Healthy Wealthy & Smart

In this episode, CEO and Founder of Practice Freedom U, Jamey Schrier, talks about creating success by changing mindsets. Today, Jamey talks about developing a growth mindset to achieve greater success, what the biggest problems are that owners face, and how to 'fix' those problems. What's your goal for the next 30 days? How do you keep your energy tank full? Hear about the different growth mindsets that owners get wrong, reacting versus responding, and get some valuable advice on how to grow and become more successful, all on today's episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways "How someone thinks determines the actions they take, and the actions they take produces results." "The eyes only see, the ears only hear what the brain is looking for." "You have got to look at a yourself as the owner, the CEO, the entrepreneur, the head honcho." "Being busy is not an owner mindset." "You have to slow down. You have to pause. You have to spend more time getting out of the immediate present." "The biggest problem with the overwhelmed operator is there's not organisation in place, there's not systems in place, there's no control over one's time." "The more you can bring people in an organised, systematic way, the less overwhelmed you'll be later on." "The best is yet to come. The future is brighter than the present and it's brighter than your past." "Business is all about trying things, failing, learning, and trying again." "What you focus on, what you pay attention to, grows." "You don't know what you don't know, and you never will no matter how smart you are." "It's not enough to be busy - so too are the ants. The question is, what are you busy about?" "Keep your tank full." "Reacting is an emotional response. Responding is a rational response." "When things get busier at the office, there's one thing that you sacrifice more than anything else - that's your self-care." "You don't strengthen the weak by weakening the strong." "Overcome your ego. It's okay you don't know everything. Enlist some help. Invest in your business. It will pay off dividends in your future - not only to you, not only to your family, but for everyone that's around you."   More about Jamey Schrier Jamey is the founder and CEO of Practice Freedom U, and the best-selling author of The Practice Freedom Method: The Practice Owner's Guide to Work Less, Earn More, and Live Your Passion. He is a sought after speaker on systems, marketing, and elevating the patient experience. Over the past decade, Jamey has helped hundreds of physical therapists, occupational therapists, speech therapists, and mental health professionals build their highly successful practices and create more financial security without working longer hours.   Suggested Keywords Owner, PT, Physiotherapy, Business, Entrepreneurship, Purpose, Mindset, Success, Actions, Thoughts, Leadership, Freedom, Productivity, Busyness, Progress, Reacting, Responding, Self-Care,   Jamey's Book: The Practice Freedom Method: The Practice Owner's Guide to Work Less, Earn More, and Live Your Passion.   Discovery Call: https://www.practicefreedomu.com/discoverycall   To learn more, follow Jamey at: Website:          https://www.practicefreedomu.com Facebook:       Practice Freedom U Twitter:            @jameyschrier LinkedIn:         Jamey Schrier YouTube:        Practice Freedom U   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:               https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the full transcript here:  Speaker 1 (00:01): Hey, Jamie, welcome back to the podcast. I am happy to have you back. I always love having you on, well, Speaker 2 (00:08): Thank you Karen. I am so happy to be here. Speaker 1 (00:12): And so every time you come on, we talk about some aspect of the physical therapy business, which is great because I know a lot of the listeners want to know more about how to run a business, how to be successful, what's going on in the market. So let's kick it off with what is in your opinion, the biggest problem facing physical therapy, practice owners today, Speaker 2 (00:42): Karen, you're just going, you're just right out of the gate. Like you're just like, you know what? We're not messing around. Hey, Jamie telling me about yourself or, or give it. It's just, I'm going fast ball down the middle either. You're going to hit it or you're going to strike out and we're going to be done. Speaker 1 (00:57): Yeah. They, they, they know who you are. You Speaker 2 (01:01): That's a good sign though. Right? what's the biggest problem facing practice owners today? That that's a really great question. And the answer may not be what people might think the answer is. The biggest province, really what, the topic that we're talking about simply put it's how we think it's just that simple. There, there's a, there's a simple formula that, that I've been following for years now, years and years and years. And basically it's just says how we think, how someone thinks, determines the actions they take and the actions they take, including their communication and their stuff. They do produces results. And too many times I've heard people that are not happy with their results, whether it's referrals, whether that's revenue, whether it's profit, whether it's hiring, whether it's retention, whether it's time, God forbid, people want time and control. They don't have that. Speaker 2 (02:03): So if you reverse engineer the result back to, well, why isn't the result we want? Is it some strategy? Is it some technique and answers? No. It's how an owner thinks. I mean, let me, let me give you an example. We went to school, right? All your listeners went to school. We are highly educated, very smart people. Now who educated us, right? We had professors in school and we, and, and, and PT school. We had professors who were educating us on what they were educating us on how to be a clinician, more specifically, how to pass the boards, because that is what schools do. They help you pass the boards. So then you can become a licensed clinician, licensed physical therapist. So you do that, whatever one year, you're five years, 10 years, and you have this urge, you have this thing inside you that says, I want to be a business. Speaker 2 (03:07): Now I want to run my own thing. So do you go back to school? Most people do not go back to school care and they don't get an MBA. They don't get any kind of, maybe they read a book, hopefully my book, right? The practice, freedom method, plug, shameless plug, but they, they just signed the dotted line. And now they're an LLC. And what are they doing? They are making decisions with the brain that was built and created with all of the information of how to be a talented clinician, which they are. But now that same brain is making decisions around business and there lies the problem. Speaker 1 (03:48): Okay. So you just described most physical therapy owners. So how do we fix this? How do we, what do we do if this is, if this is our mindset or if this is where we are, this is where we're thinking. And you know, everybody gets, I think people start their own practice because they want to help people. They want to see patients the way that they feel they should be seen, et cetera, et cetera. Right. So how do we take off the clinician hat and put on the owner hat? Or, or do we split it into, how does that work? How do we fix it? Speaker 2 (04:27): Yeah. So there's a great quote by one of my mentors, Dan Sullivan, and it says the eyes only see the ears only hear what the brain is looking for. And we've seen this, right. You know, you're, you're thinking about buying a car. You know, the last car I bought was a Jeep. Right. I bought a Jeep. I've never seen Jeeps on the road. Oh my God. I feel like the whole world has a Jeep. Right. You're seeing them everywhere. Did they magically all of a sudden become more Jeeps in Maryland? No, because you started your, you started to tell your brain Jeeps, Jeeps, Jeeps. So it really starts with recognizing that this is an issue and you don't know what you don't know. And Karen that's, that's hard for a lot of people that was very hard for me because I'm a smart person. Speaker 2 (05:24): I did really well in school. So did you, so did everyone, I haven't really made a million mistakes in my, at least academic life course. We wouldn't have been through school, but then you get in the business and you realize that, you know what, I, I don't necessarily know how to do this. Maybe I should get help, whatever that means. Like, I think it's just recognizing that I shouldn't be an expert at all this business stuff, because I'd been taught. I've never been trained. I haven't done self-development and work on that. I think that's one of the biggest things we just need to recognize. We'll get into, you know, I have some specific things that people can do, some tangible things they can do. But I think I just want to get people just to recognize that that's the issue, because if you don't think that there's a problem, even though you're working 50, 60 hours a week, you're not making the revenue you want your, your staff is coming and going, or you can't get them to actually do what you want them to do. Speaker 2 (06:30): So you're taking on some of their job, all those things that we complain about, if you don't actually say, look, you have created this model. So the only way to uncreate this model is to start to change how you're thinking about the business. And that starts with how you think about yourself. You have got to look at yourself as the owner, the CEO, the entrepreneur, the head honcho. You have to see yourself like that. That's scary, right? I don't think myself, I'm just a PT. The problem is that's how everyone else is looking at you. And you have to own that. Now you are playing multiple roles here. I've said one time, multiple personalities. It's not really multiple personalities. It's multiple roles, but your role as a clinician own it when you're treating treat. But when that ends, you have got to shift your mind to perhaps the role as the director, and then you have to shake. Speaker 2 (07:36): It shifts your mind. The role as the owner, the mindset you have for each of those three is so different, especially between the clinician and the owner, how you see your business, how you see your staff, how you communicate to people. That's very different than a clinical mindset. So I think that's the first thing we have to own it. The, the, the other big thing is success is 90% preparation and 10% perspiration people may have heard that they may have heard it in different types of things. 99%. This 1% that I've heard that before, never really understood what it meant. What does that mean? It means that we are by human beings. We are naturally doers. We do do, do I call up the home Depot model, you know more savings, more doing we're here to help the doers. So doers like to do they get off on doing stuff. Speaker 2 (08:38): And then those people like to be busy, busy, busy, busy, which is, seems to be the mantra of everyone nowadays, what are you doing? I'm really busy, but that is very different than being productive. That is very different than being efficient. So being busy is not an owner mindset. An owner mindset is how can I be more productive? How can I run things more efficiently? How do I utilize my time? Better? That alone will change what you focus on and how you start putting your business together. So this 90% preparation stuff is all about. How about having time to think about your business. If you're busy all the time, constantly filling your schedule with patients, with meetings, with putting out the fires in your business, just constant stuff. Where's your time Karen, to just think about what is it, where's my business going in the next month or three months or week. Speaker 2 (09:39): You don't have that time. You're just on the hamster wheel of doing, doing, doing busy, busy, busy, and the results don't really significantly change or worse. They start to improve a little bit, but they improve only because of the effort and the work that you're doing. So now you're trapped because if you shift that all of a sudden the results will, will go down. So you get trapped by that. So that, that, that motto of 90% per preparation and 10% perspiration and having this shift of you have to slow down, you have to pause and you, we have to spend more time getting out of the immediate present. And that is my first mindset shift. Speaker 1 (10:30): Yeah. It's hard to sometimes get out of your business so you could work on it, you know, and how, if you can make that mind shift, I think you still, so you can make the shift of like, Hey, I'm the owner. I need to not just work in my business, but work on it. Be creative, things like that. So what advice do you have for people to, let's say once they've gotten that mindset, okay. I am a business owner. There are other things I have to do here. What, what can they do to get to that, that area of creativity and of, well, let's look at how we can streamline things and be more efficient if you're always like, well, I have to treat patients because if I don't treat any patients that don't have any revenue coming in and that's not good because I don't have a business. Right? Speaker 2 (11:26): So unless you bought an existing practice, we all come in as what we call it at practice freedom, you a committed clinician, right? Your solo preneur, that's it. Maybe you have an, a, maybe you have a part-time PT PTA or somebody, but it's really just you. Okay. That's how we all come in. That's how I came in. That's how you started your business. We all do that. Now committed clinician. The biggest challenge, because the challenges are different between the two examples I'm going to give the challenges with that person is, well, you got to get busy and most of your bills, dizziness is going to, or you got to get busy, meaning you got to generate more work referrals and get your schedule busy. So your job is to start delivering great care, maybe going out, meeting some different referral sources. That's what most of us do. Speaker 2 (12:17): And your schedule will get busier. It always happens. Then there's going to come a point where you're like, I'm running at a time. Every time I start to mark it by place gets busy. And when I stopped play starts to go down. So we call that kind of, that role of poster. And you start teetering on the next slide level of business ownership. And the next level is called overwhelmed operator. Love that term. I coined that term years ago because it just describes that type of owner. This owner has hired people. And when you start hiring people, you probably don't have a lot of organization and systems in place. You just kind of doing it. You're trying to, you know, I got some good people. I know how to judge people, but you're you still have your schedule. You're still doing your stuff. When you hire people, now you're responsible for them. Speaker 2 (13:12): So now all of a sudden this whole HR there's human resources stuff comes into play. Ignorance is an excuse. It doesn't matter if you're ignorant. Like I broke the law department of labor, reached out to me and say, Jamie we got to investigate you because you're doing some illegal acts. What? Well, you're supposed to be paying overtime to certain employees. I'm like, I didn't know that. I thought they were a exempt from that. Like, no, these are exam these. I mean, then all of a sudden I'm like, well, I didn't know that. And I'm like, well, you're going to find out, cause we're going to find you. And I'm like, okay, from now on, I will make sure I have someone on my team that knows that stuff. So what happens with the overwhelmed operator? You start bringing in staff, not only do you have your job now, Karen, but you start taking on other people's jobs. Speaker 2 (14:01): Maybe not the whole thing, but you're taking on a little bit of it. Right? And there's reasons for that. The biggest problem with the overwhelmed operator from I call it crossing the street crossing well sometimes. So it's a big, big, huge river crossing over to more of this idea of practice freedom, which I'll get to that in a minute is there's not organization in place. There's not systems in place. There's no control over one's time because you're busy, busy, busy. That's why I started with the idea of the problem is we're not thinking like an owner. You are still an overwhelmed operator thinking like maybe not only a clinician, but you're probably playing the role of clinical director is not an owner director. So leadership position in your company, but it's not where the practice owner needs to be. Right? If you're a director, you need to remove yourself from that position. Speaker 2 (14:58): That's where people are. They're in one of those two categories. So if you're, if you're a committed, if you're an owner, if you're a committed clinician, your job is to start bringing people in. But the more you can bring people in, in an organized systematic, having some things in place way, the less overwhelmed you'll be later on, there's still going to be somewhat overwhelmed. It's just kind of part of growing a business, but there's a way to do it where it's not so much. So one of the things that we that, that, that I want to share with the group, one of my mindset shifts that nobody spends any time on. I never did. Cause I thought it was a waste of time, whether you're committed clinician, whether you're a overwhelmed operator is the mindset shift of the best is yet to come. Speaker 2 (15:52): The best is yet to come. I won't get into the story around this, but really what it means is the future is brighter than the present. And it's brighter than your past. The future is brighter. You have a vision, you, you have something that you want. Is it written down? Have you taken the time to describe it? John Lennon CRA wrote, imagine, right? Talking about peace and unity. Martin Luther king has I have a dream, not, I have a project plan. I have a dream little kids go to Disney world and Disney land. But when you get older, you think that's stupid. Why? Because you're too busy doing it, doing it, doing it, doing it. You don't step out of the fray and say, where is this all leading to you? And I, before this call, we're talking about you know part of, part of the program that you're taking is focusing on, well, what are your personal goals? Speaker 2 (16:58): What's your purpose about what are you about Karen? See, we all have something we're about. And when you start to create that and develop that, that gives you your north star, that starts to give you direction. That's a shift. We all have to have to make, you know, I love Bruce Springsteen like the next person, but let's not have glory days. Our favorite song. Cause that means the best is in the past. So we have to shift that. Why is that important? Because it gives you a a plan. It gives you kind of like the horizon to know the direction you're moving the company. What, it also does, little known secret. What it also does is let people that you're hiring, know what they're a part of. Most of us, most of the owners, at least I can share my own story. Most of the owners I've talked to Karen. They don't have a clue, dental have anything written down a lot of a plan. They don't have a vision. They don't even have, they couldn't even articulate just a dream. Like the, you know, I just imagined the place being like this. It's usually a half a sentence of kind of, sort of, because they're just overwhelmed and busy and that's the place we have to start. Speaker 1 (18:17): Yeah. And, and I think getting, making that shift in the beginning, I know I can speak, well, I can speak for myself. Is uncomfortable of like, well, wait a second. I'm not in the, in this role. Speaker 2 (18:34): So Karen, why I agree with you, but is it uncomfortable? Speaker 1 (18:39): And, and again, I think it's, it's I, and again, I'm just speaking for myself. It's hard to like, let go of that control. It's hard to step away from being the clinician because part of my identity as a person and an owner is wrapped around being a really good physical therapist, not an entrepreneur. Speaker 2 (19:01): So what you're really saying is a there's some fear there. And the fear is, and this has been my experience working with hundreds of practice owners. What if I'd only achieve it? Yeah. Karen, I'm not used to failing. What if I don't achieve it, then I'll feel like a failure. I'm already overwhelmed. I'm already feeling bad about myself. I'm already feeling ashamed that I didn't deliver what I said to my spouse and my friends, what I would do when I opened my practice. See, I think it's more about that fear of failure. And that's one of the things we have to learn to embrace because this isn't school, business is all about trying things, failing, learning, and trying again. That is business. And if we want to protect ourselves in a little too Kuhn, you're going to be miserable. And I hate to see that I was miserable for so many years. Speaker 2 (20:03): You'll never hear anyone say it because I've been there. I've been in the private practice section. Now for 10 years, I've never heard one person ever telling me they're not doing well. Even though the odds are 85% of them are, how is that? Because it's pride and you don't want to tell people that stuff, but it's really happening. So by writing it down just for you, this is the exercise. Just write it down, create what's your vision. I don't care if you use six months, a year, two years, something reasonable, but just write it down. If anything was possible. And remember anything you want to do has been done a hundred million times before. There's nothing you're going to want that some other company hasn't created. So it's not like it can't be done, but anyone that helps you, you come to me, first thing I'm gonna say is, well, what do you want? Speaker 2 (20:58): Well, I don't know. Then how can I help you? I don't know what you're trying to keep. If you're going to hire someone, a good somebody, a good person that is going to work for you, better