselves. Some may not even realize it, but that's why they have the emptiness feeling on the inside at times. Speaker 2 (21:38): And I really just dove into so much studying and research and spiritual tools and practices and, and, and went back to school and just really wanted to put a program together for everybody. You know, someone said, who is this book for? And I said, everyone who can read, because we all need these practices, just like, we all need to exercise our physical bodies to stay healthy and fit and strong. And it's not about looking hot in a bikini. It's about being able to navigate the world and do everything that you, you want to do and can do whether it's travel or get out of bed. This isn't about a six pack abs, but this, my program will give you a six pack spirit, and that will lead to health on every level. So I just encourage everyone, even if it's five minutes a day to do some of these practices, I wrote this book and a fun is in the subtitle. Speaker 2 (22:27): So this is fun. It's, it's a workout you're going to actually want to do and return to. And, and I return to these practices daily because it's just like exercise or sleep or eating. It's, it's part of our health that we need to tune into every day and, and give ourselves this gift. And if I've learned anything this past year, my wellbeing comes first, no matter what, I'm not willing to go to a dark place. Again, I, I'm not, I'm not doing it. And I, I just, I see so much struggle around me. I it's been such a challenging year for everyone. That life was challenging way before COVID and then everything else we dealt with, especially in this country this past year, it has just been trauma and chaos after trauma and chaos. And so this is really within these pages, just such a place to be in self discovery and be in self-growth and really get acquainted with yourself again and feel really good. And it's all there for you. So let's go, I'll just do it. Speaker 1 (23:28): Yeah. And I loved it. The thing that I really picked up on, you said, you know, you want to be able to like you work and you exercise and you move to help kind of expand your world. Right. I mean, as physical therapist, I mean, I have patients who are in pain, osteoarthritis of their knees, so they can't walk. They can't, they can't do the things they want to do. And they, and, and she said to me, just today, she's like years ago, my world was, I could do anything. Now it's just narrowed so much because I don't have the physical capacity to do the things that I used to do. And, you know, you hear that. And it's, it's so upsetting to hear, you know, and she has some other systemic issues going on as well. But so when you just said, you know, you want to kind of work on your inner spirit and your inner self, just like you would your, your health on the outside. Because again, you don't want to narrow your, your mind and your spirit, like you would, if you didn't exercise and move on the outside. That just so Speaker 2 (24:37): Brilliant what you just said. Yeah. Speaker 1 (24:40): It just really, when you said that, I said, oh gosh. And we see it all the time. And people from a physical standpoint, and we don't often give ourselves the grace to, to expand our inner selves as well. So I, Speaker 2 (24:54): I love it. That's such a great analogy. And that's why I did, because there is such an obsession with the physical and this world, right? What we physically look like face hair, skin, body, all of that. And the obsession with, with working out where it goes too far, the other direction where it becomes unhealthy and that's the whole diet culture and all of it, but that's such a perfect example. And people see that like, oh, I break my leg. I can't do X, Y, and Z, but so many people are injured on the inside because, or they're there, you have the spiritual flag, the emotional flag from just not working out are inside. And it's the same. It has the same limiting effect. And so when, when you do get fit and strong and resilient and optimistic on the inside, really the world is yours. Speaker 2 (25:37): And you, you, like I said, you attract the opportunities, experiences. You become the person who can actually attract and achieve your cherish goals and live the life you say you want to live. And I think a lot of us have forgotten that we have access to this and that we are powerful. And so I'm just gently reminding everybody to tune back into that and to live from that place so that you don't feel limited. So you don't feel like you have a broken leg or like, oh my gosh, I can't physically even exercise. I feel miserable. We're doing that to ourselves, with our minds and with our hearts and our spirits. We just, we don't even realize it. Yeah. Speaker 1 (26:15): And you know, I was going to just ask you what is the book's core message, but I think you just said it, is there anything you'd like to add? Speaker 2 (26:22): I mean, I, it is, I, I get very, almost like dramatic and passionate about it. Just reminding people who they are and, and being comfortable with who you are right now in this moment exactly where you are and reminding yourself of, of your strength and your inherent worth, and that you can do whatever you decide is important. I think people think, oh, this is just as good as it gets, or I can't have that. Or even had some woman say to me, well, you're beautiful. You can get anything you want. And I think, wow, are we still doing that to each other where we're, we're judging or policing or thinking that it's about what we look like? Or you can do everything because you have a nice house and, and diminishing each other and, and everyone is struggling with something. And, and I wish people would, would talk about it more and tell the truth. Speaker 2 (27:09): And even if you don't tell someone else to tell yourself the truth and sit, I call it my sit and stare time where it's, non-negotiable at least five minutes a day. And I sit and stare out the window or stare ahead. And I talk to myself like I would a small child and say, how are you doing, what do you need? What's working. And it has saved me so many times. And, you know, I can hear some people saying, well, it must