Healthy Wealthy & Smart

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Leigh Hurst on the show to discuss breast cancer awareness.  Leigh Hurst is a breast cancer survivor and the founder of the Feel Your Boobies® Foundation, which she started to educate young women (under 40) by reminding them to "feel their boobies" - a call to action that can save their life. Feel Your Boobies® is one of the largest followed breast cancer awareness foundations on Facebook and has inspired women all over the world to feel for lumps starting before they are formally screened for breast cancer. And, most importantly, it has directly resulted in countless women finding lumps early and giving them a better shot at living a full, meaningful life after their diagnosis. The Feel Your Boobies® Foundation has been featured in The New York Times, New York Daily News, and other national publications. At one point, Feel Your Boobies® was the largest cause on Facebook, with more than 1 million supporters. In this episode, we discuss: -Leigh’s experience advocating for her own breast cancer diagnosis -The story behind the Feel Your Boobies Foundation -Why women need to prioritize self-care -The voices of breast cancer survivors in the book Say Something Big -And so much more! Resources Leigh Hurst Website Say Something Big Book Say Something Big Facebook Say Something Big Instagram Feel Your Boobies Website Feel Your Boobies Facebook Feel Your Boobies Twitter Feel Your Boobies Instagram      A big thank you to Net Health for sponsoring this episode! Learn more about the Redoc Patient Portal here.    For more information Leigh:   LEIGH HURST is a breast cancer survivor and the founder of the Feel Your Boobies® Foundation, which she started educate young women (under 40) by reminding them to feel their boobies - a call to action that can save their life. Feel Your Boobies® is one of the largest followed breast cancer awareness foundations on Facebook and has inspired women all over the world to feel for lumps starting before they are formally screened for breast cancer. And, most importantly, it has directly resulted in countless women finding lumps early and giving them a better shot at living a full, meaningful life after their diagnosis. The Feel Your Boobies® Foundation has been featured in The New York Times, New York Daily News, and other national publications. At one point, Feel Your Boobies® was the largest cause on Facebook, with more than 1 million supporters. Hurst is also the author of the new book, Say Something Big: Feel Your Boobies, Find Your Voice. Stories About Little Lumps Inspiring Big Change (Oct. 2020) Beyond her work with Feel Your Boobies®, Leigh regularly speaks to audiences large and small, sharing her own personal journey and inspiring others to “Say Something Big” amidst life’s hurdles and hardships. She resides in Pennsylvania with her family. Feel Your Boobies® uses innovation around media to reach women across the world with their important message. For more information, visit www.leighhurst.com or www.feelyourboobies.com, and connect with Leigh on Instagram, Facebook, and LinkedIn.     Read the full transcript below: Karen Litzy (00:01): Hi, Leigh, welcome to the podcast. I'm happy to have you on. Leigh Hurst (00:05): Thanks for having me, happy to be here. Karen Litzy (00:07): Yeah. And now we're in the month of October. And for those of people who don't know October is breast cancer awareness month. And in the past, I've had shows about breast cancer during the month of October, but this is the first time I am speaking to a breast cancer survivor. So thank you so much for coming on and sharing your story because I know it's going to be so helpful for other women and men listening to this podcast. So before we kind of get into everything, I'm going to just throw it over to you so that you can just kind of tell your story how old you were when you were diagnosed. How did you find out? So I'll send it over to you. Leigh Hurst (00:51): Okay, cool. Thank you. So I was officially diagnosed when I was 33 that I had felt the lump for some time leading up to the actual diagnosis. So I think I was probably around 30 or 31 when I started to notice the lump. And I was living in New York city at the time and I was a marathon runner. So really health conscious, certainly educated about my health felt very kind of plugged into that kind of thing. And for a little while, I didn't really think much about it. I just thought it was, you know, something no big deal. I really small breasts. So I felt like when I'd go to the doctors, I'd let them sort of do their exam of my breasts and they would never notice it until I would point it out. So I would literally take their hand, put it on my boob and say, this kind of feels a little different to me. Leigh Hurst (01:39): I don't know if you notice it or not. It's like a ridge on the outer side of my left breast and then they would feel it and then they would say, I don't really think that's anything to worry about. I had no family history, so I wasn't exceptionally worried about it. Although, as I know now, that's not necessarily a primary risk factor. It is, but most women diagnosed don't have a family history. So I was pacified about that for a while. You know, that kind of went on for maybe a year or two. I eventually decided to sort of simplify my life and I moved out in New York city. I was in a really kind of super corporate job, traveled a lot for my work on a weekly basis. And I was just trying to find ways to sort of step out of that. Leigh Hurst (02:20): And so I moved back to central PA, which is where I live now. I'm kinda got set up on a house was back near my family and it came time for my annual exam. And I went again to the doctors and again, it wasn't noticed, but I mentioned it and it was the first time someone's like, Oh, she probably should just get a mammogram. It can't hurt to sort of just see if it's something or not. So that's how it started and ended up having the mammogram showed some areas of concern, took me right in and did an ultrasound and eventually at the biopsy a couple of weeks later and it did turn out to be cancer. So that was 2004. And you know, needless to say, I was very concerned because I knew I had had the lump for quite some time, so I wasn't sure what to expect, but it didn't turn out to be stage one, so early stage breast cancer. Leigh Hurst (03:09): And so, yeah, that's kinda how it started with, you know, finding out that I had a lump and went through treatment. I decided to have a lumpectomy, the lump was small stage one had no lymph node involvement. So that was good. And I did do chemotherapy because I was young. So they suggested that because of being premenopausal and being so young at the time, it was some preventative. So I did chemotherapy than I did seven weeks of daily radiation treatment to the lump site. And then I took five years of a pill called Tamoxifen, which is estrogen reducing medicine at the time they were still prescribing it for five years. I believe now the regimen is 10 years. But so the actual treatment itself was about six months start to finish. And then it was the five years of the Tamoxifen following that. Karen Litzy (03:59): And at the age of 33, you must have been kind of shocked. Right. Cause it's not something that we hear a lot of, you know, like even to get a mammogram, they don't suggest getting a mammogram until you're 40. Leigh Hurst (04:15): Correct. Yeah. And you know, it was, you know, looking back on it, I remember thinking, gosh, I never talked about breast cancer, never talked about it. I didn't know anybody who had had it. I'm not even really sure. I knew anybody who’s mother that had had it. So I was really taken aback by that when I was diagnosed and I was single at the time really hadn't thought about having a family quite yet. You know, I was living in the city, it was very common to still be kind of doing your thing. And so there are other issues that came up other than of course the life or death issue with breast cancer. There were the other possibilities of losing your fertility through chemo. Certainly that's a possibility certain decisions that you might be faced with can also, you know, if you decide to remove any of your female organs, ovaries, whatever, to minimize your risk, of course, those are big decisions when you haven't started a family yet. Leigh Hurst (05:08): And I wasn't really sure I was going up, but I didn't want that choice to be taken away from me. I didn't want it to be something that I couldn't do at a later date. So yeah, it was, it was shocking. And you know, out of that, I really started to like, think about why didn't I talk about this? Why didn't I think about this? And so that's kind of how the feel your boobies idea came about is that I just made some t-shirts for friends. Cause I would joke around during my treatment, I was actually still running and I didn't get sick. So I was really happy about that. And I just made sure that said, feel your boobies for fun. I'd always wanted to make t-shirts. I was kinda crafty kind of thing, you know, hobbies on the side. Leigh Hurst (05:47): And so my friend and I mocked up a tee shirt and I got a hundred made, put a website up, my background's in technology based learning. So I was kind of techie and I'm just send it around to my friends that had lived in the cities where I had moved after grad school. And I started selling shirts to people. I didn't know, very quickly, it just kind of went viral. I was getting checks in the mail from people. I had no idea who they were. And so, you know, that whole idea of, of using a message, like feel your boobies, which is lighthearted, but very pointed in terms of what it's trying to get you to do. Made me think about, you know, is this really creating behavior change? Is this creating a meaningful dialogue among a population of women like me that never really talked about it before? Or if they did, it was the third serious town and it was about their mother or it was in the context of a doctor's office. And so to that accidental t-shirt, that was just a hobby sort of evolved in time into something that took over my life quite honestly, and quickly I had to figure out what I was doing with it. So that's how the foundation itself came to be. Karen Litzy (06:53): Yeah. It's amazing. The things that happen to you that can just do a 180 and change your life. Right. So you could have had this diagnosis and then just went on and got a job and just went on your way. Right. But instead you were like, wait a second, like I'm young, I never talked about this. There's gotta be other people out there just like me. So how can I reach them? Leigh Hurst (07:15): Right, right. Sort of back fitting it. Right. Because I didn't create the tee shirt with that in mind, but I watched it happen. And that started to make sense to me with my background in behavior theory and that kind of thing. And so I kind of ran with it and, you know, we were able to support ourselves for quite some time just through t-shirt sales. So fortuitously, unlike other nonprofits that you know, have to submit for grants and you know, really the funding side of it is the tricky part. We were fortunate in those early days the t-shirt sales themselves allowed us to do a lot of creative things through social media before that was a standard way of spreading our message. And so we really tried to leverage the idea of media and the peer to peer sharing because what I saw when somebody would wear the tee shirts, like a happy hour or a cookout was I was watching like a 20 something talk to another 20 something or a guy even who might say your shirt says feel your boobies. Leigh Hurst (08:16): Can I feel your boobies? And then they would say, it's not about that. It's about breast cancer. Or you got to feel your boobs to see if you find a lump. And to me that was a productive conversation. It was somebody articulating something very simple, but in a playful and a more friendly and lighthearted way than trying to impart stats or other types of things that I think a lot of campaigns do, or certainly they have the aesthetic and the sensibility that feels like it's for an older woman. So you may relate to it because you're trying to just be proactive and educate yourself about health. But the messaging itself is not really created for you. It's not created for the younger population, the style of the images, the style of the graphics, and even the use of the channel that you use to spread it. Leigh Hurst (09:01): Right? So a tee shirts, just one way you can not, but you can do that in many other ways. You know, we flew aerial banners up and down the Jersey shore in the summertime on all the very populated beaches. And I'm thinking of these young women that are like dragging themselves out to the beach after going out Friday night. And they see a, you know aerial banner and they say, Oh my God, that says feel your boobies. And I'm like, that's wonderful. That's a great way to kind of intersect with them where they are in a way that they can relate to. And, you know, it's created testimonials from women that say, that's why they found their lumps. So very proud of the campaign. And eventually I went on and left my corporate career and ran the foundation full time. So it really wouldn't do that 180 for me, that you mentioned about changing your life. It was definitely that for me. Karen Litzy (09:50): Yeah. So we can definitely see how your life has changed after diagnosis, but what are the big lessons that you learned? Leigh Hurst (10:00): Well, you know, I definitely learned I'm type A, very much of an ambitious overachiever and, you know, Karen Litzy (10:06): Well, I mean, you were in New York city in a corporate job, we get it, that came across. Leigh Hurst (10:12): Right. And so you kind of like play these scripts out in your head. Like I really should slow down this. Isn't really how I want to spend my time. I'm really too busy. I wish I could make more time for X and part of my move home quite honestly, before breast cancer was in an effort to sort of really operationalize some of that stuff to sort of extract myself out of the environment that wasn't really fueling me anymore. It was draining me. And so, you know, earlier in my career, there's coast to coast flights on a Monday morning to get to a meeting on time. That was exciting. And as I got older, I'm kind of like, I don't really want to do that anymore. I don't care how much money I make. I don't want to be on a plane. I want to be involved in the place that I live. Leigh Hurst (10:55): And so my move was in part to get that going right, to really start to be outside more to, you know, I decided to go part time cause I kept my job in New York city. So I didn't need the amount of money I was making where I lived anymore. But I didn't truly step out like that until breast cancer came. And then I quite honestly, I got depressed at the end of my treatment, I got depressed and I took three months off work. I called it my be nice to me times. So I like got weekly massages. I went to get therapy because I felt like I needed to sort of sort through some things, you know, I felt like I should be getting back to normal, but nothing about my life felt normal. Everything had changed, you know, whether or not. Leigh Hurst (11:39): So I think during that time is when I started to realize what it meant to say no, that you can say no and not give a reason. And that having lots and lots of friends, which I had is great, but having a lot or having fewer really good friends became more important to me. People that I could really keep in touch with and have meaningful conversations. And my family quite honestly, too, was a big part of that. So I would say that that was the biggest thing slowing down. And I still struggle with that because that's not my genetic makeup. My genetic makeup is to, you know, attack a problem, and make a change and go through something like breast cancer, trying to get back to normal is tricky because you really can't change the future. You never know if it's going to come back. Leigh Hurst (12:26): That's just a fact with breast cancer. And so I think learning to live with the ambiguity of not knowing, you know, and accepting that, truly accepting that that kind of translates out into other parts of your life, where you can, if you really allow yourself to sit in that space, you can apply that to other uncomfortable things that come up, right. Things that happen with your job or relationships or other things that make you feel anxious. Like you want to make a change or you want a resolution immediately. I think I have a better sense of pause around that where I trust that in time things will sort themselves out and I will have a greater sense of peace around whatever it is. I'm stressing about things that came out of that period of time in my life. Yeah. That's so powerful. I don't do it well by the way, but I work at it all the time. Karen Litzy (13:19): Well, I mean, I think the fact that you were able to identify that as, Hey, listen, this is something that I know I need to work on. And of course we're all a work in progress. Nothing's perfect. But to just be able to recognize that and say, I need to make a change. Like this is too much, that's so powerful. And then to be able to kind of leave the city, move to central PA and say, I know I'm doing this for me. And that was even before the diagnosis. So you were already, you know, heading in that direction. And I also really appreciate that. You said at the end of treatment that you were depressed, that you were unsure, you know, because I think oftentimes when people see breast cancer survivors or they hear from, or just looking at a picture, let's say, right, it's a person smiling or it's I beat it, or, but you don't really get into the background of that. Leigh Hurst (14:22): I talk about the mental health side all the time, because I think it is something that's not discussed as much as it should be and not everybody gets depressed, but I do think everybody has down days. Of course, I mean, when you're struggling with something that's life or death and that happens at different times for different people. For me, I was fight or flight during the treatment. For me, it was like a project, right. I knew I had a plan and I had to do it. And the tricky part for me was when I entered into that gray space where I was kind of released from all of that care. And I had to make sense of my life on a day to day basis, be my own cheerleader, quiet those voices in my head that would raise all those scary thoughts and realize that this was going to be forever. You know, like you can't let this consume you. And you know, being brave enough to say I'm depressed. I wasn't brave enough to say that right away. You know, I went into therapy, very hesitantly feeling like, what do you have to be upset about? It was stage one, you got through it, shouldn't you be happy with it? Karen Litzy (15:22): That self-defeating language, right? There's someone worse off than you. Leigh Hurst (15:27): Right? So therefore you can't feel any sort of emotion around your own words is not true and very dangerous by the way. And so, you know, I really try to bring that up when I speak to women who are going through it or who have gone through it, who I sense might be struggling with a little bit of that, because there's so much, and it's different for everybody. If you might be balancing kids, I wasn't, but it might be balancing kids, little children and trying to mask what you're going through to keep them from being afraid. And so that you're hiding your own emotions for some period of time, or same thing goes for spouses that can have issues. So finding a place where you can be truly honest with your own feelings and dealing with that is I think really important because it delays your ability to heal. If you don't find your way. Karen Litzy (16:18): You have to say to yourself, okay, this is the situation and I need to live with this. What's the best way I can move forward. Right. We discussed that a lot with people who have like chronic pain. So the pain may never go away, but can you get to a point where you're still doing all the things you want to do, but in order to do that, you kind of have to accept it. Leigh Hurst (16:48): Yeah. And the way you choose to do that, whatever steps you take to make that possible in your life. The biggest thing for me was realizing that other people don't have to get it right. Like if I had a choice, things that make me able to have good days or days that I need to step out for a little bit, I don't have, I shouldn't have to worry, or I can't worry if that makes sense to somebody else, because the only thing I can do is reconcile within myself. What makes me the best version of me, the fullest version of me, for the people that need me. And the way I choose to do that is probably not going to be the same as the way someone else chooses to do that, or should it yeah. Nor should it be. Right. So looking for affirmation about those decisions outside of yourself is a real challenge. You know, if you're a pleaser or you're, you know, sometimes you just gotta bone up and do what you have to do, right. You always just satisfy your needs. But the times when you have choices to flake out on plan that you just don't feel up for, or push something that you thought you should do today to tomorrow those things are okay to do, and you don't need someone else to tell you they're okay. Karen Litzy (18:01): Right, right. It comes down to like giving yourself the permission and the grace and the ability to do what you need. Like you said, to do what you need to do in the moment at that time, that's going to be best for you. That's going to allow you to show up fully as the person you need to be. Leigh Hurst (18:20): Right. Yeah. That makes total sense. I thought it was a great way of putting it as like self care is not the same as selfish. So making those choices, you have to be, you know, polite, honest, a good person when you're doing all of those things, but taking care of yourself, the self care part of it is not being selfish. It's about being in touch with what makes you the good person that you are. Karen Litzy (18:46): Right. And I think also being able to communicate that to someone maybe it's your partner or your spouse or your children or work, I think the way you go about communicating, that makes all the difference, right. Because there's a difference between, listen, right now, maybe you might have felt, you know, I just need to be by myself for a couple of hours, you know, that's what's best for me, but if you don't communicate that properly or if you just flake out and go stout on people like that is not that that's how you, you create a lot of friction. Right. So what advice would you give to people if they do have to make these decisions to do what's best for them? What's the best kind of language? Cause I know you're very good at communication and all that other stuff. Leigh Hurst (19:38): So I have two small children. I had kids after breast cancer and I'm a single mom now. And I was since they were very little good friends with their father and all of that, but still, you know, being I'm 50 now, but I was 40 and 42 when I had them. And so, you know, the loss of independence around raising two children alone when you're used to like literally flying coast to coast, you know, rewind five years. And it was like, the world was at your feet. So I found myself becoming