Healthy Wealthy & Smart

In this episode, Owner of Access Physical Therapy, Clarence Holmes, Jr, talks about generational differences in physical therapy. Today, Clarence talks about burnout, the idea of value, and the different ideas of pay structure. Why is the measurement of productivity problematic? Hear about the promise of mentorship for lower pay, the problem of toxic positivity, and finding the better way in each new generation, all on today's episode of The Healthy, Wealthy & Smart Podcast. Key Takeaways "The reason why things are fluid and changing with every generation is because there's always a better way." "We have to be open to that better way." "No one loves PTs as much as PTs love PTs." "It is so heathy to have a full well-rounded conversation that points out the bad and the good, and you don't have to finish with a positive statement in a conversation." "Get comfortable with being uncomfortable." "It's become an expectation in this country to overwork." More about Clarence Holmes, Jr Dr Clarence Holmes, Jr is a native of Cleveland MS. He attended Mississippi State University for his undergraduate studies and received his Doctor of Physical Therapy degree from the University of Mississippi Medical Center in 2014. Dr Holmes then completed an orthopedic residency with Mercer university in Atlanta GA in 2015. He has worked in various settings to include sports/outpatient orthopedics, acute care, and the state jail system. Now, he owns and operates Access Physical Therapy, a concierge cash based physical therapy practice in the Atlanta metropolitan area. He also works as a staff physical therapist with Kindred At Home. Dr Holmes has been involved with APTA at various levels to include 2 terms on the Student Assembly Board of Directors, delegate for the state of Georgia to the House of Delegates, and currently serves as a board member for the Georgia Foundation for Physical Therapy. In his free time, he also owns and operates The Travel Doctor, a full service travel agency as well as tackling small woodworking projects. He also scuba dives and enjoys traveling the world with his beautiful wife, Turquoise and their golden retriever and chihuahua/terrier mix puppies. Suggested Keywords Healthy, Wealthy, Smart, Healthcare, Physiotherapy, Burnout, Generational Differences, Productivity, Mentorship, Improvement, To learn more, follow Clarence at: Website: https://www.accessptatl.com Twitter: @matterundrmined Instagram: @caholmes6 Facebook: @clarenceh3 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: Hello, this is Jenna Cantor with healthy, wealthy and smart. I'm really excited. I am interviewing Dr. Clarence a Holmes Jr. Just wrote on Zoom, or we're doing the interview. And Dr. Clarence who said, just call me clearance. I'm like, Okay, hi, Clarence, said that he works with home health and is the owner of a concierge cash based practice, which everybody who listens knows I'm cash based. I'm like, Yeah, hello, Conrad. I love that so much. Let's serve our people, our patients. We are coming on because we met at a conference. And there was a discussion on generational differences in physical therapy. And Clarence had some real interesting thoughts on this. And I was like, this is a podcast in the making. So I approached him right away. And I said, Can we do this topic and a podcast? And fortunately enough, he said, Yes. Like a proposal. It was beautiful. So here we are talking about generational differences in physical therapy. I think this is a really, really important topic. Now. I just let's just start diving in to one we're saying general racial differences, everyone, please don't refrain from getting offended with how we, how we try to describe this, because this is one we're differentiating between ages. And I saw I saw individuals struggling with that trying to be appropriate. So if we do say anything in our descriptions, inappropriate, feel free, please absolutely correct us. But be nice, because we're doing the best we can. But this is a very important conversation. So we'd rather take the risk in in really diving into the topic. So yeah, just let's all be nice. Okay. So regarding generational differences, I'm assuming that we're talking about the more seasoned crowd, people who have been around for a long period of time, compared to newer people in the physical therapy. Oh, right. Correct. Am I missing anything? Or is there any other way we need to define it? 02:39 No, I mean, and honestly, you're talking about me when you said if you recognize people being uncomfortable, trying to differentiate between these these generations, in conversation without trying to fin that was me at our conference. I didn't want to say the boomer generation, I didn't want to say the millennials simply because a lot of people tie a lot of negative connotations to those. And we're 03:03 also missing Gen X, because Gen X is actually the y'all are the youngest practitioners right now. Not millennials. Yeah. 03:09 Yeah. And I think there's a lot of similar Z 03:12 is Z. Oh, my God, ie, Z. Oh, my gosh, I missed the letter in the alphabet. Yeah. It might 03:17 be x. I don't don't hold me to it. But But, but yeah, so that was one. But But no, you captured it perfectly. I do think there is a a riff between the older generation and the younger generation to just put it put it lightly. Yeah. Just simply because and I mentioned it in the conferences that the older generation are the ones who are owning these practices, traditional practices. And the younger generation, our generation are the ones who tend to be more of the employees. And that's natural. But what's what's unnatural? Well, this is also natural to have some generational difference was unnatural is the riff, the, the battle that kind of comes along with it, and how we respond to it. So 04:03 yeah, so let's, yeah, I love that. Let's do what we're aware. I was very interested. Let's go back and and just do one general generational difference at a time and then if we okay, I feel like that's what pops in our head for now. And that's it. That's great. So one, just named one at the top of your head one Gen. Gen. Oh, my gosh, why is this? So? General? generational difference, let's start with one. 04:29 So I mean, there's two big ones that stick out to me. One is just this idea of pay structure. And specifically in the PT realm of, of how long has someone been here? versus what is this person doing for my company? And the best example I can give is me personally, of working in a job my first job post residency. I'm an ortho I'm a lover, or I will consider myself an ortho PT, even though I work in the home health arena, and the concierge cash base, I will consider myself an orthopedic physical therapist. My first job post residency was at a private practice in Atlanta, and I was paid the least amount of all the therapists across the entire company, which was four practices in Atlanta. But I was the second highest producing therapists in the company. And so, you know, generational differences comes down to the old way of doing things was, who has the most experience, they get paid the most? My personal opinion is, that's not logical, we're, I'm a logical being and a lot of my generation are, if it doesn't make sense to us, we're going to be vocal about it. And it didn't make sense to me that I was producing one paper, more money, better outcomes than the majority of the therapists and I was paid the least, that's one major win. And it kind of feeds into the second you asked for one, but this kind of feeds into it. Younger generations, older generations value loyalty. You know, they expect somebody to come in and work for them for 10 to 1520, almost 30 their entire careers. And my generation just, we're not happy, we're going to move on. And so that puts a lot of responsibility on the employer to find out what makes us happy. And sometimes that just doesn't, that doesn't translate well. 06:39 Yeah, I see where these connect, let's focus on the first one, because that is a really good, interesting point, I have definitely mentored some dance PTS who are burnt out, and they are in a situation where, Oh, Gosh, darn it, what is it productivity, productivity is measured. And that has been very problematic for them, because they'll come in, and they see that they are, they know, they're getting paid less. But they're not more because in your case, you actually saw the data, but they're seeing the, they are seeing the exact number of patients as a seasoned professional, there, and they're just they don't understand why they're getting paid less, if they're seeing the same amount, then they were there, they would imagine, I would be seeing less patients, then that would make more sense, you know, but no, that's not the case. And therefore, that income would still be it is assumed that income would still be made. So it's almost like they're being profit, they're more of a profit is being made off of them. They're exhausted, you know, but they're not getting a lighter load to feed that exhaustion, that adjustment, they're getting treated just the same. And so they don't understand that pay difference when they come in. And I'm going to bounce off this a little bit more because of what the reasoning so it's going to get a slightly off topic, but I'm always okay with that is the promise of mentorship as a reason for why they are paying less that can be a reasoning behind it, which still, there are some clinics that actually provide mentorship, but the majority of them do not actually provide that mentorship, so it's more verbage. Or they have some sort of automated system, that's there maybe videos or something. So there, it's not really an extra effort. It's something that's already there that can help streamline what's going on. Especially if you're in a place that measures the productivity. You can promise it as a as a somebody owns a clinic, however, who's the physical therapist, and how much time do they actually have to really mentor? So if there really, it doesn't make sense, right? This reasoning of oh, why, you know, and these are generational, different thoughts, but for I think that's what you're hitting is that the younger generation will speak their minds and say, hey, you know, they're not getting that mentorship, they're not getting that value for them to go. Oh, that's why then because they get oh, you know what, I'm getting great mentorship, kind of like where people think residencies, getting great mentorship that get one in paying less I get it. I totally get it. That's not the case. No, no, in a lot of circumstances. 09:33 Seven years, I think I've been out seven and a half years for a PT school. And I've never been in an environment outside of residency that that had any type of formal mentorship. But you're correct in that I've have had several interviews with several companies that have promised mentorship because that was important to me. I kind of did less the reason I worked at the job that I did that I'm mentioning in this in this interview. This conversation. The reason I took that job, and I knew I was getting paid less than I was worth. Um, the reason I took it was because my clinical manager and the only person who was more productive than I was a personal mentor, who was my was one of my direct mentors in residency. And so I saw it as an opportunity to continue getting mentored. And so I'm getting an exchange of additional mentorship. I will take less pay. 10:32 Okay, yes. And your, your through your apps, you're like, Oh, yes, yes. 10:36 Correct. But there was no formal mentorship. Now, I did continue work with this guy. I did learn a lot from him. But there was no formal. 10:45 That's a big, that's a big deal. It's not exactly, 10:48 exactly. And there's no when is the end point? I mean, when is the point where I say, Okay, I've received enough mentorship now I'm ready to get paid. Okay. Right. There has to be some kind of trade off there. So. But you're absolutely correct that that is there is a common promise of these employers to employees, younger, generational PTS, of mentorship, in exchange for, you know, lower, less than ideal pay, but is delivered upon. 11:20 Right, right. And I think that's the thing, because there's different ways to work around depending on the clinic, and everything that can happen in these rooms for negotiation. So when these different mindsets come into the room, for it to work out, but you got to follow through on both sides. One is providing the mentorship and the other side is accepting, that's what you accepted, and knowing that owning that. So, but it can be I mean, you know, what I was about to go into different things you can negotiate, but this is not a lesson on negotiation. So I'm going to skip over that. So yeah, when you when you are going into a clinic, I feel like that is a way to potentially solve the problem, but it's just not being solved right now. It's it's still, these gentlemen are the we have people who own these businesses who are getting annoyed about the the younger generation talking about money, but then they're not looking at, they're not really listening and taking in what is being said, because it's it's a block that we can get our own bias on how we lived our lives. And, and we need to get out of ourselves. I say that, as a practice owner, myself, we have to always work to get out of ourselves all the time, in order to better listen, to be with the changes of the world. And the reason why there are changes, but the reason why things are fluid, and it's always changing with every generation and so on, is because there's always a better way. Right? And we may not answer to it. But But there's always a better way. And and you got to figure out, you know, what's what's going to if you really care so much about keeping them around for a long time. And that's, that's a big deal for you. And absolutely, totally get that it's great to have somebody there for a long time, then what is it that they care about? What is it that they care about? You know, and how do you and then if you want to do something that is not financial? Because your your clinic can only afford so much? What are those intangibles that you can bring to the table? Or even the physical therapist coming into work for them? What are those intangibles, and that's where you can really come to the table for a better exchange with those generational differences. I think, you know, and, 13:36 you know, and one of the things that you kind of touched on is that we have to be, there's always a better way, and we have to be open to that better way. And I think that's where we run into an issue of when a younger generational PT says, well, this doesn't make sense to me, I want this amount of money. That's not us complaining. And I think that can be perceived as, as as, as a complaint, US whining, because we were known as the whiny generation. We you know, we complain a lot and what compared to what we're told is that we complain a lot, we're whining, we're never satisfied. And it's not that we're whining. It's not that we're sad. It's just that we grew up in the information age, we know what the PT next was making. Well, we know what the average PT makes. And so we come to the table and ask for this. It's not as whining and it shouldn't be perceived that way and we shouldn't be promoted as the whining generation is annoying. Having the information available to us and trying to benefit on or not even benefit just just be pay. We're given what we're worth. You know, we're rainbows and clouds profession. I mean, we we are a just a happy, just beautiful people and we just love people love everybody. And we're so happy go lucky and lovey dovey and I love that about us. But one thing that we do tend to forget is that the word can mean that we are healthcare practitioners first, but this is also a business. We have to be sustainable, to be able to provide the jobs for our employees, we have to be fulfilled in our careers to be able to provide the care the level of care that our patients deserve. And some of the ways that we do that is to ensure that our employees are happy. Somebody brought up at the conference, the idea of valuing your employees. And value in itself. I think, for us as this lovey dovey profession means so many different things, but value in itself as a word is a financial word. What is the value of me as a a physical therapist? I know my financial value, if you cannot meet that, as you've already touched on, if you can't meet what I'm asking for what else can you meet me, meet me halfway meet me with increase vacation days, maybe with an increase a formal mentorship program. We're supposed to meet and you're supposed to meet me where I am as an employee. And so I think that's where there's a big barrier as well. And that sometimes we're a little bit too focused on intangible things where a lot of or several of us are looking for tangible benefits in my generation. So I think that's a big riff. And it's a it's got to do with our identity crisis in our profession that I said this at the conference. Nobody loves pts. As much as PTS love BTS. And that's our issue as as a profession that we have to address. And I think that kind of that kind of flows over into this this generational difference. Oh, my God, it does. It does. Absolutely. Absolutely. And so that's, you know, I don't want to get too deep here, but I want I actually 16:55 want to bounce off you because, yes, because they popped in my head earlier. And I was like, I just let the idea, you know, because I just want to listen to you. But yes, it's the Pete, the best thing to T PTS, you know, and there's nothing wrong with us, the more seasoned professional that I mean, yes, ever. When I say this, I know they're seasoned. Like, I know, they're sick, we're not perfect. But the C's, they they live on this rainbows and clouds. I'm just saying, I know, it's a harsh way to say it. I hear I hear what I'm saying. But whatever I'm gonna say it. And then we have where the younger generation, I think it's Gen Z, because Gen X is before. So okay, so we have the Gen Z, and the millennials are newer in the profession. And they're not afraid to point out things that they think are wrong. But I think then with that in mind, I think from higher up there is toxic positivity. And I think that's where that comes in. Where it's pushed upon, you cannot say anything bad. But then we lose this honesty and transparency in what's going on in the communication. And, and God forbid, something bad is said, you know, boy, and guess who's on social media, everyone? So if you're talking about, you know, like, oh, there's younger people are complaining. Facebook is older people, man, Twitter is older people. Like there's some younger on there too. Yeah. But like the hotspots to be at are tick tock and mostly ticked in my opinion. Tick tock. Yes. And then I think I never looked at the data. So yeah, but I think Instagram is secondary, but that also has to do with like, how I like to watch the videos personally, I can I can scroll through the Tick Tock thing and then I can go to Instagram Instagrams a little bit not as smooth I go back to tick tock okay. So um, but but that's you know, that's where it's so far talking about all the younger they all they do is complain that's, that's all ages baby. That's all ages, we all we we all like don't I think it is so healthy, to have a full well rounded conversation that points out the bad and the good and you don't have to finish with a positive statement in a conversation about it's okay to end in a gray area. It's okay to end in a dark area and both see it you know, yeah, that is I don't have a solution. Like that's actually that's not a good thing. It's okay. But we but this toxic positivity puts anybody going through anything on the spot if you're anybody who might be oh gosh, dealing with somebody who is has poor health in your family and you can't talk about it or mention it at all and you're yet to put on this face. I get it. That's you know, I'm putting in air quotes professionalism, but professional professional only means literally other profession. Everything else is defined by you. Or defined by me. So literally, that's all perfect. Like everything else is like up in the air up for grabs. however you interpret it. So the you know, took like, place these these random rules on what professionalism, professionalism is from that point on is is purely subjective. And that's where that toxic positivity comes in. Yeah. And then in then we get these risks these butting heads, because everybody has different core values, which is great. And I think that is a huge generational difference and where we lose and miss out on opportunities to listen and hear more. 20:29 Correct, correct. And that's where the issue becomes. I spoke on generational differences, as in the context of what is leading to burnout in early career professionals are the career pts. And I spoke on generational differences as one of the things that I thought was a key key difference. And one thing to note to note is that this isn't specific to pt. It's not burnout is not specific to PT, these generational differences is not are not just specific to physical therapy. This is a doula globally, this is definitely an issue in our country. There are, you know, I'm gonna make this a political conversation. But you know, there are, you know, 21:16 whatever all's fair game when you're with me, 21:20 you see, there's a group of people that believe that, you know, there's no, this is the greatest country on Earth. And that this is there, they would, they would know, they would not live anywhere else. And to say anything bad about our country is anti American. And then there's another generation that says, this is a good country to live in. This is, hey, I'm happy to live here. But there's a crap ton of issues that we need to address to make this country as great as it could be. And so that is, I say all that to say that there is no, I don't think we solve this issue. I don't know if there is a solid solution to the issue. But as I stated before, I do believe there are pptx, specific generational difference issues that we can address. And we should address. And as long as everybody is willing to hear each other out. Yeah, compromise, which is kind of where my conversation was with with the gentleman at the conference that we spoke about earlier. I had an opinion, but I heard him out. And I still don't agree with him. 100%. But I can identify a little bit more with where he's coming from. And I think that's key, I think it's important to have these conversations get uncomfortable with being, you know, get comfortable with being uncomfortable. And have these uncomfortable conversations to say, yes, these are the issues we have with your generation. These are the issues y'all have with mine. Where is that common ground? You know, is they always is, like you said better than we are? And so So, you know, I don't know, I don't know, I'm not the visionary, I see that you I can't give you the solution. I 23:08 don't know where I know, it's just to have a conversation. So that's all we're just having a conversation about this, which I think is great. You know, to get your minds and everyone's minds to start to think you know, are there you know, generational differences and everything. And be careful as you listen, it can be very hard because we there are a lot of people we're going to people help, we're a service business. And with that we get these people pleasing mindsets, where we can lose ourselves. And I would actually say definitely big time in the younger, newer generation. And in order to please the generation that has been around longer, we don't listen to ourselves and just agree it's okay to disagree. It doesn't mean you have to disagree. But really keep challenging yourself to get more and more in tune with what you believe in. And greater conversations can happen, greater solutions, greater growth and progress between all of us can happen, which is so cool. And it may not happen overnight, where you feel comfortable to talk about it. But keep I definitely agree with what you're saying. It's just if you can just keep even if it's a little bit challenge yourself a little bit more every time to just, you know, get there, you know, not easy, not easy. No. I love it. Any any other generational differences that you think oh, Jenna this or have we reached kind of your like, those are kind of the main ones where we 24:41 Yeah, no, I I do think those are my, you know, very inter intertwine those two that I talked about. I don't think that as as a this is sort of like a final word if you Yes, yes. I do think that specifically to this country, we value overwork For example, I, you know, I think that we value the the clinician or the co worker, not just in PT, but in general, we value the person who does the things that they're not required to do as a part of their job. That's what we use to determine who is who's that shining employee, who's the one that that goes above and beyond. Right. And it shouldn't be that I mean, for example, I remember, at this same job, we hit a low point, we hit a low point, always in January, it's an outpatient clinic, deductibles reset, so we're January, it was a low period, had a lot of openings on my schedule, so that everyone else and I was sitting in and getting caught up on documentation, going over some things with my mentor, learning new skills, in walks the owner, are asked, What are we doing? I tell him, you know, I'm trying to learn some things. And he says, Well, why don't we are marketing? I say, What do you mean? He said, you know, your patients, your schedule is low, why aren't you are out, you know, getting us new clients. And I'm like, that's not my job. Is that is you are the employer, you hired me to see the patients that frequent your establishment. Okay, I'm not the one to go out and beg these physicians to send us, okay, how much begging you do, the deductibles reset, that's going to be a phenomenon that happens every single year. So, but that's what the expectation from some employers have. Yes, I hired you to see patients and turning the documentation on time. But in also, I expect you to do these things, these these things that I didn't tell you about in your interview, but we expect you to do these things is become an expectation in this country, to overwork to do things that are not required to view and that is how we measure our employees and not on the job that they do. If you see all the patients on your schedule, go home on time, get your documentation in on time, and it's all you did for the rest of your life as a PT you'd never be promoted and you know in traditional practices so I say that's that's another generational thing is that I think we older generations value overwork working you all you need to be busy all the time. And we value we being the younger generations, a healthy balance of work and home life. I think that is another riff all of these are intertwined, but I think that's a another riff that's that's that's causing an issue, not just in our not just in our profession, but but across this whole country. 27:42 Now, yeah, definitely. I love it. Thank you so much for coming on to talk about this. If you are listening to this podcast, and you have some other ideas and stuff, feel free to write in the comments, just keep the conversation going. I think it's always good to just talk about it. And then And then if you're somebody who's about to go in for job interviews, write these things down for you to consider what you're going to bring to the table for your negotiations track on both sides, what was discussed in that interview? So it's very clear. If things come up that are that we're not included, it's so you can have a better chance of being on the same page. Yes, you're correct. We didn't bring that up, or you know what we need to make sure we bring that up, because that does come up, the more we can be on top of that transparency in the communication can better help address generational differences right off the bat, do keep in mind seasoned professionals owning your own practice when these students are graduating, they have a very low sense in general sense of self worth. So for the overwhelming majority, they usually jump at a job faster than they should. Because they are so excited. Anyone wants them. And that is a big thing that happens often at clinics. So just be aware of that them saying yes doesn't necessarily mean they were listening to what they wanted in the first place. Because they feel so grateful that they were not rejected, they were accepted. And that takes over everything. It helps it feeds into them eliminating what their core wants are because they struggle with self value. Alright, that's it. Where can people find you on the social or email, whatever you feel comfortable with sharing. 29:40 So I laugh when you say the old people are on Facebook and Twitter because that's really what I use is 29:48 and I'm in that category. So I feel comfortable saying 29:51 I'm not a Snapchatter I do have an Instagram. My Facebook name is just mine. That's what I'm primarily on. That's where I'm most entertaining. Book 30:00 is it clearance a home's nobody's claiming homes, clients homes, 30:05 parents homes as well. I'm the one that's scuba diving in my photo. 30:11 If it changes to hiking, everyone's gonna get confused. 30:14 I know why it's not going to just all my photos are nice. And then my instagram name is CA Homes six ca h o l mes the number six. Oh, I 30:27 love it California. You're not from there. But it's fun to say. Wonderful. Thank you so much for coming on. Everyone. If you're listening, please be nice. Be nice. Yeah, you can communicate but be kind. If there is any possibility that what you wrote might be in a way interpreted in a mean tone. Don't write it. I just don't I don't see. Like, honestly, it's just why and I'm not being toxic positive. I'm just being real. Like it's only going to just why why? Like go speak to your legislative representative about it, you know that you can actually make changes. Alright, that's it. Thank you for coming on.

In this episode, President of IFSPT, Luciana de Michelis Mendonça, talks about her research and the upcoming World Congress of Sports Physical Therapy. Today, Luciana talks about the importance of the WCSPT and the results from her research. Why are organisations like IFSPT important? Hear about why sports PTs are important in injury prevention and reduction programs, pre-season assessments, implementing prevention programs, and get Luciana's advice to her younger self, all on today's episode of The Healthy, Wealthy & Smart Podcast. Key Takeaways "We should assess our athletes to make the most amazing tailored prevention program." "Injuries happen, but if you can decrease the time that the athlete is spent outside the game, then that is a win for the team." "Warm-up sessions with the physical therapist were the methods used to prevent injuries." "Be lighter, less stress, [put] less pressure on yourself." "I am where I am because I'm good at what I do." More about Luciana de Michelis Mendonça Luciana is a professor in a federal university in Belo Horizonte (Brazil) and develops research in the field of sports physical therapy. She has participated in the last four IOC world conferences on injury and illness in sport with poster and workshop presentations. She was involved in organisation of physical therapy services for the Rio 2016 Olympics and Paralympics Games. She was the first female president of the Brazilian Society of Sports Physical Therapy (SONAFE), in a country with many restrictions to women's participation in sport and politics. Since 2017, she has been an executive director of the World Physiotherapy subgroup International Federation of Sports Physical Therapy (IFSPT) and is now IFSPT's president. She is committed to enhancing the dissemination of sports physiotherapy good practice and knowledge globally and to increase equity in sports physiotherapy. Suggested Keywords Healthy, Wealthy, Smart, Healthcare, Physiotherapy, Sports, Research, Injury Prevention, Prevention Programs, Exercise, Recommended Reading How injury registration and preseason assessment are being delivered: An international survey of sports physical therapists How injury prevention programs are being structured and implemented worldwide: An international survey of sports physical therapists Sign up for the Fourth World Congress of Sports Physical Therapy To learn more, follow Luciana at: Website: https://ifspt.org Twitter: @luludemichelis Instagram: @lucianademichelis 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: 00:07 Welcome to the healthy, wealthy and smart podcast. Each week we interview the best and brightest in physical therapy, wellness and entrepreneurship. We give you cutting edge information you need to live your best life healthy, wealthy and smart. The information in this podcast is for entertainment purposes only and should not be used as personalized medical advice. And now, here's your host, Dr. Karen Litzy. 00:35 Hey everybody, welcome back to the podcast. I am your host Karen Litzy. And today I'm very honored and excited to have on the program Dr. Luciana de mckaela Mendoza. She is a professor in a Federal University in Belo Horizonte in Brazil and develops research in the field of sports physical therapy. She has participated in the last four IOC world conferences on injury and illness in sport with poster and workshop presentations. She was involved in organization of physical therapy services for the Rio 2016 Olympics and Paralympic Games. She was the first female president of the Brazilian society of Sports Physical Therapy in a country with many restrictions to women's participation in sports and politics. Since 2017, she has been the executive director of the world physiotherapy subgroup, International Federation of sports, physical therapy or ifs PT, and is now IFSP T's president. She is committed to enhancing the dissemination of sports physiotherapy, good practice and knowledge globally, and to increase equity in sports physiotherapy. And in today's podcast, we will talk about some of her research into injury prevention and the role of sports physiotherapist in those programs. And of course, we will also talk a lot more about the fourth World Congress is Sports Physical Therapy, which is happening in Denmark this August 26, and 27th. That's 2022. So if you want to find more information about that, you can click on the link at podcast at healthy, wealthy smart.com. To find out more about the fourth World Congress is sports physiotherapy, again, taking place in Denmark. So we will talk a lot about that. And we will also get a sneak peek of some of Luciana has talks there. She's speaking and she is moderating. So she's got her hands full for sure. So I want to thank her for coming on the podcast and everyone enjoyed today's episode. Hi, Luciana. Welcome to the podcast. I'm excited to have a conversation with you today. Hi, Carrie. Thank you very much for having me. Yeah, it is my pleasure. And now before we get into the meat of our interview, can you tell the listeners a little bit more about you about your history in sports, physical therapy. And as I mentioned, you are the current president of ifs pts. You can talk a little bit about that as well. So I will hand the mic over to you. 03:06 Okay, Karen, so I'm from Brazil. I'm a sports physiotherapist and I graduated in 2003. So I'm 20 years as a physiotherapist. And I'm also a professor in diversity here in Brazil. I'm based in Belo Horizonte. And 03:28 I started to work. Since the as a students and sports team, I wanted to do physical therapy because of sports. I am passionate about it. And I, I started in this political scenario in the Brazilian society of sports, physical therapy. And I started it was in 2016, it was the year of real to tastic significant part Paralympic Games. So it was a really big challenge. I also work in the physical therapy services during the Olympics and Paralympic game here. And I started being part of the Executive Board of the IFSP CI in 2017. So I learned a lot during the presidency of Anthony Schneider's in Christian torborg. And now I have this big challenge to be IFSEC. President so I'm balancing this actions related to if activity and also with teaching and also research about sports, physical therapy. And my research is mainly directed to injury prevention, and also injury risk profile. So I think that's perfect. And can you talk a little bit more about IFSP T and kind of the importance of having these organizations and what they what they do, what are they there for 05:00 Yes, so the International Federation of Sports Physical Therapy is a subgroup of the word physiotherapy. That's our main our mother organization. So as a subgroup, we have to engage countries all around the world that have specific group related to sports, physical therapy to join the IFSP team. So nowadays, we have 34 member organizations in the SSP T. And our main mission is related to disseminate good practices, support research on sports, physical therapy, of course, and also promote actions to support our members, the whole community. So improve the practices around the world. And also it's a good it's an important way to connect with people. So I think the most amazing gifts that I had, being in IFSP T board is to network with people around the world. So it's a really 06:18 important way to have our professional, our profession, organize it. And so I probably will be in the presidency for the next four years. That's the plan. Yeah, that's, that's amazing. And one of the things that, like you said, as part of the organization is networking, and we'll say this will probably repeat this a couple of times, but the Fourth World Congress is sports, physical therapy is coming up August 26 27th, of 2022 in Denmark, and obviously, you will be there and you are a part of several presentations. 06:57 But like you said, your research is around injury prevention and assessment in sports, in sports. So can you talk about why the sports physical therapist is an important component of these injury prevention programs or injury reduction programs? 07:19 Yes, I just want to stress that, yes, the Congress of sports, physical therapy, it's important action that IFSP t also have, we are one of the main organizations, the main sub groups of world physiotherapy that deliver International Congress. So we have the first one in Bern, the second one Belfast, the third in Vancouver, and now illegal in Denmark. So I, I went to Belfast to Vancouver, and now I will be enabled for sure. So 07:55 I'm sorry, Carrie, I forgot your question. Oh, yeah. No, so my, my question, like I said, you're doing you're doing a ton. You'll be doing a ton in Nyberg. But one of the things that I know you are talking about is about your research that centers around injury prevention, and something that you're passionate about as if the sports physical therapist should really be involved. So why is that? 08:19 Yes. So I always thought that the main action as a sports physical therapy in a sports team, of course, I should be aware that, for me, I need support all athletes available to the coach to the head coach to train. So for me, it's, it was always a good time to have like the physical therapy department, empty without athletes there, because all athletes should be on the fields playing and training. 