be nicer. I don't have time to do that. Just like people say about meditation. And I say, I don't have time to be angry. I don't have time to treat people badly because I'm exhausted and overwhelmed. And at the end of my rope, I don't have time to be miserable. I don't have time to be sick. I don't have time to be rushed to the hospital and pay some crazy bill or whatever, you know? So I think it's just asking yourself, what do you really want? And who are you? And, and be willing to show up and just keep going and take little baby steps here and know that you're going to get stronger and stronger. And then you will crave this. You'll crave the sit and stare. You'll crave these journaling exercises and this time to really get to the core of what's happening inside of you. Speaker 1 (28:25): Excellent. I love it. Thank you so much. So again, everyone, the book is the full spirit workout. And now Kate, where can people find, you find the book, et cetera, et cetera. So Speaker 2 (28:38): You can find the book@thefullspiritworkout.com. And that will also link to my website, which is Kate ekman.tv, E C K M a N and Quebec men, everywhere on social. I'd love to connect with you. I love meeting people who are ready to kind of take on this journey and have fun with it. And we can all support one another. I really believe in community and collaboration over competition. And we're all in this together. So let's go, Speaker 3 (29:03): As you said, let's do it. Let's just do it. Yeah. Excellent. I love Speaker 1 (29:07): It. Thank you so much. One last question that I ask everyone, and that's knowing where you are now in your life and in your career. What advice would you give to your younger self? Speaker 2 (29:17): Ooh, hold on baby. It's it's all coming. It's all happening. Keep going, keep trusting. You're doing a great job. I'm so proud of you. Just go relax and have some fun. You're doing great. Speaker 1 (29:32): I love it. I love how you said. I'm so proud of you. That's so nice. Such a good exercise to do. I love it. Kate, thank you so much for coming on for your book and sharing all this great advice. And I just thank you very much. Thank Speaker 2 (29:47): You. You're the best. I appreciate you having me Speaker 1 (29:49): Pleasure and everyone. Thanks so much for listening. Have a great couple of days and stay healthy, wealthy and smart.  

In this episode, Optimal Self Coach, Jeremy Herider, talks about how he discovered, and strives toward, the Optimal Self. Today, Jeremy talks about “the Art of Becoming the Best Version of You”, why it’s important to you but more important to those who look up to you, and why we should prioritise #GenerationalHabits over #GenerationalWealth. Hear about the moment he started re-evaluating his identity, his three most important values, and his advice to his younger self, all on today’s episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways “If I’m going to have success in any endeavour, it’s going to come from what happens when no one’s watching.” “Don’t get your identity caught up in things that are out of your control.” “Integrity is do what you say you’re going to do. Character is ‘be who say you are.’” “You can be what you want to be but, at the same time, not at the expense of someone else.” “If you’re lacking motivation today, normally it’s not lacking motivation, it’s lacking clarity. When you get clear on something, motivation jumps out of you.” “You either give that thing 100% of you, or dont, because 99% wont work.” “You’re leaving something behind whether you like it or not.” “Stay the course. It’s going to take work. Don’t be afraid of the work.”   More about Jeremy Herider Meet Jeremy Herider, life coach, business consultant, professional athlete, podcaster… the list goes on. How can one person even have so many titles? That’s just what you get when you’re living as your Optimal Self. As a pioneer in two professional sports, Jeremy has spent a lifetime building the elite habits necessary to thrive not only in pro sports, but in every other venture that he’s been a part of. Originally from Lancaster, California, Jeremy found his strength as an athlete from an early age. He was a three-sport letterman in high school and an MVP in baseball. He graduated from Gonzaga University where he was an All-Pac10 Infielder. His pro baseball career took off not long after. But his drive didn’t stop there and neither did his list of accomplishments. Jeremy was the first contracted player with the Diamondbacks to get a hit in the history of the organization. He was later drafted by the LA Reign, officially making him a two-sport professional athlete. More recently, Jeremy has been named a CrossFit Champion, taking home 1st Place for the Deadlift/Box Jump event. Of course, now Jeremy has shifted his focus once again as a productivity consultant for Fortune 500 companies, private business coach, and motivational speaker. Jeremy’s Optimal Self Coaching program and podcast boil down this lifetime of achievement into tangible, attainable habits that anyone can adopt for success. No success story, including Jeremy’s, happens by accident. Begin yours with Optimal Self.   Suggested Keywords Motivation, Identity, Improvement, Habits, Wealth, Health, Smart, Success, Achievement, Integrity, Character, Generational Habits, Priorities, Clarity, Empathy, Empowerment, Choices,   To learn more, follow Jeremy at: Website:          https://www.optimalself.today Facebook:       @OptimalSelf1 Instagram:       @optimal_self YouTube:        Optimal Self TikTok:            @optimalself Optimal Self:   Optimal Self linktree   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:               https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the Full Transcript:  Speaker 1 (00:01): Hey, Jeremy, welcome to the podcast. So happy to have you on today. Well, Speaker 2 (00:05): Thank you. It's so happy to be here. I know Speaker 1 (00:08): A fellow podcast host, we'll get into your podcast later on in the, in the episode, but I always love to have a fellow podcast host on for a number of reasons. Number one, being good sound. Speaker 2 (00:21): That's so important. That's so true. Speaker 1 (00:24): So