ask you. So what's your vision? Where are we going with this? Because they're looking at themselves as what is my growth opportunity here. So it is your duty as an owner. And to your point, yes, we as practice owners have an identity crisis. We actually don't know who we are. We have to embrace the fact that we are in owner. I know I'm going against what probably people have said before. You will always be a PT. Yes, you will always have a license. You always be a PT, but mentally you have to embrace it. You're an owner because you chose to go into business ownership. You didn't have to, it's a free country. Speaker 2 (21:49): You chose it. And there is more that you want. So how about we embrace it? And when you embrace it, it's amazing what you're going to be able to achieve. And you're going to make this whole process a lot more easier right now. You're making it difficult because you are battling these two kinds of brains. You're battling that clinical brain, that kilt brain that I don't know who I am. I'm just a PT and all, but I want this. I want to go on vacation for three weeks. Oh, I want him, I want to make money so I can put money away and write a check for college or, or have this or buy this. I want to help more people than I'm doing right now. And right now I'm not helping enough people. So it's your purpose. Your impact has to be the keys to this. Speaker 2 (22:32): So that's one thing. I do want to share a, another one. If I may. The other a growth mindset shift is focus. First one is the best is yet to come. The next one is focus. What you focus on, what you pay attention to grows. Now here's the caveat. It includes crap. You focus on a flower. You cultivate that flower. You put that little seed in there and you water it and take care of it. You're going to get a nice blooming flower. You cultivate that piece of crap and make it really nice. That maneuver is going to wreak real good. So whatever. So what does that mean? What's the manure stuff. It's the stuff that you're doing. That's not moving the needle in your business and in your life. It's the things that, although may be important. It's not what you should be doing because you can't do it all. Speaker 2 (23:42): And having the mindset of, I gotta do it all. I'm a great multitask. If I get one more person, tell me how great of a multi-tasker they are. Do you realize we are all researchers and science people? There's no, it's impossible for the brain to multitask. It can only focus on one thing at a time. All you're doing is focusing on a lot of one things really, really quickly. And then there's this thing called residue. This delay, right? If you're focused on something for a while and you focus on something else that delay, that thing stays with in your brain for a period of time, come on. You're not going to have a badge of honor saying what a great multitasker you are. Now. I'm not talking about the moms out there. And I, yes, yes. That's a whole nother world and I've seen it with my wife, but I'm talking about business owners, oh, I'm doing this, I'm doing this. I'm doing this. When they do that to me, they do it like they're bragging. And I go, why, why, why would you want to do that? You don't even like half the stuff you're doing. Why can't you get rid of it? And then we get back to the identity crisis. Well, I can't let it go. And there lies the issue. So focus having laser focus is like taking a magnifying glass to your business, letting the sun come in and dialing that energy. That is so strong. It can burn through wood. Speaker 2 (25:07): You have to have as an owner. And I've never met a successful business owner, entrepreneur, CEO that didn't have laser focus, never in any industry. Never because they couldn't be in that position. They couldn't have the level of success. I've met CEOs that their company wasn't great. Oh, they're all over the place. I've seen that plenty of times. So I don't necessarily what I had my practice. I didn't call myself the CEO. I couldn't get around that day. Those two corporate is it doesn't matter what you call yourself. Just think of yourself as you're the leader. This is your business. This is your thing. But it doesn't mean Karen that they have to do it all. No one said to dude, do it all. You're making this up. You're taking it all on. And it ain't working. If it was working, I'd be like, keep doing more, do more. Speaker 2 (26:07): Don't worry. We'll add more hours to the day. Do more. We'll take more time away from your family. Do more. It's not working. So focus. How do you, do you ever see the video? The invisible gorilla talk about focus, type invisible to grill. It's also called monkey business illusion. So here's what it is. There's six people, three in black shirts. I believe three. And white shirts. They're passing a basketball, right? And the, the, the exercise is count. How many passes? The white shirt? People throw to each other. That's it? That's all the directions is. I've seen it before. The first time I saw it at the end, the person goes, did you see it? And I'm like, see what? That was 18 passes. Yes. The number of passes were 18. Did you see the gorilla? And I went gorilla fricking no gorilla. There was a gorilla that come out. Speaker 2 (27:09): I'm gonna ruin it for people, but you have to see it. There is a grill that comes through the screen that starts dancing around and then walks off the screen. 50% of the people that see it, don't recognize it. Gorilla. This was a psychology experiment by, by the person that who the psychologist who did this. So being the smart Jamie, I just watched this the other day too. I've watched another version of it. Here's what's crazy. Of course. I saw the gorilla cause I was looking for the gorilla, but you know what? I didn't see. I didn't see the background completely changed colors. I didn't see one of the people that were passing the ball leave, like it's wild. What the brain is looking for the brain will see. So we have what's called and I don't want to get too technical here, but we have, what's called a bias. Our brain has a bias. Every single one of us, more specifically, it's called a negative bias. No matter how much we think we know, we can't think outside of our own bias. Speaker 2 (28:17): So the way you can kind of play with this a little bit is getting very clear at what you are focused on. Thinking through what you're focusing, then executing the plan. That's the only way to get through the bias except to have. And this is what I absolutely recommend. Someone else, someone else that's mentoring or coaching you, you don't know what you don't know and you never will, no matter how smart you think you are. And that's one of the problems we have because we are very smart people, but intellectually smart around physical therapy and anatomy. Yeah. That's great. But that's not going to help you with your business, right? So what you focus on, what you pay attention to grows. If you want more referrals, if you want more time than focus on the things that are going to help you do that. Speaker 2 (29:17): But the mindset shift is you have to be very honest with yourself. You have to ask yourself, do I like the results I'm getting? Do I like the income? Do I, I know we feel really weird about money and income, but it does pay the bills. Right? Can't pay the bills in likes, right? Oh, I got a thousand likes. Okay. Well how much you make nothing. Okay. You know, it does take money. It's okay to make money. What about time? Do you have control of your time? We call it freedom of time. Are you controlling your schedule? You're missing your kids' games. Are you missing events with your friends? Are you doing notes on the weekends? And so I was talking to someone yesterday, say, Jay, man, I do notes until 12 o'clock at night. I go, this is your business. And he goes, yeah, I'm working for a lunatic right now. Speaker 2 (30:06): Right. But that was kind of funny. So so that's, that's the thing. So I like to break it down for most of the committed clinicians and overwhelmed operators out there. 30 days, we, we have, we have a tool called a 30 day sprint. You can use that to 30 day goals. What's your goal for the next 30 days? Not 90, not a year, 30 days. What does it do you want to accomplish and choose one thing. Karen, just blend it because it's going to be hard for you to choose one because you're used to doing 20 and not achieving really any of them at least completed. So that's, that's an exercise that everyone can do. What area do you want to improve? Like I said, I gave you, I gave a bunch of examples. There's one, there's one code. I'm not monopolizing this conversation about, you know, that you're like, this is great. I have Jamie on 32 minutes. I'm like, thank you. Speaker 2 (31:06): I'm still answering the first question. Right? Henry David Thoreau. Great, great quote. It says it's not enough to be busy. So two are the ants. The question is what are you busy about? So by focusing more, you change your busy-ness to being intentional with what you're doing, that moves to being productive. The difference between productive and busiest productive is moving towards something that is desire busy. It's just activity. And there's a whole dopamine thing that we all have in our brain that, oh, but when I'm busy and I, I, you know, I take a post-it note and I throw it I feel so good about myself. I'm like, I know it's that quick dopamine hit that you achieve something. But the reality is you throw all of them away. You keep creating new ones and then you step back a little bit and you realize you haven't moved anywhere. Speaker 2 (32:02): You're still kind of doing the same stuff you were months ago or even years ago, you know? There's a, there's, there's, there's one more thing that we have, do we have time? Are we good? We're good. There's one more thing I wanna, I want to leave your audience with a growth mindset tip. And that is and this is probably now not probably it's the most important one and that is keep your tank full. And when I re referred to the proverbial gas tank, I'm referring to your energy level. We have all been in places where we are exhausted. Our energy is zapped. Our brain is fried and we just want to be left alone. If you have kids, you've been there many a times. If you have lots of patients, you've been there many a times. If you are running a business, you've been there many a times. If you've got annoying friends, you've been there many a times. Speaker 2 (33:05): And if something happens when you are in that state of just exhausting fed up, what's happening is your energy take low, near empty. A problem happens. How do you see that problem? Well, according to research in our beautiful little amygdala or my daughter calls it, the Amy, the gala, when emotion is high, such as when you're exhausted, fed up too much, intelligence is low. Your brain is hijacked. This goes back millions of years ago. When the Tiger's coming after you, you're not going to rationalize the tiger. Your body's going to go into overdrive and start running. However, what hasn't changed, even though we've transformed and we've we've, we've, we've, we've got all this new way. And in the neocortex, this is all old school brain stop. Something can happen. And you'll still get that feeling. You'll still get that emotional, like, oh my God, I got to react to something. Speaker 2 (34:12): And when your energy is low and your tank is low, you start to make really bad decisions. And when you make a bad decision with your friend, you yell at her, right? You yell at your friend, you yell at your kids, you yell at your spouse. You yell at your boyfriend and girlfriend, whoever you yell at people. And then later on you say, I wish it ends. I apologize. I shouldn't have said that. But when you make a bad decision in your business, oh boy, this is a decision that will, that could cost you thousands of dollars or tens of thousands. I've seen hundreds of thousands of dollars with literally one decision. It can cost you employees. It can cost you culture. It can cost you time and it can cost you a hell of a lot of frustration. Now imagine you're making these types of decisions, some grander than others, all the time, that's what's happening. Speaker 2 (35:10): Karen, we are making way too many decisions when our tank is well below halfway, and we're doing nothing to bring our take back up to full. What is a full tank? A full tank is your highest, most creative, innovative place. It's the place that you just feel on top of the world. It's the place of the highest level of confidence. It's the place that your friend says something stupid. And you're like, oh, you're foolish and come on. But that same person says something. When your tank is empty, you're going to bite our head off in business. You have someone asking you a question or someone coming to you for the umpteenth time that so w w if I want to take off next week, what do I have to do? And you just blow up on the person next day. You're like, yeah, yeah. You know, I'm sorry, whatever that person doesn't forget. Speaker 2 (36:09): Something like that. And when you start doing that and you start reacting, there's a difference between reacting and responding. Responding is what we do when the tank is full. Reacting is what we do when the tank is near empty. Reacting is an emotional response. Responding is a rational response. So what can we do? The fastest thing you can do when your tank is down is evoke physiology. What we do. So what's going to turn around deep breaths, count to 10, take 10 deep breaths. I guarantee whatever the problem is, it will subside. And you will think differently about it. Exercise. I know for me, when I exercise, God, I feel great, right? Anytime. And I've, I've, I've infused as I'm not perfect at it, but I've infused as, especially the last few years, especially last year during COVID when I think I might've come on here. Speaker 2 (37:20): And you're like, Jamie, what's the secret to dealing with. COVID pause. Just pause. Just stop. Just take care of yourself. Take care of your team. Like just personally. So I'm a great thing to do is don't make any decisions until after you exercise. I don't care if it's a walk. I don't care if it's, you know, basketball, I'll give it a round of golf. If you consider that exercise whatever it is running, you will think differently about the issue. If you have a problem with an employee, take some deep breaths and pause, do not address it in a high level of emotional state. This, if you just stop doing this so often, I will promise you, your business will get better. I promise because you'll just stop making these decisions that you don't even realize. We don't even realize we make these decisions, but then all of a sudden problems happen. Speaker 2 (38:16): And then we justify why. And I guarantee, at least with me, the justification was well, Jamie it's because you're in a high emotional state. That's why this problem. No, I started looking for someone to blame. I look for the prop, the answer to the problem, somewhere outside of where it really came from, that gets expensive. That causes you then to hire people you shouldn't hire to pay. I mean, I paid so much money in marketing and stuff like that. Why I was in a really bad emotional state. And I was just trying to solve it, writing a check on it. Wasn't it, it wasn't, it, it wasn't a rational thought through issue. And I did that again and again, and I did that with a lot of other problems too. So you know, when emotions are high intelligence is low. Karen, this is an opinion. Speaker 2 (39:09): This is a fact. We like facts as PTs. This is a fact. So pause 10 seconds, 10 deep breaths exercise before decision. And you don't have to wait for your, for your tank to get low. I know we do that. Like I'm, I'm one of those. Not only does the light come on, but that, that thing gotta be at the line. Or even below the line for me to go to the gas station. We can't do that with ourselves. When that thing gets around half, half full it's time, start, start doing some things, put this into your regular routine. Here's what I've learned over the years. I didn't realize this. So I started talking to a bunch of people around this particular point of keep your tank full. And I don't know the exact number, but it's overwhelmingly more than I would say, 80%. When you, when you get busier, when things get busier at work in the office, there's one thing that you sacrifice more than anything else. That's your, self-care you exercise. Normally you stop going to the gym, right? You do yoga, you stop it, you meditate, you stop it. You go, you stop. The thing that actually is keeping you sane and keeping you mentally strong and mentally fit. That's when you have to pause and saying, I'm the most important person in this company, my thinking and how I think about this business affects everyone in the business, including the staff and the patients and the community. So when I'm feeling like that, I know it's time to do some serious take care of me time. Speaker 1 (40:57): Yeah, absolutely. So now, if we start to, we'll start to kind of wrap things up here. So I just want to review some of the things that you said that physical therapy owners can do to kind of change their mindset around them being clinician, a PT an owner, to help them be successful. So you just talked about not making decisions on an empty tank or a near empty tank. We talked about changing we talked about some little like mindset tricks and tips and things like that. What else? Speaker 2 (41:40): Well, the, the three things that specific thing could be talked about, cause a lot of them have to do with that is growth mindset tip number one, the best is yet to come. The exercise for that is take 15, 20 minutes. You can, you can, you can handle that. Write down what the heck you want one year from today, one year from today, if you and I had a conversation and we were going to look back on to this moment, what would happen for you to feel happy about your business, about your bank account, about your family, about your personal life, what would you, what would have to happen? Write that down. I don't care if it happens or not. No, one's going to call you on it, but I want you to go through what it feels like to actually put that down on paper. Speaker 2 (42:27): Don't type it out on the computer. There's something special about writing it out on paper, right hand to paper. That's number one, that's number one, number two, focus, growth mindset. Number two, focus. What we focus, what we pay attention to grows. So what are you focused on? One thing for the next 30 days? What is one outcome? One goal that you want once you do that reverse engineer, that and then say, okay, in order to achieve that goal, what happens? What do I have to achieve this week? Say that exact line. What do I have to achieve for this week? Do that four weeks in a row. And I promise you, I promise you, call me out. If I'm wrong, you will be either hit the goal, go way past the goal or make significant progress, which you won't be is where you are. Excellent is the 80 tank. Speaker 2 (43:28): Keep your tank full. If you get into a high level of emotional state resist making decisions, or if you have to make a decision deep breaths count to 10 exercise, something that helps you increase your energy level. And then of course the second part of that is incorporate that on a regular basis every day, maybe a couple days a week, three days a week, but on a regular basis. And for whatever you do, no matter how busy and crazy life gets, do not sacrifice your time, your self care is the most important thing. There is you are not a hero by killing yourself. You don't strengthen the weak by weakening, the strong you killing and sacrificing yourself is not helping anyone. You don't need to do that. And then of course the overarching thing that we've talked about is, you know, some of the ideas around really thinking of yourself and considering yourself and talking about yourself as a business owner, right. If you're treating tree, that's great. But other than that, you own a business. Speaker 1 (44:49): Yeah. Perfect. All right. Where can people find you? Speaker 2 (44:55): Yeah, learn more. You can just go to my website practice freedom, U the letter u.com. I got some goodies on there. You can download my book on there. What I would recommend if people want to dive in deeper with me and, and just kind of, you know, you want to have a conversation. I am offering a, what we call a discovery call and we'll see kind of where you are mentally. We'll see where your mindset is. We'll see where your business is and we'll see if there's ways we can help you. We do have programs. We'll see if it's a, if it's the right fit for you, if not definitely give you some things that you can do in the meantime, maybe point you in some other directions. So you can go. I'm sure you'll put that in, but you can go to practice freedom, u.com/discovery call. Speaker 1 (45:41): Perfect. And yes, this will all be in the show notes at podcast out healthy, wealthy, smart.com under this episode. So last question, Jamie, what advice would you give to your younger self? Speaker 2 (45:53): Oh my God. Overcome your ego. Jamie it's okay. You don't know everything enlist. Some help invest in yourself, invest in your business. It will pay off dividends in the future. Not only to you, not only to your family, but for everyone that's around you, including your staff and community. Speaker 1 (46:15): Excellent advice. I love it. I love it. And I feel like you've given different pieces of advice each time you've been on very impressive. Cause I've asked this question before and the advice is always different, so well done. You so thanks so much for coming on and sharing. This was great advice for anyone who is a current owner or who's maybe thinking about becoming an entrepreneur. So I thank you very much. Speaker 2 (46:41): You're welcome. Thank you so much, Karen. Speaker 1 (46:42): Yeah. And everyone who's listening. Thanks so much for tuning in, have a great couple of days and stay healthy, wealthy and smart.  