08:56 So for me, prevention was always important action that we as therapists should be aware of. So I, when I finished my PhD and start to be a teacher in university in Brazil, I started to wander, especially after I started to work in the IFSP. Board, I started to wonder if the prevention, the role that the Sports Physical Therapy had in prevention, and I know that how this works in Brazil because I was sports physical therapist and the volleyball team and soccer team. I was wondering if it was like the same, or I was wondering if it should be the same. Or if we are here in Brazil, we're doing like similar things that other professionals data around the world. So I have a sabbatical year in 2020 and I went to Belgium to work with Eric FitPro. 10:00 I was there in Uganda, the University of Ghana, as a visiting professor. And we started to develop a surveying to understand what role the sports physical therapists had in injury prevention. So I will talk about some of our results, we have two papers about this survey that were that are published in physical therapy in sports. And this helped me to have 10:33 sort of idea about the role. And we have really interesting information about this, that, of course, I will share here in this podcast, and also in the World Congress of sports, physical therapy. And also we develop a Delphi design to establish a consensus on sports injury prevention programs. So this is also an interesting 11:01 study that we could deliver an IFSP participated to, with this Delphi study linking 11:09 people from different countries. So I'm really excited to talk to you about this caring and say something that should make people a little bit curious and participate in the Congress. In Denmark. Yes. So when can can you give us a little bit of info, you don't have to give it all away? Of course, people can go and read the the 11:36 published papers, but in this 11:40 in this study, you had, how many people? What did you find? How did you do it? 11:50 So yes, for sure, I can share some of the data that we had the papers are published. And also you can indicate for your audience, I can send you the links. It's important, I totally understand caring that sports injury prevention area, we need to move forward related to research, we need to understand a lot of things. But I think it's interesting to understand what the professionals what the sports physical therapists are doing, because this can bring up some questions for future research. So 12:29 on the survey, we 12:32 we had 414, sports, physical therapists participating around the world. So I think we had like, people from 32 countries. So I know that the amount is not so high, we could have more people participating, but it was delivered in 2020, during the pandemic. So this is one thing that I should stress because, yes, we had 32 countries participating, but I, for sure, I expected to have more people there. But we had questions in this online survey that was related, link it to the synchronous sequence of prevention that were Matalan delivered, and maybe it's the the most use it, model or to make decisions about prevention. So we ask it if this sports physical therapists participated on injury prevention, sorry, injury registration. It's common here, Brazil, but I didn't know if my colleagues in other countries participating in the injury registration. We also asked if they assess it, the athletes to build the prevention program. So if they did, for example, preseason assessment, that's the more common way at least in Brazil. So I was curious about that. And also, I we asked about their prevention program. So if the pieces participated in this action or not. So about equal registration, the first thing this I think this is an amazing result, because we had more than then 80% of the sports physical therapists that participate in this study, were responsible for me to reverse the situation. So we can now say that maybe the sports physio are the are the person like more important more responsible to properly register injury in their sports team? So this brings brings up a lot of other questions. So for example, maybe we should IFSP T should deliver some actions to maybe 15:00 increase the knowledge and maybe the competence on this matter on our community. Because of course, if we are responsible for this, we want to do an amazing job. So it's, it's interesting. And it's good also to exchange some experience and learn from good examples. So this is really good. And we also ask about the main barriers. 15:29 So for sure now register the injuries. So more than a half of this physios said that lack of time in their routine was the main factor to not properly register injuries. So maybe we need to discuss also about the sports physio routine, inside the sports team. I think we talk we should talk more about this, especially in conferences that we can get together a lot of professionals from different countries, and we can learn from their experience. 16:08 So can I move forward? You have a comment about registration? Nope, I think I think that's good. And I do like that. You said, Hey, maybe this is a chance for us to get together learn from each other. Because perhaps there are ways to streamline this that people just haven't thought of that other people are doing. So you're right. It's a great opportunity for sports organizations, like if SPT to bring sports physical therapist together and say, Well, wait a second, some of you are doing this with some of you aren't. And if it's a lack of time, what can we do to give you a structure that can streamline your process? Yes, exactly. And it's one thing that here needs to be done. We just We can't like, Okay, I'm not going to register injuries, because how can I be sure if I'm going to prevent the injuries if I'm not registering? So if you're not registering, is it like they didn't happen? 17:09 Yes. And another another thing that is really interesting, what is the injury definition? That is sports, physical therapists are using my understanding, we can select different definitions, because this maybe rely on the sports modality. 17:32 But we need to talk more about this, I think we should 17:37 exchange and learned and maybe from this, maybe if aspartate can deliver some guidelines, I don't know, because it's one of our missions. Also to make the FSB T is the main resource for the Sports Physical Therapy community. So I think we will maybe in the future, we are going to have more actions based on the findings of so I'm really excited about this. Okay, so let's move on to preseason assessment. So how many are performing? And what are the barriers? I know that this is this, topics of little bit controversial, I know that we have a group that thinks that we should assess, and another group of sports physio, or research thinks that we, we don't need to. But our survey shows that 77% of the participants perform preseason assessments in their athletes. 18:45 So 222 sports fields, said that they do. This is amazing information. And I didn't expect for this high percentage. 18:59 And I was happy because I believe that we should assess our athletes to make the most tailored, most amazing tailored prevention program for our athletes. I know that this is a challenge. I totally understand this. But if I think about myself as a sports, physical therapy, if I'm working in a sports team, I will like I will do my best to assess the athletes and try to deliver 19:30 into an individualized prevention programs. So but we have like, opposite side here because only 30% of these sports physical therapists that do preseason assessment, customize the provincial program bases in the results of the assessment. 19:54 So this is a point that we need to understand better. We need to understand what is happening. Why 20:00 They sports fees you give energy to assess the athletes, but they don't apply the results to build the prevention program. 20:11 So we didn't 20:14 ask it like specific questions about this. To understand this, we only asked about the barrier. So the main barrier 20:23 that was indicated to not before assessment, it was lack of structure and organization of the sports team. 20:33 So about half of the participants indicated this barrier. 20:38 I understand makes sense, but I'm not sure if this barrier explain 100% of the reasons to not perform the precision assessment. And I think maybe this is also relied on the evidence that we have related to these. We have big discussions about injury prediction probability. So maybe we need to make some advance in research about this topic. And maybe we need to talk more about this to make more like have this issue more clear to everyone, specially the clinician. 21:22 Because I think so now, it's my opinion. Okay. I think we need to assess our athletes, and maybe maybe even the process of assessment should be discussed. Because if we, if we are here in a roundtable with sports, physical therapists, and we ask how you assess your athletes, which tests do you select, probably carrying, we are going to have different answers. So I don't I'm not sure what this means. It means that we don't have standards. We don't have like a protocol. Should we have a protocol? I don't know. But what I know is that we need to talk more about this. Yeah, I mean, oh, go ahead. Sorry. No, no, I just like, I just want to say that I was really happy with the the results that sports fields with a majority is performing a preseason assessment. But on contrary, I was I get a little sad to see that not like 1/3 of them are really applying the Results to Build provincial programs. And yeah, and so I brings up a couple of questions for me, and that is, have you seen preseason assessments? Decrease injury, are they and again, this goes on? I think what you just said that sort of prediction and probability. So if you do a preseason assessment, does that predict less injuries? I don't know. Have you seen? What are your thoughts on that? 23:06 Thank you for asking this caring, I think 23:10 preseason assessment. The main propose is not to predict injury, they may propose is to identify those athletes with more susceptibility or probability to get the injury and then we can act before this happened. I'm not saying that if we perform a preseason assessment and beta prevention program on the results, our athletes not going to get into I'm not saying that injury, always going to happen sports, but we can, for example, decrease the severity. 23:52 So if I have one athlete that I can, for example, I apply the stars question balance test, and I see that this athlete have a really low stability, functional stability in the lower league. So I can include in their provincial program, exercise to improve the stability, and maybe he will, he will, like have the ankle sprain, but I can decrease the severity. 24:26 So I will decrease the time loss. I will make this athlete more available to the head coach at the end. That's my reasoning on preseason assessment. And I think there is a misconception about this issue also. Right? Because I think, you know, if we're playing devil's advocate, some people may say, well, the preseason assessment isn't going to eliminate injuries. Why am I why am I doing it? Right? But like you said, injuries happen. But if you can decrease the severity if you can decrease the time that the athlete is spent out of the game 25:00 Yeah, then that's a win for the team. And it's a win for the coach in the organization. But if only 30% If if you have all of these sport physiotherapist doing a preseason assessment, then only 30% customize the program. Now we have to come up with some incentives for that physiotherapist to customize 25:19 the program for the athlete. And again, that may be like you said resources available to them, if it's one person and 50 players, 25:30 that it's difficult, you know that that's that that's quite difficult. But 25:37 I can understand how this can be a very frustrating part of research, because there's a lot of moving parts. And it's not just the sport physiotherapist, who has all best intentions and at at the heart of, of of their work. But there's a lot of external factors that need to come into play. But 26:03 I do I also like your that idea of being on a round table with sport physiotherapist and saying, Well, what do you do? What do you do? And maybe like you said, I don't know if a protocol is right, but maybe some sort of a roadmap where you have some basic assessments, and then you have the freedom and the ability to get creative, but to have certain certain things in there that makes sense for that sport? 26:31 Yes, I totally agree with you. Here in Brazil, I have a lot of colleagues and friends that came from the Brazilian society of sports, physical therapy. So we talked a lot in exchange a lot. So I, I myself, I have my challenges related to really delivering the prevention program that I i understand that would be like the best thing to do. But of course, this also relies on the relationship with the head coach, district parenting coach. So it's a lot of factors variables that we need to understand. And that's, that's really individual. It depends on the context of each sports team. So that's what I when I say that maybe we don't, we will not have like a protocol, because it depends on the sports team reality. But I agree with you that we can give maybe some roadmap to help everyone to organize better, considering the context, right? Yeah, exactly. Exactly. Oh, that's yeah, that's that really opens up a can of worms for people. That being said, let's move on to prevention programs. So what did you find with that? 27:53 Yes, so about the prevention program, we see that warm up. 27:59 sessions with the physical therapists were the methods more use it to prevent injury. And I think about warm up this was already expected because it was one roadmap that FIFA 11 Plus gave to everyone, not only for soccer, we have evidence on basketball, handball players. So FIFA 11 Plus really helped in this maybe this 28:31 basic organization, and how to deliver some preventive action in a more easy and accessible way. So I think it's really interesting that this survey, like confirm that one map, it's a really good strategy to include the provincial probe on athletes routine, because the athlete will need to warm up. So we have this moment, and why not. So instead of make the athlete do like, 29:06 whatever exercise or just running on the field, why not to be more specific and includes exercise that the athletes really need to do based on the sport modality. 29:20 Epidemiology. So for example, we know that in soccer, we have a lot of famous hamstring strain, we have a lot of ankle sprain, knee sprain. So why not to include some melodic at the size it some balance exercise? I think this is a really 29:38 important action that every old sports physical therapist needs, so be engaged and participate and about the individual sessions with the sports physical therapists. It's important to us and then I really expected some information around this 30:00 because we know that we have some time zone athletes that need a specific exercise that needs to be delivered by the physical therapist. So I was happy to say this because this was the methods more use it more indicated by our participants. And above the barrier, we saw that lack of time in athletes routine was the main barrier to perform the provision. This was indicated by 66% of the participants. 30:34 Of course, I expected results. And that's why warm up, it's important action because this is already in adults routine, we don't need to change the routine to include one more time and period to do 30:51 the exercise related related to prevention. So again, carry I don't know if this only this area only about athletes routine, we can understand why we can't perform major prevention. And as I said, Before, I understand the challenges. I think it's not easy. But I think it's a wonderful, it's a wonderful action that sports physical therapists participate. And it's really, of course, important for our athletes health, not only performance, because we have evidence that provincial programs also increased performance. But also I'm concerned about athlete's health, we need to, of course, help the athlete because no one wants to get into it. So this is really, it was really important. 31:49 For information that is the also indicated and these information helped us. So sort of build the questions related to the consensus, that was our second step during my experience in Ghent University with Eric. 32:11 Right. And so at W CSPG. You're going to show some data about the Delphi consensus, so you don't have to give all that away, people can go to the conference to hear more about that. But if you want to give a little preview, now's your time. So you what are the main topics investigated? 32:31 So about our Delphi, we organized the consensus in three parts. So the first part was related to how the thesis should plan the provincial programs. So this planning was about the information or the reasoning to develop the injury prevention program. So this is interesting, because we have information that, for example, sports, physio, use the reasoning related to biomechanics, or the base decision only on evidence and injury, Epidemiology, or athletes, injury history. So we have this kind of information and result and this is really brings up some discussions. So I hope that on the conference, I can, we can have this moment to discuss about our information, our data. The second part was about the organization. So how work environments before the implementation, how this affects the delivering the injury prevention programs. And the third one is about the implementation phase that I know that there is a lot of discussion and research, we have a specific we have specific groups of research that really go deep in this matter of implementation. So in this third phase, we identify barriers and facilitators to implement the injury prevention programs, and also related to compliance, if visibility. So this is how we organize the Delphi. It was a huge amount of work from all the core authors that participated in this study, and really happy that we can now say that this is accepted in physical therapy in sports generally, we can now really disseminate 34:39 this information, and I'm really happy to be part of this. Yeah, well, congratulations because that is a ton of work. And again, if people want to learn more about this, then you can come to Nyberg August 26 27th The Fourth World Congress is Sports Physical Therapy in Denmark. 35:00 And I mean, who doesn't want to be in Denmark in the summer? Right? I mean, amazing. Yeah, this will be my first time in Denmark. So my I am excited. So of course, no Denmark, but also to meet my friends from Sports Physical Therapy community, specifically before this, sorry, after this pandemic. Yeah. So I really miss my friends. And I really excited to talk more about injury prevention. And so our consensus results, and exchange and networking with everyone there. Yeah. And where can people find you? If they have questions? If they you know, we'll have the links to the studies that you mentioned in the show notes. So if people read that, and they have questions, where can they find you? 35:53 Yes, Carrie, so I am on social media. So I have my Facebook profile, Instagram, it's with my name, no change at all. And also in Twitter, is Lulu the chalice so you can find me there. And we can keep talking about information. IFSEC. I invite everyone for be like in the World Congress of sports, physical therapy, it's in August. So I'm really excited to be there. And I hope to see you there all for caring. Yeah, I will be there. I'm looking forward to it. And now final question that I asked everyone knowing where you are now in your life and in your career, what advice would you give to your younger self? Good question. Okay. So maybe, first, I would say to my own self, congratulations, you are an amazing woman in you accomplished a lot. 36:52 For sure, I never thought that I would be where I am now. As IFSP President working in federal, probably the most important federal university here in Brazil. So I'm really happy. If I could give her some advice should be be more lighter, less stress, less pressure on yourself, Luciana. 37:23 But at the end, we don't don't care if this increased pressure or stress, help in a way. 37:31 me to be here where I am. Or if I could go through this path. Be more. 37:41 I don't know light. I think the word is like, Yeah, I think so. And, and I love the fact that you said you know, you would congratulate yourself. And I think celebrating wins and celebrating what we do are things that women don't often do. Right? We're always sort of congratulating others and putting others up, but we never sort of congratulate ourselves and celebrate our wins. And, and I think if I were to go back and tell my younger self, something that would be it, like stop making yourself smaller so that other people can be bigger. It's a constant exercise. I didn't accomplished my winnings, my victories so often, but now I can see clearly that I am where I am, because I'm good in what I do. So perfect. What a way to end the podcast. I think that's great. So again, people can see you live in Nyberg, August 26 and 27th. At the fourth world, Congress is sports, physical therapy, you again will have the link on the conference and how to sign up. And we certainly encourage everyone to do that. Like you said, What a great way to meet up with colleagues to get some really great information and be in a beautiful place while you do it. Yeah, exactly. And on August 25, five, we are going to have a network session delivered by FFTT. So we are going to have also this moment to get together and exchange. Perfect. Is there anything else? You know, you're the president? So is there anything else that we missed? Talking about the conference that you want to let people know is is also happening? We are going to have an interesting conference because it's going to be I think the first World Congress of sports, physical therapy that we're going to have specific moments to do sports in the program. So we are going to have this more serious moments to talk more about our practices and research but also light moments to practice sports and be more friendly there. Yeah, so basically bring your workout clothes is what you're saying. Yeah, 40:00 Oh, yeah, that's exactly perfect. Perfect. And I don't think I mentioned that when I spoke to Katie so I'll be mentioning that moving forward that bring your sneakers bring your workout clothes, that traditional 40:13 well here in the US for whatever reason, people like always wear suits to these things. 40:20 So don't don't worry about the suits, but definitely bring your workout gear. Yes. Perfect. Perfect. Well, Luciana, thank you so much for taking the time out today and coming on to the podcast to talk about all the great stuff you're doing. Thank you so much. My pleasure, Kara. Thank you so much, and everyone thanks so much for tuning in. Have a great couple of days and stay healthy, wealthy and smart. 40:43 Thank you for listening and please subscribe to the podcast at podcast dot healthy, wealthy smart.com. And don't forget to follow us on social media.

In this episode, Nigerian Sports Physiotherapy Association Founding Member, Ummukulthoum Bakare, talks about her important research and advocacy of sports physiotherapy. Today, Ummukulthoum talks about her research on women's football, the issue of compliance and adherence, and the next steps in her research. What are the challenges for women football players, and how are they mitigated? Hear about her experience advocating for sports physiotherapy, her presentation on The Unbreakable Young World Athlete, and get her advice to her younger self, all on today's episode of The Healthy, Wealthy & Smart Podcast. Key Takeaways "Passion will drive you." "The increase in projections of the numbers of registered football players has skyrocketed by the participation of women in football." "Coaches need to understand that they can be empowered to take charge." "You don't have to think of injury prevention as this thing that is separate. It needs to be integrated." "Nothing is impossible. If you can dream it, you can do it." "The sky isn't the limit anymore." More about Ummukulthoum Bakare Ummukulthoum Bakare is a Doctorate Candidate in Sports Physical Therapy at the University of Witwatersrand in South Africa. Her research is focused on women's football and injury prevention. She is a founding member of the Nigerian Sports Physiotherapy Association and is active in disseminating the FIFA11+ injury prevention programme in her native country and across Africa. Her passion has centred around the sports of football, basketball, and para-athletes and injury prevention. She received her Bachelor of Physical Therapy and her Master of Physical Therapy from the College of Medicine, University of Ibadan, Nigeria. Ummukulthoum has worked as a physical therapist since 2001 and has won several awards for her service locally, regionally, and internationally. She is a member of the Medical and Scientific Commission of the Nigeria Olympic Committee and an Associate Editor for the British Journal of Sports Medicine. Suggested Keywords Healthy, Wealthy, Smart, Healthcare, Physiotherapy, Sports, Research, Injury Prevention, Women's Football, Empowerment, Advocacy, Third World Congress of Sports Physical Therapy To learn more, follow Ummukulthoum at: Website: https://www.facebook.com/nspa.org.ng/ Twitter: @koolboulevard Instagram: @koolboulevard 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: 00:07 Welcome to the healthy, wealthy and smart podcast. Each week we interview the best and brightest in physical therapy, wellness and entrepreneurship. We give you cutting edge information you need to live your best life healthy, wealthy and smart. The information in this podcast is for entertainment purposes only and should not be used as personalized medical advice. And now, here's your host, Dr. Karen Litzy. 00:35 Hey everyone, welcome back to the podcast. I am your host Karen Litzy. And in today's episode, I'm really honored to welcome UMO cooltone Bukhari she has a doctorate candidate in Sports Physical Therapy at the University of Witwatersrand in African South Africa. Her research is focused on women's football and injury prevention. She is a founding member of the Nigerian sports physiotherapy Association, and is active in disseminating the FIFA 11 Plus injury prevention program in her native country and across Africa. Her passion has centered around the sports of football, basketball and para athletes and injury prevention. She received her Bachelor of physical therapy and her Master of physical therapy from the College of Medicine University of Ibadan in Nigeria UMO kooltherm has worked as a physical therapist since 2001, and has won several awards for her service locally, regionally and internationally. She is a member of the medical and scientific commission of the Nigeria Olympic Committee, and an associate editor for the British Journal of Sports Medicine. So in this episode, we give you all a sneak peek of what she is going to be speaking on as one of the guest speakers at the fourth World Congress of Sports Physical Therapy, which is taking place August 26, to the 22nd 2022 and Nyborg Denmark. If you want more information on the WC SPT conference, head over to podcast at healthy wealthy smart.com. Click on the link in the show notes under this episode. If you can, I highly suggest signing up and joining us in August in Denmark. So Lumo coutume is just one of many speakers that we're going to be highlighting over the next couple of months. We have a great conversation today about the unbreakable Young World athlete which she will be speaking about Nyberg. So everyone enjoyed today's episode and be on the lookout for more speakers coming up in the next couple of months. Hey, Katie, welcome to the podcast. I'm really happy to have you on. 02:43 It's lovely to be here, Karen. Thanks for having me. Yes. And like I said in the intro, gosh, you are a real rock star in the physiotherapy world. So you are a founding member of the Nigerian sports physiotherapy Association. You are a member of the medical and scientific commission of the Nigerian Olympic Committee and an assistant editor for the British Journal of Sports Medicine. And so that leads me to my first question is How important do you feel these associations are for the profession? 03:20 Thank you, Karen. It's is really very important, especially from my side of the 03:27 of the continent where we have very limited resources. And it's always a good opportunity to connect with other colleagues from around the world. When we first started the the Nigerian sports physiotherapy Association, were just a handful of people who, you know, came together to say, look, if we did start an association like this, it would help us be able to connect with other colleagues and associated other associations from around the world. And then we connected with IFSP T, which also given us a lot of opportunity to connect with the rest of the sports PT world globally. And that has kind of enriched us over the years. And I'm happy to say that Nigeria was also the first African country to be affiliated with IFSP T. And we still have a great relationship till today. And I'm also actually, I think, the first African and the IFSP T board. The executive board. I was elected in 2019 in the last Congress in Canada, for the Nigeria Olympic Committee. That took a lot of work because it's actually by appointment. And over time, it had only just been physicians. There hasn't been any room for physios to get on board, but I think for somehow I just kept well with the National Society. I'd be the Nigel site of physiotherapy, I just kept pushing to get on visit 05:00 ability for physios get us to get, I mean, get the Olympic Committee to also organize specialized training for physios and all of that, and I was doing all this work, making sure that where they were conferences happening, I wanted them to, you know, support people to attend and all that, and a former vice president of the Olympic Committee, and as I look, I think you'll bring your loved one on board. And I'd like to nominate you to be on the on the medical commission. And I was like, Okay. And 05:34 when I got in, I was the only female and I was the only physio. But I am glad that we time a lot of things have changed. Because one of the key things I'm passionate about is to give room to allow upcoming and early career sports medicine stakeholders, be it physio psychologists, you know, doctors, physicians, but give room for the younger ones to be supported and, you know, have access to all the IOC courses and things like that. So I it's been, it's not been an easy journey, but I think you can change a lot more from the inside than the outside. And that's, that's why I took on the assignment. And so far, so good. It's, it's worked out. Yeah, it's slow. But it has worked out a bit. Yeah, amazing. And I was going to my next question was going to be what, what has it been like for you to kind of be the first to have a seat at the table? Right, the first woman which I'm not surprised, and the first physio to kind of have that seat at the table, what has that been like for you? And what lessons have you learned? 06:43 Um, to be honest, it was not a really easy thing to do, especially when you are in the middle of about, you know, 12 other people who, and you probably also are the youngest. Let me add that, even though I don't consider myself young, per se, but in that tool, 07:06 I was the youngest. So but I think luckily, I What sort of helped me was that I spoke with the chairman. And I told him Look, this is 07:18 this is the ideas that I have. And I feel like I know there's a lot of work that needs to go on behind the scenes, I'm happy to do all the heavy lifting, or writing and all that, but we need to push for more things to achieve our mandate. And he was very happy with that. And later, a lot of a lot of the other board members just felt like Okay, it looks like we have somebody who's willing to do all this heavy lifting with you know, writing proposals and stuff. And we just kind of make things work. And somehow they just realized that I wasn't really doing it for any self. For myself, as it were, I was trying to get us to have a better a wider ecosystem for sports medicine resource, be it physios, doctors, you know psychologists, pharmacists, nutritionists and stuff like that. And so far, so good. We've we have quite a sizable number of young, early career people coming on board, a lot more people are not interested in sports, physio and all that. And which is because before now, nobody really wanted to do sports physio, they felt like, 08:26 you know, you're, you're never going to be rich. Like you're always just 08:31 the government is always owing you money. And so why are you a physio per se but then I tell them that look, passion will drive you it is just a calling and you really need to understand that. 08:44 What can in any another prefer in any other specialty or physio? It's quite rewarding as a sports physio as well, if you if you're driven by the right 08:55 circumstances. So yeah, it's not going to be easy, because half the time you'll find yourself like a fish out of water, especially being a female 09:05 where you're working multisport settings and you have to work with male team and all of that you have to hold your own. But it's it is rewarding. And yeah, so yeah. And it sounds to me like some of my students. Yeah, some big lessons. There are one, being willing to put in the work and to opening the door so you can help bring other people in. It's not opening the door for yourself and closing it on everyone behind you. No, no, because there definitely has to be a transitional plan. What is the sustainability of whatever you're doing? Because at the end of the day, your time is going to come and go. So who are the people that you're empowered to continue that journey, the vision and to be able to achieve 09:51 you know, the end goal of making sure that there is that continuity, and that you have, you know, so they pay forward and they can 10:00 didn't pay forward until, you know, for as long as as needed. And we would have a big pool of sports physios because I can tell you that Nigeria is over 200 million people, and maybe about 10 million active Lee involved in sports at a competitive level. And we still don't have enough physios to cater for that number. 10:27 So there's still a lot of work to be done. I can't do it alone. It's a collective team effort. Yeah, I mean, you have to increase the capacity. Exactly. Right. So that that all of these 10 million people, which is a huge number of people cannot be seen by estimating. It could be more, right. Definitely. Yeah. So obviously, you don't have the capacity for all of that. So if you can open that door and bring in a lot of like enthusiastic, like you said, physios, physicians, psychologists, nutritionists to help you continue to build up the capacity of a sports medicine program across the country, you'll be able to reach more people. Exactly. And that's what it's all about. And now, let's talk about your research. So you've got this passion of building up the capacity for sports medicine in Nigeria, let's talk about your research, which I know you're also passionate about. So I'll hand it over to you. 11:31 Okay, so I'm currently working in women's football. I mean, it is what it is because women really don't get much attention for anything, even in football, and for research specifically, as well. But as we all know that the 11:49 increase in projections of the numbers of registered football players has skyrocketed by the participation of women in football. And we know that for women's for women, we are more or less we have certain 12:08 certain factors, that puts us at higher risk of injuries. We know football has burden of you know, contact injuries and all that but can reduce the injury rates of non contact injuries. Now, because women I hire, that when population were what areas due to biomechanical factors, biological factors as a result of hormones and stuff, biological become biomechanical because of, you know, pelvic hip ratio, you know, being at higher risk of ACLs. So you want to be able to minimize that risk. And how to do that is to actively engage in injury prevention. So trying to bridge the gaps, especially in a low resource setting where we don't really have much human resources, infrastructure and all of that, and people still want to play football. So my research is trying to bridge the gap with the population of women playing football, and the use of an evidence based, comprehensive warmup program, which is the FIFA 11. Plus, it is a basic injury prevention program, but it works. But it's not going to work if people don't know about it and compliant with using it. So it's trying to find out what are the challenges in the setting? And how can we mitigate these challenges to be able to improve compliance and adherence, and be able to achieve injury prevention goals, because even on a global scale, compliance, and adherence is a big issue with anything. So, um, since we also know that we have to always tailor things to the broader ecological context, or whatever we're doing. It's not one size fits all, because you have to figure out what are the things that can work in this setting? How can we adapt that can we adjust certain things and whose responsibility is going to take the leadership of the injury prevention philosophy, how this behavioral change is gonna affecting? So this is this is a research that I was working on, or I'm concluding at the moment. And I'm really excited because now I think FIFA also is doing trying to do a lot of stuff for women's football. So hopefully, that can help. You know, in the next five years, we'll see women's football going to a different level than we are right now. Yeah. And you know, as you're talking about that and talking about the resources or lack thereof, it really makes me think I'm in New York City. I'm in the United States where we have an abundance of resources, and people still don't comply with injury prevention programs, right. And so I can't imagine being in 15:00 In a part of the world where you don't have the the manpower, the end all of the things that we have here, yeah, yeah, in order to make these programs stick. 