important. All right. Now, before we get into the meat of the interview, what I'd love for you to share with the listeners is how your background of being a professional athlete baseball, CrossFit I can Zaga, right? Almost they almost did it. Oh my gosh. Are you just dying? Speaker 2 (00:53): Was except for that game, we didn't really almost get it. We really got crushed by Baylor. So hats off to Baylor. They, they, they did not miss a beat and they crushed us about halftime. I was, I was already turning the channel a little Speaker 1 (01:06): Defeated, but close. Yeah, absolutely. Absolutely. Okay. So enough NCAA talk. So let's talk about how your life as a professional athlete kind of shaped your views on your life now and kind of what you're doing now. Speaker 2 (01:25): But I love that question cause it can, it's, it's so many different things in, in regards to, you know, you see what most people see is the end result, right? Is, is you running on a field? In my case, it was baseball. They, they see the end result. They see you on a field with the stadiums packed and the lights are on, you know, and, and, and it's, it's incredible, right? Cause we all watch it. If those of you that are out there that are, that are sports fans, you know, it's just, but we get to see the end result. What we don't see is the work and we don't see the behind the scenes. We don't see it. So as far as is shaping me today is it's still the same way. What I mean by that is this, is that what I, what I loved about athletics was truly not the game. Speaker 2 (02:14): Although the game is the icing on the cake. I enjoyed practice. I, I love getting up and going to practice. My mom tells a story, you know, cause you know, with my girls, I have two girls in, you know, mine were like, they didn't want to go to practice. They were like dad, really again. And my mom tells the story that she's like, no, you'd get done with school and you'd walk in the door and already being your uniform ready to go. And you're like, no, I know you got like two hours and I'm like, no, no, no, let's, let's go now just drop me off. She said, you know, she'd be pulling up and I'd be, the door would be open before the car was even stopped and I'm running. So it's, that's kind of the thing that's been ingrained in me since a kid. Speaker 2 (02:57): And, and so I enjoy that work and, and moving into your adult life. And when that, you know, when that side of my life ended moving into other aspects, which now I'm in a real estate and in starting optimal self and doing what we do now, you know, I just love the work it's so it's, it shaped me the same way. Is that what I know to be true? Is that the true success that actually people see? Cause a lot of times, you know, people see that success and I, let me be clear. I didn't, I didn't reach my goal. My goal was to be a 20 year major leaguer and a hall of Famer. And you know what I mean? And, and be, you know, Canton, Ohio and be putting on that hall of fame jacket and giving a speech and B I was nowhere near that. Speaker 2 (03:43): I didn't get close to that. You know? So my w but when most people see the accolades and they go, oh, wow, you've done this. They, they think of success, right? So again, that is kind of the outsider looking in, but what they, what they never see is, is the work that's put in and that's what you have to love. And, and that happens today is whatever people think is fine. They what they see and what we see of others, that little tip of the iceberg, that's, it's poking out, right? You always see these memes and these things on the internet. It's, what's underneath that water. Well, what I learned is if I'm going to be successful or have success in any endeavor in my adult life, it's going to come from what happens when no one's watching it. What happens when they're not looking with those, those sessions in those days, in those moments. And so that's, that's probably what I learned the most. And it's, it's what I've brought into my adult life from, you know, into these other businesses, from being an athlete. Speaker 1 (04:44): Yeah. And that makes perfect sense. And, you know, I liked practicing too. I like the games. I like the practice. I like the teammates, the camaraderie, that feeling of being on a team is always so great. And that teaches you a lot as well. Just being part of a team and being responsible to someone else for someone else and, and being held accountable as well. Yeah, definitely. Speaker 2 (05:07): I, yeah, you're, you're spot on. Which is interesting because going from, you know, being a baseball player again with 25 guys on the team, nine guys on the field at a time, right. Is, is you are, you're, you're a hundred percent responsible for, for everybody around you. And, but here's what I'll say. And it kind of goes into optimal self as well. Cause it's the optimal self is the art of becoming the best version of you is that one of the things that I think I failed at in those days was not is, is focusing on, on wanting to be the best at my position or in that league or whatever. And what I should have been doing, what I've learned over time is just truly be the best version of me. Like that guy is still, could be the best, but, but if I'm just stopping and always, then I lose sight of just truly who I am and what I can do. Speaker 2 (06:03): And so, and what you're saying is, is very true because going from baseball to where I was accountable to all those guys and coaches and, and, and, and the team, and then when I got into CrossFit and you're all by yourself, you're all by your lonesome, in that a lot of lonely nights at the gym, lonely mornings at the gym training, because nobody has that same goal, right. To, to be a champion or to want those things that a lot of guys would come to the gym and train with me, but I would have to literally put a different guy in at each time, like, oh, we're running, I'll get the good guy, the guy that likes to run, oh, we're lifting the B find the guy that likes to lift. Oh, we're, you know, and so you put, you, you put in all the different people. Cause there was nobody that was just going to be like, yeah, Jeremy, I can't wait to get up at 6:00 AM