extremely protective of my space when they were not with me. And, you know, so I was very cautious about making plans. And I would just be honest about that if it was a weekend that I didn't have them and somebody invited me to go away for example, Oh, we're having a girl's weekend. Leigh Hurst (20:24): We're going to go to a winery. Do you want to come? And I would say, well, I might, I might want to come if you need a commitment though. I can't commit because a lot of times when the kids go away, I just like to have some quiet time to myself. I don't like to come back from a weekend and be tired. So I would, I mean, that's just being honest, you know, some things, those are, it's not as easy as something like that, but you know, I think with work where there's deadlines and it's a little trickier to push things off I've gotten better at prioritizing where I'll say it has not really in it today. I know I said I would have this by two o'clock is it possible I could have it tomorrow by maybe 10. So I'm not telling them all the inner workings of what's going on in my brain, but I'm floating the idea that I'd like to shift the priority around because I think it would work better for my mental state. You know, so those are just some ideas for how I do it. Karen Litzy (21:20): Yeah. That's great. That's great. Thanks for sharing that. And now what I'd also like to talk about is your book. So you're about to release, well, this will be out the first weekend of October. So the book should hopefully be out by then, right? They will be. Okay. Perfect. So say something big, feel your boobies, find your voice stories about little lumps, inspiring, big change. So first of all, congratulations, because writing a book is no joke. So tell us a little bit about why you wrote the book and what's in it. Leigh Hurst (21:57): So I wanted to write this book for quite some time. You know, I do a lot of speaking and people often say, Oh, your story is so inspiring about how you just created something and then you ran with it and you saved lives. And now you have this big foundation. And I do realize that that's inspirational, but I kind of tire of my own story over time. So every time I would sit down and try to write about it, I was like, Oh my gosh. But what I found inspirational enough to get me going this time. And it was really an honor of our 15th anniversary, which was last year. I was hoping to have it done by them, but that's the 15th anniversary of the foundation. And it was also my anniversary from breast cancer is the same as the foundations university. Leigh Hurst (22:39): So I started writing it back then and the way I got inspired to really get into it was as I started writing about my own story, I was things were coming to mind about these other women that I had met over time through my path, as you know, being very involved in the breast cancer community and quite honestly, their stories while different were very similar. So they were young when they were diagnosed, they found their own lump and they made some sort of change that was remarkable that they hadn't really pivoted from one path to another and really in an effort to give back. And so, as I started seeing that sort of common thread through some other women that I respected, I thought, well, what if I wove their stories into mine? And so, you know, our stories are different. So how I felt it, this part of the journey, you know, when I found the lump, the way I found it is different than the way one of the other women found it and how I felt during chemo is a lot different than the way some other people felt during chemo. Leigh Hurst (23:38): So if I can weave their stories in to mine, then it will relate to so many more people because can kind of say, Oh, I really relate to Leigh. When she was deciding if she wanted to have a mastectomy or lumpectomy, but I really, really related to Holly during chemo, cause I'm really struggling with it. And she struggled with it too. And so there's lots of tidbits of inspiration and advice that come out of all of these stories. And so after each chapter, I write a little piece that's called big lessons from little lumps. And it's basically trying to suss out the things that I felt were common through each of the women's stories at each stage of the breast cancer journey. And then of course at the end, you know, they've all sort of found their voice. They've started their own nonprofits, where they started a company to create underwear, lingerie line that's meant to make you feel sexy, even if you've had your breast removed. Leigh Hurst (24:35): And that was because that particular survivor did not feel sexy after she was diagnosed and had surgery and she was a designer. So she decided to do that. And so I just found great inspiration and listening to their stories and trying to weave them into mine. And, really at the end of the entire book, what I found were basically three ideas that I saw across all the women that I think can relate to anybody that's going through any sort of difficult time, not just breast cancer. And one of them was that I really noticed that each woman found a frame for their situation that really focused on the idea of looking forward into the future versus looking only backwards and only wishing they could redo it differently. Right? Like being sad about what had happened. They all had those emotions, but the way they ultimately framed things was with the idea of looking forward. Leigh Hurst (25:31): Then each of them also talked a lot about finding a passion, something that really, you know, gave them those goosebumps or that feeling you get in your stomach when you're doing something right. And that is what they chose to spend their time on. And they really made an effort to strip anything out of their life that got in the way of them being able to focus on that type of activity. And then the thing that we talked about earlier, but the third thing is that they all recognize that change is continuous, right? It's not like you flip a switch and say, I'm going to make this change, or I'm going to start fuel your movies. And all of a sudden I'm happy because I started a nonprofit and it does good things. I mean, it has all the same challenges that a normal job has. Leigh Hurst (26:11): So change is truly this continuous thing, but because of the passion and they're focused on the future, they were able to realize that, sure, there's going to be some bad days throughout this process, but nothing is going to get in the way of my path to create this change towards the way I really want to live my life. And I found that so powerful when I saw that kind of trend throughout each woman. And I really think a lot of people will benefit from watching how each of them kind of, you know, injected that into their own lives. Karen Litzy (26:44): And isn't it amazing how storytelling creates such great learning moments, right? I think that's the way to do it. People they remember the stories, they think it's digestible, they internalize it. Like you said, what someone may not relate to you, but they may relate to someone else in the book. And it's those stories that weave through that come up with these great themes that anyone can relate to. So I just always think that I'm such a huge fan of storytelling and storytelling makes things real and relatable. Leigh Hurst (27:16): And I think that's an important way. It's one of the things we try to do with the foundation too, is when we do provide messaging or things, we try to really make it relatable. And that we're telling a story about someone who is real, someone who was young when they were diagnosed. So when you say that looks like me, I can relate to that. I also think women who are brave enough to share their story and I, by no means think it's wrong to not share your story. I think you're a private person and that's how you heal, then that's what you should pay attention to. But for those who choose to, and they don't always realize they've chosen to one of the women in the books that she never talked about it. The first time she was diagnosed, she was 26 and she was embarrassed. Leigh Hurst (27:56): And then she unfortunately was rediagnosed nine years later with metastatic cancer at 45, which means it's terminal. And at that point she really became braver to start talking about it and she realized how much strength she got from sharing her story. And so I think when women put their stories out there they have no idea how many people they touch when they do it, because no one's gonna necessarily walk up to you and say, I really respect that. You said that, or I want you to know that that really made a change in my life that day, but it does. It does. And it goes beyond what you will ever actually know. Karen Litzy (28:32): Absolutely. Yeah. And I love that sort of women pushing other women forward and building them up and paying it forward. It's just such a lovely, a lovely lesson for anyone. But as we all know, you know, the power of women in groups is very powerful. Leigh Hurst (28:52): Unstoppable. Exactly. Karen Litzy (28:54): Exactly. That's better unstoppable. Yes, absolutely. And so before we kind of wrap things up, what I would love from you is what would you like the audience to sort of take away from maybe from your experience or from our talk today? Cause I know that you do and you also, I also want to point out that you also talked to a lot of young people, college students, things like that, right? Leigh Hurst (29:18): Yeah, I do. I do. Yeah. So one of the aspects of our campaign in the past has been what we call our college outreach program, which we provided free materials to college health centers nationally through sororities and women's centers and so forth. And that was in an effort to get our message out to the college campuses. And we've also started running a media campaign which we did last year called are you doing it was a minority outreach campaign focused on young African American women in low income areas. African American women have a higher, are diagnosed at an earlier age than white women. And once they're diagnosed, they have a higher mortality rate as well. And so it's a very important audience to target. And so we funded a campaign that leveraged billboards, bus shelters, bus wraps, as well as targeted digital outreach to that demographic of women specifically to spread the message and that incorporated five local survivors, real survivors who were diagnosed at a young age, we did a photo shoot, shot a video with them. Leigh Hurst (30:22): And we shared that through all the channels that I mentioned, but we got over 6.2 million impressions with that campaign. Amazing. Very amazing. So, yeah. So we reach out to that younger population, like you mentioned in a lot of different ways, but I mean, I think if you asked me what the one thing is, I want someone to take away is that, you know, it sounds cliche, but I really do believe that one voice matters. I feel like the ripple effect from one person's passion and when one person's devotion to an idea can really make a difference and they don't have to be big actions. The things that you choose to do, don't have to necessarily change the world, but you can start small. And the actions that you choose, the words that you choose and how you choose to navigate your life, I think affects other people. And this book really showed me that in the smallest of ways, people can have the biggest impact in their communities and in other people's lives. And that's, I think that's a really great lesson for anybody to take away. Karen Litzy (31:24): Absolutely. And now if people want to get in touch with you, where can they find you? Where can they find the book? Leigh Hurst (31:31): So the book will be available on Amazon. Starting October 1st, I believe. You can read more about the book leighhurst.com. You can follow the book on Facebook, which is, say something big as well and Instagram to say something big. So those are all the channels. And then of course, if you're interested in feel your boobies and the work that we do, the Facebook pages you know, at feelyourboobies on Facebook, Instagram, and Twitter, and our website is feelyourboobies.com. Karen Litzy (32:08): Awesome. And we'll get all of those links. So for everyone, if you don't have something to take it down, or you're not right in front of the computer, we'll have all of the links. You can go to podcast.healthywealthysmart.com. And we'll have a quick link to everything that Leigh mentioned today throughout the podcast. So not to worry, everything will be right there. So Leigh, thank you so much for sharing your story. I just know, like you said, even if one person hears this and they say, Oh, well maybe I will feel my boobies, mission accomplished. Well, thank you so much for sharing your story and coming on the podcast. I appreciate it. And everyone out there listening. Thank you so much. Have a great couple of days and stay healthy, wealthy and smart.     Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Sandy Hilton, David Butler and Bronnie Thompson on the show to discuss persistent pain during COVID-19.  In this episode, we discuss: -Shifting current healthcare curriculum to better educate clinicians on persistent pain -Can passive modalities empower people to pursue more active treatment options? -How to create more SIMS during the COVID-19 pandemic -Can telehealth appointments adequately address persistent pain? -And so much more!   Resources: International Association for the Study of Pain Website Factfulness Book David Butler Twitter Sandy Hilton Twitter Bronnie Thompson Twitter   A big thank you to Net Health for sponsoring this episode!  Learn more about Four Ways That Outpatient Therapy Providers Can Increase Patient Engagement in 2020!                                                                      For more information Bronnie: I trained as an occupational therapist, and graduated in 1984. Since then I’ve continued study at postgraduate level and my papers have included business skills, ergonomics, mental health therapies, and psychology. I completed by Masters in Psychology in 1999, and started my PhD in 2007. I’ve now finished my thesis (yay!) and can call myself Dr, or as my kids call me, Dr Mum.   I have a passion to help people experiencing chronic health problems achieve their potential. I have worked in the field of chronic pain management, helping people develop ‘self management’ skills for 20 years. Many of the skills are directly applicable to people with other health conditions.   My way of working: collaboratively – all people have limitations and vulnerabilities – as well as strengths and potential. I use a cognitive and behavioural approach – therapy isn’t helpful unless there are visible changes! I don’t use this approach exclusively, because it is necessary to ‘borrow’ at times from other approaches, but I encourage ongoing evaluation of everything that is put forward as ‘therapy’. I’m especially drawn to what’s known as third wave CBT, things like mindfulness, ACT (Acceptance and Commitment Therapy) and occupation.   I’m also an educator. I take this role very seriously – it is as important to health care as research and clinical skill. I offer an active knowledge of the latest research, integrated with current clinical practice, and communicated to clinicians working directly with people experiencing chronic ill health. I’m a Senior Lecturer in the Department of Orthopaedic surgery & Musculoskeletal Medicine at the University of Otago Christchurch Health Sciences.   I also offer courses, training and supervision for therapists working with people experiencing chronic ill health.   For more information Sandy: Sandy graduated from Pacific University (Oregon) in 1988 with a Master of Science in Physical Therapy and a Doctor of Physical Therapy degree from Des Moines University in December 2013. She has worked in multiple settings across the US with neurologic and orthopaedic emphasis combining these with a focus in pelvic rehabilitation for pain and dysfunction since 1995. Sandy teaches Health Professionals and Community Education classes on returning to function following back and pelvic pain, has assisted with Myofascial Release education, and co-teaches Advanced Level Male Pelvic Floor Evaluation and Treatment. Sandy’s clinical interest is chronic pain with a particular interest in complex pelvic pain disorders for men and women. Sandy is the co-host of Pain Science and Sensibility, a podcast on the application of research into the clinic.   For more information on David: Understanding and Explaining Pain are David’s passions, and he has a reputation for being able to talk about pain sciences in a way that everyone can understand. David is a physiotherapist, an educationalist, researcher and clinician. He pioneered the establishment of NOI in the early 1990’s. David is an Adjunct Associate Professor at the University of South Australia and an honoured lifetime member of the Australian Physiotherapy Association.   Among many publications, his texts include Mobilisation of the Nervous System 1991 The Sensitive Nervous System (2000), and with Lorimer Moseley –  Explain Pain (2003, 2013), The Graded Motor Imagery Handbook (2012), The Explain Pain Handbook: Protectometer (2015) and in 2017, Explain Pain Supercharged. His doctoral studies and current focus are around adult conceptual change, the linguistics of pain and pain story telling. Food, wine and fishing are also research interests.   Read the full transcript below: Karen Litzy (00:00:23): Hello everyone. And thank you for joining us today for this webinar. For those of you who are here live, you got to hear a little bit of pre-conversation which is great. And of course in that pre-conversation we were talking about all the things happening in the world today, specifically here in the United States with a lot of unrest and protests for very, very good reasons, in my opinion. And so we just want to acknowledge that and that we see it and that we are trying to learn, and we are doing our best to be allies to our fellow healthcare workers and citizens across the country and across the world for all of the other countries who have been showing solidarity. So I'm Karen Litzy, I'm going to be sort of moderating this panel of minds and I'm going to now go round and just have each of them say a little bit about themselves. So Sandy I’ll start with you.   Sandy Hilton: Okay. Hi, I'm Sandy Hilton. I'm a physiotherapist here in Chicago, Illinois with Sarah Haag. We have entropy physiotherapy and our clinic is predominantly working with pain. It's like a hundred percent of my case load is people in pain and about 80% of that is pelvic pain in particular. But I still see, you know, the rest of humans. David Butler (00:01:49): Hi, I'm David Butler from Adelaide Australia. I'm a physio, although I'm completely a professional and I believe everybody has the exact same role in treating pain. I'm trying to hire, but I can't retire. And then in world, our changing knowledge and our changing potential just keeps me, keeps me on track. So yeah, any sort of pain I'm happy to talk about. Bronnie Thompson (00:02:16): I’m Bronnie Thompson, I'm an occupational therapist by original training with some psychology thrown in, and I'm an educator and clinician as well, but a teeny tiny bit of research, but not much. And I'm a painiac and quite proud of it actually.   Karen Litzy: Excellent. So again, everyone, like I said, if you have questions as we go along, please feel free to put them in the Q and a part. And I will be looking at that as we're going through now, like I said, we've got some questions ahead of time, but before we get to some of the questions that some of the listeners and viewers have wanted to ask, I also want to just quickly acknowledge that we've got a bit of a mixed audience, so we've got healthcare practitioners and clinicians and we've also got people living with pain. Karen Litzy (00:03:11): And so as a clinician for me, it's a great opportunity. I think to address people in pain who maybe don't have the access or the ability to kind of get this information that's in their town or where they're living. So I am really, I'm really looking forward to this discussion, especially for those people that are watching that are living with persistent pain. So the first question I'm going to ask is and I'll ask this of all of you. If you were to give a piece of advice to a new professional or a healthcare professional that is sort of newly working with people with persistent pain, what would that piece of advice be? Sandy Hilton (00:04:11): I'm in Chicago. I'm just going to take it. I really like to stress, especially to students that, you know, we get this concept that the longer you've been in the field, the better you are at it. And, I think that maybe we make different mistakes, but everyone is learning this. And there's so much about pain that we're learning. And so if you're just starting in, I don't know that you might have an easier time because you have less bad habits to get rid of and can start with some of the better newer research and avoid some of the mistakes we made. Bronnie Thompson (00:04:50): So she's doing the popcorn approach. She looks at me. And so I think my advice would be, listen, listen very carefully to what people tell you and trust that they're telling you your experience. Don't try and read stuff into it, just listen and reflect, show that you're listening by reflecting what you've heard. So you can give that you've understood one another, because it's really easy to come out of school with all of this knowledge packed up and your brain thinking, Oh, I've got to do an info dump just like that. And it's not that great for the person, stop and listen. David Butler (00:05:37): They are lovely comments. I'd add. I would welcome anybody to the most new and exciting area of health. And there is a true pain revolution out there. And I would say to anybody, when you come in to just lift your expectation of outcome or what, might've been five or 10 years ago, because the clinical trials and our knowledge of the potential for humans to change is just increasing so dramatically. And I say, now we can say think treatment, not necessarily management because for many people recovery or some form of recovery is on the cards and what's leading the charge is the talking and the movement therapies. It's not the drug therapies for chronic pain. And, I just like to reflect as an older therapist now, patients who maybe 10, 15 years ago with maybe complex post pain surgery or Phantom limbs or complex regional pain syndrome would have thought, and I can't really help here. Now we welcome them through the door and you can get such pleasure, pleasure from treating these people no matter how long they've had the problem. Karen Litzy (00:06:48): Great. And, I would echo what Bronnie said is, you know, really listen and also believe, you know, they're giving you their experience. So try and take your bias out of it and believe what they're telling you and try not to talk them out of it because you see this quite a bit of, Oh, I have pain with this. And well, do you really have pain with that? Or is your pain really that much? And as the patient, it's very frustrating to have someone try and tell you what your pain is. So I'm looking at it from the person who has lived with the really chronic and at times debilitating neck pain is just listen, which is good. Believe them, and try not to talk people out of their experiences because it's very frustrating and it's very sort of dehumanizing for the patient, you know? Karen Litzy (00:07:54): And when I look back at when I first met David and went up to him at an APTA event and said, would you like to be on my podcast? And he said, yeah, sure, but I'm going to New York. I said, Oh, well, that's great. Cause that's where I live. And so then he met me at my, where I was working at the time and spent two hours with me. And I just, after that felt like, Whoa, like this is the first time that someone really listened and didn't interrupt and believed what I was saying and really set me on a path that just changed my life. Like, I don't know where I would be, had I not had that encounter with David. I think it was like 2011 or 2012. And so I always reflect on that and try and be that person, because I know what it felt like. Karen Litzy (00:08:45): And then when someone does come in and, and gives you their full attention and their time and their understanding, and then says, well, challenges your beliefs in a positive way, it was something for me that, you know, and I've talked about it many times that just completely changed my pain and my life. And so, you know, try and be that person is what I would say to people.   