15:13 Exactly. So this is one of the things that I found out is, along the course of my research, is that coaches need to understand that they can be empowered to take charge, rather than coach to see me as a medical person, like trying to take over their job, I'm not trying to take over your job, I'm only trying to help the team so that he can have more players available for selection and team can do better because at the end of the day, it's inversely proportional, the less injuries in the team, the more the team, you know, can can can progress and be successful. So at the end of the day, I think the messaging also matters, the messaging about, Okay, Coach, if you do this, you're going to have more players available for selection. And when you do have more players available for selection, then your team has a better potential to fight for the title to get to win a trophy. And when that happens, you get a bonus or something in your pocket. And it all everybody sort of it's a win win situation when your players do or injury free. They have longer carrier carrier longevity and so many other things. So the reason begins to change, you know, begins to change and at the end of the day. And then another thing I say to them that look, you don't have to think of injury prevention as this thing that is separate. It needs to be integrated. And there is no flexibility to adapt 16:45 and just integrate, it will still work. The most important thing is that you are committing at least twice a week for these exercises to be done. And you will see the difference that it brings to your team. Yeah, it's all about incentives. Right? How can you how can you meet the people where they're at with the incentives they need? And like you said, it's all about the messaging? Yes. Okay, wait, mindset changes, right. And that kind of takes us into I think what you're going to be speaking about at the fourth World Congress is sports physiotherapy, which takes place August 26 and 27th of this year in Nyborg, Denmark, and that is the unbreakable Young World athlete. So talk to us a little bit about that, and a little bit about your presentation. We don't give it all away, of course, you know, we want people to come and see you live, so we're not giving it all away. 17:46 We can dangle some highlights out there. 17:50 Okay, so the first thing is, I think that right now, everybody knows the potential of sports. So 17:58 everybody wants to start young. Now the pressure there on the young athlete is to begin to perform at a professional level at a young age. And that impacts a lot of things in terms of because you know, the type of dedication that you need to, to perfect, whatever sport that you're doing. And, you know, many parents and guidance, everybody wants, oh, I want my child to be Cristiano Ronaldo, I want my child to be messy. Now the pressure is much on these kids. And one of the biggest challenges that then these the burden of having to deal with that kind of pressure, whether physically, psychologically, and every other thing that makes up these young athletes would really be a huge load for young athletes out there. How can we balance that? Now, I will be talking from the perspective of law resource where I'm coming from a lot of many people. 18:57 In the developed countries, they have a lot of support for young athletes. And be it nutrition wise psychology, and so many other things that you we don't have the luxury of that. And many times, the kids who just want to play like they don't want to do anything serious or anything like that. But there's still the pressure and demand on them to excel. Because people see that if you if you're a good sports person, or you're able to make a break in either football or basketball, which is one of the top spots in Nigeria, then we can change our economic situation. And that helps us out of poverty, and all this kind of and all this type of thing. So I'm just going to be talking from that perspective of low resource and how the young athletes 19:50 as much as you want to encourage sports participation, but there has to be that striking balance to enable them to succeed 20:00 That's a lot of pressure on a young kid. 20:03 Yes, yeah. Yeah. Well, I mean, I know I'm definitely looking forward to that talk in Nyborg. Is there anything else that you're working on projects moving forward? Anything you're looking forward to in the future, whether it's future research, speaking gigs, getting more involved in in the profession as a whole? What do you have coming up? 20:30 Okay, so I'm trying, I'm rounding up my doctorate right now. So hopefully, I can get a postdoc position as well to continue to work in women's football. 20:44 That is what I'm hoping for the next maybe six months there about, but other projects that I'm passionate about involves power athletes, I'm very, very passionate about walking with our athletes, because also they too, were like a minority 21:01 group. But I see that they are really the super humans, you know, with everything. And with the limited resources and everything you can think of the still strive very hard I want to get on on the world stage. They are the ones who put Nigeria on the on the on the map for medals, because I was with the team in 2016, in Rio, and 21:27 we won eight gold medals, set new eight world records. 21:33 So I feel like yeah, there's a lot more that I want to learn. And 21:39 I'm also trying to do some technical courses. And 21:44 there's something called classification for power athletes, where it's like, you're trying to make sure that all the athletes are classed, 21:53 in in the desired classes that they can compete on a level playing ground. So apart from the technical officials, they also need the medical people to come and do all the assessments of you know, movement, muscle power, and all these things, just to be sure that, okay, we have classes athletes properly, and they can compete without having undue advantage over the other colleagues in a similar category. So yeah, so I think that's really the next thing that I want to do. It sounds amazing. 22:27 Some of my students trying to move on to postgrads. I've just provide them some of my own shares, some run experience, support them along the way as well. And so that's, that's what I think I'll do. Amazing. Well, it sounds like you have a busy time coming up and doing really, really great work. So congratulations on all of that. And now where can people find you? If they want to reach out to you? They have questions. They have thoughts, where can they find you? 22:56 Okay, so you couldn't find me on social media? You'll see on Twitter, it's at cool Boulevard. 23:04 And it's also the same handle on Instagram at cool Boulevard. So and that's cool with a K, correct? Yes. K with the K Yeah, yeah. And we'll have all of that information and links directly to all of your social media in the show notes for this podcast, so people won't have to search too far. And now as we wrap things up, one last question that I asked everyone, it's knowing where you are now in your life and career, what advice would you give to your younger self? 23:35 Um, nothing is impossible. If you dream it, you can do it. So just surround surround yourself with people who will always find your flames. People will always ginger you to keep going. And I think, you know, the sky isn't the limit anymore. 23:55 You can keep going so that I'll give to my younger self. Excellent advice. And just if people want to see Katie speak in person, like I said a little bit earlier, she will be speaking at the fourth World Congress is sports, physical therapy, August 26, to the 27th of this year, 2022 and Nyborg, Denmark. So again, we'll have a link for that as well. So you can go on and take a look at the whole program and sign up and come to Denmark in the summer, which I'm assuming is going to be great. I've never I've only been there in February when it's pretty chilly and snowy and rainy. So I'm excited for I'm excited to go. And I'm excited to listen. I have never been to Denmark. This will be my first time. So yes, I am looking forward to meeting you. And the rest of the delegates from around the world. Yeah, it's gonna be great. So Katie, thank you so much for taking the time out and coming on today and talking about all the great work you're doing. We are all inspired. So thank you so much. Thank you for having me. 25:00 and looking forward to see you soon. Yeah and everyone thanks so much for listening. Have a great couple of days and stay healthy, wealthy and smart. 25:08 Thank you for listening and please subscribe to the podcast at podcast dot healthy, wealthy smart.com. And don't forget to follow us on social media

In this episode, Physiotherapist and Sports Injury Researcher, Kerry Peek, talks about sports injury research and the neck. Today, Kerry talks about her research into sports injuries, developing training programs, and evaluating feasibility and adherence to programs. How can greater neck strength assist in reducing head and neck injuries? Hear about measuring neck strength, defining "normal" neck strength, and get Kerry's advice to her younger self, all on today's episode of The Healthy, Wealthy & Smart Podcast. Key Takeaways "You wouldn't send an athlete out without doing knee exercises, and yet we do it quite regularly with the neck." "We need to do some isometric exercise but with ballistic intent." "I don't think isolated neck exercises is going to give you the best bang for your buck." "The best exercise is the one they're going to do." "We need to make sure that the research in this space is high-quality research." "We need to be more critical in the way that we apply research in neck strengthening." "If you're really good at designing exercise programs, get creative." More about Kerry Peek Dr Kerry Peek (PhD) is a physiotherapist, behavioural scientist, strength-and-conditioning coach, and sports injury researcher with the University of Sydney. She has over 20 years of clinical experience in both Australia and the UK working with many athletes across a range of sports, age groups, and playing levels, including elite athletes in football (soccer), rugby, motor racing, American football, and athletics. Her current research is focussed on mitigating sports related head and neck injuries and has just completed a project on neck strengthening and heading funded by a FIFA Research Scholarship. Kerry has presented to the UEFA medical committee and assisted in drafting UEFA's heading guidelines. Kerry is the Chair of the New South Wales State Council for Sports Medicine Australia. Suggested Keywords Healthy, Wealthy, Smart, Healthcare, Physiotherapy, Research, Injury Prevention, Neck Strength, Exercise, Training, Recommended Reading The Effect of the FIFA 11 + with Added Neck Exercises on Maximal Isometric Neck Strength and Peak Head Impact Magnitude During Heading: A Pilot Study Injury Reduction Programs for Reducing the Incidence of Sport-Related Head and Neck Injuries Including Concussion: A Systematic Review Purposeful Heading in Youth Soccer: Time to Use Our Heads Higher neck strength is associated with lower head acceleration during purposeful heading in soccer: A systematic review The effect of ball characteristics on head acceleration during purposeful heading in male and female Heading incidence in boys' football over three seasons The incidence and characteristics of purposeful heading in male and female youth football (soccer) within Australia Neck strength and concussion prevalence in football and rugby athletes To learn more, follow Kerry at: Website: Kerry Peek Twitter: @peek_kerry ResearchGate: Kerry Peek 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: Hey, Carrie, welcome to the podcast. I'm so happy to have you on. 00:06 Thank you so much for inviting me. 00:09 And just so people get our connection, I was in Monaco for the IOC conference, and I went to one of the platform presentations, and you were discussing your research, and I found it to be fascinating. So you do a lot of work with the neck and head and I just absolutely loved it. I loved your presentation. I learned so much about it. And then as I dug deeper into you, I realized that you and my friend Evangelos Pappas, there was a connection there. So I texted Evangelos. And I said, you know, Carrie peak? He said, Yeah, I'm like, Oh, cool. Could you like, tell her that? You know, I really liked her presentation, because I was like, and, and I'm, I'm sitting right behind her. I don't know if he texted you that you're like that. It was like a psycho or something. I'm like, I'm sitting behind her. 01:01 He did text me that and it was just really funny to have this funny conversation between Australia and we're in Monaco, and you're American. And yeah, saying, oh, Karen sitting behind you make sure that you introduce yourself. Yeah. After the presentations are finished. 01:15 Yeah, that was funny. But I loved your presentation. So now I can't wait to talk about your research on this episode. So I'll just kind of throw it over to you to talk about kind of the body of your research and why you chose the topic that you did. 01:30 Yes, I am. I'm a physiotherapist. And now a sports injury researcher and I started in the early 2000s, working with Don gatherer, who is the former England rugby physio, and was the Chief Medical Officer The is the Chief Medical Officer. Sorry, I'll start that again. So yeah, so I started as a physiotherapist, I graduated in the late 90s. I graduated in the UK and I worked with Don Gajraj, who was a real mentor to me, and he was the former England rugby physio and also went to two Olympic Games. And he'd really developed a practice which specialized in neck rehabilitation. And this was an area that I don't really remember studying an awful lot at university, like we did manual therapy. And really, as soon as you got patients pain free, they were free to go like I don't remember really doing a lot of neck exercises. And so we had lots of players that played rugby, we had OpSite athletes, and we had Formula One drivers coming into the clinic, who had had a history of head or neck injuries. So concussion, which wasn't really talked about much in the 90s. But looking back, a lot of them work and cast. And we started doing a lot of rehabilitation, and I really am an exercise based physiotherapist. I really like doing manual therapy. And so it was just fascinating to to really come from that perspective to see, okay, what's the mechanism of injury? And how can we replicate this, you know, doing various exercises are really sports specific. I then moved to Australia and had children and got distracted bit by doing other things for a few years. And it wasn't until my son as an eight year old was heading a football, that I thought, actually, we should probably be looking at neck exercises in this cohort, considering they're using their head to you know, deliberately redirect the ball. And that really sort of got me down this, I suppose research rabbit hole, because at that time I was doing my PhD. And since then I've moved to the University of Sydney. And so really what my research is focused on now is how we can mitigate sports related head and neck injuries. 03:39 And so of course, you know, my next question is, what is the rationale for why training the muscles around the neck can play a role in reducing sports related head and neck injuries? Because, boy, it seems like some low hanging fruit right doesn't cost a lot of money, easy to implement. So what's the rationale there? 04:02 So I mean, first of all, I want to say that I don't think that next month is going to solve every head and neck injury. You know, I think it's part of a multifactorial approach where we will look at more changes and look at, you know, whether that's body checking or collision. But it when we're talking specifically about neck exercises, I mean, the notion that greater neck strength can reduce head acceleration, particularly during heading or during collision sports is that stronger, stiffer, next, increase the coupling of the head to the body, and then help to stabilize the head on contact. So whether that's body contact or head contact, and so really, we're looking at the stiffness, which is the ability to resist defamation, and then the strength which is then you know, being able to increase neck stiffness. And so it is really that coupling between the head, neck and torso. 04:54 And how do you explain this to a patient that you're giving these exercises As to increase neck stiffness, because I know a lot of people might think well wait a second, I don't want my neck to be stiff. So how do you can? And I love that you define that? Would you mind repeating it? Because I think it's really important. And how do you explain that to a patient. 05:14 So I tend to explain to my patient by using sort of the picture of a bubble head, so I do call them bobble heads. So you've got this figure, and then this head that moves really freely. And you think if you, if you nudge the, the head, it wobbles, you know, quite a lot. And so that's a lot of head acceleration, even if you touch the body, the head will also move. And so if you think if you are being tackled in sport, or you're heading the ball, then there's a lot of head acceleration there. And we use sort of head acceleration, we measure it, you know, with inertial measurement units, thinking that you know, this, if the head is moving a lot, the brain is moving a lot. And so if you can reduce the amount of head acceleration by increasing the strength and the stiffness between that bubble head and that fixed body, then that's a way to hopefully reduce some of the movement of the brain within the skull. 06:08 And that makes a lot of sense. And I think that is a great way to say that your patient, because they'll better understand what you mean by neck stiffness. Because I can just see, like, eyes getting wide, like, I don't want a stiff neck. But you're like, Well, when I wait a second, that's not what we're saying, We want you to be able to the neck is still mobile, but we want you to be able to accept those forces when they're placed upon you. Right? 06:35 Exactly right. And, you know, we know that head injuries and things are getting more prevalent in, in sport, and whether that's because of increased reporting, or whether it's just because the athletes are getting fitter, faster, stronger. And so some of the hits that you see in American football, and in rugby league and rugby union, I mean, they're horrendous. And, you know, if you've got this head that is really not well connected to the body, and you're being hit by a, you know, 100 kilo athlete, then that's such a vulnerable component. And I think that the neck, really working in this space, it's the last area of the body that we routinely exercise, you know, you would never send an athlete out, whether they're that's a prevention or whether they're post injury, without doing the exercises, you know, you wouldn't have an ACL and say, right, there's no pain there, off you go. And yet we do it quite regularly with the neck. 07:29 Yes, very much. So. And now when we're talking about strengthening the neck, how do you measure this, the strength of the neck. 07:40 So there are lots of ways that you can measure the strength of the neck. And a lot of these different methods have been shown to have good reliability. My issue is whether they're valid, and they're valid within particular sports cohorts. So when you're looking at assessing neck strength, I mean, generally, when you're looking at any assessment of muscle strength, there's reasons why you do this, you might be using it as an outcome measure. But generally, you're doing it to inform the load that you will input you you will apply when you're then exercising. So when you measure neck strength, it has to have some carryover to the position that the athlete is going to be in for their sport. And it also has to have some carryover to what you're trying to resist. So in with the neck, for example, you're trying to resist lots of head accelerations. So generally, you need to assess the neck using isometric or maximal isometric contractions, because you want to resist movements. Most sports are upright, you know, they're running, jumping, walking, running, and, and so you need to be upright when you test them. If that's how you're also going to exercise them. Now there may be differences. So if you're a rugby forward, you're going to be in a scrum position. So there may be reasons why you want to replicate a scrum position to test an athlete. But some measurements of neck strength are done in a supine and prone position. And these can often give you very different neck strength profiles, to when you actually assess somebody's upright. And there's problems if you are assessing someone in supine or prone, but you want to exercise them upright, because because you just don't know what the actual maximal strength score is in that sport specific position. So the way that I mentioned extreme is that I get them fixed in a seated position because I can standardize that position much better. And I use a break technique. So this is really looking at eccentric loading in an isometric position until you can break the contraction, I guess, of the neck. And this is shown in lots of different areas of the body that a brake technique will yield much higher scores than a mate technique. And so again, if you're using the brake technique, particularly because you're generally trying to keep the head and neck still when there's contact placed on the head or body, and then that is sort of like an eccentric load. So this will give us our maximal score, for which Has the flexes extensors left or right side flexes. And then this gives us a much better maximal result that we can use for percentage of one rep max when we're thinking about load. 10:14 And are you using a handheld? dynamometer? for that? 10:18 Yes, I probably should have said that first. Yeah, but I am using a handheld dynamometer with a load cell in series that's placed on the head with a with a head harness. And so yes, you do incrementally load that. 10:31 Yeah. Nice. And now, how, how do we know what normal is? Like? What's a normal strength profile for NEC? And and then how do we know what's normal for a position within a sport? 10:43 And that's a great question. Because when you when you look at the literature that's out there, the first thing I always do is I look at what was the method to assess neck strength. And if it is in a lying position, then I take the results slightly with a pinch of salt, because they too tend to give you a different neck strength profile. So there are a lot of studies particularly in rugby that have been tested using the same method that I that I use. And this was first developed by by Don gatherer. So it's not any great surprise that I use that because we used in clinic for a very long time and tested hundreds of athletes. But now having moved into that research base and had a look at all the different ways that you can test neck strap, it's still my preferred method. And so we've tested rugby athletes, we've tested football players. And what we're generally finding, and this is sort of consistent with the literature. And what we expect a neck strength profile to look like is that the extensors should be the strongest. So if you look at a result, and the extensors are not the strongest, is it related to the testing technique or the position that they're tested in? Or is there a problem there, so it isn't an injured population, that might give you something that's a bit different. So extensors should be strongest flexors are generally the weakest. And side flexors will sit somewhere in the middle there, depending on the population. So in rugby and American football, you often do want to have the side flexes to be stronger, and a lot stronger than the flexes. So they tend to have a very wide sort of neck radar if you were to plot this on a graph. Whereas if you have football players, for example, because of the conditioning from hitting a ball, they may actually have quite strong flexes. So I always have a look and plot the results on a radar. And then I also calculate the flexure to extensor ratio to see what that looks like. And so in the literature, normal is often considered around point six of a flexor extensor ratio, but I have seen it as low as point five as high as point seven. But I always think if in a sporting population, if it's below point six to me, that's that's honestly a red flag, but it's certainly a yellow flag. 12:47 It's problematic, or can lead to can lead to more problems. Yes. And where can people if they're wondering like, hey, where can they find the method that you use to strengthen? Is there a paper? Is there something you can point to because we can sort of put it in the show notes? 13:04 Yeah, so I do detail the the method for assessing neck strength and a paper that we published earlier this year in sports medicine. So we looked at the neck strength of football players, adolescent football players from 12 to 17. And then we implemented an X strengthening exercise program and to see whether by strengthening the neck this actually had an impact on reducing head acceleration during heading, and we found that it did so that the neck strengthening method is is detailed in that paper. 13:34 Perfect. So we'll have that paper, we'll put it in the show notes a link to it so that people can read it at their leisure. Now, we talked about why you're looking at it, how you're evaluating it, what does a training program look like? 13:50 So that's, that's really interesting as well, because I think, because there's not a lot of published literature on neck strengthening, I think you tend to find that you have different camps of people, some that are very pro neck strengthening, and that that certainly is myself. And, you know, a bit like you were saying earlier is that it's low hanging fruit, you know, why wouldn't we try and strengthen it because the potential gain is huge, and it wouldn't not strengthen any other area of the body. So I kind of think what, you know, why wouldn't you do it? But on the back of that, we also have to think what's the best way to strengthen the neck and I think some people are quite negative towards neck strengthening, because some of the papers that have been published, the exercises that they use are sort of self resisted exercises where they're pushing against their forehead and holding that and doing isometric holds. And a number of studies have shown that this doesn't really have an impact, it may not even impact in which increasing strength and it may not have an impact in reducing injury risk as well. And that makes sense. You know, I don't implement those exercises because When you're talking about reducing something like concussion or heading in football, those hits happen in fractions of seconds. So we don't need to have high insurance of the neck or just isometric control over a long hold, what we need to be able to do is fire those muscles really, really quickly. And so we've been playing with some neuromuscular exercises. So it isn't our paper that was published in sports medicine, but I'll try and describe it, but you're kind of in a setup position, but you're rolling backwards and forwards, and you're trying to stop your head from hitting the ground. And so the idea from that is really to try and contract the neck flexors really quickly if the heads in neutral, and then we turn the head to the side and the other side, and we do the same exercises. But the idea is that you've got that anti gravity strengthening, but you've also got, you know, you're trying to stress the muscles to fire really quickly. And that's what they have to do. So most of the the literature that is talking about neck strengthening is sort of indicating that we need to do some sort of isometric exercise, but with ballistic intent, and that's the bit that is often missing, for most of the neck exercises in the literature. 16:10 Yeah, and that's the exercise you described in Monaco, sort of, for people, if you've ever taken Pilates, it's rolling, kind of like rolling like a ball is kind of what that's kind of, you know, that's, that's at least what I got from it. And I remember I got back to my room, and I was like, we're gonna try and see what happens here. And it is it not as easy as it sounds. 16:32 No, and, and it does, it does work the net quite hard. And you can see it, you can see the net contractions in somebody else that's doing it. But the way that we sort of played with this exercise, and I will just credit to bursting, but also, we meet on a regular basis. And we talk about neck exercises. And he's also widely published in the neck strengthening arena, and was part of this paper as well. But what we were trying to do was come up with an exercise that use no equipment that didn't take long. So these exercises take 90 seconds. And that could be added to an existing neuromuscular program. So in this case, we added it to the part two of the FIFA 11 plus. And this is really important because I actually don't think isolated neck exercises is probably going to give you the best bang for buck either. I think we need to integrate it into, you know, other strength and conditioning programs. And again, this is sometimes where you see in the literature that they're just adding neck neck exercises without thinking about, or what is that neuromuscular control to the trunk as well. And how are we stimulating that? 17:31 Yeah, that makes so much sense to not just do things in isolation. I mean, gosh, especially when you're talking about athletes who rare? There's not many athletes that do things in isolation? 17:45 No, no. And and I think that that's just really important to get that adherence as well. Because if they think it's an add on program, and it's going to take ages and 10 minutes to an athlete is actually quite a long time when they're doing so many other areas of the body, that if we could integrate it into existing programs, or integrating into multi joint movements, then it makes sense to them. And it and it's, it's it's integrated. It's not an add on. 18:09 Right? Because of course, as we all know, as physio therapist, one of the hardest things through a rehab process is the patient that doing the rehab. Right, so the best exercise is the one they're going to do. So if you explain it well. And you integrate it, you're more likely to have that patient do the exercise. Have you found that? Have you found difficulty patients adhering to the program? 18:38 So, so we didn't, we did, we did look at the evaluation of feasibility. So my PhD is actually on adherence to exercise. So it was something that was really at the forefront of my mind when setting any exercise intervention, that we need to have some sort of process to evaluate it and see whether the, you know, the players and the coaches found it feasible, and did it take too long could they see the benefits of it, and it's generally scored really, really highly. And I think that is the fact that we tried to just minimize the time that it took that it was complex. So you know, the youngest athletes were sort of 12 years of age, and you know, they all understood what they needed to do, but also to make it you know, applicable to their sport. I think that's really important. 19:21 And what are your thoughts on different kinds of strengthening you know, we see things on YouTube people will see things on YouTube and I don't mean to go down a rabbit hole on that, but you know, tying weights around their head bands around their head doing things with bands and weights with movement of the neck. What are your thoughts on that? 19:44 So there's certainly some crazy stuff on on YouTube or Tik Tok and I think that's not necessarily specific to the neck. I just think that again, what you've got to try and do and, you know, I think exercise therapists, whether that's physios or exercise physiologist that do exercise really well, they understand the sport and they understand the mechanism of injury. And so if you're going to add a weight to your neck, you've got to think, Okay, well, how am I adding the weight? And how is it replicating, you know, the risk of injury, or what I need to do within my sport. And so if you're in a crouch position, which I've seen in lots of videos, where they've got a head harness, touch the neck, and then there's really, really heavy weight at the end. And I kind of think, why you're doing that, what's that for? And maybe in the scram, maybe that's applicable, but you know, I can think of very few reasons why you would need to do that. And when they hang weights off the top of their heads, you know, you think of that, you know, that axial loading that they're doing. Again, why would you want to do that? 20:51 Yeah, I don't know. That's why I asked, and so we got an answer. I don't know, I really do not know why you'd want to do that. But now now listening to you talk about your research, it just makes so much more sense to integrate it in a neuromuscular based exercise, you know, integrating it with other muscles within the body and making sure that it makes sense for the position and the sport of the person. Yeah, absolutely. 21:21 And I think this is about knowing, knowing your patients, knowing your athletes, and, and if you apply that sort of methodology for any exercise, you know, whenever you see someone, so I've been invited to do some work with the RW F here, so the Air Force, and I don't know a lot about PILOTs, but you just go in here, talk to the pilots, and you say, okay, so what do you do? And you know, when does your neck hurt? And? And how long are you in that sustained position? And how much G force are you being exposed to when you're in a fighter jet? And you just kind of start to understand, you know, what, what's happening to this person? And how is that potentially, you know, making them at risk of injury? And then how do we need to train those muscles in a way that stimulates, you know, what they're exposed to as part of their job or part of their sport? I mean, you do that with every other joint of the body? You know, I think we routinely do that. But we just need to do it at the neck as well. 22:19 Yeah, and great advice. And now is there anything as you know, throughout our conversation today that we didn't touch upon, about your research, maybe about your PhD work that you think would be audience would really love to hear more about? 22:37 Um, I think that it's important. I think it's important than I think I sort of said this a bit earlier on that, we really need to make sure that the research in this space is really high quality research, and that we understand, you know, the mechanism of injury, particularly things like concussion, that we don't think that neck strength is going to solve everything. But you know, when we're reading papers, it's understanding, you know, what method did they use, you know, are the results actually believable, or didn't the way that they measured neck strength have given you such an unusual profile that actually shouldn't read any further in the paper, or it's just not applicable to your athletes, for example. And so I think that we need to be much more critical in the way that we apply research in neck strengthening. And I think that, although I'm very passionate about next trend thing as an intervention, you know, I don't think we should overplay what we can potentially do in this space, either. It's just part of our toolbox, but it's not going to be everything. 23:38 Yeah, there. It's not the panacea for all ills having to do with head and neck injuries. 23:44 That's right. And I think that if you don't understand about how to integrate a neck strengthening program, I mean, I'm very happy for people to reach out to me, but, you know, talk to people and, you know, as I say, critically appraise what's going on. And I think, you know, if you're really good at designing exercise programs, get creative, you know, have a little bit of a play of what you're trying to do. And I think that's often how we get really innovative in the way that we approach exercise programming as well. 24:11 Yeah, and it also sounds to me like there's not a one size fits all. Approach, exercise or program. No, 24:21 I mean, I think there's things you don't do. And then everything else is kind of open to Yeah, depending on your athlete. So yeah, don't hang away off your head. 24:29 Yes, that is fabulous advice. And now as we start to wrap things up, I'm going to ask you the question that I asked everyone, and that's knowing where you are now in your life and career. What advice would you give to yourself as a new grad right out of physio school, your younger self? 24:50 I think that's a great question. And I don't regret anything that I've done in my career, but I would say that I've probably come to really specializing in neck strength is a bit too late. So we started in the early 2000s. So my first paper was published in 2005. And as I say, I got distracted doing other things. And I wish I'd continued with it. And I didn't partly because I was having children, and I'd moved to Australia and just life got in the way. And when I came back to it in the probably about 2015 16. So 10 years later, and nothing had moved forward, really. And I just thought that was a really missed opportunity. And so I if I could go back in time, I would probably, yeah, I would probably want to squash those 10 years into maybe 18 months. 25:40 Well, that would be pretty amazing time traveling. So where can people find you? If they have questions, they want to follow you on social media, where can they go. 25:51 So the best place to find me is on Twitter. So I'm at peak underscore Carey, I don't tweet about anything other than my research. So that's the best place to find me. And then you can always drop me a message through there. Otherwise, you can probably find me via Google, at my email address at the University of Sydney. 26:09 Perfect. And just so everyone knows, we will have a link to the papers that we've mentioned today. So if you want to read up on those that don't worry, they will be in the show notes at podcast at healthy, wealthy, smart, calm. And Carrie, I want to thank you for coming on. Like I said, I really loved your presentation in Monaco, which was just a short snippet of kind of the amount of things that we talked about in the podcast today. So thank you so much for taking the time out and coming on. 26:36 No, thank you actually went to your presentation in Monaco as well. And you've informed a lot of what I do as well about, you know, I think that most research is quite ego driven. And I'm not an exception to that. And we think that if we publish a paper that somebody is going to read it and we're going to change the world. And that rarely happens because players and coaches don't read research. And so your presentation was about you know, engaging with the media and doing a lot more in the social media space. And that really hit home to me that we have to try and bridge that gap if we can to translate research to practice. So no, thank you. 27:10 Oh, well, that's nice. I'm glad to hear that I will pass that along to my partner Osman, as well. So thank you for that. And again, thank you for coming on. I really appreciate it. And all of you listening. Thanks so much for tuning in. Have a great couple of days and stay healthy, wealthy and smart.