with, you know, Jeremy, I can't wait to be there until nine o'clock at night with you. So again, I, I, I love what you're saying. Cause that's true. And the truth of life is you do have to have some accountability and the team would definitely show that. So yeah. Speaker 1 (07:03): You're spot on. Yeah. And now you mentioned sort of the art of becoming the best version of you. So mentioned it a little bit. Nice segue into why is that important to you? Speaker 2 (07:16): So it goes back to that same timeframe is when, when baseball ended and for most people in, in an athletic endeavor, it doesn't end on your terms. Very often, there are very few people that, that get that right. They get to Speaker 1 (07:32): Be Derek Jeter, Speaker 2 (07:36): Jeter, Tom Brady's like very viewed people are, are those, those people, right? That get to win the world championships, get to be the MVPs and then get to say CNR when they, when they choose. So, you know, most are on, on, on my side where they, they tell you to you're you come to the stadium and the uniform is not in the locker room anymore. We're not renewing your contract. And thanks for your service. It's no. So, but I mean, that app is everybody. It's, it's nothing, but what I learned and I went through a time and I'll be honest. I didn't know it was this right. Is that I was in a form of depression if you will. Is that because I didn't have an identity, my identity was attached to a hundred percent to baseball. Like I was a baseball player and I knew I was in trouble. Speaker 2 (08:28): It wasn't that the game was over. I was okay with that. Honestly, like I knew that there was more things I had, you know, two little, little girls in those days, they were tiny, right? Like dad got to be around and we got to go to the park and I got to, I get to do stuff that I, that I hadn't been able to do really. So that was wonderful. But what I was, what I failed to, to start to understand was how my identity, how I had attached myself to being a baseball player. And I was in the store one day and I ran into a gentleman that, that knew me. And he was like, yeah, Hey Jeremy. And all his Isley comes over and he's like, how are you? And I say, great, man, how are you? One of those guys that you see their face, you know, but you don't remember their name. Speaker 2 (09:09): Right. And he's like, can you stay here for a second? I want my son. So he calls over. Then here comes his little dude rolling up seven or eight years old. And he goes, Hey, you know, Mason, this is Jeremy, this is the baseball player I was telling you about. And I hadn't played baseball in a few years. Like I hadn't got a paycheck or been on a baseball field in a few years. And it crushed me inside. It was that moment that I realized like, oh shoot, something's wrong. And so I talked to him and we talked baseball and you know, gave him some pointers and you know, you can do this kind of thing. Right. I was the little guy and, you know, we, he was like, he's so small. And I was like, you know, so it was, I, I didn't grow till after. Speaker 2 (09:53): Yeah. And we talked a few stories, but when I left there that day, I knew, I was like, okay, I got it. I gotta get this together. Because that, that it shouldn't feel that way. Right. And I knew at that moment that, because he called me a baseball player and I knew I was not a baseball player anymore. Right. Or in the side of being a physical, getting on the field, practicing, playing, getting a paycheck from the Mino, a major league organization. So that's when I knew, I was like, okay, we got it. We got to work on some stuff. We gotta figure some stuff out. Cause th and again, now it becomes getting away from putting my identity to anything more than just being me. And who is that guy? How does he show up in the world? How does, what is the, what are those fulfilling things that happened that I can do on a daily basis that beat me up. Speaker 2 (10:45): They, they get me excited. So that, and again, when somebody says, Hey, you're not a baseball player. Cause I almost stopped them. Like I almost had to say, Hey, no, I'm not what to mean. It was just like, oh my goodness. And here's this little boy, you know, and you know, try to keep it together on the outside because on the inside I was just dying. But I hope people, what I hope people get out of that is understanding that don't get your identity caught up in things that are out of your control. It was out of my control of being a baseball player. Somebody had to give me a chance. Somebody had to say, yeah, this is this guy's good enough. Here's a contract. We'll take a chance on you. Somebody has to say, Hey, here's a scholarship. We'd love for you to come to play at our university. It's it's, it's not totally in your hands. The practice, the work, the time, the energy, the effort, the desire. Yeah. That's stuff that I can control. That's the stuff I got to work on, but not tying my identity to the actual act. Right. It's what I do. It's not who I am. And that was a big turning point for me. Speaker 1 (11:48): And what advice do you have for someone who maybe is at this crossroads of, you know, maybe they lost their job. Maybe they are came out of a relationship, a long-term relationship where that was part of their identity. So what advice do you have for someone or maybe an exercise or something that you did that helped you pivot that at that moment? Love Speaker 2 (12:13): It. That's such a great question. Perfect. So, you know, there's a lot of different ways to look at this and what I, what I go back to is, is the clarity piece in the sense that, who am I? And so then it becomes, start answering that question of what do I stand for? What's important to me. Right? And you know, there's so many different catch words and I'm just going to give you mine for people. So when I sat down and said, okay, what, what matters? Well, what matters the most to me is, is integrity. And so that is a pillar of my life. One is integrity. And what integrity means to me is simple. It's do what you say you're going to do. If you're going to meet me here at five 30 Pacific standard time, then I'm going to be there and I'm going to be ready and I'm