Bronnie Thompson: It's like, we've got to remember that people with pain and I live with fibromyalgia, those of you that don't know that's my reality, it's our experience and what it's like to live without pain. You know, what it feels like to know the things that sit at off things that settle it down and our relationship to it, to that pain and conditions. We come in with a whole lot of knowledge about other people and what we've seen. So we are experts and a whole lot of stuff, but what we're not experiencing as this person's life, their experience via what they're wanting from us even, what's important to them. And that's where when we meet and we can kind of share the hidden paradigms things that we don't know about each other, then we've got a chance to make a huge change and that as we know, I just feel so good about what I do. I just love it. I'm such a pain geek. Sandy Hilton (00:10:09): And I think the pain science or the science of pain really gives as a clinician, a lot of comfort to the listen to them, believe them, you don't have to prove it. You don't have to go. And like they say, I hurt here. You don't have to go poke it to reproduce the symptoms to believe it. And that's how I was taught of you have to reproduce the symptoms so that you can document that it's true. And it was like, that's a giant piece of unnecessary that we don't even have to do anymore, which really saves us a lot of time, not to mention establishing that trust and not being one more person. That's poked them in the sore spot. But, that's the thing that I was taught in school. Bronnie Thompson (00:10:58): So the question is, do you think that all chronic pain patients were not treated particularly when they were having the first or second episodes of their acute pain or are they in any way destined to become chronic pain patients? Well, my story is I hurt my back. I was what, 21, 22, doing a tango with the patient and a doorway patient was bigger than me. I landed on the floor on my back and I had all the best evidence based treatment at the time, maybe not, maybe not all the ultrasound, but you know, they didn't lie. They're really and relax a bit. Bronnie Thompson (00:11:48): But I didn't recover. I was then seeing the Auckland regional pain Center with amazing dr. Mike Butler, who is a rheumatologist and founded, and basically was one of the first in this initiations of bringing the international association for the study of pain to New Zealand, good friend of Patrick Wall knew her stuff very well. Gave me the book the challenge of pain to read. So essentially an explain pain paradigm back in the eighties, I know pain pretty well. My pain has not gone away. So there are some people who will not have a complete recovery of all of their pain, but because none of our treatments provide a hundred percent abolition of pain and actually I'm comfortable with it. I live with the pain and it gives me some stuff that some other people don't have access to. I know what it's like to have every bit of my body feeling really rotten. Bronnie Thompson (00:12:53): At the same time. I'm not limited by my pain. And I think sometimes we look at pain removal is that end goal. But I think our end goal is to help people live full, productive, satisfying, joyful and enriched lives. And some people will bring the pain along with them and many people won’t have to and that's amazing. Let's let the person make that decision about what is the most important outcome. But yeah, sometimes we can do all the right things, but if you have a spinal cord injury and you've got a smashed up spine, probability is that at the moment, our technology doesn't give us a solution. We can help, but we can't always take it all away.   Karen Litzy: David, what are your thoughts on that, that sort of movement from acute pain to chronic pain? You know, what are your feelings on that is, is like you said, are you destined to have it are I know, cause I get this question a lot from people like, well, you know, it started out with like an ankle sprain or it started out with a knee sprain and now it's turned into this. So did I do something wrong or was something not done? David Butler (00:14:12): I think you’re not destined to have it, but I think our treatment or therapies and the politics of treating acute pain probably gets in the way. And I also think if someone's hurt their back or any part of their body bad enough to see a health professional, the data is that 50 or 60 or 70% will have a recurrence in the following year. Now most health professionals think a recurrence is a reinjury, but if they really explored what happened, that reoccurance probably happened at a time when they would look at down and flat the immune system's a bit out of balance and they might've just done something simple, lifted up and picked something we would now from pain science, reconceptualize that as well, that's quite good. It's your body testing yourself out like a fire alarm with all the stuff you've been through in the past. It's no wonder your brain. Wouldn't want to play it again to check out how your systems are working, but that just simple piece of knowledge and usually should check to make sure nothing serious has gone on because you check and you can normally say, well, that should ease in a couple of days. That's an example of a little bit of knowledge dampening down. They don't have to go through the old acute process again of more, x-rays more tests, more power. David Butler (00:15:31): I think if that's correct, that observation was seen for many years, it could save governments Billions. Bronnie Thompson (00:15:37): Oh, absolutely. We've got a great thing. The language we use don't we, is it an injury or is it just a cranky body? David Butler (00:15:46): That whole linguistics? And for me and my treatment, you're now a physio by trade. I feel it says important to help someone change the story, to have a story, to take their experience out into society and let it go. That to me is as important as having healthy movement, although they obviously like go together. Sandy Hilton (00:16:07): I was gonna say that the saving of money for systems, for sure, but also the saving of time for people and the saving in our healthcare system. Every test you go do is going to cost you a lot of money. And, that time that it takes to get it in a time away from work and family and the concern of what the test results will be. If we can divert them wisely to not do that when it's not really indicated, that's just so good.   Bronnie Thompson: Yeah. And then I also for, you know, I've had a test now I'm going to wait for the results and now I'm going to wait for what are they going to do as a result of those results? And then, Oh, it's the same. And it just feels very demoralizing to people. And I think that's something we need to think about with make the decision about when and we to stop doing investigations often. That's the sense of the clinician worrying that something, are they going to sue me? It’s not a good way to practice.   Karen Litzy: Yeah. here's another, we'll do this from Louise. She says, picking up on something David had said earlier, how do we move towards being more, a professional? How do we move the pain industry toward this goal? Excellent question Louise. David Butler (00:17:51): There's a lot of answers to it, but a couple would be, I think you just got a quite badly out there would know sports trainers who could deliver an equally good management strategy to some physios, to some doctors, et cetera, right? This pain thing is across all spectrums, which is why the national pain society meetings are so good. And why everybody there is usually humbled and talks to all the other professionals because they realize the thing we're dealing with is quite hard. And we need all the help that that's a weekend get, but it ultimately comes back to provision of pain education throughout all the professions and that pain education should be similar amongst all the professions it's not happening yet. We've tried pushing it, but it's not out there. And it's incredible considering the cost of pain is to the world is higher than cancer and lung diseases together. Karen Litzy (00:18:51): Yeah. The burden of care is trillions of dollars across the world. And, you know, even in the United States, I think the burden of care of back pain is third behind heart disease, diabetes. And then it was like all cancers put together, which, you know, and then it was back pain. So, and, and even I was in Sri Lanka a couple of years ago and I did a talk on pain and I wanted to know what the burden of disease of back pain was in Sri Lanka. And it was number two. So it's not like this is unusual even across different, completely different cultural and socioeconomic countries. And, you know, David kind of what you said, picks up on a question that we got from Pete Moore. And he said, why isn't it mandatory that pain self management and coaching skills isn't taught in medical schools? Is it because there isn't expertise to teach it? Well, I mean, David's right here. He's semi retired. David Butler (00:19:58): Why isn’t that mandatory? That's a big, big question. I would say that the change is happening. Change is happening. I would say that at least half of the lectures or talks I give now are to medical professionals and out of my own profession or even more than half. So yeah, change is happening, but it's incredibly slow. It needs a bloody revolution, quite frankly. A complete reframing of the problem and awareness that this problem that we can do something about it and awareness that there's so much research about it let's just get out and do it now. Sandy Hilton (00:20:40): The international association for the study of pains curriculum and interdisciplinary curriculum would be a nice place to start. And I know some schools here in the States are using it in different disciplines to try and get at least a baseline.   Bronnie Thompson: The way we do it as the core for the post grad program, that I am the academic coordinator for it. Doesn't that sound like a tiny, tiny faculty. But anyway the other thing that we know is that looking at the number of hours of pain, education, Elizabeth, Shipton, who's just about completed. If she hasn't already completed her PhD, looking at medical education and the amount, the number of hours of pain, it's something like 20 over an entire education for six to six or more years. In fact, veterinarians get more time learning about pain then we do then doctors medical practitioners do, which suggests something kind of weird going on there. Bronnie Thompson (00:21:50): So I think that's one of the reasons that it's seen as a not a sexy thing to know about and pain is seen as a sign of, or a symptom of something else. So if we treat that something else in pain will just disappear, but people carry the meaning and interpretation in their understanding with them forever. We don't unlearn that stuff. So it makes it very difficult, I think for clinicians to know what to do. Because they're also thinking of pain is the sign of something else not is a problem in its own, right? Persistent pain is a really a problem in its own right. Karen Litzy (00:22:29): Yeah. And wouldn't it be nice if we were all on the same page or in the same book? I wouldn't even say the same chapter, but maybe in the same book, across different healthcare practitioners, whether that be the nurse, the nurse practitioner, the clinical nurse specialist, the physician, the psychologist, the therapist, physical therapist, it would be so nice if we were all at least in the same book, because then when your patient goes to all these people and they hear a million different things, it's really confusing. I think it's very, very difficult for them to get a good grasp on their pain. If they're told by one practitioner, Oh, see, on this MRI, it's that little part of your disc. And that's what it is. So we just have to take that disc out or put it back in or give a shot to this. Karen Litzy (00:23:25): And, and then you go to someone else and they say, well, you know, you've had this pain for a couple of years, so, you know, it may not be what's on your scan. And then the patient's like, who am I supposed to believe? What am I going to do? And, and you don't blame the patient for that. I mean, that's, you'd feel this that's the way I, you know, I had herniated discs and I say, you just get a couple of epidurals and the pain goes away and then it didn't. And I was like, Oh, okay, now there's so my head, I was thinking, well, now there's really something wrong.   Sandy Hilton: That's the problem. Because yeah, if you think it's the thing you did that helped you or didn't help you, then you lose that internal control. Karen Litzy (00:24:13): Yeah, yeah. Yeah. So I think, I think it's a great question and, and hopefully that's a big shift, but maybe it'll start to turn with the help of like the international association for the study of pain and some curriculum that can maybe be slowly entered or David can just go teach it virtually from different medical schools, just throwing it out. There is no pressure, no pressure. Okay. Speaking of modalities, we had a question. This is from someone with pain and it's what can be the appropriate regimen for usefulness of tens, for acute and chronic cervical and lumbar pain of nerve origin. So Bronnie, I know that you had said you had a little bit of input on this area, so why don't we start with you? And then we'll kind of go around the horn, if you will. Bronnie Thompson (00:25:24): I think of it in a similar way to any, any treatment, really, you need to try it and see whether it fits in your life. So if you are happy and tens feels good and you can carry it with you and you can tuck it in your pocket and you can do what you want to do. Why not just is, I would say the same about a drug. If you try a drug and it helps you and it feels good and you can cut the side effects, there's nothing wrong with it. Cause we're not the person living life. It's more to think about it in a population. How effective does this? And my experience with tens is that for some people it does help and it gives a bit of medium, like a couple of hours relief, but often it doesn't give long sustained relief and you have to carry this thing around. That's prone to breaking down and running out of batteries, right when you need it. So to me, it's agency, but then I put the person who's got the pain and the driving seat at all times to say, how would this fit in your life? Do you think you want to try this one out? It's noninvasive it's side effects. Some people don't like the experience and sometimes the sticky pads are a bit yuck on your skin, but you know, that's more bad. So yeah, that's my, my take on it. David Butler (00:26:44): I haven't used it for 40 years after the second world war. When you start to stop, when they, I was friendly with the guy who invented it and I'm thinking it'd be happy pet we'll would be happy to, with these comments that I agree with what Bonnie said. Absolutely. I would also say that, hi, wow, you have got something there which can change your pain by scrambling some of the impulses coming in. You can change it, let's add some other things which can change the impulses coming in or going out as well. So let's use that. Let's get you building something, maybe something repetitive or something contextual or something as well. So you you've shown change you're on the track. So I would use it as a big positive to push them on keep using it, but on the biggest things. Sandy Hilton (00:27:32): Yeah, the advantage is it's. So it's gotten so inexpensive. So for something that has minimal to no side effects and has the potential of helping them to move again, which I think is always the thing that we're aiming for. It's not very expensive. But now like several hundred dollars, right? You can order it online. Now you don't even need a prescription or approval or anything like that. Karen Litzy (00:27:59): Yeah. Yeah. That's true. And something that I think is also important is, you know, you'll have people say, Oh, those passive modalities, that's passive. You know, I had a conversation with Laura Rathbone Muirs. Is that how you say the last name? I think that's right. Laura. And we were talking about this sort of passive versus active therapies and, you know, her take on, it was more from that if they're doing these passive modalities, they're giving away their control. And, she said something that really struck and, kind of what the three of you have just reinforced is that no, they still have that locus of control. Cause they're making that conscious effort, that conscious choice to try this, even though it's a passive modality, they still made the choice to use it. Karen Litzy (00:29:03): And I think that coupled with what David said, Hey, this made a difference. Maybe there's some other things that can make a difference that I think that I don't think they're losing that locus of control, or I don't think that they're losing they're reliant on passivity, right.   Sandy Hilton: When they have their own unit and they're not coming into the clinic to have it put on you. And you lie there on the bed while you do it.   Bronnie Thompson: It's something that you have out in the world. It's not different to sticking a cold compress on your forehead when you're feeling a bit sick, you know, we did it. That's just another thing that we can do. So I see it as a really not a bad thing. And it is in the context, you know, if you can do stuff while you've got it on, then it's the hold up problem, as long as you like.   Karen Litzy: Great, great. Yeah. As long as you like it. Exactly. Yep. Okay. so we've got another question that we got ahead of time and then there's some questions in the queue. So one of the questions that we got ahead of time was how do we explain pain responses like McKenzie central sensitization phenomenon in modern pain science understanding. David Butler (00:30:35): I'd answer that broadly by saying that the definition that we've used and shared with the public in the clinical sense is that we humans hurt when our brains weigh the world. And judge consciously subconsciously that there's more danger out there than safety. We hurt equally. We don't hurt when there's more safety out there, then danger. So somebody who's in a clinic and is bending in any way and it eases pain. There will never be one reason for it. So it might just be, that might just be the clinic. It might be the receptionist. It might be all adding up. It might be the movement. They might've done one movement. And so, Oh, I can do that. And then all safety away, we go again, the next movement helps within that mix. There may be something structural. You've done to tissues in the back and elsewhere that might have eased the nociceptors that barrage up. But by answer will always be that when pain changes, it's multiple things are coming together, contributing to them. And they'll never never just be related to nociception. Sandy Hilton (00:31:49): I have to say this to say, I am not McKenzie certified. So this is my interpretation of that. I like the concept of you can do a movement. That's going to help you feel better. And we're going to teach you how to do that throughout the day. Maybe as a little buffer to give you more room, to challenge yourself a little more knowing that you'll have a recovery. And I just pick that part and use that.   Bronnie Thompson: I heard the story of how it all came about and it, and it's you know, it's an observation that sometimes movement in one direction bigger than another. And that's cool. It's like, you're all saying, let's make this little envelope a little bigger and play with those movements because we're beasts of movement. Bronnie Thompson (00:32:50): We just forget that sometimes we think we've got to do it one way. And you know, I can't tell my plumbers who crawl under houses. Look, you've got to carry things the way, you know, the proper safe handling thing. And I wasn't, I was the same safe handling advisors like me. But you know, there's so many ways that we can do movements and why can't we celebrate that? And the explanation, sometimes we come up with really interesting hypotheses that don't stand the test of time. And I suspect it might be some of the things that have happened with the McKenzie approach. It's same time. What McKenzie did that very few people were doing at the time was saying, you can do something for yourself that as we are the gold ones, that's what changed. David Butler (00:33:40): Bronnie, what's really helped us to start the shift away from poking the sore bit, come on, do it yourself. And, and I always give great credit to Robin McKenzie for that shift in life. Sandy Hilton (00:33:53): Yeah. And an expectation that it's going to get better. Right. David Butler (00:34:00): You think that’s showing something in the clinic that helps. Wow. Let's ride let's rock. Karen Litzy (00:34:07): Yeah. And oftentimes I think patients are surprised. Do you ever notice that Sandy, like, or David, or, you know, when you're working with patients, they're like, Oh, Oh, that does feel better. And they're just sort of taken aback by, Oh, wait a second. That does feel better and it's okay. I can do it. Yeah. And then you give them the permission to do so. And like you said, is it's certainly not one single thing that makes the change. But I think everything that you guys just said are probably the tip of the iceberg of all of the events surrounding that day, that time, that movement, that can make a change in that person. And I think that's really important to remember. That's what I sort of picked up from the three of you.   