In this episode, Owner amd Founder of Goldsmith Therapy Solutions, Dr. Philip Goldsmith, talks about value based purchasing in home health. Today, Dr. Phil talks about the pros and cons of value based purchasing, and prioritising results over productivity. How will value based purchasing in home health turn out? Hear about OASIS assessments, the difficulties of working with insurances, and get Dr. Phil's valuable advice, all on today's episode of The Healthy, Wealthy & Smart Podcast. Key Takeaways "It looks like value based purchasing in home health is going to be a good thing." "Home health therapists are probably, unfortunately, some of the worst offenders at underdosing strength training." "Professional communication is where the good are going to be separated from the bad." "Most of the private insurances base their policies on payment on what Medicare does." "You've got to be involved with advocacy if you want to see change." More about Dr. Philip Goldsmith Philip Goldsmith, PT, MSPT, EMT, DScPT, COS-C, is the owner and founder of Goldsmith Therapy Solutions, a provider of high-quality management, consulting, and clinical solutions for home health providers. Dr. Goldsmith has been a practicing physical therapist for more than twenty years, with experience in home health, skilled nursing, and outpatient orthopedic environments. Dr. Goldsmith received his BS in Health Studies from Boston University in 1996, his MSPT from Boston University in 1998, and his DScPT from University of Maryland School of Medicine in 2011. Additionally, Dr. Goldsmith has extensive experience in leadership and financial management of small and mid-sized not-for-profit corporations and has won more than $200,000 in grants for public safety organizations with which he is affiliated. Dr. Goldsmith lives in Hanover, PA, with his wife and son. Suggested Keywords Healthy, Wealthy, Smart, Healthcare, Physiotherapy, Results, APTA, Home Health, Value Based Purchasing, Insurances, Advocacy, To learn more, follow Dr. Phil at: Email: pgoldpt@gmail.com LinkedIn: https://www.linkedin.com/in/philip-goldsmith-a81a692 Twitter: @pgoldpt APTA Home Health: https://www.homehealthsection.org/leadership 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: Alright, let's go. Hello, healthy, wealthy and smart. I am Jenna canter here with the Dr. Philip Goldsmith, who we're going to refer to as Dr. Phil, don't you love it? I'm so grateful to have Phil here, because he has a small business owner who runs a business in which he provides Oh, I'm gonna mess this up. And I'm so excited to where he brings stuff to the home health people and they're happy and they smile and say thank you. Without it and I get it. 04:05 That's pretty close. 04:08 Would you mind summarizing in that perfect sentence you just said a second ago of what it is you're more details on your business, like 04:14 elevator speech. It's called Goldsmith Therapy Solutions. And I provide high quality clinical consulting and management services to the home health industry. 04:26 I love it. And that's an elevator speech we all need to have you know for each of our own individual businesses, anybody who interviews with me knows I don't spend too much time going into the bio stuff because that will just be in the people can read it and then Wounaan go oh my gosh, I love Dr. Phil, you know, look at this. Wow, incredible. We are going to dive right into the topic which I know nothing about. I'm a cash pay cash based out of network PT working with performers. So I'm going to ask all the base questions to fully understanding the situation so everyone can better get on the on the same page with this apparently, and I I'm, I'm not saying it's not but just for me, it's new, apparently topic that's like a hot topic, and that is value based purchasing in home health. I know nothing about it. So let's talk about what is that? What is the value? What is that 05:21 value based purchasing is Medicare's new payment model for certified home health services provided to Medicare party beneficiaries. 05:33 Why is that important right now, 05:36 because it's different, how Medicare is moving away from the you go do a visit or provide a service and we pay you for a service to a model where they pay you based more on your outcomes, and how good a job you do at taking care of those Medicare beneficiaries that have chosen to avail themselves of your services. 06:05 That sounds great to me from a physical therapy standpoint, because that's what we care about. So how was this? Let's start with how this is good. And then we can go how this is potentially something that could get in the way of providing care to people fully. So how is this good? 06:20 This is good, because it removes a lot of the artificial drivers that were skewing utilization. Meaning, excuse me until about three years ago. The more visits you the more therapy visits you made, the more money you got. And that was unfortunately driving practice patterns and everybody Medicare, not Medicare kind of agreed. This isn't working. Yeah, yeah. And 06:55 because that's about productivity, not about results. Yeah. 06:59 Right. And it was it was too much widget counting, and a lot of home health agencies were making a lot of money on providing therapy visits that weren't necessarily necessary. Hmm, Mm hmm. So, you know, the the interim step on the way was this thing called pdgm that we're in now where it's all based on functional states and diagnoses? And that's about it. 07:28 Yeah, it's not nothing to push getting them to where we need to get them or to protect them from getting worse. If we're talking about home health. Yes, yes. Okay. Okay. So then let's talk about where this could potentially be problematic. 07:45 So the, the concern is, are you comparing apples to apples, meaning they're dividing the agencies up by state by geography and buy large versus small volume, to try to make apples to apples. But the big issue is, this system works literally by robbing Peter to pay Paul, somebody is going to make money. And somebody is going to lose money. So the other people at the other end of the scale can make money. 08:25 Where could you go and give some details on this? Because I'm not really following on on how this could be? Yeah, 08:31 Medicare is gonna say, Okay, we're gonna take all of the large volume agencies in the state of Pennsylvania. And we're gonna line them up by the outcomes we've chosen, they haven't told us the outcomes yet. 08:46 Deciding what the outcome what outcomes matter, 08:49 they are in the process of that now, who are the consulting 08:52 with doctors? 08:57 So there is what's called a technical expert panel, and we could do that alone. The concept of technical expert panels could be its own podcast, where basically they bring in people in the industry and ask them, What do you think is important? Um, do they pay them? They cover their expenses, do they? Do 09:25 they start to get a financial interest to sway certain ways and their responses? Okay, okay. 09:32 They're representing their industries. So, you know, they can, I could volunteer to be on a technical expert panel. And my job is to bring the perspective of the physical therapy industry. Hmm. They also do us, you know, these big beltway consulting firms that you hear so much about, and they have policy wonks that work at CMS that do this stuff. A lot of its actuaries accountants and lawyers? Because one of the big rules is this is supposed to be budget neutral, meaning the pot of money doesn't change. It's who gets how much of that pot changes, specifically, the agencies that are the bottom performers, they're going to lose it as much as 5% of their reimbursement, so that the top performing agencies gain 5%. See, 10:25 there we go. That's where I think a financial interest could sway what people say, because this could be less money towards their industry. Well, it's problematic, 10:37 home health in general. I mean, this is, it's already, you know, you're already getting paid a lump sum for the care of each individual. And that varies based on those clinical and diagnostic factors that that I talked about before. Right. The scuttlebutt is, 10:55 I don't, but I just need to highlight that. I know I love that you said scandal, but this is great. That means rumors, love it scuttlebutt, I'm going to start using that every day. 11:06 One of the big outcomes they're going to look at is readmission to the hospital, did you keep your patient out of the hospital? Because that costs Medicare more money. And they're gonna look at functional outcomes, like transfers and ambulation. And there may even be a patient satisfaction component because did you know that Medicare mandates patient satisfaction surveys in most settings, you get those annoying Press Ganey surveys? Because Medicare says Thou shalt, and they track those, and those are actually publicly reported data. 11:41 That's actually great. I think the patient what their happiness is everything. Yeah, I think that's great. That's, yeah. Okay. Okay. 11:52 So it's your secrets here. 11:54 So it's it sounds though, like it's a bit of a gamble on where things are going to lie. And what's going to be decided on what these outcome measures are? That sounds like the biggest concern, what are these outcome measures that we're going to be using? Because if we're talking about movement stuff, you 12:15 aren't talking about movement stuff. But, you know, they've already established that all of the measures, the outcomes that are going to be looked at are either Oasis based Oasis being the clinical assessment that's done in homecare at a minimum every 60 days. Okay, Mission recertification discharge, hospitalization, return from hospitalization. That standardized assessment gets done. I have 12:47 a question about that, actually. And this is just from my own experience, it's a completely different audience that I work with. So when I'm working with my performers, I'm reassessing every single time I work with them. I'm a niche practice, though. I'm, I'm small and keeping it small. And so therefore, they get like real top, you know, I know them inside out what's going on in their lives and stuff, so I can best help them. So that is very, very specific. And and I'm lucky to be in that position. So when you're saying 90 days, that sounds like a long time for like a formal reassessment. I believe in oh, gosh, PT, school, it was it was a matter of like two months. So is it because of the the age where things may take longer to see results? Why it's a 90 day spot? Like, why is that? I'm honestly asking, it's not for judgment, I'm trying to be very transparent on my own bias. So I can learn 13:37 that every 60 days, well, every 60 days, that OASIS assessment gets done. However, that doesn't change, that your state Practice Act still applies that you may have to reassess every 30 days or every 10 visits or every 14 days, whatever your state Practice Act says, and Medicare still has the every 10th Visit reassessment requirement in home health, where they expect you to be using objective functional measures, and looking at your plan of care and your goals and saying, Are we getting where we need to be, 14:16 which is what we do in physical therapy. That is we're always asking ourselves that question. 14:19 Okay. This is more of a you know, it's more of a big picture thing. Yeah. Okay. For example, the emulation question. There's independent, there's independent but needs a one handed device independent but uses a two handed device can walk but need supervision at all times. And then there's a couple of answers for wheelchair bound, or bed bound. 14:46 Yeah, I'm not familiar with this, but I'm learning as you're talking about, is there anything about risk of falls because that's like the big a big one. 14:53 They look at that from a process measure standpoint, meaning they ask you, did you assess for fall risk, and there's criteria given a multifactorial objective. So really, it's got to be a two pronged thing. They're not looking at the results. They're looking at. Did you do it? Yeah. 15:17 Yeah. Is there room for? And this may be you don't know, because this is a bit of mind reading. As far as you know, right now, is there room for measurements for neurological disorders where we know that things may they're going to decline over time? You know, are immune immune? Am I saying the wrong thing? I think he's doing the wrong thing. But is there room for that where they have a health situation where things are going to decline? We know that but we're trying to keep them functioning their best as they're going through their process? 15:50 The answer is yes and no. Okay, the questions and answers don't change. What changes is, they can tease out by diagnostic grouping and by what they call risk adjustment, where if your agency has a high population of clients with progressive neurologic disorders, that's the the term in favor now. Okay, thank you, they're going to risk adjust your statistics to reflect that, meaning, we see that you have a larger population of people who probably aren't going to get better. And we're going to do some statistical mumbo jumbo in the background to adjust for that. But that doesn't change the answers that the clinician is using. Okay. There's no, I have to pull a different document because I have a different diagnostic group. There's no, I answer these questions for this diagnosis. And that questions for that diagnosis? Yeah. Yeah, the people who very much a big picture of 17:03 the people behind the scenes, I think I know the answer this question, but I'm still going to ask it, the people behind the scenes who will be assessing the the progress progress, and, you know, if it's fitting, looking at the outcome measures and what we need for that patients, are they medical professionals? Are these just people who are trained to work for this company? Who are the Who are these people? 17:28 So field clinicians who work with clients answer the oasis for each client, the agency, then submits it electronically to CMS. And the risk adjustment is baked in to the computers at CMS that process all this information. 17:50 Also, it's a computer thing. It's all very, 17:53 and that's part of the reason the assessment is somewhat limited in big picture. Yes, it's a it's a computer thing. Ah, it's a i. i, maybe maybe not. But it's a lot of higher level statistics. That's way above my head. 18:11 Right, right. Yeah. Oh, wow. That's what this is so negative for me to say, but what an easy way as a person in CMS to point away and go, Oh, no, it's the system's. That's what they computed. Like, I can't. I'm like, Who created it? Who designed the code? Fine. We'll look at the code person I need to understand. Okay. Okay. So, I mean, it just sounds a little bit like a trip to Las Vegas, where you studied a little bit. So you know, a bit about gambling, you say, let's say you're very educated about that, and you but it's still gambling? You don't really know. I don't know, I just I, 18:53 you know, it's, it's pretty well known how they do the risk adjustment. You know, it's just the statistics of how it's done is pretty high level, but we have a good feel for what they're risk adjusting for and what questions they used to do the risk adjusting. 19:15 I mean, do you think the physical and physical therapy industry home health for this, because that's what we're focusing on? Do you think what the way we have things set up now, the way I mean, that's the whole point is to be measuring their outcomes? That is literally what we're doing all the time. Do you think we're pretty safe with this adjustment? If anything, it'll probably be for the better if you're just overall? I mean, because we did the good versus the bad. Where do you think it's, it's gonna turn out for us? 19:46 It looks like value based purchasing a home health is going to be a good thing. It is going to reward you for doing your job well, and being aware of your outcomes and delivering good health. Quality physical therapy that drives the outcomes? Yeah, there's going to be, it's going to challenge the physical therapist and the PTA to work at the top of their license and to collaborate with the other professionals. Because some of these measures don't happen in a vacuum for lack of a better term, they don't happen unless you're working as a team, and everybody's on the same page. Yeah. And that's really that interprofessional communication is where the good are gonna be separated from the bad. 20:40 Yeah. This isn't my world. Oh, continue, 20:44 there's, you know, definitely the agency is going to have to be very aware of their outcomes and their data. And the understanding of that data is going to be huge. Yeah. And I can tell you, that there are consulting firms and companies, and that can look at those outcomes at a clinician level. And they're going to tease out high performing clinicians and low performing clinicians. 21:16 Yeah, yeah. Yeah. And I'm assuming that's where the concern is, what is, oh, I'm gonna backtrack to actually what I was originally thinking of asking. What is the hot talk on the streets regarding this? What are the big things that other physical therapists and people in the industry are going like, hey, about it? Or do we already cover those things? 21:41 We've covered a lot of it. I think there's a lot of optimism around this. Because the more recent changes over the past couple of years, starting in October 2019 really pulled back on the number of visits. We were seeing clients. And some of that is real. And some of that is artificial. Yeah. And it's gotten me up on my soapbox a number of times, because home health therapists are probably, unfortunately, some of the worst offenders at underdosing strength training. Oh, yeah, you want to get me started? Don't get me started. 22:34 Yeah, yeah. So it's, it would force that that push, I would love. It 22:39 forces us to understand how to deliver strength training, how to deliver the most the best outcomes we can in in fewer treatments. 22:52 Yeah, how to get trust, motivation. 22:55 really gotta understand you've got to be a high performing clinician, yeah. To survive in this market. Yeah, because a home health agency literally cannot afford to have lower performing clinicians that can't deliver the outcomes. Yeah. And a lower number of visits. 23:16 Yeah. Yeah. Absolutely. Absolutely. I definitely get that. So I I mean, I'm all about the outcomes. I've had people a different dance physical therapists asked me about how I do my outcomes and it really does depend on my patient and everything but I have a very I have a special circumstance you know, like I'm very lucky to have this niche that I have. i There are from an outpatient not out push out. Yeah. Out not outpatient. Wait, I'm getting so confused. Ortho. From an ortho standpoint, I'm calling because I'm not, I'm not home health. So I'm just like trying to get back to my my world. There are definitely I'm gonna choose my words specifically. So if you are a person who does own a clinic, that sees a lot of patience, you are a mill, there is no way to paint that there is a reason why there is a name for that. That's like saying, I, you know, I was you know, born from two Jewish parents and I grew up I have my Bar Mitzvah and then and like, I still observe Passover, and then be saying, I don't I'm not Jewish. Like what? Like, no, I'm Jewish, you know. It's very weird comparison. But whatever. That's what I chose. And I'll go with it. We 24:41 get to the point of mills. 24:44 I've always thought that the it was because of the problem with insurance and reimbursement and it's one of those like chicken or the egg kind of thing. What happened first, which I use in defense for any clinic. I'm like, hey, they're trying to figure out how to get reimbursed but at the same time, does in this horrible circle of terrible reimbursement trying to communicate what you did and everything, and people are trying to make money, which is fine, it's okay to want to make money Hello. Is 25:15 we as a profession do wrong to allow an industry to devalue our services like that? 25:24 It's because when trying to guess this is me, because I'm not a network. So, but from what I've seen, it's it's clinics trying, they're doing their best to report what they're doing. They outcomes with the patients, while at the same time speaking the language that the insurances say, they will reimburse. And then also these insurances saying they're going to reimburse, but they're not actually reimbursing, then there are administrative staff calling over and over again, fighting to get those reimbursements, you know, getting better at that. So that's why you have certain people working on the at the front desk, and then and so then they increase the number of patients during that time, because while they're gambling per patient on honestly, this is how I look at it for a patient on getting that reimbursement. Through, you know, the paperwork we've we've been trained to do to report outcome measures and everything. They're not they're not getting paid for it. They're fighting to get paid even on the basic level. So I think, but I don't know what happened first if insurance happened first, or, and, or the, you know, provision of the services, and they decided for it to be a lot of people that's the chicken or the egg thing. I mean, I'm sure somebody could look up the history, but I think that's where people just say, Oh, the healthcare system is messed up needs to be fixed. I, that's where I kind of lean back on to kind of be fair to everyone. Not that there has to be a middle ground. But I mean, that is kind of the truth. If I owned a big business, you're constantly you're like, Okay, I've hired this, these EMR systems, you know, we're we're gonna track and write down things. I hope this is the right system. Okay, this one's not working. Let's do a new one. And then you have your clinicians going, Ah, dang it, we have a new one, I have to readjust. But it's because we're trying to do it. Honestly, we're trying to do it legally. And then insurances just go, now, we're just not gonna reimburse you, we're not gonna explain why. And we're gonna be difficult to get in contact with to discuss and figure things out. So I don't know it's a random tangent, I'm sure people will go be like, Jenna said something wrong. I'm not the person to attack here. I'm just speaking. If you have problems, go talk to the insurance companies and figure it out if you already know how it works. But that's kind of how I look at it being problematic in the Ortho world specifically, because there is a lot of measuring of my brain out there. There's a lot of measuring of what was the word that we use, the more patients you see. 27:56 Counting widgets, counting widgets. 27:58 It happens, it does happen at the larger clinics. But yeah, can you I mean, I'm not saying I'm not saying I'm not saying I agree with it. But also, can you blame on? You know, like, 28:12 you started this to make money. I get that, you 28:17 know, but, but I mean, what I am in the business to hear, I mean, that's what I'm doing my own thing, is it easy to do what I'm doing, is it easy to get the patient Oh, my God. But that's I that's where I put my energy where I put my energy. But I feel like what is happening in the home house, like, Oh, my God, this is hilarious, full circle, but I'm going to connect it, it's going to be amazing. Feel like the Home Health what you're doing with pushing that pushing forth. The outcomes, I would love that I would, but I would love to actually be that not than just saying that. We love their beat. Let's make it all about the outcomes. And honestly, I feel like that's what we've been trying to do the whole time. It's just people aren't. insurances aren't saying there aren't following through with it, what they say they're going to reimburse, they say, We can reimburse up to this amount. It doesn't mean anything. It's horrible. So I would love there to be fixing in that way. 29:13 And I think someday Medicare will come around to a value driven system for outpatient therapies. And until Medicare does, nobody else will mean, Medicare very much still drives that bus. 29:31 Yeah. Wow. I never realized that. That's yeah. How do you know how do you I mean, honestly, asking, How do you know that they're the ones driving the bus? 29:43 Because most of the private insurance is based their policies on payment on what Medicare does, 29:53 because they're so huge. Yes. Mm hmm. Oh, gosh. Not saying it. It's easy to say there's no easy road. 30:02 That's where all the that's the root of all the CPT codes and everything else. Medicare needed a common terminology to wash claims through a computer to pay people. Let's boil everything down to a five character code. 30:21 Right, right, right. Wow. Huh? She's What a hot mess. It just gives me a headache thinking about all of it. I don't like it. It makes I need cake. Or pizza. Oh, not chocolate though. My dad loves chocolate cake. Are you a chocolate cake person? 30:43 I am a chocolate person head on. 30:46 We only put like chocolate cake is so different from chocolate bars come on. 30:51 Yes. But they both have their merits 30:54 F No. Disagree? Absolutely not. All right, if you are a person that if you would handle your stress from chocolate cake, just as much as chocolate bars. Okay, your team Dr. Phil. If you're like No, chocolate, just chocolate actual chocolate, your team? Jenna. I'm interested to see if there's going to be any written debate on this or discussions I'm sure there already has, which is why you were meeting Dr. Phil was like, let's do this topic. And like, I don't know anything about this, which is good. I think it's good because then I get to learn everybody else who listens gets to learn. And oh, I'm going to just say this just because I am not a fan of meanness. Don't attack either of us in this discussion. If that's in your if that's in, if that's in your intention in in hearing this and your response, oh, just at this as a message just for you get out of here. Well, we got to be better together, we need to be able to have these discussions, talk about it, totally fine to speak on your concerns about it or all that stuff. But we're just attacking each other that is not helping out the patients at large. This is about the people we serve. So we're discussing this to see what's going on to better understand what's going on. If you are in an estate, you are close to somebody who is in legislature, the then do talk to them, or see if there's a pre written letter from a PTA right now regarding this through their app, if you're in a PTA member or see if you can get a hold of that letter through a friend or something or I'm sure it's honestly on their webpage for you to easily access to advocate sending a letter to fight this or fight for it, whatever it is, because there's there's positives and negatives and everything. I mean, sometimes there's you know, it's leaning one way, obviously, but we got to just take action. If you want to see something you got it don't just reply on here take action. Well, I just gave so many different messages and one thing at the end, but that's okay, I'm fine with it. Any last words you want to say on this matter that you that we haven't covered? Dr. Phil? 33:15 I think the take homes are twofold. You just said the first one. You've got to be involved in advocacy if you want to see change. Second, value based purchasing, like we're talking about it today is just in the home health arena right now. It is what Medicare wants to bring across the board across all settings. And, you know, they don't they want to get away from fee for service. They want to get away from ID to units. If they're x and a unit. If they're X, a unit of East M and A unit of manual therapy and you need to pay me for it. They want to know a client walked in your clinic with this problem. They had these issues that we're able to quantify. And at the end of it, the client left our clinic and the issues were gone and here's how we've quantified it. That's what they want to be able to pay you for. And if you can't be excellent with that. You're not going to have a successful practice 510 years from now. 34:34 Thank you. Thank you so much. Where can people they wanted to get in contact with you Where can they connect with you on either social media or email? 34:44 I am P gold PT on Twitter. I do have a personal Facebook. I am not fancy or cool enough to have Instagram or Tik Tok or any of those. I have LinkedIn. My email is Easy it's P gold pt@gmail.com. The other place that's really easy to find me is if you go to a PTA home health.org on the leadership page, you'll find my name. Currently the treasurer of APGA Home Health formerly known as the Home Health section. And in two weeks in two days I become the President 35:29 didn't say that at the beginning. I was like, I wonder if you want me to and you didn't say bring it and bring it out? So yes, this is a person. This is a person who's very involved with fighting and spin keeping on top of what's going on for home health. So thank you so much, Dr. Phil, for coming on for your name. I love just saying Dr. Phil over and over again. And just sending you the biggest hug from afar. We got a meet at a conference recently and you are a gem. Thank you so much, and everyone send love to Dr. Phil for for his time.

In this episode, Sports Physiotherapist and Researcher, Loïc Bel, talks about his experience as an up-and-coming sports physiotherapist and researcher in the industry. Today, Loïc talks about complexity and uncertainty, clinical work and mental health, and the importance of having a team around the patient. How does Loïc deal with imposter syndrome? Hear about Loïc's experience in Monaco, why he decided to keep getting more degrees, his thoughts on Physiotherapy Associations, and get Loïc's valuable advice, all on today's episode of The Healthy, Wealthy & Smart Podcast. Key Takeaways "You can't just use one factor to influence the whole situation. You have to accept the complexity. You can't control everything." "Nobody puts the bad stuff up on social media. It's only all the successes." "To be successful, we have to fail." "Sports and physical activity as a whole is one of, if not the best, tool for health." "As health professionals, we have to think about what we do, because it has a cost on society." "Knowledge a collective thing." "Don't give up and don't blame yourself." "If you believe in your profession, try to get involved." "Communication is everything." "Try to ask yourself more questions. Don't think that everything you learn is true, even at school. Question things a lot more." More about Loïc Bel Loïc Bel is a physiotherapist since 2.5 years ago. He graduated with a Bachelor degree in physiotherapy in Switzerland and is now in the last semester of his Master Degree in sports physiotherapy, also in Switzerland. He currently works in an outpatient clinic in a small city in Switzerland for 3 days a week, and during the other 2 days, he studies in Bern towards his Masters degree. He is currently involved in the 'Commission for the Promotion of Physiotherapy', that is a branch of his regional physiotherapy association. He is also a board member of 'Le Réseau' – which can be translated as 'The Network', which is an association that aims to connect health professionals working in sports and other professions that promote health through physical activity. On an international level, he currently is a board member of 'Long COVID Physio' as an education co-director. A recently big achievement was the publication of his first paper with his friends and colleagues, Vincent Ducrest, Nicolas Mathieu, and Mario Bizzini. The paper was about injury prevention in sports related to performance. Injury prevention is a subject that he tries to develop an expertise in, and he really fell down the rabbit-hole during his Bachelor graduation work that developed into that paper. His professional goals are to end his Master Degree in the first place. An ongoing project right now is to find funding to start a PhD on the subject of injury prevention. Suggested Keywords Healthy, Wealthy, Smart, Healthcare, Physiotherapy, Injury Prevention, Sports, Exercise, Research, Knowledge, Education, Mental Health, Read the paper: Lower Limb Exercise-Based Injury Prevention Programs Are Effective in Improving Sprint Speed, Jumping, Agility and Balance: an Umbrella Review To learn more, follow Loïc at: LinkedIn: Loïc Bel Twitter: @bel_loic 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: 00:07 Welcome to the healthy, wealthy and smart podcast. Each week we interview the best and brightest in physical therapy, wellness and entrepreneurship. We give you cutting edge information you need to live your best life healthy, wealthy and smart. The information in this podcast is for entertainment purposes only and should not be used as personalized medical advice. And now, here's your host, Dr. Karen Litzy. 00:35 Hey everybody, welcome back to the podcast. I am your host Karen Litzy. And today's episode is brought to you by Net Health. So when it comes to boosting your clinics, online visibility, reputation and increasing referrals, Net Health Digital Marketing Solutions has the tools you need to beat the competition. They know you want your clinic to get found get chosen and definitely get those five star reviews on Google. They have a new offer. If you sign up complete a marketing audit to learn how digital marketing solutions can help the clinic when they will buy lunch for your office. If you're already using Net Health private practice EMR, be sure to ask about its new integration, head over to net help.com forward slash li T z y to sign up for your complimentary marketing audit today. Alright, so a big thanks to Net Health now on to today's podcast. So my guest today is like Bell. He's a physio therapist since two and a half years ago, he graduated with a Bachelor degree in physiotherapy in Switzerland and is now in his last semester of his master's degree in sports physiotherapy, also in Switzerland. He currently works in an outpatient clinic in a small city in Switzerland for three days a week. And during the other two days he studies in Bern towards his master's degree. He is currently involved in the commission for their promotion of physiotherapy, that is a branch of his regional physiotherapy Association. He is also a board member of labor. So and I'm sure I butchered that, which can be translated as the network which is an association that aims to connect health professionals working in sports and other professions that promote health through physical activity. on an international level. He is currently a board member of long COVID physio as an education co director. Our recently big achievement was the publication of his first paper with his friends and colleagues, Vincent Newcrest, Nicholas Matho, and Mario Barzini. We talked about that paper in this interview, and it was about injury prevention in sports related to performance. Injury Prevention is a subject that he tries to develop an expertise in and he really fell down the rabbit hole during his bachelor graduation work that developed into that paper. His professional goals are to end his master degree in the first place. An ongoing project right now is to find funding to start a PhD on the subject of injury prevention. And in today's episode, we talk about a little bit more about the IOC conference that was back in November. And also we talk about clinical uncertainty, mental health of new graduate physio therapists dealing with imposter syndrome, and the importance of our physiotherapy association. So a big thank you to Luke for coming onto the podcast and being so open and honest and sharing his experience as a newer graduate in the physiotherapy field. 03:23 Hey, Lloyd, welcome to the podcast. I'm so happy to have you on and it's so nice seeing you again after it's been a couple of months since we met in Monaco. So welcome. Yeah, thanks for having me. I'm really happy to be to be here enough time to. Yeah, and I'm, I'm so excited to have you on to talk about. 03:43 We'll talk a little bit about your experience in Monaco and your big takeaways from that and tell me your what what you thought and what your takeaways were. Yeah, it was it was a last minute chose to go to Monaco. And, and don't forget that actually. 03:58 It was the second big Congress for me. So it was a bit of euphoria. I went to Geneva when there was the World Congress to So second bit Congress on sports physios. So kind of specialization I'm doing right now. And it was it was bigger than I thought it would be actually. And it was really hard to do some take home, because there was so many things to, to take with so many new ideas, maybe so many new ideas about all ideas that were totally deconstructed. So that was a goal of mine to go in. And be like, Yeah, I want to unlearn what I what I had learned during school and during my students. And I know we discussed it together quite quite some time about the takeaway. So there was one word that came a lot during the Congress. I think it was the context, context matters. So you can have 05:00 The best exercise you can have the best the best plan you can have the best program you want. If people don't do it on buying it's, it won't matter much, actually. 05:12 I think one big thing is that maybe we don't know, as much as we think we did. It discussed it with a smart non on a recent Muscats podcast to 05:25 lots of talk, discussed some things that we thought we knew. And maybe they don't work as planned, or they don't work 05:35 in the nation an efficient way, like we started did. And it was a great, great symposium on the complexity, like everything interacts, you can't just use one factor to to influence the whole situation you have to you have you have to accept the complexity, you can't control everything. And, and yeah, you go home and you don't really know what to do anymore. You don't really know if if you did things right, you don't really know if you will do things, right. So that's kind of the takeaway I took from like for me. 06:13 Yeah, and I would agree, I left like God, I feel like I don't know anything and stuff that I didn't know, I had now have to sort of deprogram myself to 06:25 reprogram with new information and new research, which, I mean, if you asked me that's a sign of a good conference. Yeah, I said the same. If I, I'd be pretty, pretty sad to go to a conference and go with only a big confirmation bias, you know, like, Okay, I did everything right. That's fine. So it's a good thing. Yeah. Like you learn something, if you unlearned things. So yeah, it was great. 06:55 Yeah, I agree. And let's, let's kind of dive into this idea of complexity in practice. Right. So like you said, there's so much more to an injury than just the injury, right? So if someone has an ACL injury, it's more than just the physical rupture of an ACL and then knee. So can you talk a little bit more about complexity in practice, whether it be your personal experience? 07:25 And and how you tolerate that uncertainty in the clinic? I mean, if if we speak about Monaco, the big thing was when when you come home is Watson, how do I apply the things I learned? And what I feel like when I when I go to Congress is or to any symposium that speak about research, I'm always like, Yeah, but in research, we control so many things. We want to control the most things we can to better understand the mechanism. And then you arrive in practice, and it's the chaos. You can't control everything you've gone through in research. 08:03 I have a pretty young conditions, I ended school like two and a half years ago. And every time I discussed the topic with some more experienced clinicians, they always answer with the Yeah, experience helps. 08:20 Yeah, but what do you do when you don't have, you don't have that much experience, you have to build some. So you try to rely on research, you tried to, to you try your things, basically, you have some tools, try to use your tools. 08:37 That gives you some idea when you try what should be best practice in research. But sometimes it doesn't work as planned, and you have to deal with it. So you try to adapt. You try to modify things a bit. And you have to go with intuition sometimes. And 08:54 yeah, it can be a hard feeling to deal with. I mean, 08:58 I tweeted like, a few weeks ago about that, because I had a rough day, I really have a rough day. Like I had three patients, it didn't go as planned. We had to go back to the search, and we had to discuss things. And it's really exhausting. I feel like to come home and nothing worked as planned. You go like with 1214 patients a day. And this tree will stay on your mind like the whole evening the whole evening. You don't know you're just thinking about how could I help? What's next try to plan for you and for them. 09:35 Yeah, I don't know we can you can deal with it. You have to acknowledge that it can happen. And you have to. Sometimes you have to take a step back and be like, yeah, what did I do? Did I do something wrong? Or not? Because maybe you did nothing wrong actually. And how could I figure out a new strategy to to advance and do better? Yeah, 10:00 It sounds to me, like what you do when you have those days, and we all have them where you're like, I'm a loser, like, I can't help anyone, no one's getting better, what am I doing? But that instead of going back and sort of wallowing in it for the whole night, I think you can wallow for a little. But it sounds to me like what you do is you kind of reflect on that re reassess how you did things, and really look at what can I do differently? I don't want to say better, but what can I do differently. And if it's something, then you always have another time to try. And if it's, you know, I think that I did what was appropriate, then maybe it's let's go in and have a deeper conversation with this patient, you know, let's see what other part of this complex person in their ecosystem will allow us to move forward. So that's what I got from what you just said that you really take that time to kind of reflect, reassess, and then move in the next day, or the next time you see them. So they agree, and complexities are also about how it works with the with the other colleagues to other professions around the patient. So you have to reach out for other people, you have to discuss things with them. And you have to you have to explain what you did you have to, to also be confident about what you did. And and that's that can be quite confronting to, to do. So. Yeah. 11:39 Many things to deal with. But in the end, you have to go forward and keep on keep going. 11:45 Absolutely. And you know, as a newer ish grad, 11:49 you know, you kind of 11:52 knowing what you don't know. And maybe knowing what you do know, how do you sort of keep putting one foot in front of the other because I'm assuming imposter syndrome may come up 12:05 every once in a while. So what do you do to keep moving forward? And maybe what advice can you give to let's say, a new graduate that's graduating tomorrow, given the experience that you have over the past couple years? 12:21 You're right, it happens from time to time. And and I mean, social media don't don't help with that. I think, as a whole, yes. Because there are lots of success story. There are not much stories about failure. Well, I mean, here's the thing. No, nobody, nobody puts the bad stuff up on social media. It's only All successes, right? So you have to take that step back and be like, yeah, maybe maybe they fail to. And to come back to Monaco, there was a great great one. That was about the biggest mistakes. So did a motor compress was something about learn from our biggest mistakes. So it was with Yvette for Heigen Carolyn, a bullying Caroline Emery to. 13:09 And I think it was great to have like to be in a Congress with what you can call like, a camera like her from speakers in the world about injury prevention, and, and, and hear them like, we failed. But we kept on moving. We kept on trying. And we did really, really better and we try every day to do better. So it was one good thing is that for once there was there were people that acknowledge that they failed, but they kept on going in and it was it was yeah, they deal with things with the tools they had at that moment and that you can't have everyday data you you want at every moment. So you have to try. And another thing I'd say is that personally, I try to really reflect and reflect on on on what I don't know I try to Yeah, we can speak a lot about metacognition and and identify your knowledge identify your lack of knowledge in some in some topics, so I try to identify my weaknesses. And then I try to read because I can't just be with patients 24/7 So I have to read about them and and and try 14:29 that said so I said I see the things 14:32 there's a quote I like that that say what I believe is a process rather than a finality. I don't know who Who is this this from but I like it a lot like you have it never stops you have to keep on moving don't stay like in a stone try to tie traveled. Yeah, and that's how I said things. Yeah, and I I missed that talk at Monaco. Now, I really wish I went to it on the 15:00 You know, yes, we failed at these things, learn from our mistakes. And I would argue that the most successful people in the world have failed more times than they've been successful. Right? Because they're taking chances. They're putting themselves out there and, and they're making mistakes, learning from them and then pushing forward, which can be your stepping stone to success. Yeah, I'm a pretty firm believer that to, to be successful, you have to fail. Because if you just have success, I mean, first of all, it's not realistic. But I feel like if there was only on the success, and you couldn't fail, 15:42 you'd stop working. You don't anything to do anymore. You. You're not on this planet. So yeah, I think that's you. But every, every failure you have is a small break towards the Big House of success. Basically. 15:59 I couldn't agree more. And you know, in talking about all of this, you know, we're talking about failures and imposter syndrome and not knowing, and you're in a clinical setting, you're working with people. With all of that on your mind, it can certainly take a toll on your on mental health as a clinician. So what what do you do? Or what advice do you have when it comes to that clinical work? And mental health? Your own mental health? 16:28 Yeah, so I feel like we have a really demanding job, from a psychological perspective, because like I said, sometimes you fail, you have that bad day, and you come home, and you're like, Yeah, rethink, everything is worthless. So you have to do to overcome that. And with that, you have to, to add all the pressure about knowing things, because patients want answer answers. So you have to know things, you're the professional they want, they want to know, as sometimes you don't. 17:02 Now to, to put less pressure on me, I am honest with the patient, when I don't know, at the beginning, during my internships, I was always trying to find the right answer. And sometimes I didn't have it. And I try to find the thing to say. And now I feel like yeah, it was really unethical. First of all, and 17:27 no idea, say, I don't know, but we'll try to figure it out, basically. And one phrase I do, I do say a lot, when situations are complicated is that we'll try to improve the best we can. But I don't know until when we can, until what level we can improve, we'll figure it out. But maybe it will be only only a small portion and, and you'll have to try other things and physiotherapy. 17:58 And basically, you have to take care of your mental health and health professional for that. So I'm not ashamed to say that I wanted to psychologist and I discussed this topic, too. I didn't go for that. But I discussed it because it was really taking a toll sometimes my on my health. And now I learned to take a step back to be honest with the situation and discuss 18:24 discussing with patients and be open to criticism from patients to isolate them, you can tell me if if something isn't right, will change what we do. Finding yourself and being confident enough in yourself to say I don't know, is very, very beneficial for everyone involved, because you don't want to make something up. 18:47 Right. So if you don't know, I think what you said, you know, I don't know, but let's figure this out together. I'll look up some research, we'll figure this out. And if we can't figure it out, then I think it goes into another topic that you wanted to cover. And that's having this sort of entourage around the patient. Right? Because it's not your the two of you aren't on an island together, and there's no one else around, hopefully. 19:14 So can you talk a little bit about the importance of that, that team or that entourage around the patient? Yeah. So I think that I'm really lucky because 19:26 I met some awesome people in Switzerland during my studies and when I went to congresses, 19:33 I can mention someone It's Susan God that was in Monaco too. 19:38 She she's she's helping me on a daily basis. Basically. I'm often writing to her and and some other colleagues, some of the friends and colleagues that are my age we try to we try to figure out stuff together too. 19:55 I think 19:57 we are in a profession where 20:00 You can't have all the knowledge and some people already belt, some strong knowledge on some specific topic. So when I have a situation, for example, with Suzanne from with the shoulders, I write to her, because she's the experts in my, in my network, she's the expert on shoulder, so I don't hesitate to, to to write her to ask the patient if I can take, for example a video of or picture of the problematic I have. And I asked, I tried this, I tried that I have this situation right now. It's not have evolving, it's yeah, it's it's staying the same. We don't find a way to, to overcome the situation. What do you think about it, and then we discuss it and, and sometimes she she has some really great things that I never would have thought about. And I do the same with with friends. 20:56 I have some friends with my part time studies. They have the same problem as me. Sometimes they write to me and I try to help sometimes they do say I do thing with them. And sometimes nothing comes out from it. But at least we tried. And 21:15 and yeah, I try to do the best with the tools I have right now. And I feel like they are getting sharper every month, every year. But right now, yeah, it's not the best strain to get the tree with the knife the moment sometimes so. So yeah, it's gonna get better. 21:33 So what made motivates you to kind of to keep going and keep learning and keep sharpening those tools? 21:40 Right now, I think that's the first thing is that I want to help the people I work with, I don't I don't often tell the term patient. I think I work with people not with patient, they're productive. So yeah, I want to help them. So that's, that's one of the reason. And the other reason is that I don't like not know, to not know. So big. So I'm really curious. And I want to know, and yeah, again, you have to cope with not knowing but but I try to dig it always a little deeper and try to understand the mechanism of what I do have of I don't know, special battleship or stuff like that. 22:24 These are the two things, I'd say, drives me the most. And then I fell into sports physio. And I was like, yeah, it can be fun because I, I always liked sports. And I always did some. But it was also because I believe that sports and physical activity as a whole is one of the if not the best tool for health. And you have to understand what you do. I mean, we speak a lot about sickness size, about active therapy, you have to understand what you do. If you just give some exercises and you don't know what consequences can be. 23:05 Again, it's not the best gear you can provide. I feel like so I don't I don't like and it happens sometimes. But I don't like when people go home and they and they come I don't know, two days, three days after the treatment. And they tell me Yeah, I was feeling horrible for for two days. Because we because I did something that was too much volume or too intense. I don't know. But yeah, basically, that's it. And I feel like you have to be a Swiss knife, you have to add some tools to your toolbox. You have to add communication, for example. That's that's one that's the most important tool in in relationship 23:47 with these people and, and personal experience, I feel like is a is a big driver, too. I feel I felt right when I went to the psychologist and I could discuss and I could communicate. So 24:01 understanding what it feels like yourself, drives me to do better for the people that come to. I think it's it's important. 24:12 Yeah, and I'm so happy that you said communication is I would say the communication is most important any relationship period. That's true, whether that be personal professional, client patient, it is number one, and that that is a skill that can be learned. You know, there are books, there are classes that you can take on how to be a better communicator. 24:35 But I think it starts with knowing what you know, and being able to admit what you don't know and learning more. So kind of everything that you said throughout this podcast, I think really comes down to that piece on communication and it's huge. I'm so happy that you brought that up. And on that note, we're going to take a quick break to hear from our sponsor and be right back with more 24:58 when it comes to boosting your 25:00 Next online visibility, reputation and increasing referrals. Net Health's Digital Marketing Solutions has the tools you need to beat the competition. They know you want your clinic to get found get chosen, and definitely get those five star reviews on Google. Net Health is a fun new offer. If you sign up and complete a marketing audit to learn how digital marketing solutions can help your clinic when they will buy lunch for your office. If you're already using Net Health private practice EMR, be sure to ask about its new integration, head over to net health.com forward slash li tz y to sign up for your complimentary marketing audit. 