going to be prepared. Speaker 2 (13:01): So, so integrity, just, just living that way. And then the second thing is, is character. And a lot of people associate those two things together, but here's the difference, integrity being, do what you say you're going to do. Well, character is be who you say you are. If you're a dad, then be the dad, right? If you're that, that worker. And I think that character shows up in many ways, especially for people. Like what you're saying right now is, you know, if you, if you had that breakup and it's going tough because, oh my gosh, now who am I without that partner? Or a job or whatever is understanding first, we got to dig inside ourselves. And so, okay. Who, who do you want to be? How do you want to show up in the world? Well, for me, character means be who you say, you're going to be, if you say, you're going to be that, then you be that every step of the way, and that type of clarity will, will, will actually help you make all the decisions in your life. Speaker 2 (13:55): And so, and the third one is empathy for me. So I'll just give you my three integrity, character and empathy. And so I've built it around their empathy. Again, to me was I grew up with women. My mom was a single mom, right? Since she only had sisters, right. Nana and Papa pop was there too. But, but my, my grandparents but, but it was a lot of Nana, right? I was, I was, I was the first born. My mom was 16 when I was born. And so that was not something, you know, no, I don't think there's any 16 year olds in the world that are truly ready to be a parent, right. Or a mother at that at that matter. And so would that being said, right? Like I've been around women that I hear, I get these. And I get blessed with two little girls. Speaker 2 (14:36): And my job for them was to empower them, to know that they can be and do anything they want in this world that, that the gender was not. And so I say this in this regard is that empathy means I need to put myself there. I need to listen to them. I don't have to agree. Right. Even if it was, you know, you can go down, whatever. I don't have to agree with you. We don't have to believe the same things, but it means a lot. If I can, if I can listen in and at least try to understand your point or your view on something, it doesn't mean I have to agree, but it does make it a lot easier. And if that, if that's reciprocal, man, how powerful that can be. So I've always wanted those girls to, to understand that. And to know that yes, you can be what you want to be, but at the same time, not at the expense of someone else, you don't have to put somebody else down for you to be for you to be great. Speaker 2 (15:26): You don't, you can just be great. It's okay. You can be unapologetically. Great. And, and the thing is, is, I mean, as we grow, so to go back to kind of summarize. So in what you asked was how could somebody would just start with yourself, start with who you are. What, what are those words that you have? And I mean, there's so many different things out there. I mean, I'd love to, free to use ours. We have, when you could sign in and get in, put your email address, we send it to you for free. It's an identity creator. It has steps in it and all that kind of stuff. But even so again, it's free, but if you don't want ours, you can, I can Google. There's so many great things out there that can help people. You know, I'm not, I'm not the one to say, this is the only way there's not, there's so many different ways, but I know this. Speaker 2 (16:16): If you're lacking motivation today, it's not, normally it's not lacking motivation, lacking clarity, because when you get clear on something, motivation, jumps off out of you, it will jump out of your skin. Right. And most people can identify with that when they go, oh yeah. When I knew right where I wanted to, where I was going, man, did I take them steps to get there? Right. So, so I think taking it back in that sense for me was all right, who am I? You're not a baseball player anymore. Who are you? What do you want to stand for? How do you want to show up in the world? And let's go be that guy. And again, it also allows you to make incredible choices because the moment you have that clarity, it's like, wait, does, is, is this who I am? Nope. Okay. That doesn't go in my mouth. Speaker 2 (17:07): Okay. That's not what I do. Okay. That's not what I, I choose to. You know what I mean? Like you can literally go from every single piece of how you move, what you eat, the people you hang around, you can start to see. And what's really crazy. Karen is this is that you start to implement those things in your life. You start to be it not no other way. Not words on a page, not just talking about it. Yeah. You actually start living it. You start to see the people around, you change all of a sudden other, your, your whole, your identity starts to attract that when you're being that. And it's an amazing with, without even, without even purposely doing it, because what you radiate, what people hear, what people see when, when they say, because again, I'll go back to my life. Like those guys that I was hanging out with, even at the end, right? Speaker 2 (17:58): Like it was nothing to go to Monday night football and have, you know, eight or 10 beers on a Monday night and drink a bunch and eat a bunch of wings. It sounds fun. And it's great. But I can tell you this, the moment that, that I, that switch started to happen for me. And I started to pay attention to it. Those weren't the choices that I made anymore because they weren't serving the life that I wanted to live and where I wanted to go. And, and it, and again, it makes things a lot easier for yourself. Cause it's, I call it a hundred or nothing. You either give that thing 100% of you, or don't because 99% won't work because there's always that 1% time that somebody something's going to crack when you leave a crack open, that crack will get used and it will get destroyed and it will be, and it will get bigger. So the more you can give to exactly what you say you are going to give, when you give that a hundred man hundreds easier than 98 or 99, because 98, 99, you haven't really made a full