In this episode, Co-President of the American Association of Pain Psychology, Dr. Rachel Zoffness, talks about treating chronic pain. Today, Rachel talks about the failed biomedical model, pain neuroscience, and effective non-pharmaceutical pain treatments. When is the right time to refer someone to a pain coach? What are some multidisciplinary approaches to pain management? Hear about the biopsychosocial nature of pain, how pain treatment in the US is actually about money, how thoughts and emotions affect pain, and The Pain Management Workbook, all on today's episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways "What science tells us is pain is not purely biomedical. It's actually this different and more complex thing, which is biopsychosocial." "Pain is complex, and doing one single thing over years and years that has not worked, is probably not the right way to go." "Pain is never purely physical. It's always also emotional." "Unless we're taking care of our thoughts and emotions, we're actually not really treating this thing we call pain effectively." "If it's okay to go to soccer coach to get better at playing soccer, it is surely okay to go to a pain coach to get better at living with chronic pain." "96% of medical schools in the US and Canada have zero dedicated compulsory pain education." "Pain, by definition, is a subjective experience." "Keep doing exactly what you're doing and follow your gut. Trust your intuition, and know that following the path of the thing that you love is the thing that's going to bring you to where you need to be professionally."   More about Rachel Zoffness Dr. Rachel Zoffness is a pain psychologist and an Assistant Clinical Professor at the UCSF School of Medicine, where she teaches pain education for medical residents. She serves as pain education faculty at Dartmouth and completed a visiting professorship at Stanford University. Dr. Zoffness is the Co-President of the American Association of Pain Psychology, and serves on the board of the Society of Pediatric Pain Medicine. She is the author of The Pain Management Workbook, an integrative, evidence-based treatment protocol for adults living with chronic pain; and The Chronic Pain and Illness Workbook for Teens, the first pain workbook for youth. She also writes the Psychology Today column "Pain, Explained." Dr. Zoffness is a 2021 Mayday Fellow and consults on the development of integrative pain programs around the world. She was trained at Brown University, Columbia University, UCSD, SDSU, NYU, and St. Luke's-Mt. Sinai Hospital.   Suggested Keywords Pain, Psychosocial, Emotional, Physical, Neuroscience, Treatment, Thoughts, Management, Healthy, Wealthy, Smart, Coach, Physiotherapy, Healing,   Dr. Zoffness Latest Podcast: Healing Our Pain Pandemic Dr. Zoffness's Book: The Pain Management Workbook   To learn more, follow Rachel at: Website:          https://www.zoffness.com Twitter:            Dr. Zoffness Instagram:       @therealdoczoff LinkedIn:         Rachel Zoffness   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 Okay, so whenever so I, you will know when we're recording because like I said, I'll do like I'll do a quick clap. And then I'll just say, hey, doctor's office. Welcome to the podcast and off we go. Okay, ready? Perfect. Okay. Hi, Dr. softness. Welcome to the podcast, I am excited to have you on today to talk about chronic pain and treating patients with chronic pain. So this is a real treat. So thanks for coming on. I think you are very cool. Karen Litzy. And I'm excited to be here. Excellent. So what I what we're going to talk about today, just so the listeners knows, we're going to talk about kind of treating chronic pain from a bio psychosocial standpoint versus a biomedical standpoint. So I know a lot of people have no idea what those terms mean. So doctor's office, would you mind filling in the listeners as to what a biomedical model is and what a bio psychosocial model is? to kind of set the tone for the rest of the podcast?   01:10 I totally Can I talk about this all the time, because it makes me so mad. Okay. So the biomedical model is the one that we all know the best, because it's the way we've been treating pain for many decades. And the biomedical model of treating pain and health in general, is essentially viewing and understanding and treating pain as a problem that is purely the result of bio biological or biomedical processes like tissue damage and system dysfunction, and on anatomical issues, and then throwing pills and procedures at it. That is how we've been treating pain for many decades. And of course, we know it isn't working, we have an opioid epidemic, the opioid epidemic is getting worse during the COVID pandemic. People are really suffering, chronic pain is on the rise. It's not being cured. It's not magically disappearing. incidence isn't even decreasing. So the way we're doing it is broken, and also very expensive for people living with pain. However, what science tells us is that pain is not purely biomedical. It has never been purely biomedical. It's actually this different and more complex thing, which surprises nobody, which is bio psychosocial, which is a big and complicated word, but makes intuitive sense, once we start talking about it, I think to people who have experienced pain, which means that yes, of course there are biological processes at work when we're living with pain, acute and chronic. And I can say what those mean to short term pain versus long term pain, longer term pain.   03:02 Yes, and there are also many other processes that work too. So if you imagine this Venn diagram of three overlapping bubbles, which I draw a lot, but I cannot draw right now, we've got the biological or the biomedical bubble on the top. And then we've got the psychological bubble. And that's the one that I struggle to explain to people the most, because I think there's so much stigma around this idea that cognitive and psychological processes might be involved in this experience we call pain because there's so much shame and embarrassment and stigma around anything to do with psychology, which is so unfortunate. But in this psychology bubble of pain, there's a lot of stuff that I think people know intuitively can amplify or reduce pain. So there's thoughts about your body and about your pain and just thoughts you're having about life in general. There's emotions, like stress and anxiety and depression, even suicidality. And we know that negative emotions amplify pain. And we know that positive emotions can sort of turn pain volume down, there's memories of past pain experiences. And those are stored in a part of your brain called the hippocampus. And we know research shows that memories of past pain experiences can change your current experience of pain. And also in the psychology bubble, we've got coping behaviors. So that's quite literally how you deal with the pain you have. And a lot of us who have lived with pain, and that does include me engage in a lot of coping behaviors that make sense in the moment. But actually, they can make pain feel worse over time. And a great example of that is the resting indefinitely plan or the doing nothing plan, as I like to call it which is totally, you know, normal and natural for those of us who pay into Engage in because when your body is telling you, you know that you're hurting, it's understandable that the thing you think you're supposed to do is stop all activity. But ultimately, what we know about that particular coping behavior is that it makes chronic pain in particular worse over time. So the do nothing plan or the stay home or rest indefinitely plan is a coping behavior that lives in the psychology bubble that can actually make pain feel worse. And of course, there's coping behaviors that can make pain feel less bad, like the counterintuitive things like leaving your house and seeing people and walking and getting out into the sunshine. And, you know, these things that we don't necessarily know can help pain. And then the third, overlapping bubble, and our bio, psychosocial Venn diagram, is the social or the sociological domain of pain. And that's what I like to call the everything else bubble. So it's socio economic status. And family and friends have culture and race and ethnicity and access to care, and socio economic status, and history of trauma and early adverse childhood experiences, and culture, and context. And environment, like quite literally, everything else your environment, believe it not changes the pain you feel. And in the middle of those three things, and I know that's a lot of things, is pain. So when we try and pretend that pain is just this simple biomedical thing, the treatments don't work. And I think all of us who have lived with pain know that our pain is much more complicated and sticky. I know that was a lot of words.   06:44 No, and, and I'm glad that you described everything in the way that you did, because I think that gives the listeners a really good idea of what's in each of those bubbles. Number one, and number two, how complex pain actually is. Exactly, it's not. So if I think if the listeners take away anything from this conversation, if pain is complex, and doing one single thing repeatedly over years, and years and years and years, that has not worked, it's probably not the right way to go.   07:15 That's right. And you know, the other misconception that we all understandably have is that, you know, the way to treat pain is just by going to your physician. And, of course, that makes perfect sense. But we have this misconception in western medicine, that either you have physical pain, and you see a physician, or you have emotional pain, and you go to a therapist, or a psychologist, someone like me, and the really fascinating thing about pain, and the reason I love studying it, and treating it and talking about it so much is that neuroscience tells us that pain is never purely physical, it's always also emotional, because the part of your brain called the limbic system actually processes pain 100% of the time. So pain is always both physical and emotional. But most people don't know that most people have never been told that. But the limbic system plays a huge role in the experience of pain. And we know that, you know, emotions are always changing pain volume all the time. So this idea that pain is either physical or emotional, is not actually a thing, you know, and the way we treat pain by going to a physician exclusively is not actually nine times out of 10, probably more than that going to actually, you know, be the answer for any sort of chronic pain problem.   08:37 And so I'm glad that you brought that up that yes, we know emotions play a role in pain. And as a matter of fact, the International Association for the Study of pain, change their definition of pain in 2019, I believe to include that it is an emotional experience. And I think that really set the stage for greater discussion and research, which I think is amazing. But when you say to someone,   09:05 let's see, can I interrupt the flow to say, they did change the definition, but the the word emotion was always in there? Oh, was it? It was? Okay.   09:16 Let me so when we talk about kind of the emotional part of pain, and I have had patients say this to me, which probably meant I was explaining it incorrectly, and I take full responsibility for that. And I'm sure you've heard this before his patients saying, so you're saying it's all in my head. Totally. And how do you react to that?   09:42 Yeah. I love that. You asked that question. I think probably the worst thing about being a pain psychologist is you know, you're the last stop on the train. You're the last person anyone wants to see nobody wants to go to a psychologist or a mental health professional for a physical experience like pain. And I know you can't see me, but I'm putting air quotes around the word physical. Because again, pain is not a purely physical experience. It's physical and emotional. But of course, no one wants to go to a pain psychologist for pain, right? You think you're supposed to go to a physician, and a referral to a psychologist means you must be crazy or mentally ill or the pain is on your head. And no, that's not what it means at all. And I find that the way that I most effectively target that is by explaining, believe it or not pain neuroscience. And I, I usually do that in the simplest way, I know how just by distilling down that, that, you know, it's easy to believe that pain is something that lives exclusively in the body, right? Like, if you have back pain, it's so easy to believe that that pain lives exclusively in your back. But what we know and what neuroscience has taught us is that actually, it's your brain working in concert with your body that's constructing this experience we call pain. And we know that because of this condition called phantom limb pain, wherein, you know, someone will lose a limb like an arm or a leg and will continue to feel terrible pain in the missing body part. And if pain lived exclusively in the body, no limb should mean no pain. So if you the fact that you can continue to have terrible leg pain, when you have no leg tells us that pain can't possibly live exclusively in the body. And I find that when I explain this to the patients who come see me, first of all, there's more buy in that the role of the brain in pain is really significant. And second of all, it sort of gives me some leverage to then explain that, again, one of the parts of the brain. And one of the most influential, influential parts of the brain that processes pain is your limbic system, which is your brain's emotion center. So unless we're taking care of your thoughts and emotions, we're actually not really treating this thing we call pain effectively, we're just treating one small component of it. So that's, you know, and I also always, by the way, validate that, of course, you have, you know, of course, it feels like someone's saying that the pain is on your head, or that it's a psychological problem. Because of this, again, this like false and ridiculous divide we have in western medicine between physical pain and emotional pain, when neuroscience has known for decades that that's not actually a real distinction, like your head is connected to your body 100% of the time, you know?   12:24 Yeah, absolutely. And as let's say, as a practitioner who's not a pain psychologist, a physical therapist, occupational therapist, maybe your yoga Pilates, and you are working with someone with persistent pain? How, how can we encourage our patients or recommend to our patients, that, hey, you might really benefit from seeing a pain psychologist, without them thinking that we're telling them they're crazy? Yeah.   12:57 I do think that taking 30 seconds, or maybe even 60, to explain, you know, this basic painter science thing. And the phantom limb thing is a really, really effective strategy. So anybody can use that. That piece of information. You don't have to be a pain psychologist. So that's thing one is just like taking a few moments to talk about how pain works in the brain. I think patients are so grateful to learn that no one's ever told them this before you're going to be the first person to ever let them know. And then the other thing that I always do is a trick that I learned from a really nerdy journal article I read years ago by a guy named Scott powers. And he said that one trick that we can use is to call pain psychologists or you know, therapists who are trained in things like cognitive behavioral therapy for pain, pain coaches, and I love that. So I usually tell physicians and other allied health professionals to refer to me as a pain coach. And the way I pitch that to families and tell other health care providers to pitch it to their patients is to say, if it's okay to go to a soccer coach, to get better at playing soccer, it is surely okay to go to a pain coach to get better at living with chronic pain. Because living with pain is so hard. And you deserve support. You know, and usually that removes the stigma and the stigma, especially when you present that in conjunction with some science that supports the role of the brain and the role of cognitions and the read the role of emotions and coping behaviors. In the experience of pain, I find that that really is super effective.   14:41 Yeah, that's really helpful and a great way to frame how to frame that recommendation to someone coming from someone like me coming from a PT because people often come to physical therapists I mean, it's in the name Because they want us to heal or to fix their physical problem, which in this case is persistent pain or chronic pain. And so then that leads me to my next question is, as a physical therapist or as someone who's working with the body, when do we refer this person to a pain coach or pain psychologist?   15:25 I'm curious to know what you're going to think of my answer. Ready? Here's my answer. I once had a friend who said to me, man, like, everyone's always going around talking about how many miles they ran today. And you know, how you like the Strava app, like, you know, how many miles they biked? And how many hours they did yoga this week? And can you imagine what it would be like if everybody, you know, came, came to each other and started bragging about how many hours they spent working on their shit? Like, what I spent three hours working on my anxiety today, or like my family stuff? Or like, my complicated relationship is, like, just why do we prioritize working on the body over working on our minds? You know, it's so strange. So my honest answer is if you're ever treating a patient who's living with chronic pain, and again, that's pain that's lasted three or more months, I think it's worth a referral to a pain psychologist or therapist who's trained in cognitive behavioral therapy. I just, I can't imagine any human being who wouldn't benefit from the opportunity to navigate the complicated experience that is living with pain and having someone in the role of support and coping behavior coach is just, you know, and partner and in processing, the experience of it just just seems to me like such a great gift to be able to give to patients.   16:51 And my answer to how I react to it is I agree. And, and again, this takes into a takes into account really this multi discipline, multi disciplinary approach to pain and approach to pain treatments and management. And so in your opinion, what makes that multidisciplinary approach effective for that patient?   17:20 I mean, what the research shows is that trying to approach and treat pain from just one angle is usually not sufficient, because as we were saying at the beginning, pain is such a complex, bio psychosocial thing. So if we're just looking at the biomedical components, we're not really doing our job, if we're just looking at the psychosocial components, we're not really doing our job. So, you know, a multidisciplinary team as a team made up of, you know, psychologists and pts, and OTS and physicians and nurses and biofeedback providers, and all these different people who are sort of coming at this complicated things from maybe slightly different angles and perspectives. And when we do that, what the research shows is, we have the most robust outcomes, the care is most effective, and the most comprehensive, and people walk away with a whole tool belt of tools to use when treating their pain, you know, across scenarios and across symptoms. So multi disciplinary is really like, how can we all come together as a team with our unique backgrounds and our unique training because, you know, as you know, trainings, especially in the United States, the disciplines are also siloed. You know, like, psychologists are trained in this one way, and pts are doing this thing over here. And OTS are over there. And anesthesiologists are over there as physiatrist. Or, I mean, it's just it's so fractured. So a multidisciplinary team is hopefully working together to target this complex animal that we call chronic pain. And what's really interesting is, you know, I have a private practice, where I see a lot of patients with chronic pain. But I feel like the bulk of my work sometimes is coordinating care with this really complicated treatment team. And I'm seeing a really complicated patient right now who has crps complex regional pain syndrome, which is a really tricky, chronic pain syndrome. And, you know, the way that we his case has been so complicated. It's been many years of treatment. And I think today as a team, we finally decided upon a treatment plan. And it really wasn't until we all were talking that that came together and jelled. So I think that's one of the most important components of treatment actually.   