Bronnie Thompson: But the stories like that kind of convenient ways of, for us to think that we know what we're doing, but actually within what this person by what this person feels and how they experience it. And the context we provide us safety, security. And I'm going to look after you, that's, you know, changes, motivations about how important something is and how confident you are that you can do it. We can provide the rationale important part. The person ultimately drives that. So we can also provide that sense of safety and that I'm here. I'm going to hang around while you do this stuff. Let's play with it. Let's experiment. And if we can take that experiment, sort of notion of playing with different movements in, we've got a lot more opportunity for people in the real world to take that with them. We can't do that. Or forgive people are prescribed. You will do this movement. And this way perfectly I salute, but the old back schools, Oh, I know scary, And they did get people seeing the other people were moving. And that's a good thing that we can take from it. It's always good and not so good about every approach. Karen Litzy (00:35:11): Now I have a question for David and then out to the group, but you know, we've been talking about Sims and dims and safeties and dangers. And so for people who maybe have no idea what we're talking about, when we're talking about Sims and dims, can you give a quick overview of what the Sims and dims, what that is so that people understand that jargon that we're using? David Butler (00:36:40): Okay, it's a model we use. There's lots of other similar models out there. So basically based on neuro tag theory, the notion of a network that there's danger danger in me networks out there, and there's safety in me networks, rather simple, structured thinking here, and we've looked at these this has emerged due to the awareness, the pain science that we have a network in our brain. But me as an old therapist, when the brain mapping world came in and we realized, hang on pain, isn't just a little nest up there. There could be thousands of areas of the brain ignited indeed the whole body ignited in a pain experience. And one of the most liberating bits of information for me and my whole professional career, because what it meant was that many things influence a pain experience and a stress experience, move experience lab experience, and many things can be brought in to actually try and change it. David Butler (00:37:39): And all of a sudden means that everything matters. So this is where dims danger in me, safety sims in me, it was just a way to collect them. So an example of a dim with categorize them could be things you hear, see, smell, taste, and touch. So for one person, it could be the smell of something burning or looking at something or hearing something noise. The things you do could be a dim. It could be just doing nothing, but then there's Sims, gradually exercising, gradual exposure seems in things you hear, see, smell, taste, and touch could be going out. One of my most common exercises I now give somebody is to go down to our local market and find four different smells, four different things to taste, four different things to touch. And then they'll say, why should I do that? Because you can sculpt new safety pathways in your brain, which will flatten out some of them, some of the pathways they're linked to pain and it comes to of the things you say important. David Butler (00:38:37): You know, I can't, I'm stuffed, I'm finished. I got mom's knees. We try and change that language too. I can, I will. I've got new flight plans. I can see the future, the people you meet, the places you're with. So it's a way of categorizing all those things in life into either danger or safety, we try for therapy, we try and remove the dangerous. It is often via education. What does that mean? And we try and help them find safety and health professionals out there are good at finding danger, but we're not used to getting out there and finding those liberating safety things. And of course the DIMS SIMS thing. It's also closely linked in, we believe to immune balance. So the more dims you have, the more inflammatory broad immune system, the more sims you have, you move more towards the analgesics or the safety. And so it's the way to collect them. It's a way to collect as we try and unpack and unpack a patient's story listing to it within to unpack it and then to re-pack it again with them in a different way. Did that make sense? Karen Litzy (00:39:49): Absolutely. Yes. I think that made very good sense. And I believe you, there is a question on it, but I believe you answered it in that explanation. It says, have you had patients that cannot find Sims or it's difficult to identify and if so, how can you teach them what a SIM is? But I think you just answered that question in that explanation. David Butler (00:40:11): Once they get it. They're on their way. And we send people on SIM hunting homework. So for example, the same might be places you go, okay, if you can get out, just walk in the park or walk somewhere, then power up the SIM by feeling the grass, touching the box, spelling something. And we pair it up by letting them know that if you do that, your immune system gets such a healthy blast, that it can also help dampen down some of the pain response. Bronnie Thompson (00:40:39): And with regard to our current situation, sort of around the world COVID-19 and all the subsequent stuff. And also the situations in the U S at the moment, is it any wonder that lots of people are feeling quite sore because we’re eating this barrage of messages to us. And so I would argue that at the moment it might be worthwhile if you're a bit vulnerable to getting fired up with the stuff said, it's a good idea to ration, how much time you're spend looking at the stuff, not to remain ignorant, but to balance it with those other things that feel good, that make you feel treasured and loved and committed. And for me, it's often spending some time in my studio, walking the dog, going outside, doing something in nature. And there is some really good research showing that if you're out in the green world nature, that there is something that our body's really relish, kind of makes sense to me. Sandy Hilton (00:41:42): So taking that concept into what's going on right now, there's been a challenge clinically of the things that helped people balance that out, got taken away from them. Yeah. So it was a complicated it still is. It was a complicated thing where it wasn't your choice to stop going to the swimming pool because it made you happy and it gave you exercise and balance this out. Someone closed the pool and told you, you couldn't go. And so there's all different layers of loss in that and lost expectations and loss of empowerment and all of these things. So we have had to help people rediscover things that they could access that could be those positives. And that's been hard and really working my muscles of how to help people find joy or pleasure or happiness or safety in an unsafe environment to really get that on a micro level when you've lost the things that used to be there. And, it's been like a lot, but you can do it. It just takes concentration. David Butler (00:42:57): An important thing. That's so important. I think a question for therapists health professionals should be a sane question should be, you know, what's your worldview at the moment. And I would ask that, and it's usually not good, but I chat and have a chat. And actually I'd like to take people through some graphs that the world is not as bad as it really is. And if you look at I've been reading a book by Hans Rosling called factfulness. And really over time, our world is getting better. There's less childhood diseases, a whole range of things, getting better, bad, and bad things, getting better. This is a hiccup. This, for example, I had a musician recently and I had a graph I could show her that say that there's now 22,000 playable guitars to a million people in the world. But 12 years ago, there was only 5,000. All right, this is just one little thing. All right, cool. There's a lot of stats that show that our world is improving, you know, children dying, amount of science, a whole range of things. And this hiccup we have that I'm hopeful humanity can get, can get through, but just a little message I pass on is therapy. Bronnie Thompson (00:44:13): Even though we can't do stuff, we can't access places. What can't be taken away as our memory of being there. So it's really easy to take a moment to back a memory that feels good to say, actually, you can't take that one away from me. I might not be physically getting there, but I can remember it, feel those same feelings. And then being mindful.   Sandy Hilton: This is funny because if you look at Bronnie's background, that's one of the memories I've been using. When I lost the lakefront, I was like, okay, I'm just going to sit there and pretend that I'm not at that beach by that pier. So it's, it's fabulous. And even pictures or recordings of things that you've done before is like, okay, now there is still good stuff. I might not have it right here, but they're still good stuff. So that's really funny. As soon as I saw the picture, I'm like, yeah. And gratitude and just, yeah. Bronnie Thompson (00:45:05): The other thing as well, we've always got something that we can be grateful for all that. It might feel trite, you know, I'm living in winter, but I've got a roof over my head. I can have a damn fine cup of coffee and probably a nice craft. I'll at the end of the day, these are things that I can do and can have any way. So we can create the sense of safety insecurity inside ourselves without necessarily having to experience it. David Butler (00:45:38): Right. Just a quick comment. I would share that with patients who can't get out are saying the things you do when you're still can be as important as the things you do when you move. Right? So let's explore. If you can't do things, you can still really work you yourself with the things you do. And you're still calm. The introspection reading, thinking, contemplation memory enhancement, go through the photo album, et cetera. And I'd also like to always say to someone to link that in that is a very, very healthy thing to do to your neuro immune complex. Karen Litzy (00:46:13): And that sort of brings, I think we answered this question. This was from a woman who is living with chronic pain and at high risk with COVID-19. So how do we get past the fear of going out where people are crowding areas to get the exercise we need to maintain our fitness and muscle tone to reduce our pain. She said, even though I'm doing exercises and stretching, I've lost the ability to walk unaided on uneven grounds through weeks of lockdown. And the hydrotherapy pool is closed. She said, she knows, I need to get out and walk more, but shopping centers, which are the best place to find level floors are out. And a lot of places that she used to go are now very crowded because people are, don't have the access to gyms and things like that. Are health professionals able to suggest options when she lives in a hilly area with only a few but all uneven footpaths or sidewalks. And she has a small house. Sandy Hilton (00:47:18): That's the kind of thing that we've been doing since it's like, okay, let's problem solve this out. Because yeah, you have your carefully set way to get through this and then it's disrupted.   Bronnie Thompson: Yeah, boy, I like having lots of options for movement opportunities. So we don't think of my exercise, but we think of how can I have some movement today and bring that sense of, we are alike to be like, if I can imagine I'm walking along the beach while I'm standing and doing something and, you know, doing the dishes or watching TV or something that still can bring some of those same neuro tags it's same illusion, imaginary stuff activating in my brain. And that is a really, really important thing because we can't always the weather can be horrible, especially if you're in Christchurch and you can't go out for a walk. Bronnie Thompson (00:48:27): Yeah. But you know, we can think novelty is really good. So maybe this is a really neat opportunity to try some play. And I've been watching some of the stuff that our two chiropractor friends do with you put, let's put, at least try some obstacle courses and the house so that it's not we're not thinking of it as exercise. And I've got, do three sets of 10, please physios change that. Let's do something that feels like a bit of fun. There's some very cool inside activities that are supposed to be for kids. I haven't grown up yet. I'm still a baby. Sandy Hilton (00:49:16): Yeah. A lot of balance and things like that you inside that would help when you have your paths back outside. Yeah, yeah.   Karen Litzy: Yeah. Great. And then sticking with since we're talking about this time of COVID where some places are still in lockdown, some places are opening up. Bronnie and David are in an area of the world where they have very, very few cases, very, very few cases, Sandy and I are in a part of the world where we have a lot more than one. So what a lot of practitioners have had to do is we've had to move to tele-health. And so one of the questions David Pulter, I believe, as I hope I'm saying his name correctly is do we perceive that our ability to be empathetic and offer effective pain education is somehow diminished by a tele-health consult. So are we missing that? Not being in person.   Sandy Hilton: I have found it equally possible in person or telehealth cause you're still making that connection. We do miss stuff. We can't read the microexpressions in people as easily. So we as therapists have to work harder, but for the person on the other end, think about what the alternative is. Sandy Hilton (00:50:46): And it's been really cool for the people with pelvic pain, that every single time they've gone to a physio it's been painful. And on tele-health it's the first time she has been able to talk to someone about all of her bits and pieces without being afraid that it's going to hurt because there was no way to see somebody inside somebody's home.   Bronnie Thompson: You get to know something more about me. I've met more pets than ever thought. It was wonderful. This is a privilege that occupational therapists have had for a long time. And I'm so pleased that other other clinicians are getting that same opportunity, because we know so much more about a person when we can see the environment that they live with. That's just fantastic, but it's harder. David Butler (00:51:39): I find I've come back into clinical practice. I thought I was going to retire because I wanted to go, but also doing it. I was hopeless at first, but I'm really enjoying it. And I actually believe, I actually believe for the kind of therapies we're doing it's equal or better than face to face. Ideally, I think I'd like to have one face to face or maybe two but then to continue on with the tele health, particularly for people are in rural areas and it's almost no this kind of therapy was coming anyway, but the COVID has hastened it. So I found myself getting anecdotally here a much more emotional, closer, quicker link to patients by the screen. They were in a safe place. They're in their house. That's number one. They're not in a clinic you're there. And you can actually look at that face in the screen, as we're doing now, I'm looking at your faces, maybe one or two feet away, and I'm just keep looking at you. David Butler (00:52:46): And there's this connection, which is there. And there's also these other elements it brings in like, you start at 10 o'clock and you finish at 10:45. So there's open and closure, which isn't really there in some of the, in some of the clinics, the difficulty I'm having with it though is I was never in face-to-face practice a very good note taker. I used to make notes at the end. I was talking too much, but what you have to do here, my suggestion with face to face is you really need to plan and make your notes straight after. What did I tell that one on the screen, last clinical context, to sort of remind you of all the little juicy bits that we've got in the interaction. So it's really, for me, it's coming back to curriculum and mind you, I'm glad I'm not doing dry needling or just manipulating it with the talking therapy, but my suggestion is to have the habit curriculum. David Butler (00:53:44): So I've got my key target concepts. I know that I've addressed them in that particular session in the next session. I know I've gone back and I've done teach them the self reflection as well. Then to come back to see if I can get it all, or if I've translated my knowledge into something functional or some change. So I'm really, I'm really loving it. And I think there's something rather new and special with this, with this interaction. But maybe that's just me as a physio who sort of used to the more physical stuff. Maybe this is something more natural to the psychologist, its perhaps, but I'm with it. Bronnie Thompson (00:54:22): I’ve been doing the group stuff. And I found that has been, I've seen, I like it because they don't have to go and travel someplace. It does mean that we can offer it to people who otherwise can't get here. You know, they can't seek people, especially rural parts of New Zealand, low broadband is not that great in many parts as well. So it gets that it's an opportunity. I'd like to see the availability of it as an option. So we can use like we do with our therapies, we pick and choose the right approach or the right piece at the right time and the right place that doesn't have to be one or the other, like you said, you could see him a couple of times in person and then a couple tele-health and then maybe they come back again and then you do mix and match.   Karen Litzy: We have time for one more question here, maybe two. So David, this was one you might be able to answer it really quickly. As a practitioner, what is the utility of straight leg raise slump and prone knee bend test and the assessment of chronic back pain. Is it still relevant? David Butler (00:55:38): Oh gosh. Oh gosh. I'm going to dodge that question and would say it, it would depend on the client who comes in so I think those neurodynamic tests, which I still do. I think the main principle from them is you're testing movement. You're not testing a damaged tissue and anytime you're doing a physical examination, the deeper thing is the patient is testing you. You're not testing them. So what that patient, what that patient offers back in terms of movement or pain responses or whatever, depends on so many things. I might however, have a client and they are out there who do have maybe a specific stickiness or something or something catchy, whatever that may well, the scar around it might well be polarized by action, where I might spend a little bit more time taking a closer look at it. Now that might be relevant. Someone might have, for example, someone might come out of hospital and have had a needle next to the IV drip, next to their musculocutaneous or radial sensory nerve there where it's really worthwhile. Let's explore all the tissues here and see that that nerve can move or slide or glide. But in the second case, I'd made a clinical decision that we probably have issues out in the tissues, which are with a closer evaluation. That's a really broad answer. Karen Litzy (00:57:11): I think it's a tough question to answer because it, sorry, got a cat behind me. I felt my chair moving and I was like, what's going on? Just a large cat. So last question. So how to manage tele-health when the patients may be kind of embarrassed of their house or context or spaces or family it's very common in low socioeconomic patients. So they may not want to turn on their camera.   Sandy Hilton: Yeah. I've had that shaking well, and I've had people in their car or very clearly like I'm kind of angled cause there's a lot going on in my house and I don't have a green screen. So where it's like, and there's just a wall behind me and it's one of the reasons like I'll talk to him ahead of time of if I'm in the clinic, it's clearly the clinic, but I'll tell them I'm at my house. Sandy Hilton (00:58:12): Cause of COVID. So, you know, no judgment, you're going to see a wall and probably a cat and just kind of be up front in the beginning of this as a thing, I've had people that start with the phone on or turn it off or whatever, you just, you roll with it. But I have those conversations ahead of time, before we even do the call.   Bronnie Thompson: It's about creating a safe space for people. You know, if somebody feels, you know, was not having the video, it won't be that long before. I hope we've got some rapport and it feels better. I'm just, I'm doing a bit of a chuckle because the reason I've got my green screen behind me as my silversmith studio, which has an absolute shambles because it's a creative space. So I'm just disguising it because it's works. David Butler (00:59:07): There is something about delivering a story of some talking in the patient's room and there's cupboard doors open and you're looking in their cupboard at the same time. And you know, looking at that, then I just look at that thing. We’re safe here. Karen Litzy (00:59:26): Well, listen, this has been an hour. Thank you so much. I just want to ask one more question or not even a question, more like a statement from all of you that, what would you like the people who are listening and they're, like I said, there were clinicians, there were non-clinicians on here. And I think from the comments that we're seeing in the chat is very valuable and very helpful. So what do you want to leave people with?   Sandy Hilton: I'm gonna echo how I started. We're learning more every single week. I'd say, day but I'm not reading that often. So even if you've gone or you've treated someone and you couldn't quite figure out a way to help them, don't give up because there's more information and more understanding and more ways to get to this all the time. And I don't think you're stuck if you hurt. David Butler (01:00:26): I'd like to mirror those comments, explore the power of tele health, lift your expectations of outcome for those patients, people who are suffering and in pain, who are listening for those who are getting into pain treatment there's a science revolution and a real power in that revolution behind what you do. So just go for it. Bronnie Thompson (01:00:52): I think don't be hung up on with the pain changes or not, be hung up on does this person connect with me. We create trust. Am I listening? Can I be a witness? Can I be there for you? Because out of that will come this other stuff. There are some people whose pain doesn't get better. It doesn't go away. And that's a reality, but it doesn't mean that you have to be imprisoned or trapped by your pain. That means you develop a different relationship with your pain. And I think that's a lot of what we are doing is creating this chance to have some wiggle room, to begin to live life. That's what I'm looking for. Karen Litzy (01:01:53): Beautiful. Well, you guys thank you so much. And for everyone that is here listening, I just want to say thank you so much for giving up an hour of your time. I know that time is valuable, so I just want to thank you all and to Bronnie and to David and to Sandy. Thank you. Thank you. Thank you. And kind of on the fly. So I just want to thank you so much and to everyone. I guess the thing that I would leave people with is, if you're a clinician or if you are a patient, the best thing that you can do, if you are in pain is reach out to someone who might be able to help you, find a mentor, find a clinician, ask around Google, do whatever you can try and find someone who like Bronnie and David and Sandy I'll echo everything. You said that number one first and foremost, you connect with and that you feel safe with. You want them to be your super SIM, you know, like Sandy's my super SIM. Karen Litzy (01:02:48): So you want them to be your super SIM. And, if you can find that person, that clinician just know that that there can be help, you know, whether you're struggling as the clinician to understand your patients or your the patient struggling to find the clinician, I think help is out there. You just have to make sure that you be proactive and search for it. Cause usually they're not going to come knock on your door. So everybody thank you so much for showing up. Thank you, everyone who is on the call and to everyone who is watching this on the playback I hope you enjoyed it. If you have any questions, you can find us we're on social media and various websites and things like that. So we're not hard to find. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Eric Miller on the show to discuss how to maximize the value of your physical therapy practice.  Eric Miller has been in the financial planning industry for over 20 years. He is the Co-Owner of Econologics Financial Advisors and the Chief Financial Advisor. He has a degree from Capital University and is a Registered Financial Consultant® and licensed insurance agent. He takes pride in helping practice owners become the financial heroes of their own stories and has taken this passion to over 600 families in the past decade. In this episode, we discuss: -How to maximize the value of your practice -The business systems that add the most value and are most attractive to potential buyers -Financial considerations when planning your exit strategy -Simple strategies to minimize your tax bill every year -And so much more! Resources: Econologics Financial Advisors Website Econologics Financial Advisors Youtube Eric Miller LinkedIn Econologics Financial Advisors Facebook   A big thank you to Net Health for sponsoring this episode!  Learn more about the Redoc Patient Portal here.                                                                        For more information Eric: Eric Miller has been in the financial planning industry for over 20 years. He is the Co-Owner of Econologics Financial Advisors and the Chief Financial Advisor. He has a degree from Capital University and is a Registered Financial Consultant® and licensed insurance agent. He takes pride in helping practice owners become the financial heroes of their own stories and has taken this passion to over 600 families in the past decade. During this time, he’s had over 15,000 conversations with practice owners regarding money, investing, practice expansion, practice transitions, taxes, asset protection, estate planning, and helping them shape their financial attitude toward abundance. Econologics Financial Advisors is an Inc. 5000 honoree for 2019 as one of the fastest growing companies in the US.   Read the full transcript below: Karen Litzy (00:01): Hey, Eric, welcome to the podcast. I am happy to have you on. Eric Miller (00:05): Well, thanks, Karen. I'm really excited to be here. Yeah. Karen Litzy (00:08): Before we get into our talk on, you know, how to maximize the value of our practice, in your bio, I read that you're a registered financial consultant. So can you explain to the listeners what that is and maybe how that differs from a financial advisor, an accountant? What is the differentiation there? Eric Miller (00:31): No problem there. So I think when people hear that I'm a financial advisor, I mean, people kind of have the same impression that all financial advisors are alike, so to speak. And that's not always the case. You know, there's some financial advisors that specialize in working with you know, ministers and teachers and all different kinds of professions. I just happened to work with private practice owners. Now, as far as am I licensed to do what I do in the financial world, there's something called being a fiduciary. And when you're a fiduciary, that basically means that you have to do what's in the best interest of your client, not all financial advisors adhere to that standard. What's called a registered investment advisor and we're held to that standard under the SEC guidelines. And then as a registered financial consultants, it's a designation that I picked up along the way. And it just basically, you know, there's certain criteria that you have to use to be able to get to that designation that's system. Karen Litzy (01:41): Got it. Yeah. So, you know, we were talking before we went on and it's kind of like if you're in the physical therapy world, which I am, and you go on to become, you know, like a clinical specialist in orthopedics or a clinical specialist and in pediatrics, it's like going on for a little bit extra education and certification and what you do is that right? Okay. That's exactly correct. Perfect. Perfect. All right. So now let's get into the meat of this interview. So today we're going to be talking about how to maximize the value of your practice, perhaps plan for an exit of that eventually. And we're going to weave in some critical tax strategies that you might be able to use to save you money. So no one likes to leave money on the table. No one likes to feel like a dope because they didn't know what they were doing. So, let's start with maximizing the value of your practice. So first, what does that even mean? Eric Miller (02:42): That's a great place to start because I think people automatically assume that when I say maximizing your practice value, it's just about money, right? It's just about, Oh, the, you know, what's the enterprise value of my business. And then that leads into, Oh my gosh, he's going to talk about like profit and loss and EBITDA and all these really technical terms. But in my viewpoint maximizing practice value. Isn't just about money. It's about the other parts of owning a business that you get value for like time, right? Like you would want to build a business that gives you a lot of time. You'd want to build a business that gives you great relationships with either your employees or recognition from your community. So when I say, if you're trying to maximize the value of your practice, it's not just about the money. Eric Miller (03:31): It's about all of those other things, because you know, you look at it, most people that own a private practice that is your largest investment. You know, it's like the thing that provides the most cash flow to your household, and it is an investment and anybody that's owned a business for any period of time knows that it's something that you have to care for. And that you have to make sure that you're treating like an investment and putting in the time and the money to make sure that you get the most value out of it. That's our definition for that. Karen Litzy (04:04): Yeah, absolutely. So how can we as practice owners then maximize the value of our practice. If let's say in the event, we want to sell it, we want to exit our practice in whatever way we want that exit to happen. Eric Miller (04:21): There's definitely some key areas like, yeah, you have to kind of assume the viewpoint of a buyer. Like if I'm going to buy your practice, Karen, like what are some of the things that I would like to see in place that would allow me to give you, you know, top dollar for it. And I think number one is your personnel organized? Okay, do you have organized personnel? Do people have job descriptions? Do they know what they're doing? Do they know who to report to? So, you know, I think that that is that's key because obviously if you have people in your organization that are aligned and are all kind of working together, you know, you're going to have a really powerful organization. If you can do that, if you don't, then you're going to have, you know, this scattered business that everyone's kind of doing their own thing and that's not good. Eric Miller (05:13): So that's certainly one thing. And then of course, just having good stable systems that are built in your business so that there's procedures that people have, that they can follow. You know, there should be an organization chart somewhere where people know like who's in charge of what I think that's going to all add value to your business. Certainly if you look at like the facility, what's the facility look like, is it in good shape? You know, do you have, if you lease the building, do you have a good lease on it? You know, is there new carpeting is, I mean, is it a nice place where people feel safe to come to, you know, certainly a buyer's going to think about that. And then I think from an income standpoint, obviously you have to be solvent. Eric Miller (05:57): You certainly don't want to have a lot of, you know, outstanding accounts receivable out there. You want to make sure your books are up to date and current, you don't owe any back taxes on the practice. You have multiple income streams in the business that you like multiple services that you provide because no one wants to be reliant upon one of anything. So I think those are all, some really key areas that if you can get those things in shape and you can get them systematized, you're really going to have something that someone else would want and they would value. And they're going to pay you a much higher amount for that. Karen Litzy (06:33): Yeah, that makes sense. So what I'm hearing is you really want to have an organization that's sort of a well oiled machine where people know why they're coming to work. They know what they're doing once they get there and reasonably happy at their jobs, if not very happy at their job. Eric Miller (06:52): Yeah. And I think that you're exactly right. And I think the key as the person that's in charge of it is that you have to know what your role is in that business. So I think a lot of people that are in private practice, and maybe you can attest to this when you first started out, you're just trying to make things happen and go, right. And, you know, as you go on, you kind of realize, look, I'm not just a practitioner, I'm also an owner and I'm an executive and those are completely different roles. And I think over time, if you can really make sure that you understand that those three roles are separate and that you have to make sure you master them to that degree, or at least hire someone that can do those things, that that's really going to create you a valuable practice, you know? Karen Litzy (07:41): And I mean, when you first start out, like I work with a lot of like first time entrepreneurs, you are the owner, the therapist, the executive, the marketer, the pay, you know, you're everything, right? So, so let's say you have a practice like that, where maybe you are a single owner practice, right. Or maybe you have one person part time person. So you don't have this sort of robust, huge practice. Can you sell that? Eric Miller (08:12): Well, you can, you can sell anything. It's just as a matter of how much you're going to get for it. So, again, looking from the buyer's perspective, he wants to buy something. That's not dependent upon one person. He wants something that's going to be basically, he can assume that there's free cashflow there. That is going to be worthwhile to him as an investment. So if you have like a single doctor practice or you're a single practitioner, I mean, you can certainly sell it. It's just not going to go for a very high, multiple, see, most of the practices that we're talking about, you know, are going to sell for maybe like a one to two times earnings. Whereas if you get a bigger organization that has, you know, seven, eight, nine, 12, 20 PTs on staff, there's executives in the office, it's going to go for a much higher, multiple could go as high as eight to 10 of your earnings. So it is, it is that kind of a game, but that's, you know, that's the journey. Karen Litzy (09:08): Right? And, you know, you had said you want to have a lot of systems in place, in your opinion, what are the most valuable or most important systems to have in place within your business? Looking at it from a value standpoint? Eric Miller (09:23): I think definitely having a good financial system is really key because look at what, you know, a lot of businesses, business owners, don't like to confront the finance part of their business, and that's why they don't have much in reserves. And, you know, they're always kind of struggling for, gosh, I can't make payroll this week. And it's just a constant battle when you don't have good financial systems in place, because they're just, they're not paying attention to their money lines. And unfortunately, when it comes to your practice, that that is the most important thing is keeping that practice solvent, which means that there's more money coming in than what's going out. So that personally, I think that's the most important. Some people would say a marketing system is really key because let's face it. If you don't have more patients coming in and buyers definitely going to want to see that he's going to want to see that you are, you have a system in place where you're constantly getting new patients in the door. Right. And then, you know, I think a good quality control system is, is really, really key. Because if people aren't, you know, getting better and you don't diagnose that quickly of, you know, why aren't people getting better because that's what you do as a physical therapist, your job is to get people pain-free, you know, or reduce their pain. So I think that's a pretty key area too. Karen Litzy (10:42): Nice. Yeah. I just had this conversation about the importance of a financial system. Cause I sort of switched my financial system within my practice around, over the last couple of years and it's made such a huge difference. You know, I started looking at the financial system in percentages sort of going off of Mike McCollough, the book profit first. And so, yeah. So how much stays in the business? How much goes to me as an owner, how much goes to taxes? How much goes to profit, how much goes, and then making sure that when that money comes in, it is automatically divided up into those percentages and it's made a huge difference. Eric Miller (11:22): That's so awesome to hear it, does it because you've instilled control over your money right now. Right. And when you look at like what's a barrier for a lot of practice owners is that they don't feel like they have control over their money. Right. And, when you start putting in good control, it's kind of like when you're adjusting somebody or you're getting someone to feel better, right. You have to kind of put control in on that person. Like, I need you to do this and move here and do that. It's the same thing with your money. You have to kind of allocate it so that you know, your expenses are you channel your money to places where it needs to go to handle whatever expense that would be. Certainly, you know, you're yourself. I think, you know, is the most important person that you need to pay first. Karen Litzy (12:07): Well, that's what profit first says. No, it's true. Like, and once I started doing that, it made everything just lighter. So now like quarterly taxes are coming up September 15th or depending on when this airs that might've just been that September 15th date. And I remember like years ago, I'd be like, Oh my gosh, I don't know how, how do I not have them now? I'm like, Oh, totally fine, my money's where it's supposed to be. I am good. Like, this is exactly where it needs to be. Eric Miller (12:43): That actually is kind of like an underlying goal and purpose that I have is I, you know, people always ask like, what's the product of a financial advisor and people think it's, you know, Hey, you know, you made me 20 or 30% or you know, helped me save in taxes. Not really, you know, I like people to feel relaxed about their financial condition and just what you explained to me right there. You're definitely much more relaxed about your condition now because you have control over it and it doesn't control you. That's really awesome. Karen Litzy (13:13): Yeah. And it's a little stressful at first because it's different and it's a change. So I always tell people if you're starting out now start off this way. And Holy cow you'll be so much easier. Everything is just, I feel so much easier. Yeah, just a sense of ease that I now know, like, yes, I have money set aside for this. It's already paid, like it's basically already paid for. Eric Miller (13:39): That's it that's right. But it also does another thing too. It does make you look at and say, you know what, maybe I'm not making enough money in my business because I can't cover some of these other things. And I think that's the most important thing that people have to realize. And I'll go off on a little tangent here, but there's really two basic rules of, for me, income and expenses. The first one is that just get used to the fact that your business will try to spend every dollar that it makes. And then some, and, and that's not just for a business, that's like a government or any household or organization just, it's just going to try to spend every dollar that it makes. And then some, but at the same time, it will also make the exact amount of money. Eric Miller (14:25): It thinks it needs to make to survive. So when I say that, people are like, what does that mean? I'm like, well, look, you know, if you know that you have expenses coming up, somehow miraculously, the business does make enough to cover it. Doesn't it? It's just like, it's just, that's the way it is. So the trick to it is simply to make sure that your reserves and your profit and your taxes are just part of what the business thinks it needs to make to survive. And if you can get that in as what you said as part of that profit first book, I think that's what he's talking about is that it sets the right income target for what the business really needs to make, because that's the biggest outpoint that I usually see with, with practice owners is that I'll ask them, Hey, what's your income target? They'll say, well, you know, I need to make $30,000 a month to pay my bills. And I'm like, well, no, that's not what you need. You actually need 45. If you want to include your profits and building up reserves and paying your taxes that they're operating on a wrong income target. So I think that's really key is to make sure you're operating on the right number. Karen Litzy (15:30): Right. So don't underestimate it completely because I think oftentimes people will just look at, well, this is my rent. These are my utilities. This is my payroll. If you're paying people and these are, you know, overhead costs that maybe we have to pay, you know, phone bills, things like that. And that's it. And they're like, okay, so that's all I have to make. Eric Miller (15:55): That's right. And that's where their demand for income is. But, and if, but if they put in, Hey, I need another $10,000 a month for myself. I need another 5,000 for taxes. I need another because I want to make sure I have reserves. So if I have to shut down for another month, I can handle that. Right. You start putting all those things in. Now the number changes from Oh, 35, I need to make 50. Oh, right. Okay. Well, that's fine. How many more patients do I need to see a week? Right. To be able to make that number, it just gets them, you know, being a problem solver now, as opposed to like, I can't do anything about it kind of mode. Karen Litzy (16:32): Yeah. And I do that. Like people always ask me, well, how many patients, you know, do you usually see a week? And I said, well, it's not, how many do I usually see it's this is what I need to see to make X amount of money per week. So that I know per month, this is what I'm making. And my costs are a little bit lower because I have a mobile practice. So I'm not paying a lease on a brick and mortar facility, but I still have to pay my own rent for my apartment. And I still got to eat. You know, these are all the things that you have to put in. So it's not just, what does the business need, especially if you're a solo preneur, what do you need to survive? Eric Miller (17:12): Yeah. And I think this is where a lot of people, yeah. A lot, a lot of practice owners and entrepreneurs gets, think that their business is more important than their household. And you know, I'm under the, you know, our philosophy, our viewpoint is that your household is like a parent company. Okay. You think about this, you look at all the big corporations out there and you know, people have opinions of them, but they do understand money pretty well. And they certainly understand that let's take Facebook. For example, Facebook owns, I don't know if you do this, like 83 other companies and they're the parent company to all of those other companies, but everything flows to the parent company. Okay. We're your households, no different, you know, you own, you have a, let's say you own a house, a business, maybe a piece of real estate 401k plan, the bank account. Right. Those are all assets of the household. So you really, you know, once you start treating your household, like the parent company, then you set up the system so that, you know, your household you're meeting the goals and purposes of the household people. I think they don't do that. They don't take care of themselves like they should. Karen Litzy (18:19): Yeah, no, I think that's great advice. Thank you for that. Alright. So we've got those financial marketing quality control systems, obviously three very important systems and we can go on and on and systems. That's a whole other conversation. So we will take those and people can run with them as, as sort of prioritizing their systems. So now we've got, we've got all of our systems in place. We've especially our financial system. So how do we plan? Let's say we're getting towards the end of our treating career, whatever your clinical career, whenever that may come. And it may come at different times for different people. How do we efficiently plan for an exit? What do we do? Eric Miller (19:05): As far as like getting the business ready to exit out. Karen Litzy (19:09): Yeah. Like let's say, let's say you're getting ready to kind of exit out of your business. Now we know that maybe you can try and sell it. Or what if you're just like, this is the business is done. You're just done. What do you do? Eric Miller (19:24): Yeah. Well, I mean, I think the first thing you gotta realize, you gotta look at your own financial readiness. Like, can you afford it? You know? I mean, I think a lot of people, they get into a position where they're tired, they get exhausted, right. Because they've been doing things for themselves or I'm sorry, just for the business. And then they just get burnt out, you know? Well, you know, burnout, you know, what burnout is, it has nothing to do with that. It's just that you don't have a bright enough future in front of you. That's what burnout comes from. Right. And I can see why a lot of practice owners getting that conditions. Like I just keep doing the same thing every day and I can't see a bright future for me, so I might as well just sell the thing. Okay. Eric Miller (20:06): So the first thing that I do is just, I try to rehabilitate, like, do you remember why you decided that you wanted to be a business owner? Do you remember like what the purpose was? And if you can revitalize that, I think you can get that person back on track, but look at the end of the day, if you don't want to do it anymore and you want to sell your business, then you know, certainly, you know, hiring a broker can help. Certainly finding someone or just finding another PT that, you know, in the area that would be willing to take, you know you