25:35 Why move on to higher and higher degrees? Right? So for you, why do a master's degree in Switzerland when a bachelor degree is enough here in the US? We had started with a bachelor's, I went to a master's. Now we're at a doctorate level clinical doctorate. So why move forward through all of that when Hey, maybe if a bachelor's is enough or a master's was enough, why why keep pushing forward on the degrees? I think it's a big topic in Switzerland too, because we have the other countries around us that all go to the master degree level, we are maybe one of the only country left in Europe that doesn't ask for a master's degree to be in the clinic, maybe I don't know not the last bit. We're not like in the best situation right now. And that's that's me. That's me, critics from our colleagues and other students in PT school actually, to to that I wanted to go further. And some some told me that I wanted to prove that I was better than them, or that I wanted to be paid more, so I can be paid more. I can't ask for more money, because I got a master's degree. So these are not the reasons. But the main reasons from me with were like when I went into my internships, during my degree, I was really feeling clueless. And I felt like I didn't have the tools to do anything. 27:06 I was a big, big, big manual therapy for years. For three years at school until the I was lucky in the last year there was the Geneva Congress, the World Congress in Geneva, and I went to the to the conference from Peter Sullivan and Jeremy Lewis. And it really blew my mind. And I was like, that's what I want to do. And it really changed my perspective on things. And I was like, Yeah, I want to upgrade my skills, I want to get a better understanding of everything. And, and that's, that's what drives me, it drove me in the first place. 27:44 provide the best care. 27:47 And I think you have to, like I said, to better understand that. And I feel like, as health professionals, we have to, we have to think about what we do, because it has a custom sort of site society, basically. And I was happy to go to that conference, because I realized what I what I participated in, when I was only providing passive, passive treatments. And now I think it's like I have to participate in reducing the costs. I have, it can be by by encouraging people to move more it can be by maybe avoiding a surgery, you can you can have ACL conservative treatments, more and more, it becomes a big bigger trend than before. And that's how I see things right now. And 28:43 one other things with the master degrees, that I like to research and you have to have a master degree to do research in Switzerland. So you I mean, you don't have to, but it's way easier with a master's degree. And I always wanted to add my break to the brick house because I really liked doing my beach law, graduation work. And I think that knowledge is a collective thing I published with the with the colleagues of mine, Mario pizzini, the kilometer in France and UK recently the my first paper and I don't feel like it's only my paper. It's like we did this. We did it us for and it's only for people that come and add just a break to injury prevention and non subject so 29:38 that's what I want to do. Basically I want to I want to add Matt, just my break. I don't want to be remembered for it. But I want to help things move on and go further. And domestically. We can help me understand the research better and help me to understand how to conduct it's basically so that was one of the reasons and 30:00 As, as a young clinician 30:03 research I rely a lot on. 30:09 And if we speak about the funnel model from 30:14 evidence based practice, you have best evidence on the top. You know, it's better than me with the conference at that spot physio. So I think that's that's an agreement. 30:26 Research is at the top. Great. But if you can't read research, you can't use it. So that's that's one of the reasons. 30:35 Yeah, well, I think that's a fabulous reason. And just so people know, we'll have a link to the paper that you just mentioned in the show notes at podcast at healthy, wealthy, smart, calm. So we'll have a link to that. Do you want to talk briefly about what give give the abstract, if you will, of that paper? That's exciting. By the way, congratulations. Thank you. It was I worked on it during my master's degree during two years, I didn't think it would last this long to publish it. But we finally made it. But the idea was, was that 31:12 was that we thought that injury prevention programs for the for the lower limbs could improve performance. And the we evaluated that through a numpy review. And the logic behind it is that 31:29 we have a big utterance problem with these programs. So how could we improve the utterance and there was a talk, we can come back to Monaco, again, about never mentioned prevention, we only speak about performance, you know, 31:42 it's it's the main driver of sports, affiliate sports. And I'd say even off amateur sports, you want to you want to win. So how do you sell it to these guys and women's? So elite athletes, athletes wanna want to be the best. So performance is a key things. 32:02 So it was the logic behind it. We want to we wanted to explore that. Does it affect performance, just by doing these programs? And we can say it has, it has an effect, it doesn't have the best effect. I think 32:17 you better trend for performance than doing these warm ups, for example, if you want to improve performance, 32:23 but it's, you can you can say that it could help. But I think more on on not much level, not knowledge level, it won't be strong enough stimulus for them. 32:39 Excellent. Well, thank you for that quick, abstract, or quick synopsis of that paper. And again, it'll be in the show notes for this podcast. Now. 32:49 As we start to kind of wrap things up, I'd love to talk a little bit more about physiotherapy association. So we have in the United States, the American Physical Therapy Association, we have world 33:04 confederation of physical therapy, which was that was hosted in Geneva a couple of years ago, I was there as well. Do you think they're important? Do you think they serve a purpose? Or no, 33:17 I think they are a big key to, to promoting our profession. Actually, I don't know how it is in other countries actually, with the with the contact with the public with maybe the politics too. 33:34 But they out. I mean, you can you can go and ask the politics and the public everything that you want. If you only one, it won't work. If you come as a group, and with tons of people, maybe it will change things. And that can come back to to the master degree. Step. Two, we need people with an expertise to push the job. And that can be made through associations. We have to actually make the knowledge and then we have to do a diffusion of knowledge. And that's a great way to help people we see so many things that are 34:14 pseudoscience on I don't know a low back pain for example, that goes to the public maybe that's if we could promote what we think is best care and what would help people it would it would be great and I think we have to do it as a group as an association, our gateway for that. And I'm on the I'm a board member of the local zoo that can be translated as the network 34:41 I'm one of our I'm one of the if not the youngest, and with the less experienced in the group but 34:49 we want to promote like physical activity for for health. We want to regroup every everyone you don't have to be a physio but everyone working in sports in 35:00 In movements, and oh, by now and go and promote that for everyone. And 35:09 and I'm also on the commission for the promotion of physiotherapy, 35:14 in my region, Switzerland, so we do, we do some, some really versatile stuff. So we are going to public conferences for everyone to attend. So we want to disseminate knowledge in an understandable way for everyone. So we invite speakers, and they tried to keep it short and simple for everybody to understand. And we have some more professional conferences. 35:43 For example, we did one a year ago, a small workshop with Darren brown on long COVID. It was not really discussed at that moment. So I wanted to have people in Switzerland health professional, 35:58 better understand they had the occasion to discuss with Iran for like, nearly an hour. And 36:06 he answered every question, and I Big shout out to them. Because he He's He's amazing. Everything he does seem to push. Yeah. Everything it does. Yeah. I don't have any words to describe him. Yeah, I don't have amazing, but yeah, that's the thing I think we have to do. And again, it's about accumulating, and if diffusion, you have to accumulate the knowledge, you have to defer to big diffusion to concern people. And I couldn't have done it without an association. And it's rich, it's stretched, maybe, I don't know, 120 feet do 36:49 that could treat lung COVID patients better. And that wouldn't just use exercise. 36:59 To try to to improve things, skirted codes, wasn't everything. So it's important to have that and it's it offers a big platform to reach public your wants. So that's why I think that you have you have to go in this association. You don't have to agree with everything. I don't agree with lots of things in the Swiss physical physiotherapy Association, and quite vocal about it. In my regional Association, I say that I don't like lots of stuff. And I tried to make things move from the inside. Not always easy. But you have to try. But yeah, the problem with that is that I'm on the board with the Huizhou. I'm on the board with the promotion of physio, I'm I don't do much to be honest. I'm on the board from long COVID physio to. And that's can be tons of projects, actually. 38:03 With all the side projects with the clinic, 38:07 with my students who have to write my thesis, I only have a few months left, and I'm crawling compare workloads right now. But yeah, you have to deal with it. And that's, that's kind of the situation right now. 38:21 Yeah, I mean, I agree with you on Darren Brown. He's outstanding. I interviewed him for the podcast about lawn COVID. And it was a wonderful interview. We're going back and forth. And I finished I said, Do you have notes in front of you? He's like, no, yeah. He's like, That's, like, yeah, I met him in Geneva, at the Indaba. Part was where everyone can come and just speak, and there were topics, didn't have a clue on the topic. And it was like you everything. 38:54 And at the end, I discussed with him and I was like, yeah, do you know something on the topic? And he was like, no, no, I was just going with the flow and okay. 39:04 But 39:05 he's just like that. He's, he's, he's an awesome speaker is a wonderful person, and I can't, I can say, Yeah, and it's more about him. That's only praises for him. I agree. I'm with you. I have 100% only praise for that man. And I think he's, he is pretty remarkable. And what a great asset to the profession of physiotherapy. And he has that ability to disseminate information to the public very well. So he knows how to simplify things, not dumb them down, but simplify them to make the average person understand and that's a very special skill. And I think he has it inherently so that he can sleep good. Yeah, it. Yeah, it's a great skill to have. Okay, so now that we're really wrapping things up here, what would you like for let's say two or three times 40:00 takeaways of our conversation to be for, let's say, younger physical physio therapists or even physiotherapy students that you can impart to them after being out in the world for the last two and a half years or so. Yeah, the first one I think would be 40:24 don't give up. Could it be an advice? I don't know. But don't give up and don't blame yourself could be a good one, I think 40:32 you have, I think that you have to deal with the situation with the tool you have at the moment you live it. 40:42 Sure, that's now some situations I had like two and a half years ago, I would deal with them better right now. And some that I have right now, I will deal better with them in a few years. But you only have these tools in your toolbox right now. And try to do your best and don't blame yourself you fit doesn't go like you planned it would go if it doesn't go like you would have liked to go. 41:12 You can you can fail then like we said it will help you change the way you do it the next times. And you'll do better. Basically, that would be the first I think 41:26 with that with the mental health. So don't blame yourself because don't take a toll on it. 41:33 I think it's important. 41:36 But to be a second ones. 41:40 Get involved. I think if you believe in your profession, if you believe in physiotherapy, if you believe in health movement communication, tried tried to get involved. You don't have to do every project like like, I think I do, or like I think many people that came on that podcast do, I think you you should choose. Just quick on that. I think that maybe we have culture and physiotherapy where we think we have to accept everything. Don't do it. 42:13 Better, choose the projects, better choose to and do it, do them greatly. And then choose eight and fed them. Choose your projects, but try to get involved. If you if you believe in it, try it, try it, it will be worth it, you will meet some awesome people, you will make some connections and it will be worth it in the end. Anyways. So I think there's that and I think that's that maybe 42:41 maybe to come back on that we should find a way to to propose these projects to young clinicians as at least into a salon. We don't have anything to anything to get them involved. Maybe we should find a better way to propose the projects to to ask them. I think they have an I have a fresh vision on lots of things. And I think that's one of the reasons why we should we should have younger clinicians come in and express themselves. Because we live in an era where things go really fast. And if we only have the same old people that do it for 50 years, maybe that won't make it. 43:26 And let think I don't know, actually, what would be the last thing? Do you have an idea? 43:34 I mean, I think what you said was great, the only thing I would just like to reiterate from this conversation. So the big thing that I took away is that communication is everything. And that really finding a mentor finding, like you said an entourage of people to help you sharpen those tools. Those are my big two takeaways from, from our discussion today. And finally, I always ask, but you probably just answered this, but I'll ask it anyway, since I asked everybody is knowing where you are now, what advice would you give to yourself as a new grad? So not random? New Grad, but you yourself going back in time? What would you say to yourself? So as a new grad? 44:26 I'd say accept, say, say no to lots more things. I say that because sometimes I get really overwhelmed, overwhelmed with the things I do. 44:39 I think I would say that. And if I go back in time even more, maybe like in my first year of PT school, I'd say try to 44:50 try to ask yourself more questions. 44:54 Don't think that everything you learn is true even at school. 45:00 Question things, lots more, even even if it's teachers, even if it's school, a question things, it's not always the best, the best that you learn our school question lots of things. 45:14 Excellent advice. And now where can people find you if they want to follow you? They want to ask you questions they want to get in touch where's the best place for them to reach you? It could be kind of on like on social media, where wherever is best for you. I think that Twitter is the best for everything physio related. You can go on what is it like Bell B, L underscore like, Oh, I see. 45:38 I think it's the best way. Oh, by all by email, if you text me on Twitter, it's my DMs are open. I think I can give you my email if you perfect problem. I think I don't think we need to give give your email. 45:54 Yeah, well, we'll we'll stick we'll stick to the Twitter app for now. So people can find you on Twitter, we'll have a link to that. Well, I want to thank you so much for coming on the podcast and you know, as a newer ish grad, if you are indicative of others in the field. And I think the future of physical therapy is looking really bright. So I want to thank you for coming on and for sharing all this great information with us and your takeaways from Monaco and everything else in between. So thank you for the invitation. It was really great. It was fun. I had lots of fun, at least it's got my pleasure. Good. That's all I liked to hear my pleasure. And everyone. Thanks so much for listening, have a great couple of days and stay healthy, wealthy and smart. And a big thank you to Lloyd for being so honest and open with us about his experiences as a newer grad physio therapist and of course, thanks to Net Health. So again, they have a fun new offer if you sign up and complete a marketing audit to learn how digital marketing solutions can help your clinic when they will buy lunch for your office. Head over to net health.com forward slash li tz y to sign up for your complimentary marketing audit today to get your clinics online visibility, reputation and referrals boosted 47:10 Thank you for listening and please subscribe to the podcast at podcast dot healthy wealthy smart.com And don't forget to follow us on social media

In this episode, AAPT President, Rob Tillman, talks about leadership and diversity in physical therapy. Today, Rob talks about being a leader, effective delegating, and the problem of bad advice by industry leaders. How Does Rob balance his life? Hear about Rob's journey to where he is today, advocating for diversity, and the shortfalls of the industry, all on today's episode of The Healthy, Wealthy & Smart Podcast. Key Takeaways "You can't get anybody stronger by giving them opioids. You can't correct biomechanics by having somebody on muscle relaxers." "Change doesn't happen overnight. Attitudes can happen overnight. Mindsets take a little bit longer to change." "Competency burns down barriers." "The key thing in business is to manage as many variables as you possibly can." "Not only do we not have diversity when we're looking at the body types we have to work with, we're not having systemic diversity at all in medicine." "You can treat everybody fair, but it's impossible to treat everybody the same." "The outcome is when you get them back to doing what they want to do in their lives." "The best leader shows people how to do it." "There's a difference between believing in something and living something." More about Rob Tillman Rob Tillman is the president of Ortho Rehab & Specialty Centers. In 1986, he received his degree in physical therapy from the University of Missouri. Rob immediately saw the need to attain a level of clinical competence that would allow him to effectively address the complex needs of his patient population. With this in mind, he enrolled in a post graduate residency training program with the Sorlandets Institute which later became known as the Ola Grimsby Institute. He is a Fellow of the American Academy of Orthopedic Manual Physical Therapy and American Academy of Physical Therapy. Rob attained the highest level of clinical certification available in the field of orthopedic rehabilitation. Since then, he has received international recognition for his research on the lumbo pelvic system and has written benchmark works on the thoracic and cervical regions, as well. Rob has presented at several national and international conferences on a wide range of healthcare-related topics. He is also a recognized authority in the arena of sports medicine, having been credited with the rehabilitation design and training programs for many professional athletes and organizations including professional baseball, a Superbowl MVP quarterback, an NBA championship-winning power forward and a four-time golf world long drive champion. Suggested Keywords Healthy, Wealthy, Smart, Healthcare, Physiotherapy, Rehabilitation, AAPT, APTA, Priorities, Education, Diversity, Leadership, Advocacy, To learn more, follow Rob at: Call the office: 501-975-4040 Website: https://www.pt-orthorehab.com AAPT: https://www.aaptnet.org LinkedIn: Rob Tillman Facebook: Rob Tillman 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: 00:00 Hello, this is Jenna cantor. I am here with the ROB Tillman who is currently the president of a PT and also is in charge of the ortho rehab and specialty centers. He is just a top physical therapist in the profession. We got I had the major pleasure of meeting him in person for the first time at the APTA 100 years Gala. Was it 100 years? It was, yeah, yeah, we were all dressed up, I got to freak him out with my excited energy, because I was so excited to be meeting you, Rob. And I, by luck convinced you to come on this fun ride and do this interview with me on healthy, wealthy and smart. Thank you so much for agreeing to come on. My pleasure. It same. It absolutely is just wonderful. So um, I would love to just start with if people could learn more about how you got to these leadership positions, start from wherever you feel comfortable. But I would love to hear how you got to now. I mean, you're heading these things. Of course, I mean, so many things. So please share. 01:10 Well, to be honest with you, I I didn't really seek to be president or leader of anything. I just really wanted to I went to physical therapy school and I wanted to do sports medicine. So I learned that while I was trying to do sports medicine and orthopedics most patients have that come to an outpatient physical therapy clinic have neck or back pain. So I decided to go ahead and learn something about how to deal with neck and back pain. So I did a residency with a group called Restore Landis Institute, which is now the older Grimsby Institute for four years and did a residency and passed by competencies and became what's called a level two manual therapist by the Norwegian standards. And I think it's still the highest level of competency, internationally recognized in orthopedic manual therapy, started teaching courses, and orthopedic manual therapy after I gained my level of competency and start working with the group was held South back then it was the world's largest healthcare Corporation geographically. And I started troubleshooting clinical operations, and learned how to do the administrative things. And then next thing you know, I'm a vice president. And then I'm a senior vice president, and then they have their accounting scandal. And then, so I started my own company about 18 years ago. And all the while while I'm doing my, my, my core competencies and working, you know, to make a living and moving up in the in the company I was with. I'm at a group called the American Academy of physical therapy that was established about 30 years ago. And 02:54 it was in 1989. Yeah, 02:57 it was it was a black folks that had concerns about access to physical therapy, school and quality care in the black community. And I learned about them through who is now my best friend, Leon Anderson, the third, his dad, Leon Anderson, Jr. is the founding president of the American Academy of physical therapy. And I just really started teaching what I had learned to the group and expose them to the specialty of manual therapy, and I just kind of hung around and enjoyed myself with them because that's the first time I really experienced unconditional love, professionally, in physical therapy, because they just made me feel welcome. A lady who's deceased now named Diane Ellsbury. I call her my PT mom. She'd says, Hey, Rob, baby, how you doing? And just hug me and just what do you need anything? Are you taking care of yourself? You're not working too hard. Are you just like an auntie type thing. And then I became more involved in the operations and joined a committee called the innovative services committee. And innovative services was that's exactly what it does. It does cool and innovative things like create programs, we established a navigation program for mentorship for for our young folks coming through an advocacy wing that was concerned about practice acts and access to care and licensure issues and things like that. In the process, I somehow got appointed to the Arkansas State Board of physical therapy. So that's how I ended up wearing these hats. And while I'm on the board and Arkansas State Board of physical therapy beginning about 1617 years ago, I'm currently still on the board. And it's it's rewarding. It's rewarding. It's a lot of work, but it's rewarding, and I'd rather be at the table than not be at the table for a lot of the things that are going on because our profession continues to evolve. The physical therapy profession continues to evolve. And as an E involves then we have to be able to apply the clinical concepts that we are. In general learning in physical therapy school. State practice acts can hinder your ability to perform the things that you've learned if you're not careful. So we really have to make sure that all of the practice extra current and access to physical therapy is available because we are the most green profession. In healthcare. It's all hands on care and exercise. You can't get anybody stronger by giving them opioids. Okay, you can't correct biomechanics by, you know, having somebody on muscle relaxers, you know, it's kind of hard to strengthen somebody while on muscle relaxers also, by the way, but as we're looking at all these things that I'm doing at the same time, it's just when people ask me to do something, I don't want to be the person that's complaining about things not being done appropriately. I want to be the person that's kind of like a catalyst, or at least an advocate or participant in moving things forward and making things better. And sometimes you don't get paid for. Okay, but but, but that's why I love the Academy because it's the service academy. It's, you know, it's a place to come and serve and love the people that you're with and be loved, have a positive attitude and move some things forward. 06:21 I think sometimes people get caught up into looking at the AAPT or the APTA as something that needs to serve them. The APTA is also a giant service group. If we look at it appropriately, and as we come together, and share concepts and ideas, the current leadership of the APTA has done a lot better on sitting down and really trying hard to understand the challenges of the black community, just so my my hat's off to past president, Sharon Dunn, and also the current president, Roger Ver, and, and Justin Moore, the CEO, and Carmen Elliott, who's vice president over Dei, I think that they're really putting their best foot forward on working towards things. I think that we all have to be patient, and monitoring the progress as we do blend initiatives and work together on things. Because change doesn't happen overnight. attitudes can happen overnight, mindsets take a little bit longer to change as far as our train of thought. But behavior patterns take a lot longer than that, and coordinating behavior with other groups and other people take even longer. So I've learned to be a bit more patients in my practice, and my working with folks. And I've also learned that not everybody that doesn't understand the EI or the hardships that other groups are having. They're not all necessarily opposed to other folks doing well, or what somebody would call a racist or something like that. They just don't get it. And sometimes people want to get it. And those are the ones that we have to engage in conversation with and share ideas and have our thick skin on, to work together on things and not be so easily offended because we've all got pasts. I try not to be so easily offended and angered by things. But also, I have still pretty good intolerance of people that are in denial about other people's hardships. That's a little bit tough to be in full denial about other people's hardships. And there's current legislation that's going through several states that actually don't want America to tell America's full story. Because some people aren't comfortable with hearing about America's past and some of the impressive things that have taken place in this nation. But while we're deleting some truths that need to be spoken about America's past, we're deleting the chance for especially when in this case, black people to tell our kids and society in general, the challenges that we've had, and the reality of how we got to where we are and what we need to do collectively about. So that's another thing that's happening in today's society, but I do believe in general things are moving forward. As far as being president of the Academy, I never wanted to be president of the Academy. I wanted to be the guy that shared the cool clinical stuff. And just got to hang out with people that were just loving folks. I became chair of the innovative service committee. When BV Clemens retired, one of our founding presidents. He was later President second president of the Academy. And when he retired and took a step back, I took over the innovative services committee. And then I was asked to run for the director position, which the innovative services committee reported reports through the director director's position. It's now under the director, our current director, Renee crater Dr. Crater, great lady. Man few years ago, they asked me if I would consider being president of the Academy. Are you sure you want to do that? But my skill set on big A former officer in a large company and my background and all the things that I've been working on and still doing, including being on boards and things like that fit the skill set that was needed for the president at that time. And again, I'm humbled and honored to serve as the president of the Academy. I've done it for the last three and a half years, I can't wait to get the next crew of people trained up and ready to take over as we're pushing forward on things. But right now, it still currently fits my skill set and and and I hope that the academy is satisfied with my leadership and innovation and my quirky ways of dealing with things but it certainly has been my pleasure still serve as president of the Academy. 10:46 I'm so everything you shared, i Nobody sees me. But I have this very excited smile, listening and everything. And I love hearing things. In your own words, you are a very, very humble individual and the amount of service you have provided to the physical therapy profession at large. Thank you. 11:06 So it's my pleasure. It's my pleasure. It really is. It doesn't even seem like work. 11:12 Right? And and that shows anyone who works with you, like I've known you for a blink of an eye. I mean, it's been, gosh, half a year now. Yeah. But like it from for you are so kind you know how to like enter a room, whether it's on email, or text or whatever, in the friendliest way. You are. So I find you to be so approachable. And very, as a leader, it's still no denying what your position is. I just really think you are really, you said, I love what you bring to the table. Love it, just enjoy very much. Yeah, from the from the amount of time I've known you. How do you handle things with being what doing what you're doing? And I've never asked you this before. And that life balance, you know, people talk about work life balance. How do you do that? From what I've seen, you have specific times, you're like, I am not replying back, which is great. Could you talk about that a little bit more where you kind of set boundaries and stuff. So that way, you're able to handle everything and not overwhelm yourself. 12:20 Sometimes I My wife's a surgeon, she's a breast cancer surgeon, the Chief Chief of breast cancer at the University Hospital here. She's comfortable multitasking and doing a bunch of stuff. I really want to make sure I'm a perfectionist and whatever I put my hands on. So if my attention is split, if my attention is split, I know that I'm not going to do the thing that I'm working on, as well as I could. So I do one thing at a time. I do one thing at a time. When I'm in clinical notes. Sometimes I can reply to a text sometimes I can't. But I want to make sure when I fix a problem, that problem that has my undivided attention, my total undivided attention and I'm giving it my best that I possibly can. As I'm trying to resolve the issues that I have in front of me. I love that I feel 13:15 like it's a very attainable way to approach life rather than just going just one thing at a time. Do that. Good. All right. I love that. I've actually even been doing that this week. Not even purposely because you said but now I'm going to be like Rob said this I'm inspired. I've been doing that this week where I I had it upon me to finish up the project we're working on together and I was like nope, let's hone in and now like it's at a really good spot you know now and then I moved on to it. I've already moved on to other things because again, 13:47 that's it's because even in relationships if I know I'm doing the best I can with that relationship even if it goes awry. At least I know for sure I did the best I could with it. Oh I love that. I love that so much that way you don't have any regrets. Yeah, yeah, yeah, it 14:03 makes me think of what that tattoo that that tattoo where it says no regrets but regrets is spelled in properly regards because I love that I kind of want I'm not into tattoos but if I got one it'd be either Disney or that. I love that so much. So now as when you are a leader of a as a leader of a PT how is that different from being a leader at a clinic? Like a clinic owner? How is that different? 14:38 I'll say it's the same it's just the objectives are different. Objectives are different. Okay. Now when when you're dealing with a clinical situation it to me if you're doing it the right way you're focused on your outcomes. Yeah. I'm not in a silo to where you know the orthopedic surgeons are upstairs and they own my my practice you They're gonna send me patients regardless of company, you know, so we're outcome oriented. And we get the things that are a little bit tougher than the guys that have the automatic referral that own their own PT practice. I've learned that competency, burns down barriers. You know, people don't care if your margin, if you know what you're doing and they got back pain, they're going to come and see you. That's true, that's true. But key thing in the key thing in business is to manage as many variables as you possibly can. Because they're variables that you can't manage. So being timely looking professional, okay, incompetent, having the tools that you need to get people better. I mean, how many PTSD see that, that work for a group that owns the practice that doesn't even have the tools to get the outcomes that they need, and they're working with the only resistive equipment they have is exercise to me. You know, you have to have what you need. And I'm our chief proponent of physical therapists independent practice, but I'm also a huge proponent of us owning our own businesses. And not working for groups that own you. 16:14 Yeah, we do. Uh, you know, I really see and feel what you're saying there, I have my own practice. And there's a lot to be said, because we all shine in a different way. We're all doing evidence based, but when we're able to come through as a as the autonomous decision maker that we've been trained to be, we can really help those patients, we can be a best service. I truly do believe that. 16:40 Yeah, I think so. But, you know, by the same token, we have to go the next step, and do what's defined by the way that the APTA is going, and the different academies and specialization. Oh, yeah, I've heard somebody give the worst advice at a three state meeting once and I'm not going to get the states because it might tip it off, it will. But this guy stood up and said, to the students, when you graduate, don't worry about training anymore. You already know enough, you know, you know, everything you need to know, to really make it. And I sit there. And then I asked the question, I said, Well, I think that the APTA is going towards specialization. So how does this fit in with that, but I know darn good. And well, after serving a four year residency in orthopedic manual therapy, that I'm a far better and more competent clinician. Also, you know, even being a co author and co author in some textbooks and defending my my thesis internationally at the First and Second World Congress on low back pain. It helped me to learn more, always active clinician, because I've learned more. And I have a more diverse patient population, because I'm a specialist in orthopedic manual therapy that's paid his dues. And and I believe we get superior outcomes when you go through residency training. Of any comment. Yeah, of any kind. So that was the absolute worst advice I've ever heard anybody give some young kids right out of school. 18:10 I think there's been a lot of advice out there that can be off, but I definitely think that's really, it's off. I'm thinking you got me thinking of I grew up as a ballerina. And ballet is impossible to perfect, however, that every ballerina is trying to perfect it what we're doing with our lines or bodies, you know, it's definitely out of the anatomical positions. And when you first start out like that, you learn all the dance steps, you learn all that, does that mean? I'm done? No. I'm always taking class, I'm always working to get better. And I learned so much from my life as a ballerina, I was pretty intensively in it at one point for a good portion of my life. And I learned the importance of always learning, always practicing and having to be passionate about it. Because if I wasn't passionate about it, I wouldn't be showing up and putting in my best. So having that background and then going into physical therapy as my new profession. Definitely was in line the idea of, of course, I'm always going to be learning Absolutely. What Why would that would make me the worst person to work with if I was start in one year of Tottenham? 19:22 No, I'm haunted by what he said. But it motivated me to teach something different to people in that. Yeah. With me, because I hear somebody saying something in full. He said it in full sincerity. He really didn't think anybody need to learn anymore. Yeah, but that's terrible. So let me go and teach people why they need to learn more. Yeah. Because especially when you're minority or a woman, you had better have it together. If you're out there on your own, you have better have a superior product because you're not in that good old boy network. Well, you're an outsider, also, if you better do it better. 19:56 Yeah, it's yes. And also If we're going off that you're going off with the research at the time that you learned it, we did not do diverse bodies, we do not have diverse bodies in research, we are massively lacking that, you know. So we need to be open and ready and seeking and creating more of that information to learn from to better serve. 20:20 I'm glad you're saying that because not only do we not have diversity, when we're looking at the body types that we have to work with, we're not having systemic diversity at all in medicine, because different people, the guy named D'Amato wrote a book a long time ago called Eat right for your blood type. And he talked about how different types of blood types have different types of foods that they can metabolize, and using their systems and have it not function in a fashion that's detrimental to the person. And lo and behold, different people can eat different things and perform differently. I'm gonna type O blood time, I need dense protein. Some people that are more of a type A blood type may not need as much dense protein, they may be able to make it by carb loading and eating pastas and things like that. If I eat a bunch of pasta before I go into an athletic endeavor, I'm going to suffer versus somebody else may be able to metabolize that and move forward with it. So everybody's different. And I think we're just now getting to the point to where we're paying respect to the difference in the different physiologic physiologies that different people have. And it just so happens that certain physiologies are grouped together in different ethnicities. Yeah, and because of because of that, because of that, then we have we have an evolving ability to specialize care to specific individuals. Yes. When When, when it's all mainly designed for just one certain group, or one certain physiology. Mm hmm. Body Type one certain athletic performance level? 21:59 Yeah, no different different, different, different, different levels of stress and anxiety, depending on what your background is. The stress and anxiety, someone gets the food, the blood type, that all affects healing. Yes. And it can definitely take away from the exercises they're doing. 22:18 Or give you a specific example of that, I'll give you some with COVID. With COVID. They're finding the people that get most sick from COVID have low vitamin D levels. Okay? Now, black people can't synthesize vitamin D, vitamin D is actually more of a hormone than it is a vitamin. Okay. And when you're exposed to sunlight, your body synthesizes its own vitamin D, which is a vital hormone for the basic function of your system, in your in your body. Okay? Well, black people can't synthesize as well, because we have more melanin in our skin. And the melanin reflects the sunlight. And so we have to have an increased exposure to sunlight to have the appropriate vitamin D level. Well, everybody was told to stay home for first three or four months during COVID. And lo and behold, black folks died at a higher rate than everybody else did. Okay, sky like, wet, your black folks have a more problem with high blood pressure, isn't it, and we eat the same thing that everybody else eats. But just so happens that affects us differently. And it may be because certain ethnic groups can't metabolize that metabolize the same foods the same way that other folks can. And so I think as we look at those things, and be more specific with it, we can teach through the whys. We're talking about, you know, masking up and what to do to not get COVID. But we're not telling people in specific you need to have this number of these nutrition nutrients every day. Okay, to where your system is more healthy. And your hydration level needs to be exactly this. I think that we could have done a far better job and still can have telling people what they need to have in their systems to be healthy. 24:07 And on that note, we'll take a quick break to hear from our sponsor and be right back. When it comes to boosting your clinics, online visibility, reputation and increasing referrals, net Health's Digital Marketing Solutions has the tools you need to beat the competition. They know you want your clinic to get found get chosen and definitely get those five star reviews on Google. Net Health is a fun new offer if you sign up and complete a marketing audit to learn how digital marketing solutions can help your clinic when they will buy lunch for your office. If you're already using Net Health private practice EMR, be sure to ask about its new integration. Head over to net health.com forward slash li tz y to sign up for your complimentary marketing audit. 24:50 I agree. I absolutely agree. And for me, I I haven't even gone into the nutrition stuff in massive detail with my patients and now you're opening up another door I've actually been getting into cognitive behavioral therapy, right now learning about that not to become a therapist, not at all. But to better compliment how I communicate with people who could do well with it or watch out for trigger words, all that kind of sensitivities. Because the individuals I find my patients really do open up to me a lot. They have been through or going through some of the most jaw dropping things in their lives. And yes, that affects their healing. So I need to make sure I'm not triggering them. By my, the way I speak, if anything, complimenting a journey of healing, as we are working towards a healthier, healthier movement, decrease pain in their life. So yeah, yeah, I definitely get it from from where I've been with the anxiety stuff. Yeah, 25:51 you're dealing with people in their complexity. Journey, people that deal with people in the same with patient care. Now, let's go back to them. You know, zoom out zoom. And you've heard me say that, Oh, 26:01 I love that. Yeah. 26:02 So the deal is, okay, let the we've zoomed in so tightly, let's zoom out so that we can see everything again. And now let's zoom back in. Because, you know, you can teach a kid how to hit a baseball, and he can hit every type of baseball pitch at every speed. But what if he gets hit in the ribcage? Oh, you don't want to get hit the ribcage again? Right? So is that going to alter his ability to perform? Well, if he's so afraid of getting hitting and hurting, then it may be in the back of his mind that he's gonna have problems. So you know, it can alter his performance. So yeah, but the mental aspect of performance of any time. You know, my daughter suffers from anxiety disorder. And and it's hard. But we have to work through it. Because, you know, let's let's be sympathetic to us. But we need to be more patient with some folks and see what we can do to integrate them into a functional position in society. You can treat everybody fair. But it's impossible to treat everybody the same. Ah, 27:06 amen. Amen. All right, I'm going to switch completely into another because it just popped into my head. And I was like, oh, I want to ask regarding leadership. I was talking with another business owner, she's actually new to owning her own private practice. And, and then there's another person who's much more seasoned with his pride, like, yeah. And he said, I'm working on delegating more. And further, and I cringe, because we like to really Oh, that is that's it? How could you talk about your journey with delegation, because as you get, you know, the more of the leader, the higher leadership position, you do have to delegate more. How do you do you know, like, 27:51 Well, yeah, yeah, but here's what needs to happen is you've defined your clinical product, okay? You have to replicate that product, either you have to do it or somebody has to be able to produce the same clinical product that you produce. And it just so happens with mine. It's it's specific care in orthopedics with a high level of differential assessment of Neurophysiology histology and Arthur kinematics, and the appropriate prescription of hands on care and exercise from that. So if somebody comes to work for me, especially in the main office, they're not going to have their own patient load for six months. Until they go through the readings. And they they learn the basic clinical practice for dealing with an upper cervical problem, a lower cervical problem, ribcage issue. Problem with a hyper lordotic spine, a problem with a hyper mobile spine, problem with pelvic issue, be it internally, as far as pelvic floor issues, or biomechanically, when the sacred tubers and sick response ligaments are a little bit loose, and they can't withstand the normal loading. But they should be able to, they have to be able to do all those differentials in there to be a predictable application based upon that assessment and diagnosis, to where we're replicating the outcomes that we need to replicate with patients that present with those pathologies. And that takes time. So now let's go back to the guy that says that the students don't need to learn anymore. Well, they're going to get their lunch eat. All right. There are guys out there that then and ladies that have been doing this forever, that have the highest level of competencies, that'll run them out of business. If the playing field is indeed level, and there's access to the same level of referrals, and getting a good outcome doesn't mean that a person comes and says, Well, I hurt when I'm riding a bike for a long period of time. Well, why don't you take a walking instead? Now that's not an outcome. The outcome is when you get them back to doing what they want to do in their lives. Yes, that's it not modifying their life but getting them back to doing what they want to do so that they can maintain the quality of life that they desire, not telling them that well, if it hurts to bend forward, quit bending forward. No, that's not. That's not an outcome. Right? Right. modification. 30:09 Yeah, yeah. And it's so interesting you say that, because always learning, I have my practice where I'm 100% virtual. And that happened from the pandemic, I was not expecting that, and my performers love it for access everything. And it got me very into, you know, I'm not going to go into the details of what I do. But regarding outcome measures, I literally, that's what we very intensely focus on what they ultimately want to do not just like, oh, I have no shoulder pain, you know, they want to know if they can do this arm movement. And when they dance, you know, every time can they do that without having to worry about it. And then we get them there. And that is why I have a massive increase in satisfaction, because we are fully getting them to that to that their specific goals. I love them for 31:01 that. I'm very, very slow to accept praise for anything that I might do. Because the patient's the one that's got to do most of the work at the end. In the very end, and you're really is only as good as your last patient. You're only as good as your outcomes. Say that you are, yeah, doesn't matter how much you walk around talking about how great you are and how smart you are, if the patient didn't get better than you fail? 31:23 Well, because it's not about us. It's not about us, 31:26 it's about them, it's about getting them better, you know, and that is the most rewarding thing. You know, like, it's, it's, 31:35 I've built my company, we've got five facilities now. But it's one patient at a time, one outcome at a time. And most of the patients that we get come by word of mouth. Nice. Yeah. So you just get after it and handle your business and maintain and be a good steward of the opportunities that come to you. And take care of people the way that you'd want to be taking care of yourself. But back to the point of leadership. Yes. Your best, the best leader shows people how to do it, instead of trying to do 32:05 Yeah, and that's a skill. That is a skill. Oh, well, 32:11 the funny thing about it is I've always gone to church, and I've you know, I've always gone to church, and different people have different ideas of spirituality and religion. But there's a difference between believing in something. And living something. Yeah. Okay. There's a big difference in believing something and living something. And I go to church now, the preachers, my brother in law, and I was kind of skeptical because my sister in law married this guy, and he's preaching, I was like, you know, just because you got to church doesn't mean I'm gonna be hanging out at church on time. That's such a good guy. He's such a good guy, and he lives it. So now I went from saying that to actually being a part of the service every Sunday and doing devotion at the start of service. So you know, if somebody sees you living something sincerely, and not saying one thing, and then doing another and behaving in a way that's totally outside of what's your professing in a crowd, and I think that's a lot. That's, that's what a lot of people away from spiritual base. Community, is, people are observing what people are saying. And then they're observing that person's application of what they're saying. And seeing if it adds up. And a lot of times that, yeah, you know, a lot of times does, yeah, and I think that's led to a whole lot of skepticism and a lot of our religious organizations. Yeah, 33:35 yeah. Actions do speak louder than words they do. It's just like, exercises, 33:41 exercises. Think about it. Think about it, you know, you know, the only Torah or Qur'an or Bible that people see in public are the behaviors of those people that profess those religions a lot of times, hmm. So, you know, are we living testimony to the Torah, or the Quran or the Bible? Are we are we living testimony to because if we were as diverse as we are with religious beliefs, if it's obvious that we're living, right, you know, everybody, I think would get along a whole whole lot better if the Pharisees were zeroed out. Yeah, 34:19 yeah. But that's where that's where you you jump in for this leadership and for all this volunteer work, because you want to start being the change you want to see in the world and be rather than just being an outsider. Like, let's take action for this change, which I so appreciate that about you. 34:35 Well, I just I'm slow to accept it. But if I do, I'm all in. Yeah, yeah. If I do, I'm all in. Yeah. It's It's It's humbling to be asked to serve in a leadership role of any form of any form, to be called upon to serve because that means somebody thinks enough of you to ask you to think about doing something and being an agent of change or or a vessel of service. Yeah, and that's what I always think about my wife gets a lot of a lot of requests to serve as well. And so we're very understanding of one another's roles. When we're asked to do things that might eat away from our our family time. 35:16 Yeah. Yeah. Kind of hard. Yeah, 35:19 it's rewarding. It's rewarding. I love that. 35:23 Thank you so much for coming on. I know this can inspire so many people. Just when you speak if you ever are at an event and you see Do not be afraid to approach Him, He is the nicest human. Like, go say hi. Ask questions, everything like you're like, Oh, God, no, I'm gonna get 35:42 this better than others. 35:44 Well, yes, you are still human. Of course, of course. But you're very good at communicating that you're like, Hey, you said that with me. You're like, now's not the time. Let's connect another so we did, which was incredible. So yeah, it definitely just a great leader to know to learn from and just, you're just good people. So just thank you for being you. 36:05 Thank you. Thank you for having me. Yes. Turned out to be the way that you wanted it to be this time. 36:09 Oh, my gosh, this is all every time. I feel lucky. 36:13 We'll do it again, if we need to. Oh, my God, I 36:15 would love to. And then, um, how if people want to reach out and connect with you? What is the best way if somebody wants to reach uncle? Oh, I want to I want to ask them a question. 36:25 Well, they can call the main office here in Little Rock 501-975-4040 Or you can look us up on our website at ortho rehab comm and leave a message there, somebody will check it. 36:41 Wonderful. 36:42 Thank you so much. And also don't forget about the American Academy of physical therapy. If people are curious about that. It's a wonderful service based organization designed to deal with healthcare disparities in the face of black community, but we're trying to help everybody, but our leg laser focus for us is to work with the black community and then try to help everybody else as we can. 37:03 I love it. Thank you.