19:38 Yeah, I, I agree. And and when you're in private practice, like you said, sometimes it can be a little bit more difficult, but the more communication you have with people on that team, again, we're doing all of this for the person in the center and that's the patient and so being being able to provide vied so much coordinated care for that patient. Like you said, the research has shown that this is that this works versus a piecemeal, one person's doing this over here. And someone's doing this over here, and they're hearing, and then the patient's hearing contradictory treatment plans. And so it gets really confusing.   20:21 Yeah, it gets super confusing when there's, it's almost like too many cooks in the kitchen, if you're not working together, because they're getting all this different advice from all these different people. And oftentimes, and I'm sure you've seen this, too, they're on, you know, 40, they've tried 40 different medications by the time they've gotten to you. And, you know, I mean, I think what it leads to is like, this treatment, burnout, where like, our patients are just so burned out on all the treatments they've tried, and they have this sense of hopelessness, like, nothing's gonna work. Nothing's working. So far. I've tried all these things. I've seen 40,000 million doctors, and, you know, I've, yeah, I've tried herbs. And yeah,   20:58 I've heard that from people like, they're like, I don't want to go to one like I'm all doctored out, if I have to go see one more doctor, or take one more medication, or do one more procedure, or one more scan, like I'm done. I don't want to do this anymore. Yeah. And I blame them. Yeah, it's exhausting. It's totally exhausting. And you know, we've been talking about things that don't work. Right. So we talked about all that being on medication after medication, opioids, we know these, they don't work for people with chronic pain. So let's talk about non pharmacological treatments. And what does work or what can work for people with chronic pain, so I'll throw it over to you.   21:44 Yeah, so non pharmacological treatments, there's like a whole host of them, there's a wide range of them. And there's a lot of literature on a bunch of different things. So what I use the most in my practice, because I really love it and have found it to be so effective is cognitive behavioral therapy, or CBT, which is different by the way than CB, cb, D, that's something different CBT cognitive behavioral therapy. And an arm off of that is a treatment called Act, which is acceptance and Commitment Therapy, which is become very big in the PT world, which by the way, originated from CBT, and was adapted for pain. There, there's also Mindfulness Based Stress Reduction, or mbsr, which has a huge literature base for the treatment of chronic pain. And there's other things too, like biofeedback, I happen to really love as a treatment for pain. And there's a whole host of other things, too. But, yeah, God,   22:43 I was gonna say, could you explain briefly what biofeedback is so that people understand what that is? Exactly.   22:50 I'm so glad you asked. I've been doing this for so long that I forget. I just forget that. Certain things are not known entities. But I also did not know what biofeedback was when I first started treating chronic pain. And so I'll someone said to me, oh, you're treating patients with pain, you should refer them to biofeedback. And I said, You know, I don't refer my patients to things that I don't understand. So I did a buttload, of reading about biofeedback for pain, and I got a bunch of books. And then I found myself a biofeedback provider. And I went to this gentleman, his name is Dr. Eric pepper. Dr. Pepper is just a great name for any doctor. And He is a professor at the University of San Francisco and I admired him right away, he was obviously very smart. And he sat me down in a chair. And he hooked me up to this machine. And he said, This machine is going to read a bunch of your biological outputs, it's going to read muscle tension, galvanic skin response, your finger temperature, and a bunch of other things, your heart rate. And I was like, what that's really interesting. And he showed me which monitor was, you know, giving me feedback about which thing and hopefully you're picking up on the fact that there's biological processes that you're getting feedback about? And he said, and now I'm going to teach you to raise your finger temperature to 90 degrees, using your mind. And I said, Excuse me, sir. I am a scientist. And I do not believe in Voodoo. And he said, Well, how about you just try it out and see how it goes. So he did a couple of techniques with me had me close my eyes, he did some relaxation strategies, and diaphragmatic breathing, and he used imagery of like hot soup and hot air flowing down my arms from my shoulders into my fingertips, and autogenic training and autogenic phrases and that's when you say things to yourself that are suggestive like my arms are heavy and warm. My hands are heavy and warm. And as I was doing, as I was doing all these things, I noticed, because the machines were giving me feedback about my biology, that my hand temperature was going up. And within two sessions, I was able to warm my hands using my mind. And I am a person with chronically cold hands, because I'm stressed out all the time. And no one had ever told me that cold hands and feet, by the way, are a sign that you are stressed out. So I can now warm my hands on command, which is absolute magic. And when I teach it to my patients, they oftentimes say things like, Oh my god, I can make fireballs with my hands with my mind, what else can I do? And that's exactly what we want. For people living with pain, this idea that the mind and body are connected 100% of the time, and that you have more agency and control over your body than you thought you did. And you can make changes to formerly unconscious biological processes like skin temperature and muscle tension and pain. And biofeedback teaches you some skills to do that. Which is why I really like it so much.   26:13 Yeah, it sounds so like sci fi doctor who kind of stuff. Dr. Pepper. Exactly. Yeah, right. Exactly. Right. But yeah, it just sounds like Wait, what? But yes, I mean, I've never I have not done biofeedback myself, but it is something that I'm just constantly interested in for the exact reasons that you just said, like, Whoa, I can control what my body does. This is pretty cool.   26:41 It's worth it, I highly recommend it. It is so worth it. It's it makes you feel like, you know, it's this sense of like, if you almost feel like the Incredible Hulk like gotta have all this untapped power and potential that I just didn't even know about.   26:55 Yeah, it's, it's wild. Thank you for giving us that kind of definition of biofeedback, because I guarantee a lot of people who are listening did not know that at all. I didn't either, I totally didn't either. Very, very cool. So now, all of this, these non pharmacological treatments, CBT, a CT, biofeedback, we can maybe put physical therapy, occupational therapy into that as well. I mean, obviously, all of these things, cost the system money cost the patient money. But let's talk about the money aspect of treating pain, especially here in the United States. So what, you know, when people think about treat treatment of chronic pain, they often don't think about the money involved. So I will throw it over to you to kind of elaborate on that, and what does what that means for the patient and for the system.   27:52 You're actually making me realize that when you asked me about non farm approaches, I of course, immediately went to like, you know, like psychological treatments for pain. But yeah, of course, you're right, PT, OT, all these things, of course, are all the things and approaches. Yeah, absolutely. So yeah, it was a really sad day for me, when I realized that the treatment of pain historically has actually been about money. That was a really sad wake up call for me. So I used to be a member of this organization called the American pain society, it was very well established, very well known organization. And they went belly up after it came out. And I don't know if this is proven or not. But I should say, after they were accused of taking money from Big Pharma, to promote the use of opioids for the treatment of pain, despite the fact that it was known that opioids a were highly addictive, and habit forming and B sensitize the brain to pain over time and are therefore not actually effective. Because if you go off of them, as most people who have tried this, no, pain feels worse, your brain is actually more sensitive to pain. And so they went belly up, and they were, and then I read this book that was formative for me, by Anna Lemke. Le MBKE, who is now a friend of mine, called drug dealer, MD, drug dealer, MD, a very controversial and very compelling title. It is a thin, little book, I think it came out in 2016. If I'm not mistaken, I read it. Or I should say, I consumed it in a couple of hours. And I am not someone who writes in books. But I must have written on every page of this book. You must be joking. Oh Mfg. Like curse words and exclamation points. Because essentially, it's the story of how pain medicine has been about earning a buck off of people who are suffering and as we all know, with these lawsuits that are now how Like with the Sackler family and a lot of and also big pharma, you know, what we're learning is that despite the fact that these people and these companies have known for many, many years that opioids are highly addictive, highly habit forming not actually effective over time. And, you know, especially in high doses. Yeah, it's sort of this story of like, you know, follow the money. It's sort of horrifying. So, you know, I also have had conversations with physician colleagues who say things to me, it's a true story that, you know, it's clear that pain psychology plays a huge role in pain and pain management, and would be hugely helpful as with all of these psychosocial treatments, but that a lot of the times because insurance doesn't reimburse these treatments, they either don't get recommended, or they don't get integrated into pain management programs, even at hospitals sometimes, because insurance reimbursement is so crappy, which is just like another eye opening moment like we wait. So you're saying that, you know, these things work? You say that, you know, they're effective, but we're not recommending them and we're not hiring pain psychologists, because insurance doesn't reimburse. So again, it's a money thing. What? So the effective treatments are out there, they're known entities. But, you know, big pharma has billions of dollars to, you know, promote this idea that pain is a purely biomedical problem that requires a purely biomedical solution. So as long as you believe that you're going to buy into that model, and you know, as long as insurance companies are not reimbursing non farm approaches to pain, then you know, we're going to say stay stuck in this loop of treating pain, like a biomedical problem when we know it's a bio psychosocial one. So it's really complicated. Just this discovery that pain medicine has historically really been about the dollar. And it's sort of nauseating and horrifying.   31:56 Well, I mean, I think you can take away pain from that and just say medicine.   32:00 Yeah. Insert health condition here.   32:03 Yeah, yeah, I think it doesn't matter what it is, right? Because it's always going to come back to following the money and where, where can you get the biggest bang for your buck? And unfortunately, that, like you said, Those non pharmacological treatments are oftentimes not covered. So you're getting zero bang for your buck. So as a business, which a hospital is, even if it's not for profit, or an outpatient clinic, are you going to do things you're not going to get reimbursed for? Right, you know,   32:35 no, you know, that's true. And like, I don't mean to sound on empathic. Like, of course, yes, hospitals are businesses, and they have to stay open, and they have to earn money. So so the question for me, like, as I roll along, in this world of this totally insane world of pain medicine, and build my own business, by the way, like, how do we change the system? Like, yeah, we really are patient, patient centric, and like our goal, actually, at the end of the day, is to help our patients get well, what needs to change first, like, does public perception and understanding of pain need to change first? Like, do we need to be training our healthcare providers across disciplines better, like in PT, school, and in OT, school, and in psychology programs like mine, where By the way, I was in school for 40 100 years, and I got zero training and pain, like in my undergrad, brown neuroscience class, we learned about pain, and I became obsessed, and then like, wrote papers and stuff, but but that was it, like not, I have two master's degrees never learned about pain. At no point in my PhD program, did we get training and pain? So? So like, do we need to go, you know, backwards and insert pain education programs in medical schools? Yeah, I know, I know, you and I have talked about this, like the statistic that I'm obsessed with, like 96% of medical schools, in the united in the United States and Canada have zero dedicated compulsory pain education. So it's like, where do we start with this problem, isn't it? Do we like go after the insurance companies and reimbursement rates? where like, where the it's the system is so broken, I sometimes get discouraged, like, where do we start? But I think I actually think what you're doing is a really great place to start, like educating healthcare providers, and the general public about pain, and getting enough people riled up and angry about the way pain has been mistreated, and the way we're Miss educating our health care providers are just not even bothering. Maybe that's the place to start. Like maybe if there's enough of a clamor, and enough people are pissed off about it. Something will change.   34:38 Yeah. And and I agree, I think education, education, education, it has to start there. And especially in medicine, in medical school, especially with the physicians who are oftentimes they are the frontline providers, right, your your regular, your local PCP, primary care physician is often your frontline person and But they're also the people who were traditionally prescribing opioids for everyone, when they would come in with back pain instead of saying, Hmm, maybe maybe you need to see a physical therapist or a pain psychologist, let's sit down and talk to you. How can we let's find out what your needs are, what your bio psychosocial needs are. And so I think if, as the practitioner if you're not getting any education in that you don't know what you don't know. So you're not going to do it. And then I agree, I think, and I think insurance companies need to reimburse doctors and therapists across the board to talk to their patients. Talking doesn't get reimbursed procedures get reimbursed. Right. Right. What's the most important part of diagnosis when you're with a patient? talking to them, understanding what's going on with them, like that is paramount, and that needs to be reimbursed. But insurance companies won't do that they won't reimburse you for talking with your patient. Especially if you're like a PT, we get reimbursed by codes. And and none of those codes are, I'm going to really sit down and try and get into the nuts and bolts of what my patient's problem is. So   36:20 yeah, we need to code for pain, education, community, healthcare provider to patient.   36:25 Yeah, yeah. And some people say, Oh, you could use like the neuromuscular, neuromuscular treatment code for that. But there should be a code for let's talk to our patients, there should be a code for the subjective exam. Yep. Yeah. Oh, yeah. Because how were you supposed to learn about their bio psycho social situation, if you can't talk to them? And ask those probing questions, ask those open ended questions, like you said, In the beginning, bio, psychosocial, a lot of things go into that bucket. And we as the practitioners need to learn as much as we can about all those things that go into that bucket, if we're going to treat this patient efficiently.   37:10 There's so many things in the bucket. And I think, when we assess issues that have to do with pain, we really are assessing the biomedical bucket like 99% of the time. And, you know, if we really are thinking about this as this Venn diagram with three bubbles, if you're only assessing or looking at the biological domain of pain, you're literally missing two thirds of the pain problem. It's just wild to think about it that way. Yeah, if not more? Yeah, yeah, exactly more right now. So like, maybe all of us should be assessing for history of trauma. And maybe all of us should be assessing for aces, the adverse childhood experiences, which we know there's like this slew of studies that show that aces impact, you know, the development of chronic pain and illness and adults, maybe we should all be assessing for, you know, abuse and, you know, poor access to care. And just like so many things that we need to assess for if we're actually going to, you know, do a workup of pain, and instead of just this, you know, tell me about your anatomical issues. And let me do some scans.   