know, sell, you can sell the business to, for Goodwill or it's not going to be very high price, but certainly you can find someone that would be willing to buy practice for some costs. Right. That may just not be very much. Right. Karen Litzy (20:52): And then what, if you were ready to just wrap it up, you don't want to sell it. Are there things that one needs to think about as they wind it down? Eric Miller (21:02): You mean just like, just close it down? Karen Litzy (21:04): You're closing it down. You're moving on to greener pastures, if you will. So you decided to close it down. Are there any financial considerations that one has to think about in that scenario? Eric Miller (21:16): Well, you know, certainly look at how much money that you make from your business. Even, you know, money that through the cashflow that you make, it's sometimes a lot more significant than what people think. And certainly you can own the business. You can just, I mean, if you're a physical therapist, you can just go work for somebody else if you want to. But you know, I think people just have to realize that, that their business does provide them a pretty good living and they just have to analyze that and say, do I have enough to replace that? Or can I go to work for somebody else and replace that income? You know, it's certainly not a good thing to do. You know, there's seven different ways to exit out of business. And that's one of them just shutting it down. It's probably the most, it's the worst way to do it, but I know that it does happen. Karen Litzy (22:05): Yeah. Yeah. What are the other ways you could just name them? We don't have to go into detail. Eric Miller (22:13): So you can die with your boots on, you can close it down. You can sell to an associate. Okay. You can sell to a competitor. Okay. You can sell to private equity. Okay. You can gift the practice to somebody else. Okay. Or you can have your employees buy it through, what's called a Aesop plan. Those are the seven ways that you can exit out of your practice. Okay. Great. What happens with most practice owners is they either sell to an associate to a private equity group, the size of the practice. Karen Litzy (22:54): Yeah. Yeah. And so now let's talk about taxes. Eric Miller (23:03): Yes. So, Oh, taxes. Hey guys, when you could see your eyes got big. Karen Litzy (23:07): Who likes to pay taxes, right. Nobody likes to do it, but we all do it because we need, we need the services that they provide. Right. So let's talk about some tax strategies that might be able to save us some time. Eric Miller (23:21): Yeah. Yeah. I think the first thing on taxes is that you have to realize that your accountant may or may not understand the tax code completely. And it sounds really weird because everyone assumes that they have an accountant, Hey, he's going to try to minimize my taxes. That's not really what their goal is. Their goal is to make sure that you are compliant, that you file your taxes on time. They're not necessarily doing tax planning for you. They're not trying to minimize your taxes. Okay. So I think that's the first thing is that you really have to make sure you're working with an accountant that has the viewpoint that I want to try to minimize this tax bill as much as I can, because it won't happen by itself. You have to be proactive. You cannot take a passive role in minimizing your taxes, or you're just going to end up paying the most. Eric Miller (24:09): Okay. The tax codes, 3 million words, and, you know, no one's going to know every single passage of it. That being said, there are definitely some strategies out there that you can utilize. One that is that I've been talked about a lot is that you can actually rent your house out for 14 days out of the year and you can collect that money completely tax free. And you're probably thinking like, well, how, how would that benefit me? So where this came about was that in a, I don't know what year it was, but if you've ever heard of the masters golf tournament, there's a lot of, there's a lot of guys that have big houses there and on the golf course and they rent their houses out for thousands and thousands of dollars. Okay, well, legally they can collect all of that money, completely tax free. Eric Miller (25:08): Okay. Because the IRS code says, you can rent your house out 14 days out of the year and get that money complete tax free. And you probably thinking, how do I take advantage of that? Well, if you own a business, your business can rent your house out for 14 days out of the year. And as long as you have a legitimate meeting at your house, maybe you have with a key executive or even with yourself, right. You have an executive meeting at your house and you document that, then you can rent, you can have the business pay for that. Okay. It's a business expense. And then you get that personally. And as long as you do it correctly, you can get that money completely tax free. All right. That would be certainly one strategy you can use. It's called the, it's called the Augusta rule. You can look it up online and, and certainly there's. Yeah, yeah. That's where it came from. That's one and, you know, right there, 14 days, let's say that it's a thousand dollars, that'd be $14,000 that you could expense out in your business. And then you can get that personally. Oh, you have to do it right. You have to have a legitimate meeting. You have to like Karen Litzy (26:14): Say it's $10,000 a night. Eric Miller (26:17): I don't know. In New York, you may be able to write. Karen Litzy (26:20): I don't know. That might be a stretch too. Eric Miller (26:22): If you needed to rent out like a hotel or a restaurant, that's what you would need to do. You need to go get like an estimate like of where you would normally hold that meeting just for documentation purposes, but like anything else it can be done. You just have to follow through and have documentation, you know? And I just have the accountant guide you on how to do that. That's certainly that's one that would be, you know, 14, 15,000. So if people have kids, they can put their kids on payroll and they can, you know, show them that would be another deduction that you can use. You know, there's certainly a lot more, I could probably go on all night. But you know, I think another thing that people can do is just look at how they take their income. Eric Miller (27:06): Like you own a business, right? And most physical therapists are escorts. And you know, a lot of accounts will tell them to take bigger salaries than what they actually need to be taking. Right? So you can actually adjust your salary downs as long as it's a reasonable compensation and then take more an owner draws. That's going to help minimize the Medicare tax as well. So it really just boils down to, you know, finding the right information, finding a right advisor that can help you and, you know, provide tax deductions that your accountant can work with to minimize it. It can happen like you should, it's your responsibility. And I say this a lot. It's like, I've never read anywhere where it's my responsibility to maximum fund the IRS. Right? Like I know I have to pay taxes. I get that. But there's no one that said that I have to like pay, you know an ungodly amount of tax. But that's the way the IRS works. They just assume that your money is their money and you have to be proactive to show them otherwise. Karen Litzy (28:11): Yeah. I know this year when I paid my taxes, when I did my taxes for 2019, I was so excited. Cause I only owed like $309 after doing my estimated quarterly taxes, which I thought, well, this is great because I'm not giving them more throughout the year. And in fact I was almost like, spot on. That's pretty good. Yeah. That was pretty good. Because like, you don't want to, like, I understand when people get refunds, but if you got a refund, that means that you gave them more than was necessary throughout the year. Correct. Right. Yeah. Eric Miller (28:53): So it is something that you have to stay on top of because as your business grows, you know, your tax liability personally is going to be higher. So you really have to make sure you stay in good communication with your accounts. Like you should be talking to them every quarter, especially now recently where I think a lot of people have gotten the PPP loan. And if you, you know, if that gets forgiven well, you know, physical therapists didn't really shut down. I mean, some of them did, but you were still collecting money. So you know, you may have, you really have to make sure that you're not going to have a tax problem for 2020, it could happen. So just, you know, just getting in communication with your accountant. I think that that will help. Karen Litzy (29:32): Yeah. During the PPP loan phase and covert, I was thinking, I was talking to my accountant like literally every other day. Yeah. I'm like, does this make sense? Should I do this? Should we do this? Should I do this? Can I do this? Does this, is this the right form? Do I feel, and I did get a PPP loan because in New York, you know, we were done, like when I say shut down, like shut down, nothing, you know? And eventually I started doing more telehealth visits, but in the beginning it was quite scary. And so I said, you know, I better apply for a loan and, and I did get it. And now they haven't even asked, we haven't even filled out the forgiveness paperwork yet, but now I'm in contact with him like weekly, like, is this the right form? Did I fill this out? Right? Is this the right documentation I need? And he's like, yes, yes, yes. You're all good. So now when the time comes, I'll be able to get that in really quick. Eric Miller (30:27): Yeah. And it won't be a problem and you know, you'll have your attention on other things that'll help expand and that's good. And then that's just, that's not my experience. Most practice owners, they kind of don't confront it, they ignore it. And then it becomes a bigger problem down the line. And that's really needless. Right. Karen Litzy (30:44): I think that's how I used to be, but I have now been rehabilitated financially. So yeah, this was great. Now, what are in your opinion, what are the key messages that you would like the listeners to kind of take away from this conversation? Eric Miller (31:02): Well, I mean, you know, for me look, I mean, you can, regardless of what your financial condition is, like, you can do something about it. Right. And I think that's always been a pretty key, you know, philosophical viewpoint that I have. Like, I don't think that there's such thing as an unwinnable game and I know that even things get a little murky and they get a little dark and you know, sometimes you don't really see, you know, the future as bright as it could be, but if you just kind of like, just do one thing right. And complete that cycle of action and then go onto the next, then I think that starts to create more freedom for yourself. Like people get overwhelmed so fast. Right. And there's like, there's so many different things to do, especially financially. Right. That they just, they don't just do what's in front of them while they're doing it. Like just complete one thing at a time. And then you can go on to the next one. Right. Like do the next thing and then go on to the next one. And then to me, that's the key to success, right? There is, is getting interested in something that you don't want to do. Right. And completing it. And I think once you do that, you'll start to see a much brighter future, better things happening to you. Karen Litzy (32:14): Yeah. Great, great advice. Thank you so much. And before we get going, I'm going to ask you the same question that I ask everyone. And that's knowing where you are now in your life and in your career. What advice would you give to your younger self? Eric Miller (32:29): I would simply tell myself that there are destructive and constructive actions that you can do in life, right. And that those destructive actions, while they may appear fun at the time will certainly prevent you from getting to your potential and leading the life that you want to lead. Right. I know we're all young. We all kind of make stupid mistakes and that's just part of the learning curve. But I would certainly tell myself, you know, your personal ethics is really part of your survival, right? And to the degree that you kind of keep yourself in good shape morally, and you do the right thing better things are gonna happen to you in your life. It's going to create more abundance for you. And I would tell myself that is just make sure you pay attention and do the right thing more often than you do the wrong thing. Karen Litzy (33:22): Excellent. And now, where can people find you on social media website? Eric Miller (33:27): Yeah. So if you want to go for a wealthforpts.com wealthforpts.com, you can download a free ebook that we have. You can certainly go to our website www.econologicsfinancialadvisors.com And then we have a YouTube channel, www.econologicsfinancialadvisors.com. And those would be three places that you can go to connect with us. Karen Litzy (33:48): Perfect. And all of that will be at the show notes at podcast.healthywealthysmart.com under this episode. So one click will take you to everything. So Eric, thank you so much. This was great. I was taking copious notes and you know, every time I have these conversations, I'm always thinking to myself, Hey, what do I need to do? What do I need to act on? And you know, a lot of the conversations that I've had with folks like yourself, accountants, even on this program and in my own personal life have just really been so valuable. So I thank you so much for taking the time out today. Thank you and everyone, thanks so much for listening. Have a great couple of days and stay healthy, wealthy and smart.     Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Stephanie Weyrauch on the show to discuss budgeting.  An active member of the national physical therapy community, Stephanie has served on multiple national task forces for the American Physical Therapy Association (APTA) and actively lobbies for healthcare policy issues at the local, state, and national levels of government. Stephanie is a nationally sought after speaker and consultant for topics on social media use, generational issues, and organizational membership. In this episode, we discuss: -Stephanie’s experience paying off student loans and still enjoying her lifestyle -The budgeting tools you need to manage your expenses -Why an accountability partner can help keep your budgetary goals on track -How to incorporate pro bono work into your practice -And so much more! Resources: Stephanie Weyrauch Instagram Stephanie Weyrauch Twitter Stephanie Weyrauch Facebook Email: sweyrauchpt@gmail.com Dave Ramsey’s Complete Guide to Money - Hardcover Book The Total Money Makeover Dave Ramsey Podcast Every Dollar App   A big thank you to Net Health for sponsoring this episode!  Learn more about the Redoc Patient Portal here.     For more information on Stephanie: Dr. Stephanie Weyrauch is employed as a physical therapist at Physical Therapy and Sports Medicine Centers in Orange, Connecticut. She received her Doctorate in Physical Therapy and Master of Science in Clinical Investigation from Washington University in St. Louis. Dr. Weyrauch has served as a consultant for a multi-billion dollar company to develop a workplace injury prevention program, which resulted in improved health outcomes, OSHA recordables, and decreased healthcare costs for the company’s workforce. She has served on multiple national task forces for the American Physical Therapy Association (APTA) and actively lobbies for healthcare policy issues at the local, state, and national levels of government. Currently, she serves as Vice President of the American Physical Therapy Association Connecticut Chapter and is a member of the American Congress for Rehabilitation Medicine. Dr. Weyrauch is also the co-host for The Healthcare Education Transformation Podcast, which focuses on innovations in healthcare education and delivery. Dr. Weyrauch has performed scientific research through grants from the National Institutes of Health and National Science Foundation at world-renowned institutions including Stanford University and Washington University in St. Louis. Her research examining movement patterns and outcomes in people with and without low back pain has led to numerous local, regional, and national presentations and a peer-reviewed publication in Archives of Physical Medicine and Rehabilitation, a top journal in rehabilitation.   Read the full transcript below: Karen Litzy (00:00): We are the facebook group so we'll be checking the comments regularly, but just know that we will be checking and we'll probably be a couple seconds behind you guys. So if you are on and you are watching throughout any point in our talk today about setting a budget definitely write your comments down like questions. Whether for me mostly directed to Stephanie and we will get to those questions as well throughout the talk or throughout this very informative talk. I was saying before we went on the air that I'm really excited to listen to this because I have always been impressed with the way that Stephanie and her husband Deland have been able to create their life and their budget, and it's still full and they get to do the things they want to do and go where they want to go all while maintaining a budget and all while they both have student loans. Karen Litzy (01:07): So what I'll do first is it's for people in the group who aren't familiar with you, Stephanie just talk a little bit more about yourself and then we'll talk about how you set your budget and what kind of framework you follow.   Stephanie Weyrauch: Well, thanks Karen, for having me on, I'm really excited to talk about this because I'm running a budget as something that was really hard for me to do for a long time. I wasn't really raised to think about money growing up. So it's not, when I went through PT school, I just got my student loans and spent my money as I saw fit. And didn't really think about my money. So I'm Stephanie, Weyrauch, I'm a physical therapist here in Orange, Connecticut. I work at a private practice called physical therapy and sports medicine centers. Stephanie Weyrauch (01:55): And I do a little bit of consulting work privately through four different companies to try to help with occupational medicine and try to prevent any type of work injuries that happened in the workplace. So that's kinda my background a little bit, but when I went to, when I graduated from PT school and went to my first job, and at the time I was working in Minnesota, my student loans were becoming due and my husband is a physician. So he has a lot of student loans as well. So at the time total, we had pretty close to $300,000 in student loans. So quite a bit. And when my student loans were coming due and my boss hands me this little application for my 401k and like all these other very adult things, I just, I panicked. And I was like, I don't even know what a 401k is. Stephanie Weyrauch (02:44): I don't know how to pay my student loans. My husband was in medical school at the time. So I was the only one working. And my boss was just like, hold on. He's like, it's okay. I can help you. And so he handed me this book called the total money makeover by Dave Ramsey. And I read it and it changed my life. It changed the way that I thought about money. It changed the way that I handled money and it really empowered me to pay off my student loans and to not be afraid of debt to basically conquer it. So that's kind of the background behind it in the book. And also on his podcast, the Dave Ramsey show, he talks about how to manage a budget and how to set up a budget and how to stick to a budget. So the app that I use is called every dollar it's free. Stephanie Weyrauch (03:30): You can download it on, you can download it on Apple or Android, it kind of looks like this. So you can kind of set up, you can put in how much money you make and also what your expenses are for the month. Basically, it's very easy to use. You can use it on your phone or your computer. And so I started using that at the time, we were a one income household. I did pick up an extra job in a skilled nursing facility because my goal was, I didn't want to accumulate any more debt. So my goal was to try to make enough money and save enough money that we could pay for my husband's last year of medical school, which he went to an instate school. So his tuition was $25,000, which is very cheap, I think, by medical school standards. Stephanie Weyrauch (04:19): And we were able to cashflow that entire year of medical school, just off of the extra job that I was working at the skilled nursing facility. So every month, basically what I do is I go into the app before the month starts, I put in how much money I'm expected to make. Now, one of the things that happens when you're in private practice, especially if you're starting out is you may not know exactly how much you're going to make. And so it's hard to put in your budget like, Oh, I'm going to make, let's say, as Karen was talking about in the last course, you know, paying yourself by, let's say by biweekly or by month bi-monthly I'm gonna make $2,000 this next two weeks. Like you can't necessarily do that in Dave Ramsey's book. He has a sheet that you can use that lays out how you can do a budget based off of an income that fluctuates. Stephanie Weyrauch (05:11): I've never had a fluctuating income, so I've never used it, but he talks all about that in his book. And it's very easy to follow because he also talks about that if you are in debt and you're trying to pay off your debt, there's a certain amount, certain things you need to pay first. So food, shelter, lights, those are like the main things that you need to make sure that you focus on first. And then also the next thing would be like clothing. If let's say you're, you need to buy clothing. For some reason, I have really don't buy a lot of clothes. So I don't necessarily have to worry about that. And then after that is, comes your debt and any other miscellaneous things. So in this budget, you set up your income. If you were planning on giving any of your money away and like doing some charitable giving, that's something that he puts in there. Stephanie Weyrauch (06:02): If you're saving any money, there's a section for that. So then you can set aside how much money you want to save. And then for housing in my budget, I have my rent electricity. I put my cell phone cause that's my phone bill in there, my internet, and then my laundry. So those are like the five budget items that I have in there. And then in that month I set how much money I'm going to spend. And he thinks of a budget, not necessarily as a restriction, but permission for you to spend your money. So like throughout the month, if let's say your needs change, you can kind of rearrange how much money you're putting aside. So let's say for transportation, I need, let's say I'm taking my car. Cause I'm going to drive to a couple of patients’ houses. But this month, most of my patients are within a two mile radius of me. Stephanie Weyrauch (06:53): They're not far away, so I don't have to drive as much. So at the beginning of the month, I thought maybe I have to drive more. So let's say I set a hundred dollars for my gas and auto budget, and now I'm realizing I don't need that much. So what I could do with that is let's say I only need $50. So that extra 