Episode Summary In this episode, Co-Founder of Aivo Health, Melissa Farmer, talks about the mind-body approach to treating chronic pain. Today, Melissa talks about the mind-body approach, getting patients to be more receptive to the mind-body approach, and how practitioners can recommend psychological care for chronic pain. How can psychology work to treat people with chronic pain? Hear about the gaps in chronic pain measurements, the psychology behind farming pain out, the Aivo Health App, and get Melissa's advice to her younger self, all on today's episode of The Healthy, Wealthy & Smart Podcast. Key Takeaways "The body and mind aren't separate. They work together, they interact, and that impacts the experience of someone who lives with chronic pain." "Just because we can't measure it with an existing tool, doesn't mean it doesn't exist." "A patient saying that they're in pain is all the proof that you ever need to believe that they're in pain." "We all have a collective responsibility to empower people who have been living with chronic pain." "One of the most powerful tools for pain relief is between peoples' ears." "Your identity is not your accomplishments." More about Melissa Farmer Melissa Farmer is a veteran chronic pain researcher-turned-entrepreneur. During her graduate studies at McGill University, she trained with a world-class multidisciplinary team at the chronic pain center founded by pain research legend, Ronald Melzack. She earned a doctorate in clinical psychology and neuroscience. Dr. Farmer went on to pursue postdoctoral training with neuroimaging pioneer Vania Apkarian at Northwestern University, where she specialized in brain imaging of hard-to-treat chronic musculoskeletal and pelvic pain. In 2018, she left academia to co-found Aivo Health, a startup with Vania Apkarian and a chronic pain patient/entrepreneur. Their mission is to bring insights from the top tiers of pain science directly to people living with chronic pain. On twitter, Dr. Farmer has an international following of influencer physiotherapists who appreciate her ability to translate basic pain science research into understandable language. Suggested Keywords Healthy, Wealthy, Smart, Healthcare, Physiotherapy, Chronic Pain, Psychology, Treatment, Mindfulness, Meditation, Therapy, Trauma, Pain Relief, Mind-Body, To learn more, follow Melissa at: Email: melissa@aivohealth.com Website: https://aivohealth.com LinkedIn: Melissa Farmer Twitter: @Farmer_MindBody 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: 00:02 Hey, Melissa, welcome to the podcast. I am so happy to have you on I have heard raving reviews from Sandy Hilton and Sarah Haig about you. So it's great to have you here. 00:15 Thank you so much, it is a pleasure to be here with you. And today we're going to talk about treating patients living with chronic pain from a mind body approach. So before we get into the meat of the interview, can you define what a mind body approach to the treatment of chronic pain is? Sure, a mind body approach to the treatment of chronic pain acknowledges that we are embodied in these, you know, this skin, muscle bone, that we feel emotions in our bodies, that sensations have emotions that are attached to them. And it also acknowledges that all of these conscious experiences like pain and chronic pain arise from the brain. So they're conscious perceptions that are shaped by our thoughts and emotions and feelings and past experiences. So it's an acknowledgement that the body and mind are separate, that they work together they interact. And that impacts the the experience of someone who lives with chronic pain. And now here's here's the hard part as clinicians, what can we do to help our patients be more receptive to this approach when it comes to pain management, because chronic pain, any clinician will tell you is not an people living with chronic pain, excuse me, it's not a it's not an easy road. So what can we do to allow our patients to be more receptive to this? Because oftentimes people will say, so you're saying it's all in my head? And that's not hopefully not what we're saying. So got it? Oh, not at all. So one of the most powerful things I think, that we as clinicians can start with is a simple statement, I believe you, which is something that many people with pain don't ever hear. And it can be such a powerful statement, because then instead of coming to an appointment with, you know, evidence that they've prepared to prove that their pain is real, you know, tests, scan results, etc. You push all that off the table, you say, I believe that you're in pain right now, and I'm ready to help you. That's, that is, I think, one of the first pieces of resistance that we can remove, just by validating their experience. 02:53 And I think especially whenever people have lived with chronic pain, and have seen many, many, many, many doctors, they get used to this feeling that they need to 03:08 convince the person in front of them that their suffering is real. And if we just if we 03:19 if we get up that out of the way, just by acknowledging that common humanity, I think there's there's one level of resistance that's removed quite quickly. And what about providers, or medical professionals who our education, whether it be formal education school, our clinical rotations, has sort of trained us to look at scans and say, Oh, this is it. This is what's causing it. So what can we do as providers to? To break us out of that, if it's in the scan, then that's, that must be what it is. Do you know what I mean? Mm hmm. I think getting in touch with some humility. So crepe is a great way to start. Because one of the issues with scans and test results is that these are things that 04:14 scientists and the medical professional has decided these are measurable, objectively accessible, indices that we've all sort of mutually agreed, indicate that something you know, there's some sort of structural abnormality or whatnot. In other words, we're testing to look for what we know might exist. Another way of saying that is that we're only testing for the things that we've thought about before, and that we know how to measure and there's a lot of things that we don't know about and we don't know how to measure. And just because we can't measure it with an existing tool, doesn't mean it doesn't exist. And, you know, from a basic science perspective, right 05:00 My background is in basic science of chronic pain, we do not know a lot about chronic pain mechanisms. And so having sort of the humility to recognize that 05:18 the nervous system is incredibly complex, the brain is incredibly complex, there are many things we don't know how to measure, and it doesn't mean that they aren't there, 05:30 we tend to cling to tests that reflect our particular training. And from a patient perspective, what that means is that they get different types of snapshots. For instance, if someone has 05:45 lower back pain, they may get MRI scan to one, you know, from one doctor, if there's comorbid, visceral pain, which could be referred, for example, they might get a colonoscopy from another doctor, each of every every, you know, we've talked about silos before, you know, in the general field. 06:06 Each of these silos have their preferences for these different tools, and they all provide small snapshots. And it's sort of like the, you know, the blind men feeling on different parts of the elephant, you know, that really handy metaphor, just because you're a trunk expert, or you're a, you know, a, an, an elephant foot expert doesn't mean that you're able to see the entire picture. So Humility is a great attribute. Yeah. And where do you think this kind of false dichotomy between the body and mind originates from? Is it that, you know, Decart Deyan? Theory, you know, that happened centuries ago that we continue to accept? Or is it that we put more weight to the objective and less weight to the subjective? Or is it both? Or is it all the above and more, 07:06 all of the above, for sure, especially in the pain field, Decart has, he said, really strong influence, and he suggested that the body is like a machine. And you can sort of causally identify almost like a, you know, knocking down a line of dominoes. A cause effect, cause effect cause effect. And that's how you understand a more complex organism. But 07:34 what he, he sort of, it's interesting, he, he essentially said that, you know, like the body, the material, it works on different rules than consciousness. And he sort of made this blanket statement that we all accepted. So in a sense, relying on the words of a philosopher 400 years ago, is the basis for our logic today is a little a little surprising. But it's something that many people haven't questioned. And, unfortunately, in the, in standard medical training, 08:09 I'm sure you're familiar that like, especially in Northern America, in medical school, they receive anywhere between four and 11 hours of pain education, 08:21 there isn't enough time to go into the depth, the proper depth that this subject deserves. So I think that it's a, unfortunately, a reflection of these overly simplistic heuristics that medical professionals and other practitioners receive. 08:40 That that just doesn't do justice, to pain at all. Yeah, and like you said, because pain is so complex, because pain is an emotional and 08:54 physical state 08:57 that I think people are always looking for the answer. I know, patients are always looking for that one doctor, that one test that one scan that will say, Oh, this is it. This is the problem because people like logical things, right? People like well, point A, here's the problem. I can do B and I will end up with C feeling better. But when it comes to chronic pain, we can't look at the body and mind as separate. And I think a lot of people do and that does really is a recipe for some really ineffective treatments for pain. So what what can we do if a patient comes to us and they have sort of accepted that their mind body and mind are totally separate? And their kindness I must have done something I've got I've had this pain. I you know as a practice, I'm sure you've heard it. I hear it all the 10:00 Time, I'm sure I did something again, or I must have done something to flare it up. So how can we respond to that in a way that's accurate and helpful. 10:12 One of my beliefs, and this may not be a popular belief is that 10:19 the body has done nothing wrong, whenever it creates chronic pain, the body and mind it that chronic pain isn't a mistake. 10:29 And I say that from a scientific perspective, because whenever I've studied the mechanisms from the nerve ending on the skin, you know, whenever pain signals or nociceptive signals are transmitted from the surface of the skin, to the spinal cord to the brain, the body is naturally designed in a way that amplifies pain signals. So amplifying pain is how nature works. And it works that way. Because pain is a really important thing to notice. Pain is a primary reinforcer. And that means, by definition, it's aversive, you don't need to condition or to pair it with anything for an animal or for a person to try to avoid something, it's painful. And that's why it's always sensory and always emotional. It's always aversive. 11:23 And whenever, you know, as I've studied chronic pain populations over the years, and I've looked and really considered and reflected on the biological changes that I see all of these, these mechanisms that sort of turn up the volume of pain, whether it's at the nerve and the surface of the skin, or in the spinal cord, or in the brain, they're all there for a reason. And it's because the signal is incredibly evolutionarily important to respond to. 11:55 And the division happens in the brain where once it gets to the brain, and creates a emotional memory, or a fear memory. That's whenever the brain adapts and changes in response to that incoming signal. So in a sense, that's the point where the brain begins to adapt to accommodate the pain in someone's life, rather than just being passively responding to the environment. And that's one of the 12:31 one of the main features of chronic pain, where it's no longer just a, you know, whenever you see a patient to 12:42 has pain that still increases and decreases in response to external stimuli. That's a great sign because it means that the nervous system is still really closely linked with the environment. Once pain fluctuations start to vary independent of the environment, that means that it's become 13:01 more hard coded into the nervous system. 13:05 So that whenever I see patients who you know, who do have pain that's responsive to seeing the environment, I congratulate them. 13:15 But again, the idea that 13:19 it's adaptive to remember what causes pain means that it's also adaptive to create pain memories. It's also adaptive to change how you move in relation to pain. And it's adaptive, to feel depressed, and to feel anxious. Those are all completely normal, understandable responses to pain. And the 13:44 thing that isn't as natural and healthy is the inability to go back to baseline after you've hit that new state. And one of the reasons is that whenever you have chronic pain, so many experiences during your daily life, reinforce that cycle that you don't have many opportunities to learn what the lack of pain is like. 14:07 And something this is something I call relief learning. So it's natural for us to pay attention to periods of escalating pain. It's something it's a skill that can be learned to pay attention to periods of pain relief. And that's something that a lot of patients don't naturally do. And it's something that 14:31 if you don't come at it from a brain perspective, you might not see the importance of it. But anytime pain is decreasing, or it's lower than it normally is. That's the time that you should be focusing on positive emotions, relaxing the body, learning new skills, that's optimal learning time. So of that, one of the reasons I bring that up is that the the brain even though it's responsible for creating this chronic state 15:00 It's also the key to changing it and shifting back and reversing to the pain free state. The plasticity of the brain is is just a never ending thing of beauty. Absolutely. Absolutely. Well, now let's talk about, because it sounds like, and I love what you just said, it sounds like we're really focusing on sort of psychological care, which is part of care for chronic pain. And I love something that you wrote in that if mind based treatment helped my pain, then my pain must not be real. Hmm. Right is maybe something that might be in the back of someone's mind someone living with chronic pain are in the forefront. So how, how can 15:45 psychological care? Whether that be CBT, or mindfulness, or you know, there's a million different kinds of, I'm sure scientists, psychological care. So 15:58 how can people use psychological care, but not D legitimize their pain experience, not make them feel like, well, if, if this helped, then 16:10 my pain wasn't real, because if it were real, then that injection would have taken it away, or that movement or that stretch, etc, etc. 16:20 One of the things about trading 16:25 one of the things about psychology is 16:30 that sort of inherent in this illusion that the mind and body are separate 16:37 is that 16:40 whenever you have a new experience, there are measurable neuronal changes in the brain, there is a physical change that occurs, there is a measurable change that occur that occurs, even if you know we don't have the tools right away to measure it. 16:58 psychological changes are biological changes. And there's what 4050 years of science that reinforces that. So just because a psychological treatment can help doesn't mean that it isn't biological, it just reinforces that this source of the biological change is different from what you expected it to be. So I know that a lot of people with pain 17:27 you know, if for instance, their lower back hurts, or if a certain limb hurts, they assume that the source of the pain must be in that body part. 17:38 And although this is getting a little high up, 17:44 in terms of mechanisms, one of the reasons why we can even tell where our body parts are, is that there are maps in the brain. For instance, you know, one of the examples of this is the homunculus. But there are actually four different maps in different parts of the brain, that help us understand where our body is in space, and where our hand is where our lower back is. So you don't know where your lower back is, unless your brain helps you decipher where in the body map it is. So, you know, in multiple levels, this this idea of separation is really artificial, it really doesn't serve the experiences of people with pain. 18:25 I understand that. 18:28 Also, that one of the reasons why patients may adopt this kind of thinking is because they're 18:37 trying to work with the perspective of the provider who's treating them. If the provider has these assumptions, patients naturally, just to adapt, they have to play the same bowl game they have to in you know, they might do this through Google searches, or educating themselves on the web, or looking into pain, neuroscience education. 19:03 In order to be heard, I need to study the way that this is described online and in the literature, I need to be able to talk to my doctor in a way that they can understand. 19:16 And even that 19:19 even even that point where it's like I need to interpret my internal experience into something else so that someone else will believe me, I feel is sacrificing their internal experience of pain. No doctor 19:35 I almost think that like 19:38 a patient saying that they're in pain is all the proof that you ever need 19:45 to believe that they're in pain. You don't need a test. I really believe this. And so much the point that you know, I've I've I worked with Dr. Vani up caring for many years. The reason why his research 20:00 has been replicated so many times and has been published in such higher to high tier papers is because he looked at the patient's perception of pain and mapped brain signals to that perception. 20:17 He listened to the patients from the very beginning, he didn't say, Well, you have to finish the standardized questionnaire. And that'll tell me, that'll be the way that I measure whether your pain is there or not. He had a moment by moment, measure of pain intensity that he used to extract the signals from the brain during these brain scans. And that's how he found his fantastic findings that have been replicated again, and again, by different by different groups. And those are the findings that reinforced that as pain becomes more chronic, the brain regions that are correlated with the perception of pain change from sensory related regions early on, to emotional related regions within a year. In other words, after a year of living with pain, emotional brain regions are correlated with the sensory perception of pain. 21:15 Another way of saying that is that the sensation becomes emotional. 21:21 And that isn't saying that it's not real that saying that it's so real, you can measure it on a brain scan, you can see the pictures, you can replicate it across studies. It's that real? 21:34 So I feel like I've sort of No, no, gone in a few directions to answer your question. But 21:44 all all patients, 21:47 all we need to do is take patients word for their pain, we don't need any extra evidence that it exists, we just need to take them seriously. And to reinforce that, it's not your fault that you have this pain, you did not cause your illness, your body was doing exactly what it was designed to do exactly what we would expect a healthy person's body to do. It's not your fault. So let's, let's work together and find 22:19 your own path to pain relief learning. Right. And obviously, everyone's path is different and individualized. And I think we can all agree on that. There was something that you had said, 22:31 as you were speaking, that popped something that caused me to think that sometimes I don't know if you've seen this, but is it easier for patients to sort of farm their pain out to sort of third person their pain, versus first person their pain, meaning they may describe it, or they may listen to the way the doctors describe it, and not think of it as their first person pain, but think of it more as third person. And I'll give you an example of what I mean by that. So I have a long history of chronic neck pain 23:07 during my 30s, like, literally, the decade of my 30s For the most part. And I had I was giving a keynote talk a couple of years ago. And so I joined a speaker salon, or speaking group to help with this talk. And it was about they wanted me to talk about my experience with pain. So I went out there and I started it like imagine a patient walked in and had all these symptoms, right. And the woman who is not a clinician, a health care practitioner in any way. She is a writer, director and speaking coach, her name is Tricia Brooke. She said, Well, hold on a second. I'm gonna I'm gonna stop you for a second. I said, yeah, yeah. What is it? She's like, Is this about you? And I said, Yes, it is. And she's like, Well, why are you talking about it in the third person? 23:57 I said, Oh, well, because at the end is the big reveal that it was me and she's like, people know, it's you. You're up there talking about it. Like so why don't we change it to the patient and change it to me. And I started and within five minutes, I was crying so much I couldn't continue. 24:15 And I was like, This is why it's not first person because it was so hard. For me it was a lot easier to sort of third person it out or farm it out. And then going through this for eight weeks, I was finally able to get through the whole talk and someone came up to like, you know, I really liked those parts when we were first doing it when you were crying a little bit. I'm like, that wasn't part of the bit. That wasn't a bit that was me not being able to talk about my experience with pain, because it's emotional and sensory. So the although at this point now I had not had pain in years. To the extent I had it when I was speaking about it right, but to your point 25:00 The emotional attachment was still there. 25:04 So what do we do with that? 25:10 That's such a great 25:13 question. 25:18 I think it's self protective. Initially, whenever just just as you described, it's self protective and that you live with the pain every day. 25:30 It's a way to distance yourself from the suffering. 25:36 So on one hand, I understand 100% Why people do that. And in a lot of the patients that I've seen, over the years have done that too. 25:50 I think that 25:58 something that comes up for me right now, is that the words that one person uses for their own pain are the most therapeutic words that they could 26:10 use. 26:12 In that, engaging in the pain memory, from a psychological perspective, is one of the things that allows you to change that memory. 26:23 And I kind of wasn't planning on going here. But it's, it's an opportunity. 26:29 One of the reasons why psychological approaches to 26:34 chronic pain care have the potential to be so effective is that if pain is an emotional memory, 26:45 we know from 20 years of basic science, neuroscience, that emotional memories can be fundamentally change. There are rules, there are very clear rules. 26:59 The rules are you revoke the memory, on purpose as fully as possible. 27:07 You ideally introduce some type of contradictory experience something surprising, because that really makes the 27:20 the brain state more salient, it makes the brain pay more attention to what's happening. And then within three hours, you induce relief, psychological relief, deep breathing, I've worked with patients where we administered propranolol under the guidance of their you know, their doctors, but deep breathing is enough. And that if you are able to induce in sort of controlled conditions, these experiences where you fully experience pain, how it is for you, using your words, the emotions that come up in your body. That is how you fundamentally changed the memory structure of chronic pain. 28:06 Fascinating, you can do that in little bits across time. 28:12 Under more controlled conditions, you can do it in one big whammy exposure session. 28:17 Interesting, I think I did it in little bits over an eight week period in front of an audience 28:23 in front of a very safe audience of 14 amazing women. And you were also in a sense, potentially reshaping your pain narrative, as you're going through this, too. So you know, per Gillette Abelton. 28:38 You know, working with the pain narrative, and changing the meaning of the pain story over time is one of the another way that 28:48 that your pain story itself can be really therapeutic. Yeah, yeah, it was. It was wild. But it's it's a good example, I think of how even though I had not had pain for years, but the emotional attachment to it was so strong that I couldn't even get through a paragraph of this talk without crying. I was like, I think I need to come off the stage. And then each time it got, you know, it took more and more time, I guess before I would have like a really emotional response. But I have to say since then it was like, 29:28 like a weight off my shoulder. You know, and this is years after not years, maybe like six years after I really had more consistent chronic pain. So it was years and it was it was years after the pain had the chronic pain had subsided. 29:45 That's interesting too, because it suggests that there's a larger memory structure underneath there that even if the sensory aspects have been remodeled, the emotional attachment can still remain. And so in a sense, perhaps 30:00 that experience helped to heal the entire memory structure in a way that it you know, it wasn't quite complete just with the sensory pain being gone. Yeah, yeah, maybe it closed the circuit a little bit, so to speak. But anyway, it was it was highly, that's fantastically effective. But it just goes to show and again, I wasn't working with a professional perhaps if I were maybe I would have closed that circuit a little earlier. Or maybe not. Maybe this was the time, we don't know, too many questions to answer. So it's just right, you didn't just write for us at the right time. So, you know, just goes to show that when we're when we are treating chronic pain, we need to target the brain. Right? I think you need to have psychological care. So what do treatments look like? Obviously, reminding the audience that everyone is different, and everyone is individualized. But what are some examples of how psychology can work with people with chronic pain? 30:57 Well, so there are a number of evidence based approaches. 31:01 So cognitive behavioral therapy is one that everyone knows about Acceptance and Commitment Therapy, Mindfulness Based Stress Reduction, even pain, neuroscience education for some people. And whenever I think about these things that I typically look at the biases of the person in front of me, is the person in front of me a highly logical, rational type of person, I'll direct them to cognitive behavioral therapy, are they more embodied emotional person, they might be more open to mindfulness meditation approaches, or Acceptance and Commitment Therapy. 31:38 I think, especially people who have been in the healthcare system, go around for years and years and have some trauma related to being a chronic pain, patient benefit from pain, neuroscience education, just because it helps them get a better understanding of what they've been working with. So in a sense, you know, we have sort of a number of different tools that we know of in the literature, and adjusting each tool based on the the worldview of the patient is the best way to go. I think that's such a great way to look at it. And what advice do you have for let's say, physical therapists, occupational therapists who are working with patients with chronic pain? What is your advice to us to recommend psychological care? How, how can that conversation initiate? 32:36 And what is the best way for us to refer out? 32:46 I think that one of the best ways to initiate the conversation is by expressing empathy, and compassion, it looks like you're really having a tough time with this. 33:01 And from what you've described, it seems to impact many areas of your life, I see that you feel anxiety, I see that you've experienced some depression, I see that this stresses you out, 33:16 have you thought about support some sort of psychological support? To help you through this, that's, I think one of the most open ways that that this can, this can happen and a lot of physical therapists that I'm that I've interacted with, have taken it upon themselves to learn some of the psychological purchase, because it's almost 33:41 because they've sort of found themselves in the position of being the psychologist whether they liked it or not, or whether they had the training or not. And I've really admired a lot of the physical therapists that I've interacted with, because they've gone extra steps to learn what it is that they might need to know in order to provide better psychological care, as you know, as a physical therapist. 34:09 However, there are lots of times whenever the degree of distress or the degree of suffering, it is beyond training, you know, the training that you might have as a, as a physical therapist. So that's whenever it's time to bring in a professional 34:29 in terms of identifying 34:32 the optimal type of treatment or making referrals. That's very tricky of because there aren't a lot of pain psychologists in North America. 34:47 Even if I were to come up with a list of them, a lot of them that I know of are in academia and the people that 34:55 are in sort of the private sector. They have that specialization just 35:00 because they have lots of experience there. So it's, I kind of, I don't have, I don't have many suggestions. In this case, I do have a suggestion of a tool that I've helped to develop, that could supplement that in a way. 35:19 But in terms of finding the optimal, 35:25 as per the optimal psychologist, I think it would come down to therapeutic alliance. And that's something that each person has to feel out for themselves. And that, okay, you have a person who's highly rational, logical CBT might be the thing for them, have them talk to three different suggests they talk to three different people who feels right. 35:45 Because I'm a firm believer of therapeutic alliance, in the larger sense. And the the foundation of therapeutic alliance was best articulated by drum Frank, in his book, persuasion in healing. And one of the things he described is the healer suffer relationship. And one of the core tenants of the healer separ relationship, the healer believes that they can heal, the suffer, believes that the healer can help them. And they come together and interact with a number of rituals together, that are intended to relieve the suffering. So if you have someone who's on your side, even if they don't have the right training, but you trust them, you feel like they get you, that's more therapeutic than their training proper. 36:35 And that's, it's it's tricky. But for instance, even just talking on the phone for 15 minutes, to three different practitioners is enough to be able to get that feeling. Yeah, that's great advice. Thank you for that. And now, as we wrap things up here, what would you like the listeners to take away from this conversation? If you could wrap it up in a bow? What would that what would that present look like? 37:06 I think 37:08 we all have a collective responsibility to empower people who have been living with chronic pain. 37:20 And I think that, 37:22 you know, based on our conversation, one of the most powerful tools for pain relief is between people's ears. And I really think that that's the most empowering approach as well. And that I, at my core, I don't believe that we, that people need to rely on 37:40 doctors or medications or even approaches nearly as much as their own brains. 37:48 I, I know that it's difficult to get access to tools and psychological approaches that enable that. One of the things I'm doing, 38:00 you know, just from a, from an entrepreneurial background, is working on tools that will help people with that. But the key to long term pain relief, is teaching people to attend to patterns of pain relief, and what really feels like even if it's just a few moments every day. So my overall bold statement would be the key to your pain relief is paying attention to whenever the pain is less whenever you have time, to enjoy things in life to engage in positive emotional learning. Those are the keys to pain relief, because the more you focus on those moments during the day, and the more we encourage our patients to focus on those moments, the better they'll get, and the more quickly they'll get better. 38:50 I love that. And now where can people find you? What do you have going on? What's coming up? Let us know. Yes. So one of the things that I've done in the past few years after leaving academia, thank goodness, is I co founded a startup with Vanya, up Korean and a chronic pain patient, make Mika Michalak. So he's an entrepreneur, finished entrepreneur who has had chronic pain himself. And we 39:18 created a tool that is essentially insights from Bonniers research in an app form. 39:29 And it contains Mindfulness Based CBT exercises and tools that I wrote, and pain neuroscience education that I wrote. So in a sense, it is a expert created tool that is designed to give all of these insights directly to a patient without them having to rely on doctors or any formal care. 39:56 Because one of the apps Oh, the app is 40:00 Ava health app. 40:02 So if you go to www dot Evo health.com, you can learn more about it. And one of the one of the things that I it's a real conviction of mine, the science that's needed to heal chronic pain exists today. 40:21 You know, this is work that Vanya has been doing for years. And the time that it takes to sort of for that knowledge to trickle down to clinicians and to, you know, clinical guidelines, is 10 to 15 years. And one of the reasons why we decided to do this was because if it exists today, patients deserve to have it today. 40:42 So it's, it's a labor of love. 40:46 And I invite anyone listening to this podcast, to recommend to check it out yourself, to recommend it to your patients. And to contact me directly at Melissa at Ava health.com. If you'd like some more information about how to use it to help your patients. I'm very open to that. I love it. And we'll have the link to that in the show notes at podcast dot healthy, wealthy, smart, calm. And again, that website is www dot A i V as in Victor Oh health.com Just so people have the spelling of that. 41:27 And now one last question that I asked everyone and 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 fresh face out of grad school or maybe undergrad wherever you want, wherever you want to take that starting point. 41:45 I would say Melissa, 41:49 you're either identity is not your accomplishments. 41:55 Think about what 41:58 drives you what creates the most passion in you. It's to help people get better. And to support people while they're healing. 42:08 instead of chasing after the shiny ego cries that other people applaud you for take a step back and focus instead on what makes people feel better now make choices to help people heal. 42:32 Now, don't worry about long term research because long term research won't help people now. 42:39 I love that advice. Thank you so much. This was a wonderful conversation. I always learn such I always learned something new. And this was a lot of new so I want to thank you for coming on. Thank you so much for having me. And I really appreciate it was wonderful and everyone thank you so much for tuning in. Again. If you have any questions for Melissa you can reach her at a vo help calm and have a great couple of days and stay healthy, wealthy and smart.