38:14 Right, right, on a scale of zero to 10. How would your pain? Oh, it's a 10 out of 10? Well, this is like my little soapbox is what I hate. I see this a lot in physical therapy, student Facebook groups, things like that. Yep. And you know where I'm going with this? They'll say, Oh, well, if someone comes to me, and they're 10, out of 10, I'm going to call the ambulance because they must need to be in the emergency room. Poor education, that therapist was not educated on pain. No, I've not. No, that's wild. Yeah, I hear this all the time. Or those similar Sam 10 out of 10. It's a really, because if like I chopped your hand off, that would be 10 out of 10. So what's your pain now?   38:57 Right? Like this? Right? This lack of awareness that pain, by definition is a subjective human experience. And whatever your patient says it is, that is what it is. And you you actually don't get to argue with them about it. You don't negotiate down someone's pain. Right. And I mean, I think what I've learned over time about pain is there's really valuable clinical information when your patient tells you, like I hear a lot of times like 11 out of 10 literally what your patient is communicating to you is I can't handle this anymore. It's beyond my capacity to cope with this level of suffering. That is what they're saying to you. And usually also, at least for me as someone who really, really likes and appreciates the pain catastrophizing scale, the PCs, which is a potentially controversial term, some people don't like the term catastrophizing, I happen to appreciate it. I think it's very valuable, but don't want to go down that rabbit hole. But the pain catastrophizing scale, but they're also telling me is that when people tell me their pains, Out of 10 or an 11 out of 10, there's a high likelihood that their thoughts around their pain are very intense and catastrophic, and that they're having very intense emotions around their pain too. So it's good clinical information. You know, like you said, You can't bargain with someone about their pain number. Yes, we don't pain haggle. Right. Right. It's not like being at the market. No, like a price price that you get on fish. But but there's rich clinical information in there, if you're willing to, like, Listen for it, they're telling me that they're having an emotional experience that's beyond their ability to   40:37 navigate. Right to cope. And, and that's where I think like, I'll ask that question to all of my patients, because for me, that's my window to crawl in, and really get down to maybe the psycho or the social part of their pain experience. So like you said, if someone says to me, oh, my pain is like, it's at 12 out of 10. Today, and I'll say, Okay, well, can you tell me a little bit more about that? You know, what are you? What are you? What are your feelings around that? Or what's going on at home? What are your responsibilities at home? How does, you know? How does that play into why this pain is? 12? out of 10? Today, right? Right, you know, so it is, like, I always ask the question, but it's a nice way to kind of get in and be able to ask more questions. And, and just because someone says their pain is 12 out of 10, it doesn't mean you call the ambulance, they shouldn't be in the emergency room, they probably worked all day have to go home and have two kids to take care of. Yeah. And they're doing all of this at a 12 out of 10. because like you said, they've reached the end of their way to the ladder. And our job as clinicians is to increase their capacity to handle that. And how and to do that, like you said before, through a multidisciplinary approach to pain management is really the way to go. Because now you have more people who can add to that capacity. Yep. So anyway, that's my soapbox. I will come down stepping down from the soapbox. I appreciate your soapbox. I think Kevin, I'm Sherif share box, but it drives me crazy. Okay, so we talked a lot about different treatments. And I want to talk about treatment that you have created the pain management workbook. So let's talk about that. And how this book that you wrote, can help people who are experiencing pain.   42:40 One of the nicest emails I got in the last couple of weeks was from someone named Karen Litzy, who responded to my email and said that she really liked the pain management workbook and was referring to her patients. And I happen to admire Karen Litzy. So I was really flattered by that. So so the pain management workbook isn't on its own, like some new fangled treatment plan. But rather, I got really frustrated by what I felt like was a lack of resources out there for people living with pain, and also for healthcare providers. In particular, you know, I am a nerd, like a real nerd. And I think pain is just so interesting, and complex and fascinating that I have like, amassed all of these books and journal articles and, you know, resources. But I felt like there really wasn't something that synthesized it in language that all of us can understand and easily give to our patients. So I took a lot of stuff that I loved and was reading, like there's a book called pain, the science of suffering, that I happen to really love. And there's all this work by Lorimer, Moseley, and Adrian low in the PT world, I happen to really love the way I love the language they use for explaining pain. And there's all this neuroscience literature out there that I think is so fascinating and so useful, like melzack, and walls, gate control, theory of pain, and all the things that have evolved from there. You know, and there's all these workbooks on cognitive behavioral therapy for pain, but I couldn't find something that, in my mind, put together all of it into one resource that, you know, anybody with pain can pick up and use right away and use have exercises and guided audio and handouts and all that stuff. So So I wanted to create something that was very user friendly, and I felt like especially during COVID, having accessible and affordable resources could not be more important because here we are talking about how pain at the end of the day is often about money and care is so expensive, and you know, cognitive behavioral therapy and these other things that are not easily or readily reimbursed, end up costing families and patients, sometimes many 1000s of dollars and it should Then be that way. So I literally took everything I was doing in my practice, and everything I was reading and stuck it in a workbook. So it's a lot of pain education. And I have to say, you know, a big thanks to Lorimer Moseley, and Adrian Lowe, who both of them were kind enough to agree to read through my pain education content and give me feedback and consultations and edits, which was like, so kind, and they didn't even charge me anything. And I offered to pay them both. And I wish they had taken my money. But yeah, I wanted them to vet the content. So there's this pain education piece, and then it's a series of chapters of tools. So, you know, again, affordable, accessible care isn't just, by the way, here's how pain works. It's now what can I do about it? So I wanted to make sure that I was offering, like a tool belt of options for healthcare providers to offer their patients like here are 17 different pain management strategies that have evidence of effectiveness that come straight out of the literature, you know, pick a few that work for you, whether it's mindfulness or using guided imagery, or, you know, cognitive strategies, or, you know, sleep hygiene and nutritional tips, like, how do we put this all together to create a unique pain management plan for each one of our unique patients who walk through our door with a unique profile of suffering. So that's how that happened. And I should also say that the book almost did not happen, because my deadline was in 2020, which, as everyone knows, was a shit show of the year. My, my bandwidth was zero, I would sit down to edit, you know, my lovely publishers would send me a couple of chapters, and they'd say, here are some edits, go ahead and make some changes. And I like, couldn't even read through the work I had written, I like my brain just was on overdrive. And I was trying to process what it meant that we were in the middle of a global pandemic. And I sent them an email, and I was like, you guys, I don't think I can do it. So the book almost didn't happen. But in December, it was actually shockingly painstakingly born. So I'm more proud of it than anything I've ever done. I don't know if anyone will ever read it. But I, I'm very proud of it. So I hope it's of use to health care providers to people living with pain.   47:21 Yeah, absolutely. And is this only for adults.   47:25 So the pain management workbook I wrote in language that's usable for everybody. I mean, it's not only for adults, it's. So the book I actually wrote first is called the chronic pain and illness workbook for teens. So it has a lot of similar content, but I wrote it for kids, because there just isn't anything out there for kids. And there's even less for health care providers who are working with kids with pain. So this is adapted from that it has like twice as much content, I would say and is expanded content. So the pain management workbook is sort of intended to be for everybody. And the chronic pain and illness workbook for teens is more specifically for kids in the health care providers working with them. But I've been told by people who just have that book that they have used it successfully with adult patients, too. So   48:14 yeah, so excellent. And where can people find all of this and find you if they want to get in touch with you? They have questions. They want the book, they just want to chat, where can they find you.   48:24 So the pain management workbook. And the chronic pain and illness workbook for teens are both on Amazon. And they're like 20 bucks, which is so much less expensive than around of cognitive behavioral therapy. But I do recommend oftentimes to healthcare providers that they offer the book to their patients, and then offer to go through it with them. Because it's just so nice to have a pain coach to be going through a treatment protocol with. But of course, it can be used as a self help book, you know, on your own. I   48:50 just like love that. I   48:51 love the supportive model. So yeah, there are those are on Amazon. And yeah, I have a really dorky website that has a ton of resources on it. It's just my last name. It's softness, calm. And there's a resources page with like, apps and websites and books and podcasts and guided audio and all sorts of stuff for people living with pain and their healthcare providers. And I also joined Twitter during the pandemic, because I don't know, it seemed like social media was where everybody was, and I couldn't see any of my friends and I couldn't go to conferences. I couldn't have conversations with cool people like you. So I joined Twitter and Twitter, my Twitter handle is at doctors office. That's been really interesting and fun. It's been a really interesting platform. That's I think that's actually how I found you. And then I'm also on Instagram where I post some pain education content too. And that's at the real Doc's off, because I couldn't think of a better name and I got really nervous because social media makes me nervous. So   49:49 well, at least now people know where to find you. How to get in touch with you where to get your book. So this is great. This was a great talk. I you know, I could keep going on and on and on too. about this, I could do like a 10 hour podcast, just on on pain alone. Because it's something I'm passionate about. And it's there's just not enough good information out there for people to access. So hopefully people listening to this will then access some of your resources and education, education education right. Now, before we end, I have one last question for you. And that's knowing where you are now in your life. And in your career, what advice would you give to your younger self?   50:33 What advice would I give to my younger self? Oh, wow, you know, the advice I would give to my younger self is keep doing exactly what you're doing and follow your gut. And trust your intuition and know that following the path of the thing that you love is the thing that's going to bring you to the place you need to be professionally. Like, I wanted to live at the intersection of medicine and psychology, and education and science writing. And I couldn't figure out how to do that. So I had all these different jobs. You know, I was like, a science teacher at the Wildlife Conservation Society. And I was a science writer at a Science Magazine, and I worked at the NYU child Study Center, and I got a PhD and I just couldn't, but but I think, you know, organically what happened over time, just from following my passion, my like, actual passion is that I was able to do all these things. So now I have a private practice. And I'm seeing patients, and I'm writing books. And I have a column in Psychology Today called pain explained where I do a lot of science writing about pain, and I'm teaching pain education at Dartmouth, and at UCSF, which I deeply, deeply love because I get to connect with physicians and other health care providers. And, you know, it's just sort of the it is sort of naturally and organically, exactly what I feel like I was called to do you put it out, you put it out into the universe, and it happened. Yeah, I mean, but not without a lot of trial and tribulation. But I think I would just tell my younger self to trust your gut and trust your instinct and you you actually are on the right path. If you're doing something that you love, you are on the right path, even if you don't know   52:09 Excellent advice. Well, Rachel, thank you so much for coming on the podcast and chatting today. I really appreciate it and I appreciate you. So thank you so much. Thank you for having me. Absolutely. And everyone. Thank you so much for listening, have a great couple of days and stay healthy, wealthy and smart.

In this episode, CEO and Founder of The Bold Leadership Revolution, Tara Newman, talks about creating a better relationship with money. Today, Tara talks about Profit First, her EMS Framework, the common blocks that women face, and helping women feel more comfortable talking and thinking about money. How do you raise your rates? How do we shift our energy without losing money? Hear about startup burnout, improving your relationship with money, and get Tara's advice to her younger self, all on today's episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways Profit First helps women make and keep more money. "I'm really passionate about teaching women to change the way they think, and even talk, about sales." The EMS Framework: Energy. What is the energy in which you're approaching sales? Mindset. What is your beliefs and attitudes around sales? Strategy. This is your sales process, and how you come at it with your energy and mindset. "When we feel good, good things happen." "Shifting your energy and feeling good does not actually have to cost a dime." "Selling is about empathy. Women are empathetic. Women are fantastic listeners. They ask great questions. These are all the things that being a good salesperson encompasses." "The secret to sales is to keep going." "It's okay to be uncomfortable. It's okay just to listen." "Women think that they need to be perfect in order to make money." "I hear from a lot of women that they don't feel safe with money. We were never taught how to make it, manage it, keep it, and use it for growth reasons." "There is nothing more frustrating than wanting to do good work in the world, and not having anybody to do that work with or for." "Raising your rates is actually easy. Can you communicate the value and not the amount?" "Don't take yourself so seriously. Be weird. Be yourself. That's what people want. People buy from people."   More about Tara Newman Through her podcast, The Bold Leadership Revolution, as well as her association, The Bold Profit Academy, Tara Newman is the Leader of Leaders. She supports leaders as they embrace their ambition and leave the grind behind. Using decades of entrepreneurial experience and a Master's in Organizational Psycholgy, Tara is uniquely qualified to teach leaders to run businesses without sacrificing their health, relationships, or integrity by establishing behaviours, habits, and rituals aligned with their vision of success.   Suggested Keywords Sales, Leadership, Money, Income, Lessons, EMS, Energy, Mindset, Strategy, Profit First, Responsibility, Relationship, Communication, Expectations, Healthy, Wealthy, Smart   Revenue Goal Calculator: Profit First Revenue Goal Calculator   To learn more, follow Tara at: Website:          https://theboldleadershiprevolution.com Facebook:       The Bold Leadership Revolution Instagram:       @thetaranewman LinkedIn:         Tara Newman   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:                https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the full transcript here:  Speaker 1 (00:02): Hey, Tara, welcome to the podcast. I am happy to have you on. Speaker 2 (00:05): Thanks for having me, Karen. I'm excited to be here Speaker 1 (00:08): And I will say right when I got on the call. So you can't see this everyone because it's a podcast, but we both have the same rode podcaster microphone. So it's like, this is destiny, but I have a question Speaker 2 (00:23): Because I think I know why we have the same ones by any chance. Did Jason help you set up your podcasting stuff or did you ask him for it? Speaker 1 (00:32): You know, and we're talking about Jason van Orden, did he? No, no. I just did a lot of research and I went to be my gosh. Speaker 2 (00:40): He is like the King of podcast equipment. Yeah. So see, maybe he helped you. I know, I think I got my, this suggestion from him. Speaker 1 (00:48): Yeah. I think I just looked around, I went to BNH and I asked them like, this is what I'm doing. BNH photo is a big store here in New York city. And I said, Oh, I'm debating between like, what's the other one that everyone uses the Yeti. Yeah. The Yeti and the route. And they were like, no, you want the rode podcaster? And I was like, I'll spend the money. I'll do it. I'm going to do it. So so yes, when we came on, I was like, Oh my gosh. And then of course we have all these people in common as well. I guess just a New York thing. I don't know. I know, but you sound less new Yorker than me. Well, I'm originally from Pennsylvania, so that explains it. That could explain it. But I was telling Tara when Tara, when we got on that, I saw her speak at Tricia Brooks speaker salon a couple of years ago, year and a half ago. And I thought to myself, Ooh, I like her mental note, like reach out to her for the podcast. And then, you know, 2020 came and, well, we all know what happened there that we do. We all know what happened there. So I feel like I already know you, but now it's a chance for the listeners to get to know you. So let's get into it before we start. Can you give the listeners just a little bit more about you about kind of why you do what you do? Speaker 2 (02:13): Oh yeah, sure. That's like a, a loaded question. I feel like I could talk about that forever, but I really teach female business owners how to increase their sales so they can have more cashflow and they can have more profit in a way that's simple and without as much stress, because I know that, you know, when I'm working with women business owners, they're usually really amazing at what they do and they're experts and they love it. And they're passionate about it, but they're not as passionate about running a business and I'm actually passionate about the running the business part and the sales part. So it winds up being like a fantastic Speaker 1 (02:55): Partnership. And I will also add that you're also profit first consultant now in my business group that I ran with physical therapists. That was the first book. I said, you have to read this book. Right. And so now this is not a profit first based podcast or anything like that. And we're going to go into a little bit more, but what, what was that like to become a consultant from profit first? Did you read the book and it changed your business? How did that come about? Speaker 2 (03:26): So I actually read the book in 2014 when it first came out before, like right before I started my business, but I wasn't, it's not an easy book to read to be honest. And I think like when I read it, I didn't really read it. Like I dabbled, I think my husband read it. And, and so I didn't actually fully read the book until after I was certified, but I had implemented profit first ish in my business in 2006 teen. And it really changed everything. It made things so much easier. I used to have plenty of revenue coming in, but the cash wasn't there, like the cashflow was off. So I get really stuck. And I remember being in a mastermind and being in my hot seat and just being like, I have no money. So that's really why I love profit first is because it really helps women keep, make and keep more money. And I think that we don't think about that when we start out, we think about like, we have this great idea. We love what we do. And it's like gangbusters out the door and then it's like, Oh wait, like there's this money component. Speaker 1 (04:38): Absolutely. And especially with women, it seems like and I, I know I'm this way. I hear this from people it's Oh, well, it's, it's the charging part. It's how do you bring up to people? What your, what your fees are and, Oh, I feel weird about it. And that the money issue, especially with women can be really sticky. I'm sure you found that. That's why you do what you do. Speaker 2 (05:06): It is really sticky. And you know, we weren't, a lot of us weren't raised with the language for money, especially for me, I'm a gen X-er, I'm 44 years old. My mom stayed home most of the time. She didn't go to work outside the home until later. And, you know, I always say like, women, women come to me and they're meeting me like 15 years into my journey leading them. And so they don't realize that I started exactly where they started. You know, even when I first started my business, that was the first time I was really responsible for my own money. I always tell people, I'm like, I'm so embarrassed. But like, even from before my husband and I were married, I just used to hand him my paycheck and be like, just pay the bills and deal with it. So that was like a really rude awakening when I started my business and my own. And that's really why I've become so passionate, not just about profit, but about helping women sell. Speaker 1 (06:04): Yeah. And, and let's get into that because you have created a framework inside the bold profit Academy, which is part one of the offerings that you have to help women and their relationship with money. And it's called the EMS framework. So we know it's not emergency medical services. I Googled that. It's not it. So what is the EMS framework? Speaker 2 (06:31): I always joke around though and say it's equally important. So the Amis framework, I'm really passionate about teaching women to change the way they think and even talk about sales, right? The way we have absorbed sales and the framing and the lens through which we look at sales is, is actually not really in alignment