decision yet. And you know, this decision is the, is the key to all of it. Cause the moment you do make that decision, man, how the, how the universe will conspire with you to make it happen. Speaker 1 (19:08): Yeah, absolutely. So it sounds like I'm just going to recap quickly that when you're at that sort of crossroads of, of your identity, of, of who you are as a person, you really want to try and get clear on your values, write it down, write down the value, why it's important to you and really like dig deep, you know, it's might be uncomfortable. It might Speaker 2 (19:34): Be uncomfortable making that. You're, you're Speaker 1 (19:37): Really asking yourself the tough questions. And if you don't like doing this on your own, like you said, there are tools out there. You have a tool, there are tools out there, ask your friends, ask your family. If you have good relationships with said people if not, you can hire someone and they'll help you. But really getting deep and asking those questions. It's the same thing that you would do if you're an entrepreneur and you're trying to figure out your vision of your business, you know, you just want to figure out that vision of yourself as well, and it'll probably help your business. That's a whole, that's a whole other conversation. We'll be here for hours. Now I love when you were kind of talking about what people can do when they're at that crossroads, and you talked about your mom and your grandparents and your children and, and you know, we're talking about generations of a family, right? And so a question I have for you is why generational habits should be taught versus generational wealth. And if you can even explain what you mean by generational wealth, do you mean wealth of money, knowledge, X, et cetera, et cetera. So I'll hand it over to you. Speaker 2 (20:56): Yeah. So that's, again, what we see in, in, in at least in our country for sure is, you know, we, you know, that there are families that have, you know, through industrial age, in, in, in all the different times that have handed down, then let's talk w in this case, we're talking money, right. Wealth, right? Whether it be real estate, whether it be, you know, the buildings and things like that, whether it be business, the railroads or the steel or, or whatever that is. And what's, what's, what's incredible is that the majority over time gets, it ends up failing by the third, by the second generation or the third generation. And the reason we say that is the person who built it. They might be handing over the wealth side of things, but they haven't handed over the habits that it took for them to get there. Speaker 2 (21:50): And so when you start to get second and third generation away from the actual being that that created it, it starts to dissipate. And so they don't have those same habits, that work habit, that work ethic, that, that mindset that they, that this was built under. So when we talk at optimal self, when we talk about it, we talk about leaving that generation. We start talking about generational habits. And the reason we say that is this is that you're leaving something behind whether you like it or not. You're leaving a legacy, whatever the term is you want to use, you're leaving that now, right now, somewhere, somehow you, because you have interaction with people, whether you have children or not children, you have interaction with people. You're, you're either at a job. Your, you know, if you're in school, right, they're going to know you, somebody, some they're going to be able to describe you and what are they going to describe? Speaker 2 (22:45): What are you leaving behind? So what, what we talk about is, and this goes back to what we started this with, is that the only way I can help and I, and I use my family, I use because that's the direct connect, right? My girls, the only way I can help them is by me being a better me. Because again, how many of you out there right now are telling your kids to go make their bed? And they walk by your room and your bed's not made, what are we really telling them? Right? What are we really teaching them? And so when I talk about generational habits, I'm talking about, listen, be the person, right? You've, you've heard Gandhi. You've heard it for years of, of all kinds of Nelson, Amanda, about we have to be the change. Well, well, truly, all you have to do is you can be the best version of you and you will inspire others to do the same. Speaker 2 (23:35): What are the habits that you want those children or the people around you to have? What do you want them to learn from you? And if you, if we can at least frame it up that way, then the chances of us living to our own standard are much better. Because sometimes that's what it takes. You know? I mean, our world today is built around social media. Let's be clear, right? It is whatever your view is on it. I don't want to go into my own view because it's really doesn't matter. But there is a bit of it that is corrupting all of us in, in ways myself included. And that's what kind of spins us away from it. So let's get back to saying if, if, because you, we do, I like to tell people I don't care what you think, but I do. Of course I do. Speaker 2 (24:20): Like, and I don't mean that I'm going to do something different because of it. If you don't, if I, if I'm living to the best version and you don't like that, then let's have a conversation. Cause, cause I, I, for sure don't want it to hurt somebody, right? That that's, that's not the case, but with generational habits, if we can leave, if we can start to create and be the difference in our own households, that's how we start to create better environments at all times. So we put our kids in better environments. We choose better environments because those environments are, are more conducive to what our habits are. So yeah, we talk about generational wealth as well, because there's nothing greater than that. I mean, if, if my girls can have more than I had, how incredible would that be? That's that's and their kids' kids, right? Speaker 2 (25:09): Like, let's talk, let's, let's make it. But at the same time, what I have to be able to help them and what they need