50, that I'm saving, I could potentially move to, let's say my savings, or if I have debt that I need to pay, I can move it down towards my debt. So you're giving yourself permission to spend that much money per month. The next item line item is food. So I've had groceries. And then I have, we have a section for restaurants. So if we want to eat out now with the pandemic, one of the things that was kind of nice about the pandemic is we weren't eating out nearly as much, but our grocery bill went like way up. Stephanie Weyrauch (07:38): So I noticed that we've been spending a ton more money on groceries. And I think it's mostly because food has gone up. So I had to adjust our budget based on that. Now this month we're, you know, things are starting to open up a little bit more here in Connecticut and Deland and I really haven't been able to go out and eat very much. And so now we're trying to put a little bit more money towards our restaurant budget because we want to enjoy that experience since we haven't had it for so long. So typically I set aside maybe $150 a month for restaurants, but this month we doubled that just because we haven't hardly eaten out at all in so long. So again, it's permission to use your money in the way that you think is going to be good for that month. Stephanie Weyrauch (08:27): And then there's a section for lifestyle. So I put like my subscriptions in there. So my Peloton subscription and my Netflix subscription, and then I have a vacation with my mom, hopefully coming up. And so I've been, you know, find some hotels and stuff for that. So I've been putting that under that, and then this one's going to be big if you're in private practice insurance and taxes. So there's another section for that. So if you have your, let's say it's the month where you have to pay your quarterly taxes, or let's say, instead of saving all this money and doing it in one month, you divide it up into three months. Well then you can kind of equally divide that four month, and then that way you're not forgetting to pay it. And then of course the last line item is debt. And so how much money you're going to be spending towards your debt that month. Stephanie Weyrauch (09:20): And then what happens is it will take, it'll give you like a picture and a graph of how much you're spending. So let's see if I can bring that up. So, so basically this is my debt and how much I spend this, this past 12 months on different things. So you can see that most of what I've been spending has been on my debt is debt, the green light, this light green color, this big one, that's all how much money that I've spent on debt this year, so far this year. So, you know, Karen had mentioned the other day that deal and I paid a lot on debt and we have, since I've been on this budget, I have been dedicated to becoming debt free. Stephanie Weyrauch (10:09): And our goal has been to be debt free in a total of seven years. So right now we're in year four of that. And within those four years, we've paid off $150,000 in debt, which is a lot. And that includes the cashflowing of Deland’s medical school, plus our move that we had to cash flow from North Dakota to here in Connecticut. So I'm not saying it's easy, like I'm not saying I live a luxurious life at all, but I would say that I definitely, like Karen said, I'm able to like go, I'm able to go well before the pandemic, I'm able to go to New York city, like once a month and see Karen and like hang out with my friends. But I plan for that every month. And if something comes up where I'm not able to do that, then I just have to make sure that I don't do it. Stephanie Weyrauch (11:00): And so it takes discipline, which you're all in private practice and you've started your private practice. So you obviously are all disciplined individuals. I will say that when you're managing a budget too, it always helps to have a partner who will keep you accountable. I am a spender and Deland is a saver. And so if I had my choice, I would probably go over our budget every month. But Deland is very good at saying now, Stephanie, do you really need that. And I fortunately must admit many times no. So having an accountability partner is really important. If you're in a private practice, that accountability partner can be your spouse or your partner, or it can be your business partner, or it could be a trusted friend. So having maybe you guys are both managing budgets at the same time and you can kind of be each other's encourager. Stephanie Weyrauch (11:53): So that is something that's how I run our budget. It is definitely, I definitely don't live a very luxurious lifestyle, but I wouldn't say that I'm just sitting at home, eating ramen noodles all the time either. So I'm able to put most of the money that we spend every month goes towards debt. So probably half of our budget each month goes towards debt, but that's just because we are dedicated to making sure that we become debt free within the next four years. So, yeah. And, and there may be people on here who have no debt and don't awesome. Right? And so that part of the budget and the app, I mean, how wonderful, if you don't have student loan debt, maybe you have credit card debt, and you're putting something towards that each month. But I think if you don't have, if you're past the student loans or you didn't have to have, you didn't have to take out any student loans, then you can certainly take that money that would go to debt. Stephanie Weyrauch (12:57): It would be substantially smaller if we're just talking about credit cards and you could say, you know, I'm going to dedicate it to XYZ. Now what happens? Oh, quick question. So what was the Dave Ramsey book? I put two books. One was the total money makeover and the other's complete guide to money. I put them both in the comments section here, but where was the one that said he had like that's total money makeover. Okay. The total variable with the variable income. Yep. That's at the very back of it. And you can just copy and I mean, I'm sure that there's a copy of it too, on the internet. You could Google it and it's palatable.   Karen Litzy: Okay, great. Yeah. I think that for me, I look at, you know, this I'm taking care of your budget. I think a big part of it is writing everything down, right? It's the same way when we say to our patients to keep a journal or an exercise log, or if you've ever done weight Watchers, you have to write everything that you eat using weight Watchers. This is kind of the same thing. It sounds like this app, and you're really having to write everything down each month is definitely keeps you accountable, but also gets you into the habit of doing it. Stephanie Weyrauch (13:44): Yes. I definitely agree with that. And you know, the other thing too, that Dave Ramsey talks about in his book is he has these specific baby steps that you work towards to building wealth. So obviously I think all of our goals, some days to be financially stable and successful, right? So even utilizing his principles towards your business, I think is really important, especially because look at what happened to us during this pandemic. Stephanie Weyrauch (14:34): I mean, 80% of Americans are living paycheck to paycheck, and a lot of us needed PPP loans. And like some people's businesses just weren't prepared for this. So in his book, he talks about like having a small saving, like emergency funds, you know, paying off debt so that you can become debt free would be the next step after that. And then saving three to six months of expenses. And, you know, after this pandemic, one of the things I think I've learned is having that six months expenses saved is like so important and notice that it's six months of expenses, not six months of your monthly budget, but expenses. So then when you have an emergency, like something that you just can't even control, like you feel more in control, you're able to maybe provide more for your employees, or if you, you know, or even your help your patients out a little bit more pay your bills. Stephanie Weyrauch (15:31): And then the last three steps, which if you're a business owner, I mean, it's pay for kids' college, which you don't have to worry about that as a business owner, but pay off your mortgage. So if you have a brick and mortar practice paying that off, and then the last one would be to give charitable giving. And if there's one thing I think this will therapist are really good at it's giving to charity, i.e. giving out our services for free sometimes. So, I mean, at that point, when you're in that point in the baby steps, like you hypothetically are set enough that potentially you could do some pro bono work with your business, which would then put your business on the map as being a very solid community practice as well. So, I mean, I think a lot of the day to day principles that he talks about in the total money maker, that's meant for day to day stuff could easily be applied to business. Karen Litzy (16:21): Yeah. And I'm glad that you brought up the pro bono because the question that Gina had was, how do you decide on that pro bono? How does that fit into the budget? What kind of a sliding scale do you use and how do you do that? If you are a private practice, what kind of sliding scale are you using and how do you decide what to charge? And, you know, I say like I have a real Frank discussion with the individual patient. And if they say, you know, listen, I really need the help. If they were referred to me from another therapist who they were seeing using their insurance. And they say, you know, so-and-so says, you're the best person. You're best equipped for this. This is what I can afford. Can you do it? And because my business is at that point now where I don't, I can, I'm able to offer that kind of service. Karen Litzy (17:11): Then I say, yes, I can do it for this price. You know? So that's kind of how, and it's also depends on like, if the person, if I have to travel an hour and a half to get there and an hour and a half back, then it might not be best. Which in which case, I'm happy to find them, someone that will work for them. So I think when you're looking at the pro bono costs, if you're traveling to patients, you have to look at your travel time. You have to look at how that's going to cut into your overall budgeting and your overall key performance indicators, which we'll have a whole other talk about KPIs. But I think the bottom line is you have to know how much does your business need per month to be able to do everything you just said, right Stephanie. Karen Litzy (17:57): To be able to keep the lights on, to have shelter. So how much does your business need each month just in expenses? Have you met that goal, then? How are you able to pay for your insurance and your taxes, which I would say go into just the sheer expense of running the business. Yes. I would agree with that too. So that's the sheer expense of running the business. Do you need another new fancy gym equipment or this, that, and the other thing? No. Right. So if you can forego that to maybe help someone else at a pro bono rate or at a reduced rate, then my inclination is to forgo the fancy new treadmill and to treat the person that needs it. So I think how you decide what that pro bono rate is, I think depends on the person in front of you. Karen Litzy (18:51): And you could say, you know, you can ask, ask around and just say, Hey, listen, this is what other physical therapy practices are doing. This is what I'm comfortable with. This is what the least amount I can charge so that I break even. And I think people understand that. So I think when you're thinking about what's the lowest charge you can give to someone that would be it, or you can go perfectly free. If you can say, you know, I can treat, I can do one session free per week, and I'm still, you know, in the green and I'm not in the red, then go for it, you know, but I think you have to know how much you can make to keep your company in the green, and then you can decide, well, this would be my lowest pro bono charge. Karen Litzy (19:37): And then if someone comes in, who's really, really of need, or you're volunteering through an organization or something like that, where you're treating someone for free, then, you know, I think in my opinion, I think that's the best way to go about it. I'm sure there's some legal aspects around that. But from what I can tell in speaking with lawyers, they say, it's your rate. You know, you just have to be clear about what it is. You, Stephanie, where are you where you are? Do you have a pro bono rate?   Stephanie Weyrauch: Yeah, so typically our pro bono rate is like $40 per session is what we'll do, but we are flexible. I mean, again, our practice, luckily my boss, he's been an amazing leader throughout all of this. We didn't have to fully lay off any of our physical therapists and we have five physical therapists, but we were very strategic with how we worked and when we worked. Stephanie Weyrauch (20:30): And so we've had that freedom from kind of how we've been running our practice to allow for us to sometimes even treat patients where they pay like $10 for a session. So, I mean, it varies from situation to situation. Things that we consider is how dedicated is the patient? Is this a patient that's actually going to come to therapy? Or is this a patient that's going to flake out on us because we don't want to save them a spot and then they not show up consistently also we've had instances where we've had maybe some where we've thought the insurance was one thing and it came out somewhere else. And so we ended up using the visits that we were given and the insurance company won't give them any more visits, which is a mistake on our part. So we always want to do, we always want to do right with any mistakes that we make. Stephanie Weyrauch (21:21): That is another thing that we'll consider, or sometimes if we have a Medicare patient that can't afford their copay, you know, we'll exchange services and other ways, you know, whether it be like they come in and maybe fix something in our clinic. And then we exchange that with our services, bartering, bartering. Yeah. So, we've been able to be flexible. But again, we built up our practice enough. We've been in business now for over eight years and we're a well established in the community that we are able to do that if you're starting out, you may not be able to do it right away, but you can work up towards that as you start to manage your money and start to make a profit. Karen Litzy (22:12): Yeah, yeah. Yeah. Thanks for that example. And I think that you'll find that in most physical therapy practices, they have a pro bono rate. They work with people they're flexible. Every practice I've ever been in the owners have been super flexible because in the end, we're all in the business of getting people better. And sometimes that business, maybe doesn't yield a profit of $200 per person. Maybe sometimes it's 10, but if our business is to get people better, then that's what we want to do. And I will also say this just because that person let's say your patient needs that pro bono care, they can't, it doesn't mean that they don't know people who they will scream to the rooftops of how wonderful you are and how great you were and how easy you were to work with too. A lot of their friends or to their communities. And then all of a sudden you're bringing in more business because you did a good thing. Karen Litzy (23:05): So don't discount that. And perhaps, you know, that person can be the stellar Google review you need, they can be that video testimonial on your website. They can be that written testimonial on Yelp or on your website. So these are all ways to like, incorporate your pro bono services by saying, Hey, listen, we're happy to do this. If you're pleased with your service, if you feel better, we would love for you to put up a thing on Google or put up a review on Google or Yelp or on our website, if you're comfortable doing that. Right. I totally agree with that. That's another great way. So that's right. It's the same thing as, like I said what would the other night talking about lead magnets, put something out there that people can use. They then give you their email. And all of a sudden you've made this really fruitful transaction for the both of you. Karen Litzy (24:00): And that's what that pro bono type of situation can do. So just always think there's always ways to leverage a visit that has nothing to do with money. That's right. So, all right. So Stephanie, let's talk about if you would like to sort of wrap it up on the big budget issues that people need to be aware of. And I also put just so people know, I also put every dollar, the app in the comments as well.   Stephanie Weyrauch: Perfect. So I would say that the first thing that you need to know is you need to stick with the budget. I mean, there's no point having a budget and you don't stick with it. Accountability partner, I think is key. Having somebody there that will keep you accountable. I mean, you're in private practice. You're probably a very accountable person, but it's still good to have somebody there that asks that says, do you really need that this month? Stephanie Weyrauch (25:02): Or are you sure that this is what you want to spend on this specific line item? So having the accountability, I think is the key and sticking to your budget is the absolute key. I think that if you allow yourself to go over your budget and you're like, Oh, it's just one month that develops bad habits. You just gotta break all your bad habits right now. And that budget is like your gospel. You need to have a monthly budget meeting with your staff. If you have a staff, if you don't have a staff, it's just you with your accountability partner and say, this is what I'm going to spend. You know, I have a little bit of extra money that I can spend it on. What, what should I spend it on? Should I spend it on my charity work? Stephanie Weyrauch (25:48): Should I spend it on my debt? Should I spend it on getting new equipment and have that accountability partner help you with those decisions? If you want somebody to help you, but at least they can be there to basically ask you those questions of is this really necessary? I think if you can stick to your budget, you will feel so much better about your business. You will be less stressed. Like Karen said, you will feel like you've been like you, you have all this extra money because you know where all your money is. And the reason that the every dollar app is called every dollar is because you give every dollar a name. You don't have any extra money floating around in your budget. You put it where it goes for that month. The other thing is, is that to think of the budget as permission to spend money versus being super strict with it. Stephanie Weyrauch (26:41): So you still have the bulk amount of money that you're spending that you, that you have for the month. But, you know, if you notice again, like let's say you don't have to drive as much, you can take that extra money that you would typically spend driving and put it towards a different line item, but just make sure that your budget always adds up to all these total $0. You have nothing left. Everything is going to something in the budget and it has a name. Your budget is your baby. You would not name your baby nothing. Well, no, I'm just kidding. Karen Litzy (27:26): Yeah, no, I think that's a really great point. And even if that money is savings, right, it goes, it has a name. So nothing thing, I'm just going to leave it in the bank. It's going somewhere every month. I love that. All right. So we have stick with it. Don't break it, give it a name, anything else? And just accountability partners. Yeah. All right. Well, this was great, Stephanie, and I hope that people this gives everyone an idea of having a good starting point, downloading the app, maybe reading the book. Like I said again, to repeat the name of the book, the total money makeover by Dave Ramsey, and every dollar.com or every dollar app. And in there, it also has in the book, like Stephanie said, it also has information for people who don't have that steady every two week paycheck. But if you're an entrepreneur, it gives you ways in order to kind of work around that as well. Stephanie Weyrauch (28:27): And if you do end up, if you guys are podcast listeners, and if you download the Dave Ramsey show podcast, a lot of his podcasts focuses on entrepreneurship and on business ownership. And so he has a lot of really great advice on running a business and budgeting for business. The budget that I talked about is more, it can be both used as a personal budget or a business budget, but he does talk a lot about business ownership in his podcast as well. So I would definitely recommend checking that out. If you have extra time and want something to play in the background, it's a good podcast to listen to in the background. You don't have to sit there and like learn from it. It's just kind of there. And he's a pretty entertaining guy. Yeah. I took one of his it was like a longer course a couple of years ago. So I still have all of the materials and everything like that. So yeah, he's very entertaining and he knows what he's doing and it works. Stephanie Weyrauch (29:15): And I will say, you know, you can have a personal budget and a business budget. You don't have to have just one. You can have personal, you can have business and then you'll know exactly where literally every dollar in your business and every dollar in your personal life is going. And like I said, on our talk, you know, after reading profit first from Mike, I just found it amazing of like, yeah, I know now where every dollar is going to. So now that I know where every dollar is going to my big buckets, I can now use this to see where it goes to the very last dollar.   Karen Litzy: Right. Yeah. And like I said, when you do a budget, it's amazing how much extra money you have. And you're like, wow, I didn't know. I had all this money. What was I spending on before? Stephanie Weyrauch (30:03): Right. What kind of nonsense was I doing before?   Karen Litzy: Yeah. That's one thing that I have to tell you after instituting profit first, I was like, the hell was I doing like, seriously? What was I doing before? Because I have so much more money in savings. I don't have to worry about paying taxes. Everything's awesome. Like, what was I doing? I can't explain it, but now it's like, yeah, now I get it. Now I understand. And I feel like you know, like you said, Oh, this is a grownup thing. Oh yeah. So I was like adulting hardcore when I learned this. So I think that's great. And now Steph, before we jump off, where can people reach out to you or find you social media if they have questions?   Stephanie Weyrauch: So I'm on Facebook. Stephanie Weyrauch. Or you can find me on Instagram or Twitter at theSteph21 and I'm available on any of those platforms.   Karen Litzy: Perfect. Well, thank you so much. And everyone, thanks for indulging us, at least here in the Northeast on a very rainy, very rainy Saturday to talk about setting your budget, sticking to your budget and creating more wealth from the money you're already taking in. So Stephanie, thank you so much. And everyone, thanks so much for listening.   Thanks for listening and subscribing to the podcast! 