for a lot of women. Right? And they, you mentioned some of the challenges that they have, like asking for their rate or understanding their value or not having the confidence to have those conversations, not knowing how to have those conversations. They've never been taught. And if you were anything actually like me and my husband, when we first started our first business, we didn't even realize we have to sell things. And what happened was, is we went out of business. Well, I guess we might make sense. And we went bankrupt. Speaker 2 (07:30): Right, right. And we didn't even realize we needed to sell. So ever since then we have made it kind of really a part of our mission is to help people learn from the lessons that we learned. So I've created the EMS framework and it stands for energy mindset and strategy in that order. So what is the energy in which you're approaching sales? Is it desperation? Is it fear? Is it, you know, tense and gripping what's happening with your energy and how can we get you to shift that energy before you even do anything else? And then it's like, what is your mindset around sales? Is it that you don't believe you can sell? Maybe you don't believe you have the personality of a salesperson. Maybe you don't believe that, you know, how any of those things, what are your beliefs and your attitudes is in the mindset piece. And then in the strategy piece, that's your actual sales process. And honestly, any process will work. They're like the same seven steps, all that jazz, but it's how you come at it from your energy and your mindset that makes that the strategic action that you're going to take in your sales process. So much more powerful and potent. Speaker 1 (08:47): And what are some common things that you're coaching your clients through? Let's start with energy, right? What are some common energy blocks that women have and how do you help them get over it? Speaker 2 (09:03): So I think it's one, and I wouldn't say it's necessarily a block. I think it's our conditioning. Do you believe you deserve to feel good as a woman? Like, do you like, do women have this belief that they should, Speaker 1 (09:15): And I have to think about it. So I saw you, right. Speaker 2 (09:21): Because when we feel good, good things happen. And when we feel good, we're more confident when we feel good, we have a better self concept. You know, Brian, Tracy, he's a sales you know, well-known sales trainer. And he just says like, can you just say in the mirror, I like myself, but that's so hard for people to do, especially women to stand there and be like, I actually liked myself. Right. But when you can do that with your self concept and how you see yourself in the energy and what you bring to things that changes everything. Speaker 1 (09:53): Absolutely. And it's, isn't it sad that I had to think about that. I'm like, yeah, I think I deserve good stuff, but it shouldn't be, I really struggle with it Speaker 2 (10:03): That w they struggle with like, feeling joy and pleasure and enjoyment and just good. Right. And it's not fake good. It's not coping in wishing good. It's like, and it's not even like, what's your morning routine, but everyday when you wake up, what are you doing for your energy? Speaker 1 (10:26): Is this a question? No, I'm just [inaudible] Oh, no. What am I doing? Well, what, one thing I do that actually does help with my energy is I get up in the morning and I make my bed first thing. And that actually helps with my energy Speaker 2 (10:44): A hundred percent. Right. And I think you bring up such a great point, because when I talk about this in the, in the framework, what I want women to hear is it doesn't have to cost to me shifting your energy and feeling good does not actually have to cost a dime. It doesn't have to take a long period of time. You know, you can do it at any point during the day, you know, depending on what you're feeling and where you're at. And so if you, if everyone can just wake up in the morning and think to themselves, you know, what am I doing to care for my energy? What am I doing to feel good today? Speaker 1 (11:20): And, and that's a big, that's a very powerful shift, especially in these times when everything there's like tension on top of tension on top of tension. And you know, a lot of people that listen to this podcast are physical therapists. There are health and wellness professionals, and it's, it's stressful, you know? And so being able to do one thing that doesn't cost any more money, it may cost you a tiny bit of time. Not a lot. It takes me two minutes to make my bed in the morning, but I feel like, all right, I've accomplished something. This is good. Speaker 2 (11:56): And Speaker 1 (11:59): When it comes to, so let's say, you've, you, you are working on your energy. And that obviously flows right into the mindset part of things. Right. And oftentimes, you know, you hear a lot of women say, Oh, I don't want to like sell things. Cause it just feels like icky. I don't want to be like that used car salesman, quote unquote. And that is a mindset issue, right? Speaker 2 (12:24): Yeah. I mean, those are your beliefs that you have around, around selling. And so what I like to do is I like to reframe things. So for example, I'll hear somebody say, Oh, I need to create this opt-in so I can lore people in yeah. Loring people. And these are human beings, right? Like you're welcoming people and you're inviting them in, you're sharing something with them that can help them. And the funny thing is, is like women, I think are so naturally gifted salespeople. They just do all the things that great salespeople do it. We just haven't been presented that like, when you think of, of amazing salespeople, I just mentioned Brian, Tracy, right? Like he's a dude in there. There are really great, amazing women salespeople, but there are fewer. And the ones that maybe we think of right off the bat, or like the used car salesman, I hate going a Bob's to buy a couch. No, like that just doesn't work for me. But I think too, like thinking about when you've been, when you've had somebody sell something to you and it's felt really good to kind of shift that perception and to reframe that is really helpful as well. So not looking for the reasons to believe selling is icky, slimy, sleazy, smarmy, whatever your words are for it. And, and finding the examples of it being done really well. Speaker 1 (13:50): And do you have examples of people doing it like women in particular who are doing it very well? Speaker 2 (14:00): So I can share with you the reason why I think women will sell Stu sells really well. So it's about selling is about empathy and that completely gets missed, especially in the online business space, or like as soon as you like flip open an app and there are all these internet marketers swarming about or anything like that, you, you know, you see it in the health, the health and wellness field, it's, it's gross. It's, flat-out gross. The way that people, and I think they just particularly happen to prey on people's pain, specifically women. So we tend to see it as not feeling good. But women are empathetic. Women are fantastic listeners. They ask great questions. These are all the things that being a good salesperson in campuses. Yeah. It's not so Speaker 1 (14:52): Much the sort of vomit all over the person. This is what I do, and this is what I can offer. But instead, it's you doing a little less talking and doing a little more listening. Speaker 2 (15:05): Exactly. Exactly. So from my perspective, when we have women in the bold profit Academy and we're teaching them how to sell, we're not teaching them how to do anything different than they're already doing. We're teaching them to leverage the things that already come natural to them. And they experience success so much more quickly because we're not actually asking them to change their behavior. Speaker 1 (15:30): Right. You're just, you're kind of putting this obviously into a framework, but almost into a, I don't want to say a script, but into an outline, is that the right or no Speaker 2 (15:46): Going to correct you slightly. So the way we do things in the bull profit Academy is through frameworks. And the reason why we pick frameworks is because it gives you a guideline and then you can take that and adopt that to itself. So I'm saying to you, energy is important. You, yoga might be it for you or like throwing around heavy weights might be it for you. Or, you know, I love my Peloton, but someone else might do something else. Right. Someone might not choose to do anything physical, you know? So because I love Peloton, I take Tuneday's classes and she always says she has, I'm giving the class of classes, the recipe, and then you season to taste. And so that's why we do frameworks, because like I said, in the beginning, women business owners, any business owner goes into business because they love what they do. Right. And they're passionate about being the expert that they are. And sometimes the business piece doesn't excite them as much. So we give them a lot of frameworks and templates for them to customize in their business to do that heavy lifting Speaker 1 (16:50): Yeah. Template. That's the word I was searching for. It was not coming into my head template. Listen, and I will tell you the people who listen to this podcast, we love that kind of stuff. We love that. Having a little structure around things, you know, we're, we're a little more kind of type a like, let, give me some structure and I'll run with it. And so how has this EMS framework, how does it impact daily sales habits for small business owners for these female entrepreneurs? Speaker 2 (17:22): Okay. So there's your secret about sales? I'm not one for telling secrets, but there's a secret. The secret to sales is to keep going. So the whole point of the EMS framework is to build resiliency because if you're taking care of your energy and you're looking at your mindset before you take the strategic action, that's resiliency. So when you wake up in the morning and tired and you think, what can I do for my energy to get me to feel good? Right? You're not just rushing into your strategic tasks, feeling like hell and then burning yourself out or, or feeling like poop, right? Like you're, you're actually feeling, you're always feeling good and you're always able to move forward. You're always fueled up and really taking care of yourself so you can keep going. And that consistency is what brings in what brings in the sales and fills your pipeline. Speaker 1 (18:22): And I think you hit on something really important and it's that burnout. And I hear that a lot, especially from women who are just starting their business. They're like, I don't, I feel like I'm already burned out and I haven't even started yet. Right. I haven't even gotten out there. I haven't done the sales yet. I haven't. And I'm already burnt out. So how do you coach those women? What do you, Speaker 2 (18:46): I'm sure they come to you, but that I just actually posted on Instagram. I want to be, I'm going to host be hosting a free conversation around women and business and what I'm calling a global crisis of fatigue among women. The number one reason why women come to me is fatigue, tired, feeling like poo, whatever it is, right? Because we have been conditioned to jump through every hoop imaginable for our success. Women's sex women and success. It hasn't typically come easy. We're the first ones to raise our hands were the first ones to volunteer. We are the first, you know, we do a tremendous amount of unpaid labor throughout our, throughout our lives. And we're exhausted. And then we get into our business and we think that we don't know anything. We think we're doing it wrong. We think that you know, we should be doing it differently. Speaker 2 (19:55): The marketing messages start to come in preying on the fact that women want financial freedom, but have the things like I'm not good enough. I don't see my value. I'm not con right. Like if you, if you really think it's insidious and it's gross. And so what happens is, is there's more hoops. Well, now I need to go take this training and now I need to go take this course. And now I need to go do more. And if it's not happening fast enough, I must not be doing enough. And if it's not right, all the time over and over and over again. And none of that is true. Speaker 1 (20:28): And I have thought that all the time, I still think that all the time, Oh, maybe I should take this course, or maybe I should do this, or maybe I should. And yeah, it's, it is. And it is gross, but it is, it's hard to get that out of your head, because like you said, we've been conditioned you and, and you'll find this really interesting as a fellow podcaster. Talking about that sort of conditioning of how we, we just don't think we're good enough. A, a, a physical therapist or a physio from, from Europe said, how come, how come? I don't see a lot of women as guests on podcasts. I don't understand if we're in a profession that's 60, some percent women. How come all the podcasts are men? How come all the podcasts are hosted by men? Where are all the women? Speaker 1 (21:23): And, and and so a pod, a male podcaster, I guess, sent she's like, well, we asked 30 women, 20 of them said no, and five never got back to us. And, and so I think to myself, this is a tough nut to crack. Is it exactly what you said? I don't know anything. Is it all, this is it. They don't have time because they're raising kids, they have to do this. They have to work. And then I brought up, well, maybe it's a way they were asked because I will ask people to come on and I have had women sad, and I don't know what I would talk about. And I said, well, I wouldn't ask you to come on the podcast. If I didn't think you had something to talk about. So I coached them through and we work on a podcast together. Right. And, and so, I don't know. What are your thoughts on this? I mean, you're a podcaster. Speaker 2 (22:11): So I think, I think that there's, there's a lot of, there's a lot of things that could be at play here. However, what I do know for sure is women who are experts, don't see themselves as experts, right? Women don't see their value, and that's why they struggle to make sales present themselves. And this is whether you're in your own business or whether you're working as a professional in somebody else's business. Right. And so I know that they struggled to see their value and they struggled to see their con like that they're good enough for that contribution. I, myself, when I was first starting out in my business, I turned down oppor opportunities that I was referred for, where people were like, no tower, you need to go and do this consulting gig. And so I do some corporate consulting as well. And I was like, Oh, that company's too big. Or the topic they're asking, I don't feel confident enough on. And you know, I think that's part of, what's keeping women in a, in a financial bracket. That's, that's not sufficient. Speaker 1 (23:15): And what do we, what do we do? What do we do? That's the big question, right? What's your best advice on that? What, like, what do you tell your ladies? Speaker 2 (23:27): So I think what's important about this is that I started a couple of years ago in the mastermind that I run, where we had a quarterly money date that we just got together and we talked about money and we do this in the bull profit Academy as well. And it's okay to be uncomfortable. It's okay. Just to listen, I have had women sit on these calls, looking like they were going to vomit. That's how uncomfortable they were. But I think you have to have these conversations with the right people who understand all that's there around money. And that it's actually not about your mindset, because that's what people get told that this is, Oh, this is your money mindset. You're in scarcity. Yeah. That's why. Yeah. Right. No, that's a marketing message. I mean, yes. Women feel scarcity, but you know, I think that there's a lot to unpack around how we think about money from a generational standpoint, from a societal standpoint, from a racial standpoint, like there are so many intersections when it comes to money, you know, you know, my dad, my dad, my dad's a business owner too. Speaker 2 (24:47): And he laughs at me sometimes when I start to get a little tight fisted, because he's like, you're just being a refugee Tara. This is like the refugee in our family. Like, cause my grandmother fled Poland and it like in 1920 and he's like, you're not in the shuttle anymore, Tara, like you can, you know, and I'm like, that's right. Like they do. I, I, you know, we, we feel that way and it's not always ours that we're carrying, like our parents have passed down messages or grandparents have passed down messages, society. We don't have the language for money. We feel shame around it so much shame around money. Women think that they need to be perfect in order to make money. They think they have to have the perfect family to be successful. They think they have the perfect marriage. They think. I mean they, the stories. Right. And I think that if you can find a safe environment to talk about that so much more and get that support as possible. Speaker 1 (25:42): Yeah. I think that's wonderful, wonderful advice for, for people out there and it doesn't have to be formal. I mean, you can have like a group of, of girlfriends or fellow entrepreneurs that you've, that you trust and that you feel, you can talk about these issues with, because it is hard and I'm gen X as well. And it's the same thing. My mom, wasn't working for most of my childhood and then went back to work a little bit later. And, and it is, there is this, Oh, I don't know if I deserve to make that much money or I don't know, Oh, this seems expensive. Or if I run things even by my parents or something like, Ooh, that seems like a lot, Oh, I, how could you charge so much? How could, and so those messages get stuck in the brain, you know? So it, it does take a lot of work to get that unstuck. Speaker 2 (26:36): I will also say, this is where profit first comes in really handy because it gives you language for money. And it gives you a system for money that if you just do the steps and you just do the system, it takes a lot of I find any system in any structure calms. My nervous system makes like literally my nervous system calms down. And so having that structure for my money calms my nervous system way down and allows me to approach my money from a much different perspective. Speaker 1 (27:10): Yeah. We, in the PT world, we would call that a SIM, which stands for safety in me. So throughout your day, you have Sims, which are safeties in me or dims, which are dangers in me and from a pain science standpoint it is hypothesized that the more dims you have during your day then Sims, you may feel more pain, especially if you're a chronic pain suffer. So we try and have those have more Sims introduced into, into one's life to outpace the dims. That's actually really good. Speaker 2 (27:40): Interesting, because I hear from a lot of women that they feel, they don't feel safe with money. They don't feel responsible with money. We were never taught how to make it, manage it, keep it, and use it to for growth reasons. Like those were things that were not, that were not taught to us. Speaker 1 (27:59): Yeah. And I, I will say like using profit first using that system, I started using that a couple of years ago and I was like, Oh, I do have money. Oh, I see how it works. Oh, when it comes to paying my taxes, I'm not stressed out. Like I turned my quarterly taxes up, it's right there and I just pay it. And it's so like, I feel like so light and I do have a history of chronic neck pain. And, and I will say, this is for me a big, it's like a super SIM for me, because I don't feel that anxiety and stress and around tax time, because I know it's there, I've already done it. It's true. And, and it just makes such a huge difference, but you're right. There is that conversation needs to be had for women around their safety, with money and with sales and with, with confidence around all of that. It's hard. And the thing that's so Speaker 2 (29:03): Interesting about women too, is that they do such a great job suffering in silence. I'm sure you see this. Speaker 1 (29:09): Yeah, yeah. Right. Yeah. Right. Speaker 2 (29:14): Bring in silence and not asking for help. You know, not wanting to receive support. I know a lot of women that I work with feel like they need to