to be able to see from me. Not just words on the page or words out of my mouth, but what they need to be able to see from me is how I live. How do I personally get up every day? What is important? What, you know, my hydration, how we eat, the things that we do, the things that we consume, right? Consumption what, not just what we eat, but what we hear, what we watch, what we say, because those words are very powerful. Every word that we, we say, we say to ourselves, you're your cells are eavesdropping that they're paying attention. That subconscious is paying deep attention to that. So again, generational habits or what are you leaving behind? What habits in art. Speaker 2 (26:01): And again, because you asked that question and you're like, oh man, as I've done it for myself, I'm like, oh my God, I do do not want my kids. When the kids are a little, this is this is some of you out there that our parents can remember the time that you said something, maybe to you, your wife or your husband or whatever, and your kid repeats it. And you're like, oh, you don't even realize it. Right. We're like, oh my goodness. So again, thinking along those lines, just even if you don't have kids, is what are the words that I'm saying, how am I being and can I help? So can I show people better habits that can, that can inspire them to do the same? Speaker 1 (26:43): I love it. That makes so much sense. And, and we'll hopefully be able to instill confidence and allow those next generations to keep building on whatever it is. You're leaving from a wealth, even from a wealth standpoint, from a health standpoint. It's, it's just a great, great way to look at that. Handing down of one generation to the next. I love it. I love it. Okay. So before we start to wrap things up here, where can people find you? How can they get in touch with you? Great. Speaker 2 (27:19): So we are on all the social media platforms, Instagram, Facebook optimal self Facebook is optimal. Self one. Igg is optimal underscore self as well. But our, our webpage is optimal self.today, optimal self.today. And on there our, we do have some courses everything up there that we're even showing, right, right now is, is free. So we can, you can jump in we'll, we'll get you in. We have a private Facebook group that we, we put a ton of stuff in that you can actually, you know, it's getting, it's getting pretty good. There's a lot of really cool people in there doing some really cool things. Because again, it's not about us. It's not about me. It's about building a community of like-minded people that want to pull for each other root for each other. You know what I mean? Like environment matters. And so we're trying to build an environment that, that, that people are, are, are trusting of. But they're also contributing back to, because man, to see some of the things that these people are doing just using some of the principles of optimal self is pretty amazing. So we'd love to have everybody. So if you're interested, please optimal self that today. We'll get you there. Speaker 1 (28:30): Awesome. Thank you so much. And who can want a little more encouragement and support in their life. And now before we end last question that I ask everyone is knowing where you are now in your life and in your career. What advice would you give to your younger self? Speaker 2 (28:48): Man, so much. No, I think that I, I think for myself is the thing that when you, when you ask that the, the, the very first words that came to my head is stay the course and what that means, what I mean by that is a lot of times we, we believe something. We want something we're afraid to talk about it. And I will say this as an athlete. You know, when I was very little, yes, my, the, you asked me what I was doing. And I was like, I'm going to be a baseball player. Like, that's what I was doing, you know? And I wasn't the best. Let's just be very clear. I wasn't your all-star game guy. I wasn't the kid hitting home runs as a kid who was getting tired. I was opposite. I didn't make all star teams. I didn't have all that stuff. Speaker 2 (29:40): And so, you know, it was, it was a turning point. I'll share this really quick because I think it'll help people out. There is I was 13 years old and my best friend's dad was our coach. My best friend was the best player, if not in the league, definitely on our team. And we grew up together. He's still one of my best friends to this day. And he was, it was a bigger kid growing up. You probably, you guys probably remember this. I was not that kid. I was the little munchkin kid, you know, you just hit over at second base or, you know so, and at 13 we won the championship in our league and it was probably the best year I ever had as a, as, as a baseball player at that young age, I thought for sure, man, this is the year I'm going to make the all-star team, right. Speaker 2 (30:23): This is the year and I didn't make it. And our team had won. So we had this, you know, the, the, the, the pizza party after. And, and so I went up to coach who was also, you know, I'd been on vacation with him because I was, you know, got to, you know, he's, his son was my best friend. And I said, you know, he's like, what's the matter? What do you want? And I said how come I didn't make the all-star team? And he looked me dead in the face. Can I can tell you this? I, I can tell you to this day, which is not even know how many 40, 30 years later he, and I said, and he, I could tell you what he was wearing. I could tell you what he smelled. Like, I could tell you everything about it. Speaker 2 (31:02): Every I could tell you what I was wearing. And he said, because you weren't good enough now don't get me wrong. The crushes, any 13 year old boy or girl, probably. But that 13 year old boy in me was crushed. He was, he still is to this day, but I'll tell you this. And I went to the side, you know, and got away from where everybody was. I went up to the lady, the pizza counter, and I asked her if I could use the phone, if she'd call my mom, because her mom wasn't there, she could dial the number for me. I asked her to come get me. She's like, what are you doing? I said, mom, please come get me, please come get