In this episode, Dr. Jenna Kantor talks with Dr. Drew Contreras about the rigors of working as a PT for the President of the United States. More about Drew Contreras: Drew Contreras, PT, DPT, SCS – received his Master of Physical Therapy from Gannon University in 1998 and his Doctorate of Physical Therapy from the University of North Carolina at Chapel Hill in 2008. He is board an APTA board certified Sports Clinical Specialist since 2003. His professional interests are sports medicine; manual therapy; blood flow restriction; bio-technology; musculoskeletal injury prevention, diagnosis and rehabilitation as well as human performance optimization. Serving over 20 years on active duty as a career military officer and practicing physical therapist within the US Army & Department of Defense, Drew has served in a number of settings and military units throughout his career before his retirement in 2020. He spent his early career at Ft Benning, GA and then moved on to Ft Bragg, NC. His skills were put to work extensively in 2006-2007 during a 15 month continuous deployment during Operation Iraqi Freedom where he was the first physical therapist to serve in sustained combat operations with the 82nd Airborne Division. After returning Drew moved to Washington DC to work at the Pentagon Health Clinic where he served as the Director of Wellness and Physical Therapy. During this time he served as a consultant to the White House Medical Unit and was then chosen as a by name selection by President Obama to serve as the first ever full time physical therapist at the White House. There he served as the Physical Therapist to the White House Medical Unit and President of the United States Barack Obama from 2010 until the end of the administration in 2017. To learn more, follow Drew at: His Website Twitter 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: Welcome to the healthy, wealthy and smart podcast. Each week we interview the best and brightest in physical therapy, wellness and entrepreneurship. We give you cutting edge information you need to live your best life healthy, wealthy and smart. The information in this podcast is for entertainment purposes only and should not be used as personalized medical advice. And now, here's your host, Dr. Karen Litzy. 00:35 Hey everyone, welcome back to the podcast. I am your host Karen Litzy. And today's episode is brought to you by Net Health. So when it comes to boosting your clinics, online visibility, reputation and referrals, net Hills Digital Marketing Solutions has the tools you need to beat the competition. They know you want your clinic to get found get chosen and definitely get those five star reviews on Google. They have a fun new offer if you sign up and complete a marketing audit to learn how digital marketing solutions can help your clinic when they will buy lunch for your office. If you're already using NET Health's private practice EMR, be sure to ask about his new integration, head over to net help.com forward slash li T zy to sign up for your complimentary marketing audit today. All right onto today's episode, Dr. Jenna Cantor is back and today she is interviewing Dr. Andrew contrary us he received his master of physical therapy from Gannon University in 1998 and his doctor physical therapy from the University of North Carolina at Chapel Hill in 2008. He is board certified sports clinical specialist and has served over 20 years on active duty as a military officer and practicing physical therapist within the US Army and Department of Defense. He has served a number of settings and military units throughout his career before retiring in 2020. After retiring drew moved to Washington, DC to work at the Pentagon health clinic where he served as the director of wellness and physical therapy there. During this time, he served as a consultant to the White House medical unit and was then chosen as a by name selection by President Barack Obama to serve as a first ever full time physical therapists at the White House. There he served as the physical therapist to the White House medical unit and President of the United States, Barack Obama from 2010 till the end of the administration 2017. He has worked with a wide variety of government officials as well as police and law enforcement agencies. And today he's going to talk a little bit more about his experience. And it just goes to show you that there are so many options and so many settings that physical therapist can work in. So I think Drew and I think Jennifer great episode. Hello, this is Jenna canter so honored to be hosting this podcast for healthy, wealthy and smart. I am here with Dr. Drew Contreras who just said Just call me Drew. And I was like, Oh, that's so cool. So Drew or gesture is one you want to get his autograph when you know what he has done. This is the the physical therapist for Brock Obama and Michelle Obama. And then the current president and first lady, which is just not and as soon as I learned this, and then got to hear him speak at a conference. I was like, this is somebody that I am desperate and enamored, inspired by must feature on this podcast. And I approached him a complete stranger. At this conference, I sat right next to him dinner and as he didn't know me, and he said, Yes, this superstar said yes to doing this podcast. So Drew, thank you so much for agreeing to come on to this podcast. My pleasure. Right, like 03:54 it 03:55 is I appreciate the kind words thank you very much. Absolutely. And that's how I'm going to be approaching this this podcast as a young professional in the physical therapy industry that saying, How did you do this? How did you get to this point, and we're just talking about executive medicine here to really understand point a point B, I feel like from the conversations I've had with people outside this podcast, there isn't one way to eat a Reese's. It's not some clear pathway if you want to get this way you you're gonna fit in this box and it's very much like the performing industry. It's like there's no it's not one agent that's going to get you that movie. So we're here to just hear hear your story where where you got started and how that led to such a 04:43 prestigious and how honor what an honor, I have a position to get to do. Yeah, um, so I think that 04:55 I think that regardless of like what you're pursuing, right, whether 05:00 That's, you know, working in executive medicine or like you said, working with a performing arts group or, you know, working with a traveling band or a sports team or whatever, right, I think the thing that people 05:14 really de emphasize, which is the exact opposite of what should happen is, you need to be really, really good at what you do. Right, there needs to be no question that you are exceptional about what it is that you provide. And I think that people get lost in wanting the end state. And they, they don't go through the process properly. Right. So just just to be blunt, right? Like, if you've got, you know, 18 months of experience, you probably shouldn't be the person on the sidelines on a high contact sporting event, who's the only person that's available? Right, that's probably not the best plan. And likewise, right, like, you probably shouldn't be the sole healthcare provider on a plane someplace when like, you barely really know what you're doing it. So I think that people get confused with, in order to get to the end state, right, I need to go through these, like, I need to know somebody or I need to, I need to have a, like you said, there's a person who will get me there. 06:17 The only thing that will ever get you there is is being exceptional what you do, right? Because when you start talking about things, especially like executive medicine, you have to realize that the people that make it to this point or this level up are exceptional at what they do, right. And they have made a living off of calling people out on the BS card. Right? Like, they know when you are not exceptional at what you do, because they they've seen it for so long. So if you're not at least there, right, if you haven't found your, your, your apex of your skill set, it's not a place you want to be. Right. So first get there, right, get really, really good at what you do. And then if that's if you've made it to that point, opportunities will unfold themselves, right? If you're prepared if you're really good at what you do. So I think that's the best thing I can say to people is, like you said, there's no, there's no cookie cutter path to getting into this, as there shouldn't be right, because it's certainly not for everybody. 07:23 Yeah, I think that's really well said, and I want to tap on the assessment of what it means to be good at what you do. And this is my opinion, but I'm going to put it in here. And then I would love your thoughts. But don't base your success off of other PTS opinions based off of other patients opinions. 07:47 I think we really mix that up. I think we really do. And it's just not everyone. What are the patients saying? What is your success rate? There are the ones that if they do get do they come back to get I would base it off that I think we worry too much about what our 08:02 comrades that's the word that's in my head right now are thinking. I think you're absolutely right. Right. Like if 08:11 I think there's a difference between 08:15 external validation, right, which is kind of what people say about you. And that can be rewarding, right. It can also be incredibly destructive, but but it can be rewarding for some people. And that's different than than defining 08:31 a level of expertise or level of success. Right. That should be pretty objective. You should be able to measure that with clinical outcomes. You mean, like you said, even just sheer recommendations and referrals from existing patient? Right, or sources? Right. That's it. That's a better 08:51 litmus test than who said, what about you on Twitter? Yes, yes, yes. Or if you're, if you're there a different way. So what about you or say you go to a conference like CSM, and everybody has been in this industry for certain periods of time. And when we create relationships with people, the ones where we are really more connected to we just generally bond with just like our friends in life outside of the business? Are even if they're not, you're not friends with the right people. It doesn't mean anything. It doesn't mean anything. I have a friend who just got on Broadway, she had zero friends who are on board, you know, like, she wasn't like, let me see of friends on Broadway, but not like close, close. You know, I just I think we can get stuck in that. Like, I'm associated with them. So therefore, like I can't, in the, like I said the reality is, even if that association gets you a conversation or a phone call, right? It won't sustain you for very long. Yeah, yeah, absolutely. What is the schedule and 10:00 Life, like in regards to when you're doing such a high profile job? Yeah, you know, I bet 10:12 I think I would average it out to people would call me get a hold of me at least two or three times a month and say like, they wanted to be the White House physical therapist, and I finally got it down to like, okay, um, that's, that's great that you're interested, I need to know, if you're okay with this, you will not have any vacation days throughout the year zero, you can never buy a ticket. That's non refundable to anything, you must be okay, giving up attending any sort of family event, kids sporting games, whatever it may be. 10:47 In the event that you actually do get to go on vacation somewhere, you must be okay with it, they call you you have to leave immediately and come back. If you're okay, with these basic things, we can have a conversation, right? And most people immediately are like, well, that's not what I wanted. I just wanted to fly on a jet. You know, and, you know, have people think that I'm, you know, in this prestigious environment, like 11:11 all these things come in a price, right? It's, it's not, it's not an easy price, right? I will forever 11:19 hold Brock Obama responsible for the fact that we both started there with black hair, and ended up with gray hair. 11:28 super stressful environment, it's long hours, it's unpredictable at times. chaotic, and it's just not an easy place to to exist in, if you aren't already comfortable in your own skin, right? So to basically understand is that 11:47 your professionalism has to supersede what your personal goals are, or your personal life is if you're going to be successful in that environment. And that's just the level of dedication that it takes. When you say professionalism. Would you mind defining that? Because professional means of a profession? And so that can be very vague. Yeah, I think that it means right. 12:12 I think that it means that you need to be willing to put forward 12:19 your best on any day in any place, and do the best you can for those patients, or those people that you're serving. And it's really, you know, kind of a, a selfless service attitude that would make you successful. And that's what I mean by professionalism. Right? It has to come first, right? It doesn't matter if you had, you know, plans to do a thing, or you were supposed to be going out to dinner with your spouse or whatever, right? Like, that's the level of professionalism that's expected. Absolutely. I like thank you so much for that. I was thinking it was singing, it actually really reminded me of swings on Broadway, they have a very similar situation, except they're not the main person, but they have to be available at a moment's notice. So just like and during the Christmas breaks that the leads or the ensembles take, they're the ones that jump in, and if anything comes up, they're the ones that are, I mean, if I want to say somebody who truly has probably the least brake, in the run of a Broadway show, it's the swings. So that's it. That's just where my brain went. because theater is my background theater is my sport, my sport. Absolutely. So I like that. That's so interesting. And, and I think it's always good to know the full picture of what it means to do something. I'm going to compare it to Broadway and musical theater because that's what I know. It reminds me when including myself when you first graduate school and you're a performer, singer, actor, dancer, you're like, oh, I want to make it on Broadway. However the schedule on Broadway, it's six days a week, one day off, the main holidays you are going to be performing that's when you have the most people attending. You're going to miss on so many things that go on in your life for being dedicated to the Broadway show. So knowing that you're going to miss so much of life not just a little like a lot like your nephew's events, whatever you're going to miss everything. And in in your downtime the days that you have one show your whole day is revolved subconscious or consciously around putting on your best performance that night so you have to be careful with your energy everything because that is there that is your main job that's your main go to so it it really does sound so reminiscent of that you got to have a passion for it as much I do think there's a little bit more selfish and that's okay to be selfish. It will regarding performing because you are a person who loves applause loves that stage and everything you are of course giving I would say it's like 15:00 5050 But I do think it would be different compared to the physical therapy job that you're doing. Because the only reason why and we discussed this before, the only reason why we can even say your name in association with a be with these people is because they have publicly said your name, you know, and that's that's an end. But if you didn't have that we would not that's that would we would be doing all this other words to go around it appropriately, you wouldn't talk about in the reality of it is 15:33 another, I was doing something else. And somebody asked me, they were like, What would you consider one of the biggest achievements that you've done professionally? And I would say that 15:44 until after 2017. Right? Nobody knew who I was and what I was doing. Right. And that was that was my goal, right was that nobody knew that. I was a White House physical therapist, nobody knew who I was where I was at the things I was doing, because that was the job. Right? The job wasn't to be. It's not it's not the world's business. Right. Right. And then so, and I think that that's fair. Right. I think then that and I think that that's really important. And then so like you said, you kind of have to understand that like, 16:16 the people who are concerned with the trappings, right with, like, what do I get out of it? Right, will be severely disappointed. And executive medicine, because that should never be what it's about. Right? It should never be about what are you getting out of it? Because if that's the case, you know, you won't be doing it for very long, right? There's, there's a saying in the in the Gulf PT community is, you know, if you want to be around a long time, you don't want to be around all the time. Right. And basically, what that means is like, you should not be trying to be, you know, the inner circle person. Right? You shouldn't try to be the best friend of these, these high profile individuals, if your goal is to, you know, be of service and do your job for a long time. Because you because that's just not the way it works. Right. So that's just kind of a reference point that I, I found, just like you said, very similar to performing arts, right. It's just kind of there's there's parallels and all these different sub communities. I mean, it really goes back to just loving truly loving what you do, and it's okay, if you don't, it's okay. Not every job, or every specific thing is meant for everyone. That's why we have so many different options and more options keep popping up after the pandemic now. 17:34 Yeah, you have to love what you do. You have to love what you do. See, I love being the center of attention, because I'm a performer and a physical therapist. So I know, right off the bat, that couldn't be for me, because for me not to be able to be like them. And the way that I was in like, doing a whole photo shoot there trying out different heels for the photoshoots. All that stuff. Like that would be the I would be the worst person because I'd be mourning getting to do that. It's so right. So there's always the question, people would ask, like, Oh, can you do this there? Or can you do that? Or can you do this? And the answer is always you can do whatever you want on your last day. You want today to be your last day. Feel free to do that. Yeah. Yeah. I mean, it's HIPAA compliance. I mean, that's the biggest thing. It's a HIPAA compliance. And then we have people they're just taking care of the United States. 18:29 That's such a high level. It's such high level, you know, I mean, wow, wow. 18:35 I was wondering for you, because it's this level of executive medicine is very 18:45 high profile. There's a lot going on there. I'm not asking for details behind the scenes. That's none of our business. But I'm, I'm curious about how it affected your stress levels and your anxiety while there and how you manage that during that time to make sure you were able to be fully present and helpful, even though it may have kind of fallen on your shoulders a little bit. And on that note, we'll take a quick break to hear from our sponsor and be right back with Drew's response 19:17 when it comes to boosting your clinics, online visibility, reputation and increasing referrals, net Health's Digital Marketing Solutions has the tools you need to beat the competition. They know you want your clinic to get found, get chosen and definitely get those five star reviews on Google. Net Health is a fun new offer if you sign up and complete a marketing audit to learn how digital marketing solutions can help your clinic when they will buy lunch for your office. If you're already using Net Health private practice EMR, be sure to ask about this new integration. Head over to net health.com forward slash li tz y to sign up for your complimentary marketing audit. 19:53 You know the best way 19:58 to kind of describe that 20:00 Is is, I think that it's important to surround yourself with, with people that are understanding of your situation, right? Because because 20:13 it's inevitable that you will have conflicts or that you'll have to back out of things, right. And if people don't understand your situation and the level of service and dedication you have, they just think you're selfish, right? So like the, I'm sorry, I know, I said, I was gonna come to your barbecue, but I just can't, I can't make it now. And, and I need you to be okay with that, and may not provide you an explanation of why. Right? And that's a hard thing, right? And you will find out pretty quickly, like, who, who's accepting of you and who's not? Right, because because most people will just stop inviting you to things right? Or they'll just, they'll just cut you out of their life. And there's some degree rightfully so. Right. 20:52 So I think it's just important to make sure that you surround yourself with that. And if you're a person with the family, right, like, this has to be an honest conversation that you have upfront. 21:02 This is not something that you kind of tiptoe around or like, make it up to you. Like, you'll be saying that forever, you'll never make it up, right? It just needs to be an acceptance of like this is this is part of what's acceptable. 21:17 And that's not like you said, That's not for everybody, right? It's absolutely not for everybody. So I just think that in order to be able to perform at a sustained sustainable level, right, for a duration, not just like, 21:31 once, or like, twice, right, but to continue to do that, you have to accept that. So I will. Another thing that comes to mind is, I once saw an interview with Michael Jordan, who is, you know, arguably one of the greatest basketball players of all time, regardless of what you think. Right? And Michael Jordan was interviewed and, and, and he said, you know, what's, what's it, what's difficult about it, and he said, you know, people who want to be Michael Jordan for a day or a game, you know, like, of course, I'd love to be Michael Jordan for a day or a game. But being me for a season, right? Or for a year, or for a couple of years of a championship run year after year after year, right? The commitment and sustainment that that requires, like, people don't want to do that. Right. And that's what I would say to people to like, it's super cool to work at the White House for a day for a weekend. Right, right. But do it for do it for a year, or an administration. Right? Or be stupid enough to come back and do it again. If somebody asks you, right, like, that's, that's a whole different level. Right? So it's super exciting. You know, it's interesting for for a weekend or a day or whatever, but like, but long term, right? Like, it's a commitment. Yeah, that makes me think of certain roles. I'm always going to bring it back to theater because that's my brain. It makes me think of Elphaba in in Wicked or Vita in Aveda, where Aida and Aida where they are literally doing like vocal aerobics, they don't stop singing. So when they are outside of the show, from 23:09 what I've learned, and especially if you're talking about a Broadway one, so they are doing what is it seven to eight shows a week, they get the one day off, they are not talking much outside of that show. If you want to reserve like or if they do they know what they can and cannot handle. Because the amount of singing. Elphaba I've learned is such a difficult track because of how you're, you're going from one part even if you're not in a scene for a moment you're rushing doing a costume change it's it's a very non stop role. So if you are looking to lose weight, no, 23:47 no but it so it just makes me think of that, you know, different things can cut you out of living your life, which is why I've always said I would love to do Elphaba at a regional theater for three weeks. 24:03 done done like like he's like Michael Jordan said for temporary. I think it's so good to take in this perspective and take things in as a whole. We were talking when we met the group was discussing how really understanding in this is a bigger picture thing but really understanding what physical therapy is before you even decide to join the profession as a big deal that needs to be much more transparent. And we can sit there and see all these shiny other things like oh, I want to trade for Broadway or I want to do executive medicine or oh, I want to work for this sports team. But really asking yourself all the tough questions on what goes into that? Well, I mean, if you're talking about money, great, but like, Have you ever had money and then like how fast did that money go? Did it really make you happy? So many so many things on that. 24:52 But 24:53 the details of the job will that will you enjoy that? That's your life. You're going to spend the majority of your time on the job not 25:00 off the job. So you got to make sure it's something that you like and really do your due do your due diligence in that. But I think it can be very difficult to give and provide the full picture to for anything. I don't know, I don't really know, have a clear way to make it clear. 25:20 I think that 25:23 I think that like part of that, I think is our own fault is PTS, right? I think that the general public struggles to understand what we do as a whole, right? It's, it's easy to do it in in subsets. Like it's easy to understand. Okay, well, I was on crutches. And I had a cast, and then I had to see a PT because my ankle was broke, right? Or the, you know, 25:52 mom had a stroke. She's in rehab, she sees a PT every day, so she can get better and come home. But the hard thing is like, 26:03 the professions bigger than that, right? It's, it's more and we've overcomplicated it instead of really kind of simplifying it down. Because the reality is right. What do PTS do? Well, we help people do whatever it is they want to do. And we get them back to or allow them to do the things that they want to do. 26:24 And that's it, that that's the that's the big selling point of it is, if you're not interested in doing that, I'm, like you said just about every day of your life, this is not the right profession for you. Right? Like, if you thought that, well, I would, I will have a very nice car, and I will have these set hours and I will you know be able to do these things like you're going to be miserable hate because I think that people didn't get into the profession for the wrong reasons, just like any job. When eventually, right? It will be taxing to you. And if you're not down with whoever that person is, it's you're talking to and working with, if you're not okay with, I'm here to get you to where you want to be. So that whatever that thing is, whether that's walking your kid down the aisle at a wedding, whether that's going on a hike, again, whether it's walking the dog, right or like putting your shirt on by yourself, right, whatever those things are. Now in a handstand, of course, 27:26 like if you're not okay doing that, 27:29 we're never going to be happy with with what PT does, right? So I think that that's the thing that people need to kind of understand if I wish, if I had anything to say to anybody who's listening who's like thinking about it, think about that. Are you okay with doing that, that be your role in life? And if that is not appeal to you, you need to find something else. Yeah, absolutely. Absolutely. It really is a 27:55 job board, you're of service, but you have to love being of service in this manner. Like if it doesn't feed your soul, like then how, like no money can ever pay you enough. It's never never enough. It'll never be enough. And that's okay. That's okay. It's I take like, exactly, you got to figure out what you love. I feel pretty lucky. Because I went into school, dreading that I was going to school and I felt like public embarrassment in the musical theater world because I entered school as a quitter. Because that's what it looks like, like, I'm leaving my profession. And so I had people offering me get professional gigs while I was in my first year of school. And I was embarrassed. Meanwhile, other people were posting and going, Oh, I started up in school, because it was a prestigious school and everything. And I was like, quiet for the first at least a year, if not more about what where I was. 28:52 I mean, it's all perspective. But then I learned I got a sometimes don't just take that one experience. And for me, I had that which was beautiful, seeing how it can change people. And yeah, yeah, but if that doesn't work for you, it doesn't work for you. I love that. Yeah, so for you. In executive medicine, I don't know if you know, the data on this. I don't even know if it exists. But is there kind of an average of how, how long medical professionals usually stay within executive medicine? Or is there kind of like, usually it's about five or 10 years or something just because it is such a commitment and you're talking about family and all these things. Just wondering, I think that there's a there's a there's it is a 29:38 Oh, I think there's a short hump and a long term home. I don't think there's a lot of people in the middle. Oh, interesting. Yeah. I think that if most I would probably say two thirds right. It's a short 29:55 I don't know. I'm guessing you know, five to seven year experience, right? The people 30:00 Do that short. Yep. And then 30:04 yes, yes. I think there's nobody that's kind of in that like seven to 15. Year. And then I think you get another the the last third is in the 15. year plus right. So wow, a career choice, or have made that shift for whatever reason. In that direction. I think they kind of stay there. 30:28 But I don't think it's, yeah, yeah. I don't think it's a mid career thing. It's either a stop along the way, or eventually it becomes your, your pathway. The business side, I have a real dorky question here. It's not dorky. And because there are people who be curious, I'm curious about documentation. For some reason, I feel like it's gonna be theirs. Let's compare to a Rite Aid receipt versus a CVS receipt. I feel like it's probably a CVS receipt, am I wrong? 30:59 Here's what I would say. Right? 31:03 If you treat everybody the same, and document the same, you're always okay. That's it. Right? In, that's where you have to be, again, like you got to be good at what you do. And you got to be very comfortable with that, right? Because 31:18 you people, you'll be second guessed right, there will be consultations with other providers. That's just the nature of executive medicine, right. And so you need to be okay with what you're doing. And documentation is part of that, right, making sure that you're you're very clear about your plan of care and the things that you're doing and why you're doing them. 31:37 But if you, you know, if you do it the same, it doesn't matter, right? It's universal precautions, right? If you if you do it the same no matter what you're good to go. So that that'd be my two cents on that. And then we also think it might differentiate and regarding plan of care, because we're talking about exercise adherence, which is something that physical therapists are was talking about, it's one of my biggest passions is getting exercise. And it's so great when it works. 32:03 For your patients in general, that have a high anxiety life, lack of sleep life, how do you achieve that adherence in a realistic way to get results? Does that make sense? I'm trying to generalize, even though every patients different, but this is we're talking about a very specific level of high stress. Right? I think that you have to understand that when you're working in this kind of subset, the biggest commodity for people, their biggest asset, the thing that is the most valuable to them is time, time is their most valuable asset, right? It's not money, it's not, you know, I have stuff do I have, you know, it's not the resources of equipment, or what, like, it's time, their time is very valuable. 32:55 And you have to, you have to be a good steward of that, right? You have to respect that. And so you have to, 33:04 you're not going to give somebody you know, a printout with 15 exercises, that's going to take an hour and a half for them to do and tell them to do it three times a day, right? Like, this is not how this how it's gonna work. Right. So I think that if you understand that concept, in build your plan around that about what is the most effective thing I can do with you, or this amount of time, which is limited, and then you have to understand that that's, it's finite, right? There's not It's not unlimited, that there's a million priorities that are trying to take that time. And if you are, are good about using it and understand that it's a limited resource, then they'll appreciate it. 33:49 I just realize you have unusual, wonderful access to collaboration over there. And I started to think about food. Could I mean, you could No, here's, here's No, there's a purpose, because digestion, if their digestion is off, that actually can have a big effect on their healing process. Have you had opportunities to collaborate with the the shatter? That is so cool. Oh, that is like the best. Right? And again, right, like you, you have to get the most value out of the things that you can write. And it's really interesting in this world is that like, it's, it's usually a matter of making sure that you know, that people are meeting the caloric minimum, right that there because again, they're so busy, or figuring out what is the more effective way of doing this or how can we provide the requirements despite a busy travel schedule, right, or all the other you know, things that are demanding and then right and then also right, like, yeah, work with chefs nutritionist. Work with other 35:00 With personal trainers, massage therapists, you know, other health care providers like you just so cool. Like you're part of the bigger picture. 35:11 If you're there for that it'll work itself out. Yeah, it sounds like I mean, I'm sure there are discussions that have to happen. But it sounds like the dream collaboration because you have access to literally everybody in the picture that you would want to be present in the picture there. That is just so cool. 35:28 Like, Oh, yes. Oh, God, if I said that to any of my performers, hey, can you connect me with your, your nutritionist or your chef, so I can work? And be like, Are you kidding? Get out of here. 35:40 But wow, that's that's really, really cool. That's, that's getting the opportunity for next level. Next level stuff. Um, I was wondering if you have any fun memories from your first day on the job without getting specific about the individual, but just any? Yeah. So. So the very first day, 36:04 you know, I'm working with President Obama, right. It's a 36:09 White House is an interesting place, because 36:13 there's the work areas, there's were offices and whatnot. But then there's also an area called the residence, and that's where the family lives. And it's off limits to the staff, like people don't, nobody goes into the residents. That's their home. Right. So I was going to see the President and 36:33 in order that we were going up through to the president, so we get into their private elevator, right. And it was, you know, people that Oh, my God, he's getting in the elevator with them. And I didn't know any better, right? So I just, I just introduced myself to him. He's like, okay, hey, come with me. We're gonna go on the elevator and go upstairs. And, you know, I'll get changed up and then we'll go start work. I was like, Okay, great. So I come in the elevator, and he's like, you know, Hey, man. 36:58 What part of the island are you from? And I was like, I'm sorry. He's like, You. You're from Hawaii right? Now, in context. He's Hawaiian. Right? And people probably can't see me, right. But, you know, I'm absolutely a Pacific Islander. And I said, Actually, man, I'm from Cleveland. And he was like, wait, what? I said, Yeah, I'm, I'm from Cleveland. He's like Cleveland. And this was big, right at the time, where LeBron James had just left Cleveland to go to Miami. And if anybody knows anything about Obama, he's quite the basketball fan. So he turns to me and says, Cleveland, ah, that's too bad about LeBron. Like, without, like, I just met this man. Like, and, and so like, you know, growing up in Cleveland, like, I immediately got defensive. And I was like, well, that's too bad that Chicago sucks and everything. Right? So like, immediately, like, and then I was like, oh, oh, I'll be shooting that right. Like, but like he put, I just was completely caught off guard and put me on my heels. And I got defensive about clean. He was like, looked at me, and was like, we're gonna be okay, like, we're gonna get along. All right, right. So that's great. Then people always ask, like, What are you talking about? What you know, what things and things I would tell people is, like, we talked about three things for the majority of our entire interactions, sports, weather, and kid. Those are the three topics that we could talk about, if the conversation ever went somewhere else, right? My answer was usually, like, there's probably somebody who could talk about that, but it's not me. But you mean, referred to. And I think the weather is going to be crappy today, right? Like, and I kind of focused on that right to make sure that I was doing my job, right. And those topics we kind of came to through through just general conversations, these topics are safe and easy for us to talk about, and allowed him to be a patient and allowed me to be a clinician. Yeah, because if you want into anything else, Woof woof. Yeah, yeah. Yeah, too much. That's really cool. I like I like how you found a way to be sensitive and helpful with that sensitivity, you know, to give a human a break. 39:20 For real Oh, that's so magnificent. I think this is perfect. We're going to end here thank you so much for coming on. I'm not sure if there is is there a way for people to reach out to you and contact you if they wanted to? I don't know somehow connecting you can probably the easiest way for the general audience is just find me on on social media. Right? You can find me on Twitter, you see on Twitter. Yeah. DC underscore PTS easy to find me. You know, and eventually I'll, I'll look at it and get back to people but that's probably the easiest way for Pete for this audience to get a hold of me if somebody you know, is interested or just wants to you know, 40:00 Here's something else let me know. Thank you so much for coming on and looking forward to people. Hearing this interview I have learned so much and grown so much and honestly just left very, very inspired. Thank you so much drew for coming on. Thank you. A big thank you to Jenna and drew for a wonderful interview. And of course, thanks to Net Health for sponsoring so again they have a new offer if you sign up and complete a marketing audit to learn how digital marketing solutions can help your clinic when they will buy lunch for your office. Head over to net help.com forward slash li tz y to sign up for your complimentary marketing audit so you can boost your clinics online visibility, reputation and referrals. Thank you for listening and please subscribe to the podcast at podcast dot healthy wealthy smart.com And don't forget to follow us on social media