know it all or they need to get it all right. Speaker 1 (29:27): Yeah. No, you hit it. You hit the nail on the head before when you said it has to be perfect before I do something. And that was me for years and years, if I'm going to put a program out, it has to be perfect. I have to have, it's all planned out, needs to be perfect. And it doesn't not at all. And it doesn't. And just having, knowing that was very freeing. Speaker 2 (29:50): Yeah. I watch I watch women put a lot of obstacles in their way and, and I know I get that. We do that for self protection. Yeah. To feel safe, to, you know, to, to not fail to, you know, not look silly or foolish or whatever our stuff is. And at the same time we really need to get on with that. Yeah. And we need to find a way to be courageous and brave now more than ever Speaker 1 (30:25): Agreed. Agreed. It's just, yeah. And what would you say to people who are like, Oh, it's so daunting. I'm just not even going to bother. Speaker 3 (30:33): Yeah. Speaker 2 (30:36): Well, I mean, we can have a conversation around what's that costing you [inaudible], you know, and, you know, peel back the layers to that because I can guarantee you that, you know, that's affecting you in ways beyond which you're even able to conceptualize because you're, you're shutting it down and you're closed off. I mean, ultimately people have to be willing to do this and which is why, you know, around the work that I do, it's really important to me to always reiterate to people. It's okay. To be scared. It's okay. If a spreadsheet feels intimidating it's it's okay, like, please don't overthink this, please. Don't overcomplicate this. I am giving this to you the way it is so that all you have to do. I do, we do a lot, like a lot of it in the bowl profit Academy, we do a lot of calculators that like just takes all of the, all of that stuff out of it. Right? Like that charge that, all that charge out of it. If I could just remove all of the barriers and all of the obstacles, I will do that. Speaker 1 (31:50): Yeah. And that's what I think that's what women need, you know, it's what we need to feel good is to say, how can you take away using the analogy? So before, can you take away some of those hoops? Speaker 2 (32:04): Yep. Yeah. Don't don't you dare go into your money without checking on your energy first and your mindset. Do your EMS before you look at your money. Speaker 1 (32:15): Yeah. And that's, that is good advice because we we've all gone into our bank account when I did it the other day, which has happened. What's just happened here. And, and whether that be good or bad. Right. but, but you're right. You have to use that energy that in order to, to get into the sales process, to make money, to help more people, right. Like you said, women want to get into business so they can help people. Well, guess what, if you don't have a good framework what's going to happen. Speaker 2 (32:53): There is nothing more frustrating than wanting to do good work in the world and not having anybody to do that. Good work with her for I have been there. Yeah. Speaker 1 (33:06): And it's an, and then that can lead to this sort of demoralizing mindset. The, I failed. I can't do it well. Oh, well, I was, this is, this is, I'm done. Speaker 2 (33:17): Well, here's where women, here's where women go. I must be charging too much. Yes. So I'm just going to lower my prices. But the reality is, is we just need to up our skillset. Speaker 1 (33:31): Yeah. And, and I I'm guilty of that. I've certainly done that in the past. I'm like, Oh, I'll just, Oh, well maybe I'll just lower the rate. And that will get more people to come in. And it doesn't, it doesn't Speaker 2 (33:45): No, because then you're looking at perceived value of what you're selling. Right. People will be like, why is she, so why is she so cheap? Right. Speaker 1 (33:54): Yeah, absolutely. Absolutely Speaker 2 (33:56): Not know what she's doing. She must not be confident. That's Speaker 1 (34:00): So true. And, and I try, and you know, a lot of physical therapists now are, are sort of using an out of network model or a cash based model where the person pays you up front. And, and it is hard for women to raise their rates. Men are like, after six months, I raised my rate by $50. Oh, I raised it again. No problem. No problem. Women are like, so how do you, what do you say to someone who's like, I can't raise my rates. Speaker 2 (34:29): All right. So there's like the practical piece complex. I mean, it isn't, it's not, so I think there's a couple of things at play. I think if you think that you can't raise your rates, raising your rates is actually easy. You change the number, you put it on your, your chart or your website, right. I mean like the actual act of raising your rates is easy. Maybe we need to do some talking around like how much should you raise them to and whatever. But the reality is is can you communicate the value and, and not the amount, it's not about the amount, it's about the value. And it's about understanding how to talk to people, have a sales conversation and overcome whatever concerns they have around that. So it's, it's not actually a price issue. It's again, it's are you comfortable with selling issue? Yeah. Speaker 1 (35:27): Yeah. And that's like you said, where the listening and the empathy and stuff, that women are so good at any way that they're probably doing naturally, they just don't know it. They just need a framework. They just need a little bit of guidance. Speaker 2 (35:38): Think about someone who, who, or something you've just bought recently. And like, you just couldn't wait to buy it or you couldn't wait to give them your money. Right. Like why, what happened? What was that conversation like? And inspect that because someone is, is like excited and can't wait to give you their money, you know? Gosh, if somebody's back is bothering them. Or I had sciatica last year, that was like my worst hell ever. So, you know, I would have paid millions of dollars for someone to make that go away. It wouldn't have even mattered. I wouldn't even cared if you were like, I can help. You'll be like, awesome. Speaker 1 (36:13): Yeah. And, and I hear that so many times over and over again from people who are not physical therapist or not health and wellness professionals. And I think it's, I love that you said that because I think it will give the people a little more confidence. Speaker 2 (36:30): Yeah. I mean, if you're, if a lot of your audiences like physical therapists and chiropractors, I will tell you that, like I had, I've worked with a couple of chiropractors and they're like, I went to the chiropractor convention, I'm going to be facetious and silly. I went to the chiropractor convention and I came out with this 4,000 page manual on how to run my back office and my front office and all this stuff. And I'm like, great. So what are you going to do to actually stand out? Because the 5,000 other people that went with you got the same 4,000 page manual. And so I find a lot with health practitioners that I work with, they really it's beneficial to get outside of that health practitioner loop and, and, and look to find strategies from other industries talk to people who are outside that industry. Speaker 1 (37:23): Yeah. Yeah. Great advice. I Speaker 2 (37:25): Mean, that's with any industry, but I just specifically know sometimes that, you know, or, or in health industry too, you, you tend to have a lot of regulations and quote unquote rules. Right. So you'd get very stuck in like, well, the regulation, the regulation, the regulation. And so I sometimes come in and I'm like, Speaker 4 (37:47): Is that really the regulation? Speaker 1 (37:54): But yeah, it is that, that is true. There are some perimeters from which we have to work around, but you can still work around them and be successful and, and have a better relationship with money, which is all, you know, what we're talking about here today is just to how to have a better relationship with money and how to not be afraid of it and how to move forward with your business, knowing that it's, it's part of business. Yup. Period. When we take it personally, but it's business, it's business. Yeah. It's business. And now before we wrap up, is there anything that maybe I over or that we didn't cover that you're like, Oh, I really want to, I really want the listeners to know this. Speaker 2 (38:43): I think we really we really covered a lot. Actually. We talk a lot, we talked a lot about money and sales, which is so exciting to me cause I can talk about that forever and ever and days. Speaker 1 (38:56): Well, speaking of which, where can people find out more about you to learn about when you're, when you have events and learn about your programs and follow you on social media and all that fun stuff. Speaker 2 (39:08): Okay. So the first thing that I want everybody to do is I have a resource for your crew. So if they go to the bold leadership revolution.com forward slash resources, I have a revenue goal calculator that actually you plug in your personal information, it tells you based on how much you need to make to cover your expenses. It tells you how much revenue you need in your business. And it'll plot it out with profit first. It is nifty Speaker 1 (39:39): Amazing. And we'll have that link in the show notes. Speaker 2 (39:44): Yup. I like to hang out on Instagram. So I'm at the Tara Newman and I have a podcast, the bold money revolution. Speaker 1 (39:51): Awesome. So Tara, last question, knowing where you are now in life and in career, what advice would you give to your younger self? Speaker 2 (40:03): Hmm. Don't take yourself so seriously. I'm a serious person. Like I could be super serious. And I think like if I had to do it all over again, just like be weird, you know, be yourself. That's what people want is people buy from people, right? Like you're humans are out there and they want to work with you and they want to know you in all your weirdness and all the things like just be you it's, it's really that simple. Speaker 1 (40:34): Yeah. And I remember having this conversation with someone else on the podcast and said, you know, you want to be the Flamingo in a sea of penguins Speaker 2 (40:45): For sure. Speaker 1 (40:46): Because there's like you said, there's someone out there who's looking for you for you. And if you're like everyone else they're going to miss you. Speaker 2 (40:54): They, yes, there are people who are out there. And I think here's the thing when you beat, when you're more, you, you S like other people feel seen. And when you tell your story and you can connect with people, like just super quick, I just had a recent ADHD diagnosis at 44. And I, when I was like, Oh, I think I need to get an evaluation done. I went and we went to listen to the whole bunch of podcasts and I just typed in ADHD. And there were all these women podcasters with ADHD, and I would listen him. And I would cry because I didn't know how to, I was so normalizing what was not normal, but I lived with it my whole life. And I didn't know. And them sharing their story helped me see, like, what was normal, what wasn't normal, what I needed to talk to my doctor about places where I could be releasing guilt that I felt about things. And so I think it's just so important. Speaker 1 (41:59): Yeah. And thank you for sharing that. That's so, so powerful for for people to know that there are others out there going through the same thing and that yes, you're seen in your herd. And I think that's a great way to end the podcast. So thank you so much, Tara, for coming on, and I really appreciate it. And I can tell you that all the listeners do too. Speaker 2 (42:21): Thank you so much for having me Speaker 1 (42:23): And everyone. Thanks so much for listening in today. Have a great week and stay healthy, wealthy and smart.  

In this episode, Physical Therapist in Detroit, Ted DeChane, talks about his experience living with Long Covid. Today, Ted talks about his Long Covid timeline (including attempts to return to baseline, his relapses, and his work), the Long Covid Physio group, and the mental aspect of managing Long Covid. How has Ted adapted his life and work around Long Covid? What is the most common question people ask him about Long Covid? Hear about the importance of peer support and shared experience, the role of Physio in managing Long Covid, and how cognitive and emotional fatigue can set off Long Covid, and get his advice to his younger self, all on today's episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways "Long Covid in itself is not caused by anxiety, depression, and those things, but they certainly do exist." "Finding the things that help you get through the day is really important." "If you don't allow yourself that pacing, that rest, you're going to be forced into it." "It's so much more than just the physical aspect of having Covid. Emotional and cognitive overload can cause these physical symptoms as well." "We [physios] can play a huge role in the Long Covid epidemic." "Sometimes these symptoms can come days later." "Helping them [patients] log what's triggering their relapses is helpful." "If youre interacting with people with Long Covid, just have a little sensitivity around some of these questions. They can be triggering, and they can be stressful, and can be something that can increase symptoms of Long Covid." "10% of people who are diagnosed with Covid may have Long Covid symptoms." "Don't be so rigid in your box of knowledge. What you learn in PT school is great, but there's so much more out there. Be open to things you haven't heard of or things that don't fit what you've heard." "It's okay to step outside your box and look at something from a different lens. Even if it doesn't quite make sense yet, be open and willing to learn about something a little different."   More about Ted DeChane Ted DeChane is a physical therapist in the Detroit area specializing in pediatric therapy. He covers multiple settings including school-based, outpatient, and acute care. Ted became ill with COVID-19 in March of 2020, and continues to experience persistent symptoms. As part of the Long Covid Physio group, he has contributed to podcasts, articles, and peer outreach.   Suggested Keywords Covid, Long Covid, Physical Therapy, Physiotherapy, Recovery, Mental Health, Support, Fatigue, Symptoms, Adaptation, Relapses, Healthy, Wealthy, Smart,   Resources: Ted - "Living and Working with COVID." Uncharted: Patient Experience With Long COVID   Round Table Talks: Round Table Talks   To learn more, follow Ted at: Website:          https://longcovid.physio                         https://teddechane.wixsite.com Twitter:            @TedDeChaneDPT                         @LongCOVIDPhysio Instagram:       @longcovid.physio LinkedIn:         Ted DeChane   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, Ted, welcome to the podcast. I am happy to have you on this month as we're talking all about long COVID. So welcome.   00:10 Yeah, thank you for having excited to be able to talk about it. Okay, so   00:15 let's start out with the basic question. What is your interest in long COVID?   00:22 Yeah, unfortunately, it's kind of been thrust upon me, it wasn't something I chose to be a part of. I became ill with COVID symptoms in March of 2020. right at the beginning of the pandemic, I work in an acute care hospital in the Detroit area, which was a early hot spot, so hard to say where how I contracted it. But regardless, I did, and I had the pretty classic textbook COVID-19, acute phase, cough, fever fatigue, lasted about probably two to three weeks, that initial acute phase, and I had recovered mostly so I thought, went back to work back to exercising back to running, living, all those things and just couldn't, couldn't quite get back to where I wanted to be and was pre illness. I had just been suffering from fatigue, and since some heart rate issues, inability to tolerate exercise, and it was beyond the kind of normal deconditioning. You know, I've been in and out of running for years. So I knew that, you know, when you first get back into it, it's not always fun or pleasant. But it wasn't that normal, fun or not fun or not pleasant feeling it was this, just complete debilitation, you know, laying on the couch in a dark room, couldn't even tolerate sitting up kind of thing. And that's when I initially knew that something was wrong and started reaching out to healthcare professionals. My own health care professionals couldn't really give me an answer. It was unheard of at that point, that early on. But I connected through Twitter of all places with some other people who were experiencing nearly identical thing that I was. And that's when we kind of realized that this was a bigger problem than it had seemed to be initially. So that's kind of where we, especially a group of physical therapists got together and kind of began bouncing ideas and symptoms and trial and error off of each other and realized what was working, what wasn't working. And it was through that, that we kind of became this long COVID physio group to try to help each other initially and then realized that we needed to start helping others as well. So that's kind of how I got involved in the long COVID. process.   02:50 And it must have been quite scary in the beginning, because like you said, the doctors didn't know no one knows. So very early on. Do you remember when that diagnosis of long COVID symptoms or you know, being diagnosed with lung COVID? When When did that happen? Like what was the timeline on that?   03:14 Yeah, it's definitely a fuzzy gray area in the beginning, you know, I was sick in March, God, quote, unquote, better April, May. And then June is end of May, early June, is when I really began trying to pick up the running, I was like, Okay, I have to get going. You know, it's time I've been down for a month and a half now. And that's kind of when my gears started turning that it wasn't right. It wasn't until probably October or November that for me the phrase long COVID really hit home and, and I kind of gathered that that's what was going on. So it, it took a long time for me to realize for others to realize that this wasn't right. It's not, you know, expected progression of what we thought was supposed to happen.   04:03 Yeah. And I think Daria echoed a lot of what you just said, in that she was like, I just wanted to get back to running. I'm a PT, so I'm just going to use graded exercise. And that did not work.   04:15 Yeah, it's, it was really kind of a mindset shift. When you when you really get down to it, you know, we as pts we know that we need to go or we think we need to go I should should correct myself. You know, we thought that's what we had to do. And we tried it and we we did not it didn't work. So yeah, that really clued me especially in that, you know, this wasn't right, you know, as pts where we're supposed to be the experts at monitoring Response to Intervention so that I just, you know, it's hard. It's easy to do in when you're monitoring a patient's response to intervention, but when you're kind of monitoring your own, it really was another hurdle to cross to accept that. You know, I Can't do these things right now. So   05:02 and you know, dari and I also talked about that mental aspect aspect of it, and how, gosh, so challenging? So what what have you done around your mental health and the mental aspect of living with long COVID that maybe you can give advice to others?   05:20 Yeah, that's a really important part of it is the mental health aspect. You know, we always stress that there is can be a lot of anxiety, depression, fear over a long coat COVID in general, but especially long COVID diagnosis. But we also want to emphasize that that is usually a secondary issue, you know, you know, long COVID in itself is not caused by anxiety, depression, those things, but they certainly do exist. And it's, it would be remiss to, to not mention them. For me, personally, you know, there was a long time where you kind of get that dark cloud over you, and you think, am I ever going to get better, and I still have those days, to be quite honest. But, you know, I think just focusing, and thinking about the positives, and the gains that I have made, personally, has really helped me. You know, I, I see it a lot on my Twitter and my Facebook history timeline coming up, especially this time, on my runs that I did, and all my failed runs that I did, and you know, even not going to work some days not getting off the couch some days, and those days are less than less than less now. So really looking back where I was, and where I am now is, it's been really important for me, to see that there is progress being made. It's it's not linear, it's not quick, but it's there. So that has helped me personally kind of get through that. But in addition, the peer support has been really instrumental, um, that we've created kind of through long COVID physio, there's a whole group of us who kind of have a very similar mindset, a very similar training, and a very similar experience. So we can all kind of commiserate and, and vent when we need to, but also pick each other up when we need to share resources, those kind of things. So finding that group has really been helpful.   