me, please, please, please, please swish. She's like, find them on my lap. I didn't even wait. I just went out and sat on the curb, waited for her. Speaker 2 (31:39): She pulled up and she's like, what is going on? And as soon as I got in the car, man, tears just pouring out and she's like, what is going on? I'm like, just go, please. She's like, I'm not leaving, moving this car until you tell me what's going on. So I told her, right. I said, I wasn't good enough. And she was like, ready? Any mom? Right? Like, and here's the thing. She, you know, I said, please, don't go in there. I mean, bears don't please, please, please. Well, what do you want? What do you want Jeremy? And I said, can we go to big five? I don't even know big five as a place anymore, but in California was at sporting goods store. And I said, please take me there. And she said, what do you want? And I walked in, I showed her. Speaker 2 (32:18): I said, can we please buy me a tea? I'll never forget. It was their big yellow sign, $19 and 99 cents. And that tea is still with me today. That was my 13 year old year. And that tea, I went in the backyard and I hit minimum a hundred balls off that tee every single day. No one's watching. I didn't have many balls to start and I'd tear them up. I started using tennis balls or racquetballs and anything I could find to hit off and a hundred swings. I would not. Everyday when I got home, I'd go out and do a hundred swings or now, or I wouldn't let myself do anything else. Right. All the way through, by the time I was 18 years old, I was, I was in all league player. I was the MVP of our team. I got a scholarship and the rest is kind of history. Speaker 2 (33:02): But that, that, that T stays with me as a symbol is because that it wasn't that he was saying, I want people because most people, even when they hear this, they go, what we should have knocked that guy. And what is it? You know, where's he at today? And I'm like, it was the greatest thing that ever happened. And here's why is because he was honest with me. He wasn't saying I wasn't good enough ever. I wasn't good enough in that moment. So again, there was 12, 15 teams in that league. There's, you know, whatever, 15, 16 kids on everything. There's 80 to a hundred kids in that league. It's not like I'm the only kid that didn't make it there. 15 kids and made that all star team. If I was the 16th best kid that year, then I wasn't good enough. Right. But it's not that I'm not good enough forever. Speaker 2 (33:47): It depends on how I, how, how you look at it. But I knew this, no one was ever going to say that to me because I, because of lack of effort, you, weren't going to tell me that because I didn't work hard because I'm not, I'm telling you, I'm still not best of that in my, you know, I wasn't the best player of all time now, but I maximized my ability. I will say that like that, that's something that I want people to understand, but I want what I wanted them to see is there's somebody out there right now that has probably been told they're not good enough. They're not, they're not pretty, they're not smart. You're the dumb sister. You're the dumb brother. You're this, whatever, right. It happens to all of us. There's so many people out there that did that lives with us forever. Speaker 2 (34:26): And I'm here to tell you it lives with me today, but it lives with me in a way that he told me that, because in that moment I wasn't good enough. And I needed to prepare. I needed to get better. That was in my control. That's the thing that was in my control because I didn't make it at 14. I didn't make it a 15. I didn't make it to say let's be clear. Right. And, and I, and you probably heard this, I think it was a bill gates and say, we underestimate, you know, we, we overestimate what we can do in a year. And we underestimate what we can do in five. And again, and when I look back at those years, I think, oh my gosh, because if I would have expected after that, you know, to go out side and hit a hundred balls and then leave and go make the next all-star team. Speaker 2 (35:07): Cause I did it once I would have been, it would be a full, everybody would be like, yeah, you're crazy. Right? It's the same person that goes, oh, I went to the gym once. Like, no, it's not, that's not going to work. Oh, I had us salad. No, that's not going to work. This is about consistency. This is about finding your thing and doing consistency over time will create those results. But, but that story in that, that T is a symbol for me to remember like, Hey, starting a podcast, starting this. You're not good enough. You're not, you have to get better. And that takes the work are you with? And if you're willing to do the work, man, you get to be on cool podcasts like this with Karen. And that's that's, that's what ultimately happens. Right? You get the, you get the plug along and, and cool things happen. So I would just tell myself to understand that, listen, it's going to take work. Don't be afraid of the work. Don't be afraid of putting in the extra hours. Don't be afraid of getting up early. Don't just, just keep going, man, stay the course. Don't be afraid of the work. Cause if you do that, anything's possible. Speaker 1 (36:18): Oh, you went on mute. You're on mute. I was saying excellent advice for anyone and certainly great advice for any youngster out there trying to get better at things I want to get better at. So thank you so much for that advice. Thank you. And thank you so much for coming on today and sharing all this good stuff. We will have all the links to all of your stuff at podcast dot healthy, wealthy, smart.com. One click will take you to social media. We'll take you to the website, everything, to all the free stuff you mentioned. So we will have all of that over at the podcast website. So Jeremy, thank you so much for coming on today and giving us up, giving up some of your time. Speaker 2 (37:07): Thank you. Thank you so much for having me. I really, really appreciate it. I really enjoyed it. So looking forward to the next time. Speaker 1 (37:14): Pleasure, pleasure, and everyone. Thanks so much for listening. Have a great couple of days and stay healthy, wealthy and smart.