In this episode, Founder and CEO of CARR, Colin Carr, talks about commercial real estate for healthcare professionals. Today, Colin talks about the top mistakes healthcare providers make with their office leasing, the financial side of real estate transactions, and important considerations when making decisions on lease agreements. Should business owners buy their space or lease their space? Hear about how and when to negotiate, the importance of having representation, and hear Colin's advice to his younger self, all on today's episode of The Healthy, Wealthy & Smart Podcast. Key Takeaways The best time to negotiate the lease is typically 12 months before it's going to expire. "If you were serious about capitalising, you would've engaged an expert." "You should not be telling the landlord anything that hurts your posture or position." "When it comes to real estate, talk to real estate professionals. Don't talk to other doctors about that stuff if they don't know what they're doing." "Realise what's on the line. If you make a mistake in it, the world's not going to end, but it will cost you hundreds of thousands of dollars in additional payments that you could have avoided." "Surround yourself with the most successful people that's you can get around." "There's no substitute for hard work." "Work it as hard as you can and then learn from your mistakes." More about Colin Carr Colin Carr is the founder and CEO of CARR, the nation's leading provider of commercial real estate services for healthcare tenants and buyers. Every year, thousands of healthcare practices trust CARR to help them achieve the most favorable terms on their lease and purchase negotiations. Colin has been involved in commercial real estate for over two decades and has personally completed over 1,000 transactions. Colin educates thousands of healthcare professionals, administrators, business owners and students on an annual basis through national meetings, conventions, study clubs, associations, universities, and webinars. Suggested Keywords Healthy, Wealthy, Smart, Healthcare, Commercial, Real Estate, Negotiations, Representation, Leasing, Finance, Business, To learn more, follow Colin at: Website: https://carr.us LinkedIn: Carr Healthcare Facebook: CARR Instagram: @carrhealthcare 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: 00:02 Hey Collin, welcome to the podcast. I'm happy to have you on today. 00:06 Glad to be here. 00:08 And so today we're going to be talking all about commercial real estate for healthcare, healthcare practitioners. So this is something that you've been doing for quite some time now since 2009. So before we get into the top mistakes healthcare practitioners make when it comes to their office space, can you give us the quick version of how you got into this space working particularly with health care professionals when it comes to their commercial real estate and office needs? 00:38 Yeah, absolutely. So started in 19, Managing apartment complexes back in East Lansing, Michigan, little bit away from where I grew up, moved to Colorado, my early 20s started managing some mid rise, high rise complexes, downtown Denver, and I got into brokerage about 23. And I worked for a gentleman that did a lot of large national retailer. So Walmart's Wendy's blockbuster. And that's how I got into brokerage over the years, I started doing more industrial, more office. And a couple years in, I started doing medical office buildings and working on hospital campuses, Class A medical buildings, and just fell in love with working with healthcare providers. And after a number of years of doing that, I realized that the healthcare industry was one of the largest, most unrepresented segments and all of all of real estate, you know, every time there was a listing, there'd be four or five brokers trying to get that listing, whether it was office or medical. But when it came to actual doctors running around town trying to find space or trying to negotiate, I didn't see anyone doing it. So I've made a focus made an intentional effort to start helping more healthcare providers, and then in 2009, launched our company. 01:47 That's excellent. And as most health care providers can say, we did not go to school for any of this stuff. I can say, as a physical therapist, I didn't go to school to understand how to negotiate commercial leases, and office space and things like that. So having professionals with the best interest of the healthcare provider in mind is so incredibly helpful. And I'm sure you're quite busy. But now let's get to what are the top mistakes healthcare providers make with their office space and their leasing needs, so I will hand it over to you. 02:20 Okay, so we'll have a couple there's, there's more than a few. The first mistake that healthcare providers make is they don't know when to start the negotiation. You've got healthcare providers that are trying to negotiate with two, three years left on their lease, and there's no leverage, there's no incentive for the landlord to do anything for them, the landlord knows they're locked, and they're on the hook in that lease contract for another two or three years. And so they have no posture, they have no leverage. Other side of the coin is they try to negotiate when there's two, three months left in the lease. And the landlord is assuming that they're not paying attention. They haven't hired representation. They don't know the market, they're behind the eight ball. And so you can start the transaction too early. And it's a it's a sign that you don't know what you're doing. And you can start it too late, which is a clear sign you don't know what you're doing. And either scenario, the landlord is gauging how serious you are. How savvy Are you? Do you have other viable options? Are you willing to move? Do you really understand the market? And are you going to fight hard for the terms that are commensurate with the type of property with the the market you're in with the economic climate? Or are you just bartering or bluffing? Are you just hoping for a better deal and guessing? So starting the transaction at the wrong time? That's a that's a big one right there. And 03:38 where and where is the sweet spot then? So it's like, it's like, what is that? Is it the the three bears? Goldilocks and the Three Bears like one bed was too soft, one was too hard to kind of have to find that sweet spot in the middle. So when it comes to negotiating, when should healthcare providers be thinking, Alright, now it's time to reach out to my landlord and start this process? 04:01 That's great question typically is right around 12 months from when your lease is about to expire. If you go outside of 12 months, again, the landlord's just don't have any real incentive to negotiate, because in their mind is I'll deal with it later. They can't go anywhere for 12 months or longer, and so they don't pay attention. But again, if you get too close, if you need to relocate, you don't have time to make that transaction happen. If you need to go to a new property, the negotiation process, the site selection that can take several months on average, you know, getting landlords to respond and negotiating the terms, getting an architect involved to look at the floor plan that takes a few months, it can take a month or two just to negotiate the actual lease contract Once you agree on terms working with the with the attorneys. And then if you need build out and you have to pull a permit or get contractors involved that can take another three or four months as well. So the ideal time is right about 12 months, that gives you enough time to handle each one of those steps that I just mentioned, but it's not too far out there. 04:56 Right. Excellent. All right. So Mistake number One not knowing when to negotiate. Now we have a better idea. What's another mistake? 05:06 Another mistake? And I'd say it's probably the top mistake. It's the do it yourself approach, 05:11 do ya probably be that would probably be was something I would do? Yeah. 05:15 Well, and there's a lot of reasons people take the DIY approach. Number one, it's typically because they're so busy, they don't know who to contact, they don't have time to do the research or due diligence in their opinion. And then it just comes up if the lease agreement shows up in the form of a landlord knocking on their door or property manager saying, Hey, listen, your lease is coming up, what do you want to do, and they just say, hey, send me a proposal. And that that starts the process of them doing it themselves. Or maybe you're looking for a new location or your first office, he started driving around, and you pick up the phone, and you start calling the listing broker landlord, asking questions, and all of a sudden, you have engaged and start the process all by yourself. The problem with this is that that is not the game plan for successful companies. If you take any national retailer that people would respect and say, hey, they do a great job, you take a Starbucks or Chipotle, they don't have some random person calling on properties or asking for proposals. They have a team of in house professionals and they utilize outsource experts that all these people do is negotiate professionally for a living. So when a landlord gets a phone call from a doctor or an office manager, no matter how well meaning that person is, the landlord is going to assume they don't know what they're talking about. And it's not, they're not trying to take shots at the person, they're just going to assume, Hey, you don't know the market, you've not want to look at 10 or 15 properties, you're probably not negotiating with three or four landlords simultaneously going three or four rounds of negotiations. And at the end of the day, if you were really serious about capitalizing and saving $100,000, on your next commercial lease, you would have engaged an expert, it's it's similar to, if you get audited by the IRS, if you don't get a really good CPA involved, you're probably not too serious about getting the outcome you're looking for. If you go to court, and someone's bringing a claim against you, or they ask you to go to mediation and arbitration, and you show up by yourself, you get your signaling, I'm probably willing to accept a much inferior result because I don't have the time, the money, the resources or whatever. And so when a landlord sees a tenant show up on representative, it doesn't matter if it's health care, or, or retail or office, they just assume that that person doesn't know what they're doing. And so that's, that's gonna cost the person a lot of money. 07:31 Yeah, so you really want to have the right professional at your side, so that you're not getting taken advantage of you're not prolonging things. And like you said, I love how you said that they're there thinking that you're willing to accept an inferior result. And as as a health care provider, or a physical therapist, like if, if someone broke their leg, and they need to rehab, well, they're not going to go to their account, and they're going to want to go to a physical therapist, that you don't want to do it on your own, because you're not going to get the right results. So same thing, right? You always want to have the right professional at your side. 08:08 Yeah, I mean, this would be much different than if a patient you know, if you talk to a patient or potential patient, and they needed to rehab something, and you knew it was an advanced rehab, and it's a time you have you have instruments, you have technology of equipment. And their response is, Well, I'm just going to head and figure it out. Like I'm going to search the web and just do some research, your response would be well, there's, there's a better game plan like you can, you can do that. And you can get some type of result or some type of an outcome. Just like a landlord knows, hey, you can you can lease a space without representation, but it's probably not going to be the most effective approach, you're probably gonna waste a significant amount of time. It's probably gonna cost you quite a bit of money. It's very similar. 08:41 Yeah, yeah. Okay, so don't know when to negotiate the DIY approach. What else? What's another big mistake? 08:51 Yeah, another big mistake. And I mentioned it briefly. It's negotiating on only one property. And this is different when you when you compare residential versus commercial real estate, okay. And residential. If you're going to buy a house or buy a condo or townhome, you go look at properties, you search online. And then when you find the property you're interested in, your agent writes a contract for you and they deliver it to the seller. If the seller signs it, you're under contract, you have the ability to cancel that contract with inspection, objections, financing, deadlines, and so forth. But you submit an offer towards one property and if they say yes, you're under contract, it's a binding contract. Commercial Real Estate works on what's called a letter of intent and loi, or a request for proposal and RFP. In either scenario, those are typically non binding. 99.9% of are non binding. There's, there's ways you can make them binding, but they're intended to be a non binding negotiation. And so in commercial real estate, the most strategic gameplan is you go look at X number of properties that meet your criteria. you narrow it down to the top three or four properties that are the best fit, even if one or two property One of your properties are the clear winners, alright, but you still negotiate on three or four properties. And you might even go two or three rounds of negotiations. The reason you do this is because it gives you the true picture of the market. You can't just go off what they're asking as a quote and lease rate on a brochure, because there's too many variables. Is the lease going to be a three year term? Or a 10? year term? Are you asking for no money for improvements? Are you asking for a couple? $100,000? Do you need a free build out period? Do you need free rent Upon moving? Or the annual increases? 2% 3% 4%? Are you going to personally guarantee the lease Are you trying to have your practice or business guarantee it, there's all these variables that are there. And so you've got to negotiate with multiple landlords to get a real feel for what the market offers. And when you do that, a couple things happen. Number one, landlords get more aggressive and competitive when they know they're competing. If a landlord thinks that this is the only property you're interested in, and you tell them, hey, this is my dream location, or you show them your cards, you're not going to achieve the best terms possible. And so being able to leverage multiple landlords against each other, again, respectfully with dignity, not you know, not not doing things in a way that's that lacks integrity, or cuts corners. But if you do it properly, you're going to know if that lease rate is market below or above, you're going to know if that's the right TI allowance, the right free rent package. And if you're getting three or four landlords to do something over here, and another, and another one over here is not one that you can leverage those against each other. And that, ultimately, is how that's one of the top ways that you achieve the most favorable terms possible. 11:31 Got at first, I thought you meant Wait, how many properties Am I getting, but it's not negotiating. It's not for you to have multiple properties. But it's for you to negotiate a single property, but through a lot of different through a couple of different landlords so that you you're kind of getting a better idea of the landscape, 11:52 you're you're gonna pick three or four properties to negotiate with, you're only going to choose one of them at the end of the day. But again, every landlords motivations are different. And so you might have two properties that you like equally, one landlord might be much more aggressive than negotiation. And if you add up all of the economic terms, you might find that two properties that appear very similar, that start out with pretty similar starting or quoted lease rates, you might end up with 100 $200,000 savings on one, or 100 or $200,000, in increased costs on the other. So just because the properties look similar, because they have close to starting lease rates, by time you actually work through all those economic terms, you can end up in a very different economic situation. Oh, 12:34 my God, I love that that is such a good tip. And I'm sure that's something I would never even think about. I would just think, well, I guess I'll just go with one property. So that is a great, great tip. Anything else? What other big mistakes and I know you said there's probably so so many, but maybe we'll keep it to like four or five. 12:52 I'll do two more of this. Okay, you quit, okay, I'm gonna kind of hinted at it. The next mistake healthcare providers make they tip their hand to the landlord, they tell the landlord, this is the property I want, or this would be the perfect space for me, or during a lease renewal negotiation, which is by which is by the way, that's the number one transaction in all commercial real estate, more lease renewals happen every year than any new office or purchase or relocation, okay? The number one mistake they make there is they talk to the landlord, landlord comes their office, the landlord might even be a patient, you know, property manager stops by and they say, Hey, your lease is coming up for renewal, what do you want to do, and the doctor says something along the lines of why don't want to move, or the space works great, send me a proposal. And again, what you have just signal to the landlord is you're not looking at the market, you're not hired representation, you don't know if it's going to be a good deal or a bad deal. And most likely you will accept an dramatically inferior deal. So signaling to the landlord again, you should not be telling the landlord anything that hurts your posture position, and they're looking for you, they're going to ask you questions, trying to get you to tip your hand. So that happens all the time. Here's why healthcare providers get into health care typically, because they want to help people. They're fascinated by the science. They're fascinated by the ability to transform people's lives to help protect lives, save lives, enhance lives. And they're not getting into health care, because they want to be a stone cold killer negotiator. Yet they're going up against landlords that are not playing games that have buildings that are worth 10s of millions of dollars. And those landlords get into real estate because they wanted to be a professional negotiator. So just be very careful what you say the best way to avoid this is to hire representation, let them talk to the landlord for you. And they will keep a very tight posture in the entire process. 14:43 Excellent. Okay, what's number five? Five, the 14:46 last one? Yep. Five. The last one is healthcare providers love talking to their peers and colleagues. And then they take that information that becomes the standard. And that's a really bad way of doing business. So So you might be in a building with with other tenants might be a dry cleaner could be another healthcare provider could be a restaurant. And they'll ask those tenants or neighbors, Hey, what are you guys paying? Or what did you get on your last negotiation, and then they share that information. But what they don't realize is they're asking people who may or may not have gotten a very good deal. We had this scenario, once we were helping a doctor in a building, it was a completely medical building two floors, six or seven doctors on one floor, six, seven doctors on the second floor, and we were talking to the doctor, we were looking at his lease, and he was significantly above market. And we said, hey, who's negotiate and what the last two or three renewals you've done? And you said, Well, I've done it myself every time. And we said, you know, how do you feel about these terms? Because this is exactly where the market is. And I said, How do you know that he goes, Well, I'm, I'm good friends with three out of the six doctors on this floor, we talk to each other all the time, we refer patients back and forth, we've we've swapped leases, everyone's paying the same thing. We're all paying $30 per square foot. And I said, well, like just so you know, their marketing space in the building, way lower than that. And we just negotiated a brand new lease on the first floor for a doctor at $21 per square foot. So you're gonna dollars a square foot above market, okay? And you haven't got any free rent your last couple of renewals. You haven't got any tenant Premadasa, renovate your space, and you're telling me you didn't get those because no one gets those I'm telling you right now, you and your three or four friends have been consulting with each other, you just have no clue what you're doing. So taking advice from somebody who is bad at negotiating or getting a really bad deal is super common. And so people share stories. They're on all these, you know, Facebook groups throughout all these threads, and everyone's sharing their experience, and it is their experience, but it might not be the best gameplan. So that's another big one we see too is talk to your friends about things clinically, when it comes to real estate, talk to real estate professionals when it comes to legal things, talk to attorneys comes to financials, talk to CPAs don't don't talk to other doctors about this. If they don't know what they're doing. 17:05 What a gut punch is, right? That guy must have been like, what $9? Over? Oh my gosh, what a Yeah, what a kick in the pants. That is. Okay, so those are really great. Five Great tips, five mistakes that people often make with their commercial real estate. And throughout that one theme certainly seem to emerge. And that is having representation on your side. So when it comes to commercial real estate agents, let's start with number one. How do you choose the best commercial real estate agent? And then how much does it cost? Because the cost is probably why people end up doing mistake number two, the DIY approach, right? Okay, 17:48 both both great questions. There's a handful of ways to find a really good real estate agent. Number one, if you're a healthcare provider, you want someone that has healthcare experience, it's very different talking to a real estate agent that focuses on million square foot distribution centers for Amazon, than it is someone who's working on a 2000 square foot physical therapy space, very different transaction. And commercial real estate, you got people that all they do is apartments, all they do is Office, all they do is retail, you want to find someone that understands healthcare that works in the healthcare space, number one. Number two, you want to find someone who's only going to represent your interests, commercial real estate, and residential real estate are known for agents that try to work what we call both sides of the deal. They're trying to represent the lammeter seller, and also the tenant or buyer, that is a clear conflict of interest. You can't negotiate for two opposing parties. It doesn't work that way. And so this is the idea of saying if somebody is suing you and you're going to court and you're asking the prosecuting attorney, if they'd give you advice, like that's literally what's happening, their client, the landlord or seller, they have a fiduciary to help that person or that group, make as much money as possible in the transaction and protect their interests, they cannot do the same for you. So you need to find someone that's not going to have a conflict of interest, someone who works in the tenant buyer side, who doesn't have listings with landlords in the area that you're looking because you want an unbiased approach with someone who's going to protect you right now. So those are two really important things. The next thing you say is, well, how do I find those people? You can search online, but typically, in any healthcare industry, you're going to have people that if you ask them, Hey, who do you know that specializes in healthcare, real estate for doctors, you're gonna have lenders that tell you, hey, this person or these people do, you're gonna have architects, contractors that have worked with these agents on a number of deals. And so there's a lot of referral partners in the industry that can weigh in on the topic. And so if you ask a handful, you should be able to get a few names very quickly, people that specialize in that area, and then what you need to do again, and that process only takes a little bit of time. It's not it's not no one's asking you to take a whole week off to spend dedicated towards that. But once you find a couple names, you need to speak with these people. You need to interview them, you need to talk them and say, what would your strategy be to help me maximize my profitability in my next transaction? How are you going to protect my interest? How can I know that you are the best fit for me? And like any other relationship or service provider, you're going to know quickly? What their responses just like a patient would say to you. Hey, how are you going to? How are you going to get me healed up? What is your game plan for me to get restored? Or to get you know, rehabilitated? What do you want to do, and you've got to earn their trust, it's the same way in real estate. And I tell doctors this all the time. If you talk to an agent, and you don't think that agent is the best fit, move on to the next one. And I mean, that's what we do for a living, I tell doctors, then if it's not us move on to the next person. Like it's, there's too much on the line for you to for you to just take whoever's there, don't settle in this area, find the person that you trust that you want to work with, that you believe has your interests in mind. And then that's how you get engaged. Yeah, 20:55 great advice. You beat me to the punch, I was going to ask you what questions to ask how do you vet and you just gave us those answers. So that was amazing. Now, let's talk about the money side of things. Because health care practitioners, yes, we get in to help people, we have our own business, it's also a business. So we want to make sure that we're maximizing our earning potential, if you will. So let's talk about one How much does it cost to hire a Commercial Real Estate Agent? 21:24 Okay, so that's one of the best parts of this entire conversation, it will not cost you as the doctor any money to hire a real estate agent. It's just like residential real estate. If you are a buyer, or a tenant residential real estate, you engage an agent as your exclusive agent, and they receive a portion of the commission from the landlord of the seller. So commercial works just like residential, again, for anyone in residential that's ever owned a house, when you hired an agent, you agreed to pay two Commission's one to your agent, and one to the buyer's agent, Sandman commercial real estate. And this is one of the biggest mistakes that healthcare providers make as well, we could put this as number six, if we wanted to, is they assume they're going to save money by not having an agent. And so they say, You know what, I'm not going to hire an agent. So I'm going to save money. But here's the reality, you're not determining whether or not a commission is paid or not paid. You're not determining what that commission amount is, when you go to a property, that landlord already has money set aside for every transaction. Even if they don't have a listing agents, they're doing it internally, they still have a commission set aside for every transaction. And if you do a deal as a doctor all by yourself, the listing broker gets a double commission, not one, but two, they double up to take both sides of it, or the landlord just keeps that money. And this is this is what happens is, you know, a lot of doctors have this like the do it yourself mentality. I always joke, it's like, every time you see a U haul moving truck, it says move yourself and save, right. But if you're moving yourself and give you a U haul, yes, you save money because no one's offering to pay your $3,000 movie bill. In commercial real estate, there's a commission set aside for the listing agent, and for the tenant or buyer's agent. And when the doctor the tenant doesn't have an agent, listing broker takes a double Commission, or the landlord just pockets that money. So it's 100% free service, it's not going to increase the lease rate for you, it's not gonna cost you money, it'll save you a significant amount of time. It'll help you avoid costly pitfalls, and it should save you a significant amount of money as well. 23:27 Okay, and that leads perfectly into my next question. So you had said earlier that lease negotiations or lease renewals, I'm sorry, are the thing that happens the most when it comes to commercial real estate? So how can healthcare providers or anyone for that matter, save $100,000? Or maybe more on their next lease renewal? 23:52 Great question. So we're gonna take, we're gonna accumulate my prior answers, and we're gonna, those are all the ingredients in that. And then here's what it looks like. So 12 months prior to your lease expiring, and you're going to look at your leisure going to figure out when you're when your dates show that you expire 12 months before expiring, you're going to start the process of finding an expert, commercial real estate agent in your area that represents healthcare, attendance and buyers that knows your industry, you're going to you're going to, you're going to call x number of people until you find the right person that you want to go forward with, you're going to engage that agent and you're going to have an exclusive relationship with that person, okay? That agent is going to take your requirement, and they're going to go to the market and we're going to find every property that meets your requirement. And they're going to whittle it down to the top three or four properties, even if you don't want to move. Even if you think that moving would be a convenient, they're still going to do their due diligence, and they're going to they're going to take their time energy and they're going to negotiate with three or four landlords simultaneously. And they're going to get to what's called best and final term so we're you know, if you were going to move to the property across the street, or down the street or across the city, you're going to know exactly what it would cost to do that, and you're gonna know what the economics would look like if you wanted to transact there. Once you have that information, you can now go to your, that agent can now go to your current landlord, and can negotiate with factual data, and with a very specific game plan. And here's why this is so important. Again, you can get this thing backwards. If you go to your landlord, and you ask them for an offer, you start negotiating. Here's the question, compared to what, how do you know if it's aggressive? You can compare it to what you're currently paying. But again, what if you're above market, and they say, well, I'll bring you down $2 a square foot, you can say why just save a bunch of money? Well, if you can move across the street don't say $5 a square foot. Or if you get a better landlord, or a better space or a larger space, you can't compare your current economics unless you are comparing them to other properties. So your agent goes, the market gets the top options negotiates, and then goes to your current landlord, and says, Listen, we brought to the market, we know what's happening. I'm a market expert, my clients now educated, and we got three or four other viable options, we'd like to have a negotiation and discussion with you, but it's gonna have to meet our criteria, because we've got two or three other properties, that could make a lot of sense for us, if you don't want to get competitive. And when landlords know that you're not an idiot, you know, you're not, you're not ignorant, you're not, you're not, you're not just gonna take whatever they give you, they come to the table with a much different approach. And when they know you're represented by an agent that is an expert, they're not going to waste their time trying to convince an expert that their deal is good if it's not good. So that that's the process. In a nutshell, there's a lot more to it than that. But that's how you get to the landlords, that will actually give you a good deal. Because at the end of the day, if you do move out of that property, they're not going to get the next tenant to pay above market, they're not going to get away with not giving them a tenant proven allowance or not giving them free rent, or trying to gouge them, because the new tenant won't take it, they'll just have go somewhere else. And so the landlord, if they think they've got you know, pushed into a corner, you have no other options, they will stick it to you. If they think that you have the freedom to move that you're willing to move, you got the help to move, they will come with a much more aggressive offer. And typically, at an average space of two 3000 square feet on a five or seven year deal. Those those numbers add up to usually a minimum of $1,000. And oftentimes hundreds of 1000s of dollars, that can be one in 27:23 your favor. Amazing. Again, having the right people in your corner doing your research coming to the table with facts and figures so that you have leverage to negotiate. All makes perfect sense. And now as we start to wind things up here, I just have a one, I think really interesting question, because I hear this quite a bit chatter on social media, when it comes to at least physical therapy business owners is do you buy your space? Or do you lease your space? So can you talk about that? 27:54 That is a great question. That's probably one of the top questions that we receive. The answer to that is you should look at both your options, don't pray determine one or the other, because every markets different, every economic climates different. And you could be in some markets where where you have multiple options to own and it's phenomenal other markets, there's not one option to own. So I mean, if you're doing real estate in a suburban Tulsa, that's different than if you were downtown Manhattan. I mean, you've got to know the different markets. What we tell healthcare providers is listen, we're going to go to the market for you and find the top properties that meet your requirements. And we're going to look at office options to lease and options to purchase, we're going to look at retail options, we're going to look at office options. And we're going to show you the top of what's available, you then are going to choose which properties that you're the most excited about. And then we're going to negotiate on three or four properties simultaneously. And then economics will tell you very quickly which property is going to make the most sense for you. If you can find a property to purchase. That's that's a top property if you love it, and the economics makes sense. We are a huge proponent of owning commercial real estate, you're building an additional asset, if you sell your practice, you can lease out the space. And typically that real estate is going to sell for more than your practice will sell for. We track this across the country, we work with 1000s of providers every year, and the real estate sells for more than the practice over 75% of the time. So if you could be an immediate to pay rent or mortgage either way, you've got to pay a landlord or or pay a company a mortgage company. So you're basically paying yourself in certain aspects of it. You got to make a payment either way, if you can own real estate and economics work phenomenal. A lot of times what you'll find is are you willing to pay more to own than to lease because of the upside. And so you might have scenario where it costs you an extra couple $1,000 a month to own and you get you have to decide is it worth that? Is it worth the extra expenditure to pick up some additional tax deductions to pick up that principal pay not every month you got to check X number of dollars go to pay down principal on the loan, your net worth goes up every month. And so we have those scenarios, if it's if it's 6000, or 6000, at least that's a no brainer at the back, right? If it's 10,000, or 6000, at least, you got a decision to make there a lot of times it's, you know, 12, or $15,000, or 6000. The least. And you have to decide which makes the most sense for your practice. And then you get in another 10, different evaluations, what's the downpayment? What's the cost of entry? What are the economic financing terms available to you? Is this space gonna fit you for three years? Or five years? Because if so, we don't want to purchase that we'd rather lease for three or five years, and then have you purchased the next location, if it's gonna fit you for the next 20 years? Again, that's a different story. So there's all these different variables, there's no one size fits all. There's there's groups that we help lease a couple spaces for that purchase, purchase couple spaces, then lease a lot of variables there. 30:48 Yeah, and and again, that's where coming together with your team makes a lot of sense, and and doing your pros and cons. But I hear that quite a lot. So thank you so much for your input on that question. And now, if you could put a bow on this conversation, what are the top things you want healthcare providers to walk away from when it comes to their commercial real estate questions? 31:17 Yeah, that's a great question. I would say, just realize what's on the line. We're not talking about, you know, did you overpay for a box of gloves, you weren't paying attached, you ran out and you know, you overpaid by $2, for a box of gloves, and you can go, you know, buy in bulk next week, or you have your supplier set, you know, whatever, we're talking about a transaction that you engage in every once once every five, seven or 10 years. If you make a mistake in it, again, the world's not going to end. But it will cost you 10s, or hundreds of 1000s of dollars in additional payments that you could have avoided. And there's a lot of other things that are on the line. Like there's economic terms, there's also business terms, what happens when you want to sell your practice, can you get off the lease, or you get stuck guaranteeing a lease for the person that buys your practice, because you don't have the right assignability class. So I would say this, make sure that you're treating your commercial real estate with the respect that it's still again, I mean, you can still do a lease, you can still stay in practice, etc. But again, the world's not gonna end. But there is a cost or a penalty to messing up here. And it's pretty high. Find a good agent, find someone that you trust, and that person will save you literally 3040 hours of your valuable time, they'll save you a significant amount economically, it's usually usually a minimum of 10s of 1000s, if not hundreds of 1000s. They'll also help you avoid complications and delays that come up all the time in commercial real estate when people are not paying attention. And then the last thing I'll say and I think this is more important than all these is that person's going to give you peace of mind. You're not going to have to wander every night you go to bed and put your head on your pillow for the next 10 years, you're not going to wander Did you get a good deal or a bad deal? You're going to know exactly what what terms you negotiate and how they compare to the market, you're not going to wander if you miss seeing a better property and you should leave somewhere else you chose, you chose the third or fourth best product in the market, he's just would have gone to market you would have known better, you're gonna have that peace of mind. So we can talk about saving time saving money, avoiding complications, delays, pitfalls, but I think ultimately, that peace of mind is invaluable. And for me, that's that's what I'm trying to deliver every time that I work with a client. 33:19 Yeah, you had me at saved 30 to 40 hours of your time. You could have ended it there. But I love having that peace of mind being able to sleep at night knowing that you really got the best deal that you possibly could because you started 12 months ahead of time you hired someone you had a team by your side. So perfect sense. So now, Collin, where can people find you? If they want more information? They have some more questions. What's your contact? 33:49 Absolutely, the best way to get ahold of us is our website. And that is car that US ca rr.us. On our website in the upper right hand corner, we have a couple options on our navbar that are of importance. Number one, you can click the Find an agent in your area. We've got agents coast to coast, we represent 1000s of healthcare providers every year, and we are working, we're working literally in all 50 states plus DC. So click Find an agent in your area. And then that's a great way to start. Another thing we have is a free lease evaluation. If you want to know where you stand in the market, even let's say you signed a lease last year and you got nine years left, we can still do a free lease evaluation for you. And we'll tell you where you stand based upon the market currently, if the market corrects, as we've seen some crashes last two years, who knows what we're going to be tomorrow, let alone five years now we can update that over time. So if you want to know where you stand in the market today, in a few years, we do that all the time, we can do it very quickly. And again, we can give you the peace of mind knowing where you're at and if you're way above market, then we're gonna try to capitalize on the next transaction. If you did a good job in your last deal, again, that gives you peace of mind knowing that you're in a pretty good position. We want to protect that or reserve that in your next negotiation. And then the third thing is we have a ton of resources if you want to study up, if you want to get educated, we got literally hundreds of articles, blogs, educational videos. And if you're interested in commercial real estate because it affects your practice, and you want to know more, we will give you information that will make you the subject matter expert. 35:21 Excellent. That was perfect. Now I have one more question that I asked everyone. And that is knowing where you are now in your life and in your career. What advice would you give to your younger self? So let's say that 19 year old in Lansing, Michigan, what advice would you give to him knowing where you are? Now? 35:39 That's a great question, I would say, surround yourself with the most successful people that you can get around. If you can get around them personally, and they'll spend time with you then do it. If you can't, then get around them through watching their podcasts through reading their books, you know, following their history. And then I would say that there's there's no substitute for hard work, you're gonna make mistakes, you're gonna fall down, you're gonna you're gonna do things that in hindsight, were less than intelligent to say them politely. But you just that's part of the process, owning a practice, you know, becoming a professional, anything in life, working as hard as you possibly can, and then learn from your mistakes. 36:17 I love it. This was so great. Thank you so much for taking the time out. I mean, I was taking notes furiously over here because I think this is such great information for certainly for healthcare providers, but I would say anyone that is looking to get into a commercial space, this was wonderful. So thank you so much. Absolute. It's been a pleasure to be with you. And everyone. Thanks so much for listening, have a great couple of days and stay healthy, wealthy and smart.