07:09 Excellent. Yeah, finding that having someone who's gone through what you've gone through, or is currently going through, that peer support can be so so helpful. And we'll have a link to long COVID physio in the show notes for this episode for anyone who wants to learn more about what you guys are doing, and maybe they need the support themselves. So we'll have a link to that. And now you said something. Just before about some days, you can go to work, you can't get off the couch. So let's talk about how one can adapt to living with long COVID because we got to do things, right. I mean, most of us have to work or most of us have to do things around the home or with family and friends, etc. So can you talk about adapting all of that while living with long COVID?   08:04 Yeah, initially, that was really tough thing for me to do. And even still, it is a very tough thing to do, especially as pts, we have a very active physical job. Regardless of what setting you work in acute outpatient, you know, I'm in pediatrics, as well as acute care. So there's a lot of up and down moving, running, note taking cognitive, mental, emotional exertion that's going on, and all those things can trigger these long COVID crashes, relapses, post exertional malaise, whatever your name of choice is. So finding the things that help you get through the day is really important. Some of the things that a lot of us have found helpful. pacing is a big one. So you really have to look at your day, how can you chunk it up and kind of take things minute by minute, which is, again, hard to do when there's productivity demands and billing demands, and maybe you're a clinic owner, and you're, you know, relying on that income. So that is a really hard thing to do. But it's so important. And I always say that if you don't allow yourself that pacing, that rest, you're going to be forced into it. So it's better to do your best to plan around it rather than let the kind of disease process do it dictate it for you. So, you know, if I think I'm going to push through this week, and I'm, you know, going to make my productivity while the next week, I might have to take two days off work and then I'm not helping anyone. So, you know, really accepting the fact that you do have to listen to your body and rest when you need to and, and make the accommodations at work, whether it's building in an extra break, or maybe you need to do your charting in a dark room. You know, maybe there's a half hour in the day where you can just lie down on a mat table in a treatment room and have you know, 1520 minutes You know, no stimulation, it's really about finding those things in your day that make make it easier. So you can last, you know, through a day through a week through, you know, a month kind of thing?   10:14 And how would you suggest someone have this conversation with their supervisor, Boss owner of the clinic they work at, because you obviously have to have cooperation with the people that you work for. Now, if you're your own boss, I guess that's a different story, you can probably, you know, kind of set your schedule accordingly, maybe, but what advice do you have for people who maybe have to have these difficult conversations with their employers?   10:42 Yeah, it's, it's a really tough place to be in for the employee, and also the employer, you know, they have a budget to make to, I get why they, you know, set these demands, but at the end of the day, you really just have to be open and honest with them, and your co workers about what's going on, what your needs are, how you how you need the accommodations, you know, that's a struggle a lot of people are having, especially in the US, we don't have a lot of options, as far as you know, paid time off. You know, in the UK, there's, there's union representation, which we don't have in the US, generally speaking as a profession. So it's really important that you can connect with your boss and explain the importance of the, the needs for accommodation. You know, we do know of a few people who have been successful kind of navigating the, you know, short term, Long Term Disability here in the US under like a chronic fatigue type diagnosis. So that may be a route you have to take, if you're finding trouble getting these accommodations, obviously, try to find a, you know, physician who is supportive of your long COVID and the needs for the documentation that you might need for that. You know, but I, I'm fortunate enough that I have, you know, administration who has supported me, and I think that's do a lot in part A to them, thankfully, but also, you know, just to the open and honest dialogue that you have with them, and explaining the needs and how putting in these needs now can save you some time later. You know, so that it's beneficial to everybody.   12:26 Got it? Yeah, great advice. So just being open and honest with your communication with your supervisor, employer, etc, would be your best advice to people who maybe are living with long COVID and don't know how they're going to get through the week.   12:41 Yeah, you know, hopefully, that route works, obviously, there's going to be places where that isn't going to work, where you might need to escalate. In addition, you know, finding co workers who are supportive, you know, maybe you have a close coworker that you can confide in and kind of help you through the process. You know, I kind of had a funny story when I was kind of navigating my own long COVID process. I had a co worker who texted me and she said, Are you feeling okay, today? And I said, Actually, no, you know, how did you know because I thought I was holding it together. And she's like, Well, I can tell whenever you're not feeling well, because your voice gets deeper. And I just thought, Oh, that's really cool that she was able to notice that, because I didn't even notice that. So, so finding a co worker who you can lean on, and maybe they can, you know, help you through things, if you have a difficult patient you need help with or you say, Hey, I have to take the afternoon off, can you help cover some of these patients? So it's not, you know, such a burden on the clinic, kind of thing, just building those relationships, and being open and honest about it.   13:41 Yeah, makes perfect sense. And you sort of touched on something that I want to highlight. And that is when people think of long COVID and they think of pacing, they think of the physical pacing. Right. So moving your body pacing, but you also touched upon and I would love for you to go into a little bit more the cognitive and emotional fatigue that can also set off long COVID So could you explain that for the listeners?   14:11 Yeah, that's a really difficult piece to manage, because it's not as black and white as some of the physical things that happen. But a lot of us, including myself have noticed that with increased cognitive load, you know, we have the same physical symptoms that we would if we were to run a mile you know, just maybe we had a really hard case we needed to critically think through or or, you know, in my case, I was doing a lot of spreadsheets over the summer we were doing some budgeting things and normally that would not have been a problem for me but I just and this was before I even realized what was going on. You know, I was having struggling with these spreadsheets and and that kind of would set me back and and I would have to shut the computer off and and take a step back in a day off and Um, so those things we don't really realize are adding to the stress of our mind and our body. You know, the documentation and screen time, if you're doing a lot of notes on your computer, or you're doing virtual sessions kind of thing that can really fatigue your body and give you a lot of the same symptoms as physical would. Are you muted there, Karen?   15:25 Yep, sorry, I was just saying kind of unbelievable, right? Because it's like, it's so much more than just the physical aspect of having COVID. It's, you know, people talk about brain fog. And they, they talk about fatigue, but knowing that just emotional and cognitive overload can cause these physical symptoms as well. And I think that's something that a lot of people are not aware of.   16:04 Yeah, and I think a lot of people have set themselves back thinking they're doing a great job pacing and not realizing that they're still carrying the emotional load of their patients, or maybe there's something going on at home a relationship issue, you know, family stress, things like that can can add to your total body fatigue, and that's. So when you look at your, your work day or your home day, you also have to include that piece too. So like, for me, one thing that I found difficult was bouncing back between patient care and documentation, just the back and forth was like a lot for me to get my brain switched into like documentation mode, and then back to patient mode. So, you know, for me, what I found helpful is actually kind of, you know, doing a few patients in a row, and then then going and doing a couple notes at a time, rather than where I would normally do you know, a patient, a note, a patient a note. So everyone's different, that might not work for somebody. So it's really finding that balance of how you can navigate doing your job, but also not being a detriment to your own health.   17:15 Yeah, so it sounds like a little bit of trial and error until you kind of find that sweet spot.   17:21 Exactly. And that's kind of what we tried to learn from each other in this peer support group is, hey, what worked for you? Because I might like to try that. So   17:30 make sense. Now, let's talk about the physios role when it comes to long COVID. So where do we fit into this recovery in this puzzle?   17:41 Yeah, I think we can play a huge role in in the long COVID. epidemic, if you want to call it that, because that's what it will become if it isn't already. I am fortunate enough to not have to be treating these patients right now, especially in pediatrics, there is cases of lung COVID. In kids, it's not as prevalent. Unfortunately, I've not had to deal with that. But as physios, we are spending a lot of time with patients, more so than most, any other health care provider, you know, we have the knowledge of pacing and, and monitoring, medical status. And I think we need to use that. So being a part of the pacing process for patients I think would be good because that is a cognitive tool for someone to sit down and plan out their day. So if you can kind of help them be there to guide their day, just as you would a patient who has, you know, hip replacement or cardiac surgery, you would you would be the person to help plan their day out to make them the most efficient. So that's something you could also as a PT, and do for a long COVID patient being the one to help them through that. But But in addition, you know, as I kind of mentioned in my intro, that response to intervention is so important and what sets us apart from other providers is that we we can pay attention to what's going on. You know, and make sure that our treatment isn't a thing that's doing harm and causing the post exertional malaise or symptom exacerbation. And it's really important to look through that through a lens of not immediate either sometimes these symptoms can come days or later. So think of it more like delayed onset muscle soreness, you know, you might do a treatment on Monday, they may be fine Tuesday and Wednesday and then Thursday, all the sudden they flare up. Well, it could have been your treatment on Monday that caused that. So it's important to recognize and do a look back at each session, you know what happened kind of thing to kind of help help the patient progress because if they're going into these crashes, they're not progressing. They're regressing so it's important to progress rather than regress.   19:55 Yeah, so it sounds like it's a lot of on the physios part, certainly education. to the patient. And and I really love how you said you can help them set up their, their pacing schedules, you know, you can be the person, you You said you have the long COVID group to bounce ideas off of, well, you can be this person to help them bounce ideas off of right?   20:16 Yeah, exactly. They might not have a peer support group that they found, you know, or they might be overwhelming for them to go to a peer support group. So for you to be the patient, or the person to say, hey, let's sit down and say, Okay, so the shower is an issue for you. Well, how can we fix that maybe you need to sit down when you shower, maybe you need to shower in the evening, something like that, you know, trialing and airing with them. And you're helping them log what's what's causing and triggering their relapses is super helpful.   20:48 Yeah, I think that is great advice for any physio, who is going to be working with anyone with long COVID to kind of know that it's more than just giving exercise way more.   21:00 Yeah, absolutely. You know, you we have a huge role as far as physical therapists and it goes beyond exercise. You know, that is an important piece of, of our profession, obviously. But there's so much more that we can do and, and step outside of our, you know, musculoskeletal box and kind of really help these patients at the end of the day.   21:21 Yeah, I think that's great. Thanks for sharing that. And now I have a question. What is the most common question people ask you about living with long COVID? Because I'm sure you get questions, even if it's family, friends, if you divulge to your patients, hey, I'm living with long COVID what's what's like the main question you get from people?   21:43 Yeah, there's a lot of questions. You know, the biggest thing could be it could be questions, that's okay. Yeah. Well, the a lot of people always ask about, did you have the vaccine? Did that help you? And my answer is no, that's a big question. A lot of people did find relief from the vaccine I personally didn't. But then a lot of a lot of the times the question I just get is, how are you? And that's a really tough one. Because you never know that they want, you know, I'm fine. How are you? Or do they want the Well, today, I have to lay on the couch for an hour in the darkness. And so that that is a tough question to navigate. It's just the How are you? So if you are asking that question of long COVID of, you know, patient, someone who's living with long COVID, you know, be prepared for a full answer. You're actually intending that. So, because it can be loaded?   22:35 Yeah, absolutely. Yeah. I don't even think about that. How are you? Well, yeah, really want to know, or do you want me to write? Exactly, yeah, yeah, yeah. Yeah. I think that's a great advice for people to what's what's it a question that you wish people would ask you? Or maybe how to phrase that? How are you questions? You know, what I mean?   23:00 Yeah. You know, I don't mind that. How are you question? As long as it's coming with, you know, good intent, and, and all that. So, you know, I think it's okay to ask, but also know that maybe that can be a stressful question for for someone. So, you know, maybe, maybe instead saying, you know, is, you know, how, how are you feeling today? Is there something I can help you with kind of thing, you know, putting a more kind of purposeful spin on it rather than, you know, just kind of, for your own personal curiosity. So,   23:35 yeah, I love it. I love that. How can I help question? I asked that a lot. And it's Yeah. So nice for someone to hear that. Especially. I think people living with long COVID many of you don't look sick. You look fine. I'm sure people have said that to you. Countless times. And it drives me crazy. That's a tough thing to hear. Yeah, you look fine. It's one of those invisible diseases, and it's invisible diagnoses. And I think that can be very stressful. Yeah, you know, you do hear that. Oh, you look good today. Well,   24:15 I did a good job then. Cuz? Because I don't feel good. A lot of days. So yeah. You know, and I get where people are coming from, but it is, it is kind of just something that is a hard thing to hear. Yeah,   24:27 yeah. Yeah. So I think for people, if you're interacting with people with long COVID just have a little sensitivity around some of these questions, you know, because they can be triggering, and I think that they can be stressful and as we just spoke about stress can be something that can increase symptoms of long COVID. So we want to try to minimize that throughout the day, right? Hmm, yeah. Well, Ted, I have to tell you, this is great. I'm so looking forward to Our roundtable discussion at the end of the month with you and Daria and Darren, and maybe a surprise guest in there as well, time will tell. Because I just think, as we discussed before went on the air, it's timely, it's important. If the, if they're modeling out 10% of people who are diagnosed with COVID may have long COVID symptoms, it's a lot of people. And so if you're a physio, odds are you may be seeing someone come into your clinic with long COVID.   25:35 Yeah, and even that 10% number could be conservative. So it's, it's hard to say there are a lot of a lot of people out there and a lot of people who still haven't heard of long COVID, especially outside of the medical community, I've run across a few people who have kind of talked to me. And as they start to tell their story, I kind of have that little thought in the back of my mind that, you know, this was me 15 months ago, I can hear some of the things they're saying in myself. So   26:02 yeah, yeah, well, hopefully things like this will help get the word out to more and more people. So thank you so much for your honesty, and for sharing your own story here on the podcast now, where can people find you if they have some questions?   26:17 Sure. Yeah. So my main social media is my Twitter. It's at TED Duchaine, DPT. And then we also have just started long COVID we have our peer support long COVID physio group, but we also just started a page for people who aren't living with long COVID just for information. So that's on Instagram at lone COVID physio, and also on Facebook and Twitter at the same handle. So   26:45 Excellent. Well, thank you so much. And we'll have links to all of those at podcast out healthy, wealthy, smart, calm under this episode. And last question, knowing where you are now in your life and career. What advice would you give to your younger self? Let's say fresh out of PT school?   27:03 Sure, yeah. I would say don't be, don't be so rigid and you're in your box of knowledge, what you learn in PT school is great, but there's so much more out there be open to things that you haven't heard of, or things that don't fit what you've heard. You know, I can honestly say that have had I not been living with long COVID I would have had that little squint in my eye that a lot of pts probably have right about now listening to this. And, and that's totally normal, but it's okay to step outside your box and, and look at something from a different lens, even if it doesn't quite make sense yet. Be open and willing to learn about something a little different.   27:46 I think that is great advice. Thank you so much for that. And thank you for coming on today. It was pleasure. Yeah, thank you, and everyone. Thanks so much for listening. Be sure to catch us for our roundtable talk, and have a great couple of days and stay healthy, wealthy and smart.

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

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

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

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

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

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