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On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Adam Culvenor on the show to discuss ACL injury. Dr. Adam Culvenor is a physiotherapist, leader of the Knee Injury and Osteoarthritis Research Group and Senior Research Fellow within the La Trobe Sport and Exercise Medicine Research Centre in Melbourne, Australia. Adam’s research focusses on the outcomes of anterior cruciate ligament (ACL) injuries, in particular the prevention and management of early knee osteoarthritis in young adults following ACL injury and reconstruction. In this episode, we discuss: -The short-term and long-term burdens following ACL injury -Why patient rapport is integral to effective treatment post-ACL injury -Optimal loading strategies for non-surgical and post-surgical cases -The latest research on prevention for early-onset osteoarthritis -And so much more!   Resources: Adam Culvenor Twitter La Trobe SEMRC Twitter Email: A.Culvenor@latrobe.edu.au La Trobe Adam Culvenor La Trobe University Blog For knee injuries, surgery may not be the best option     A big thank you to Net Health for sponsoring this episode!  Learn more about Four Ways That Outpatient Therapy Providers Can Increase Patient Engagement in 2020!   For more information on Adam: Dr. Adam Culvenor is a physiotherapist, leader of the Knee Injury and Osteoarthritis Research Group and Senior Research Fellow within the La Trobe Sport and Exercise Medicine Research Centre in Melbourne, Australia. Adam’s research focusses on the outcomes of anterior cruciate ligament (ACL) injuries, in particular the prevention and management of early knee osteoarthritis in young adults following ACL injury and reconstruction. His work has identified important clinical and biomechanical risk factors for post-traumatic osteoarthritis, and he is currently testing novel osteoarthritis prevention strategies in young adults following injury in a world-first clinical trial. He has published over 60 peer-reviewed articles in international journals. Adam has worked in teaching and research at universities in Australia, Norway and Austria and is a graduate of Harvard Medical School’s Global Clinical Research Program. His research has been awarded American Journal of Sports Medicine most outstanding paper 2016, Australian Physiotherapy Association Best New Investigator 2013 & 2017 in musculoskeletal and sports research, and Sports Medicine Australia best Clinical Sports Medicine paper 2019.   Read the full transcript below: Karen Litzy (00:01): Hey, Adam, welcome to the podcast. I'm so happy you're here. And I'm excited to talk about ACL injuries with you. So welcome. Adam Culvenor (00:08): Thanks very much for having me, Karen. It's great to be here and chat. Karen Litzy (00:11): So now the bulk of your research is in ACL injuries and not the mechanism of injuries for ACLs, but what happens after that injury? So before we get into, and we'll talk about the burden of ACL and optimal treatment and osteoarthritis and why that happens. But what I would love to know is why are you interested in this subject matter? Sort of, why did you make this kind of the centerpiece of your research? Adam Culvenor (00:43): It's a good, good question. So about 10 years ago, also, now I had done a couple of years of clinical practice as a physiotherapist in Melbourne where I'm based and was interested in pursuing a bit more of the research line into ACLs because we had a patient come to myself and one of my colleagues who was a young guy, about 35 years old, who had a very active, healthy life up to that point, he'd suffered an ACL injury about when he was 20 years old, he was about 35. Now it had a number of issues. He'd got back to sport without any problems, but then now about, you know, 10 to 15 years later, started having some pain, unable to do the things he normally would love to do. Couldn't go back and play anymore. Adam Culvenor (01:33): Sport couldn't start, couldn't really play with his kids. He'd seen an orthopedic surgeon, he'd had an Arthroscope, had a bit of a cleanup now going back to the surgeon and he was really in want of a knee replacement because he could no longer do the things that he wanted. And the surgeon basically said to him, you're too young to have a knee replacement go and see, Adam and Tom, our colleague. And so what we can do, and that really opened our eyes from a clinical perspective about these types of patients and this particular young guy had on x-ray most of his changes were actually in his patellofemoral joint. So in the patella and the trochlea, and that really set my mind up to go and look into the literature in this space and see what's out there in terms of not only osteoarthritis in these young people. And clearly it was very burdensome to this young guy, but also why are we seeing this in the patella femoral joint in particular and why is it causing so many problems? And so that really set us off for my PhD, about 10 years ago, looking into these medium to longterm outcomes, ultimately trying to help these people get back to do the things they wanted to do without the pain and the symptoms that come with osteoarthritis a lot of the time. Karen Litzy (02:48): Yeah. Oh, great story, that's a shame 35 years old. Gosh, that's so young. I can understand why that would really peak your interest because you don't want to see these patients coming into you or when you do see them, you want to be able to help them with the best evidence and best things that you can. So you had mentioned in your explanation there as to why this subject interests you, is that there is this sort of burden after having this ACL injury. So could you talk a little bit more about the burden of an ACL injury and subsequent surgery? Adam Culvenor (03:27): Sure. So I'm sure it goes through a lot of people's minds, as soon as they hear that pop or click, that if they know they've had an ACL injury, that's the initial burden is, you know, that worry of, I can no longer play sport. And often if you do go and have a reconstruction surgery, it's often the nine, 10, 12 months of extensive rehabilitation, as we know, and not going back to sport that often people find a lot of personal satisfaction and get a lot of mental health benefit from playing sport and from their peer involvement and social interaction. So it's that initial burden of the extended period out of sport. Some people do really well with great rehab. They can get back to their sport. They want to play at back to the same level of performance, but there's a certain percentage at about 50% of people we know in the evidence will develop longer term, not only persistent symptoms from a patient reported outcome perspective, but also ongoing functional limitations. Adam Culvenor (04:26): And ultimately the development of osteoarthritis be that on radiographs, on x-rays. And some of our work is which we can go into a little bit more detail in a moment is looking at the earlier changes on some more sensitive imaging like MRI to try and detect these types of people who might be more at risk of developing longer term changes. So as I said, some people do really well following an ACL injury, but rehab only, or surgery. And we can chat about the differences in the treatment options later as well, but about 50% of people at the moment. And the evidence suggests that they will have osteoarthritis within about 10 years of their ACL injury. So if we think of the typical patient is, you know, the adolescent or the young 20 year old patient playing sport, they rupture their knee only 10 years, 15 years down the track. Adam Culvenor (05:16): They're still only 30, 35. That young gentleman I spoke to earlier. And they've got a knee of essentially that looks like on imaging of a knee of a typical 70 or 80 year old. And we know that imaging findings on x-ray don't necessarily match up particularly well with what we see clinically. So that's not necessarily, you know, a sign that they're definitely going to have functional limitations on symptoms, but it certainly increases the risk of that happening. And that burden at a time when people often have really important family commitments and young family commitments work commitments, and they often still want to be active in participating in sport. And so when you bring all of those in to a knee that might not be has have recovered as well, following an ACL injury, you might still have some muscle weakness if that wasn't addressed initially and create the picture of more of a persistent pain problem, then you start getting into being quite a burdensome condition that we say these types of patients clinically come back in often five, 10 years following their injury. Karen Litzy (06:20): Yeah. And I can imagine along with that, persistent pain comes decreased activity, decreased movement, and we all know all of the sort of cascade of events that can happen when you're not getting an exercise. You're not getting in movement. You know, then you have risk of obesity, risk of diabetes mental health issues. So all of that stuff can kind of stem from, you know, this burden of an ACL, which, you know, for a lot of people, I don't think that even would flash in their mind when you're looking at a 20 something year old who just tore their ACL, because we know that population who does tear are usually pretty athletic. Adam Culvenor (07:03): Exactly. And that's the thing prior to their injury. They're often very healthy and, you know, never seen a doctor or never been to hospital before and having the ACL injury can often be that initial. Unfortunately, you know, the cascade where you become less physically active in, might not be able to get back to the sport. You really want to start putting on weight. And that increases the risk of all of these other conditions, as you've just said. And I think there was a recent article a research paper actually showing that having an ACL injury increased your risk of a cardiovascular disease by about 50% longer term. So for me, that was a real wake up. This knee is not just a knee, it's actually affecting the whole person. Exact reasons you just mentioned that it can spiral into, you know, less physically activity, the pain putting on and then being the increased risk of all of the comorbid conditions as well. Karen Litzy (07:55): Exactly. And now, so you mentioned a couple of minutes ago about treatment. So you could have surgery, you can not have surgery. So can you talk a little bit as to what the optimal treatment is after an ACL and how one comes to that decision, whether you're the clinician or you're the patient, how does that work? Adam Culvenor (08:18): And that's the $64 question. And so I can have extreme of the spectrum. You can have one end, you can have everyone has surgery. The other end is no one has surgery and the truth probably lies somewhere in the middle. So if we look to what the evidence suggests in the literature, there's very little high quality evidence comparing the two treatment options. There's really only one, what we call randomized control trial. That's compared about 120 people. Who've had an acute ACL injury and they were either allocated to having early surgery. So a couple of months of having the injury and then an extensive rehabilitation period I've nine months or so, and then the other group. So exactly the same rehabilitation. The only thing is they didn't have the surgery. And so the only difference between these two groups of patients was the surgery or not. Adam Culvenor (09:15): Now the group who didn't have the surgery initially could have the option of having surgery later on if they had ongoing problems or symptoms, or desired to have the surgery later on, and they could cross over to the surgery arm. And what this study showed is initially this was published back in 2010 now. So we've not done this for over a decade, is that there's very little differences both at two years after surgery five years. And I think that the authors are about to publish their 10 year outcomes, but certainly the two and five year Mark, there's very little differences, whether you have surgery or not, in terms of pain symptoms, strength returned to sport the need to have more surgery, quality of life, and indeed radiographic knee osteoarthritis. So I was fortunate enough during my time in Europe, conducting a research fellowship recently to work with this group of researchers based in Sweden. Adam Culvenor (10:07): And we looked at the MRI outcomes in this population, as I said earlier, trying to identify people maybe earlier in the process initially after that ACL injury, to see if we can identify those more at risk of longer term problems, which might present opportunities to intervene a little bit earlier to stop that cascade of negativity and what we found really, interestingly, when we looked at the cartilage on MRI between the time of injury to two years and to five years, is it the group that had early surgery actually had more cartilage loss compared to the group that didn't have surgery and you sort of asked, well, why might that be? Because, and I think I haven't had an ACL reconstruction, I'm injuring myself, but I know from colleagues and working clinically that the ACL surgeries is almost a secondary trauma. Like you're going in there, you're drilling tunnels, you arthroscopically opening the joint. Adam Culvenor (11:04): You come out of surgery, having a very angry, hot red, swollen knee. And so I think that whole cascade of inflammation can soften the cartilage, can create a knee that's not particularly happy. And then when you go and potentially, you know, put that knee through load, maybe going back to sport and whatnot, then that might actually be related to the development of osteoarthritis more so than if you don't have the reconstruction. And so we've actually done a little bit more work on the return to sport type of thing. And, thankfully in a group with ACL reconstruction, it doesn't seem to increase the risk of osteoarthritis if you do go back to sport. So that doesn't seem to be the main things. That's a good thing for patients knowing that if you've had an injury or reconstruction, you can go back to sport knowing that you're not going to put your knee at more risk, but it's probably more the inflammatory markers, the secondary trauma of that that's reconstruction surgery that increases the risk even longer term as well. Adam Culvenor (12:03): So I think what I always tell my patients is that you should always trial a non-operative period. First, you can always go and have surgery later. And I think, I always say, you need to prove to me that your knee is unstable. So some people can do really well without having surgery because their neuromuscular and muscle systems can compensate for that ruptured ACL and the mechanical instability, the neuromuscular system, the humans are very clever. They can really compensate quite well, and they feel you don't need the ACL. If you're only going to perhaps not go back to that high level pivoting sport, where you put your knee at high stress, a lot of the time, then if you just want to run straight lines and play with the kids, then you're likely not needing to have the reconstruction. If for instance, you try a really intensive, progressive rehab strengthening program and you're starting to run, or you're starting to get back into a bit of sport and your knee starts to become unstable at that point at the level that you want to get back to, then that sort of probably instigates the conversation. Adam Culvenor (13:12): Well, maybe your knees actually not able to overcome the structural instability to the level of activity that you want to achieve. Maybe let's have the discussion of a reconstruction as a potential option, but always get them. You need to prove that your knee's unstable by going through this rehab and putting yourself through these activities. But it's not going to do well without surgery because we know that the outcomes that are quite similar for the majority of people if you have early surgery or even delayed surgery and doing a period of rehab, irrespective of whether you go and have surgery or not, will be beneficial, if you do go and have surgery. So that prehab, if you like. So that's, I think it's my take home is it's probably actually just educating the patient to empower them with the evidence because they're the ones ultimately that need to make the decision. And so presenting them with all the best available evidence and guiding them for the initial rehab stage often can change their mind that they need surgery once they realized they were actually doing quite well without it. Karen Litzy (14:17): And when you're saying to the patient, let's do a trial for a non-operative phase, so that you can prove to me that this knee is unstable. What kind of length of time are you talking about for that rehab process and knowing that it's going to vary person to person obviously. Adam Culvenor (14:37): Oh, of course, of course. So I think a period of two to three months is sufficient to provide an intensive strengthening program. Let the knees settle down initially and then actually start you know, within the first month and even two months getting them to start really loading their knee. That's the thing, if you actually don't have surgery and actually responds a lot quicker because you don't have any of the graft morbidity, you're not taking out some of the hamstring or the patellar tendon. There's no real reason why we need to be conservative about you know tearing a hamstring or whatever that might be cause of the graft or rupturing the graft because you haven't had the graft reconstructed. So it's different for everyone because different people will respond differently, but actually there's no real hard and fast rule with this because you need to rehab them to get them to a point where they're starting to do the activities that they want to get back to. Adam Culvenor (15:37): And at any point in that step ladder of increased physical activity demands that they might fail or start having, you know, severe giving way episodes. Then that's the point that you might have that conversation with someone, but if you're running and you start giving Y and these people want to go back and play elite football, then clearly maybe you're not getting, being able to run without a stable knee. You're probably not going to be able to play football with that with a stable knee. Then that might be the point where you revisit, you're running no problems and you tried playing football and it starts giving way, but really you actually just want to run, right? Playing football is just something you tried, but didn't really want to do. Then you probably don't need the structural stability. If you just want to run off another thing, I like to set a patient's, is it like a seatbelt? Adam Culvenor (16:28): Is it, we all wear a seat belt when we drive, but very rarely do we have a crack and we rely on that seatbelt to keep us safe. So if you're someone who walks around and might run, then the ACL is a bit like a seatbelt, is that you actually don't need that seatbelt on because you're not having a crack. You're not putting the need through that real pivoting type movement to rely on it. So unless you're going to go back to a high level sport and, you know, put your knee through those pivoting jarring mechanisms of movement, then you probably don't need that seat belt. You don't need that ACL to protect the knee. Does that make sense? Yeah, Karen Litzy (17:06): That's perfect. That's really great. And it sounds to me like when, if you're the clinician working with this patient during, let's say this non-operative trial period where they have to prove, again, the instability, every single person is different. So what you're going to be looking at is different meaning, right? So if I just want to be able to play with my kids, I wasn't a runner before I don't really need to run. I just want to ride a bike or, you know, you want to put people through the things that they want to be able to do. And that would kind of be the way you would test for that instability. But are you also using sort of standardized tests when it comes to seeing if people have the stability in the knee? Adam Culvenor (17:54): Exactly. so it's really a goal based discussion with the patient come. The desires of the return to activity comes is driven by the patient. And as clinicians, you know, it's good to have that discussion to then work out, you know, what level do we need to get at, but certainly there's a number of standardized clinical tests and really great patient reported outcomes that we can use with these patients. So the very common ones are the strength tests. So if you have the resources, you know, a dynamometer, an isokinetic dynamometer in the clinic to look at the three range of quads and hamstrings strengths and making, you know, the criteria we typically use in the literature is meeting 90% of the strength compared to your uninjured side. Now, there's obviously some pros and cons about doing that. Adam Culvenor (18:44): And the other tests are typically hop tests. So single leg hop, as far as you can, with a balanced landing site, decide hop tests. There's a number of different tests we can use to try and assess the stability, the functional stability and confidence of the knee. Having said that though, we've actually just done some work I've led by Brooke Patterson here as part of our team, looking at the limb symmetry index, which is the ACL rate constructively comparing to the, I mean, delayed and what we found sort of between one and five years after their reconstruction is that often the non-injured leg isn't that healthy gold standard cause that often deteriorates because it's a period of an activity, you be back playing the sport you’re back to. So that's sort of the crisis in capacity. So it's not that reference standard that we should necessarily be comparing our rate constructed. Adam Culvenor (19:44): And so there's been a couple of other bits and pieces that people have looked at alternatives to this type of measurement. And whether it's, if you have say someone initially after injury, it's a great opportunity to start doing these tests is actually the estimated pre-injury capacity. So to estimate that it's best to try and do it as soon after injury as possible, given that patients might have some fear and confidence, you know, respect that obviously, but actually trying to do a hop test quite early before that other leg has the chance to start decreasing in capacity because often the limb symmetry index overestimates, what the reconstructive legs capacity actually is. And so they're the functional type of measures that I think we should be using in this patient population, not only to assess outcomes, but also patients get in my experience really like seeing their improvements and getting feedback about having, going along their journey totally. And then an objective test of strength or a hop test they can see right in front of their eyes, how far they're hopping and if they are improving and if they're not, then why not have that conversation. And so that can be great for adherence motivation because this journey of a rehab, irrespective of whether you have a reconstruction or not, can be quite long and tedious, it can be boring. You're sitting there doing strength exercises, you know, any type of motivation to get people to continue is going to be beneficial. Karen Litzy (21:14): It's always, one of the biggest complaints is, gosh, these exercises, when do we get to the X, Y, Z, you know, that you see on, on Instagram or on YouTube. And I was like, you know, you're a month in buddy. This is it. Adam Culvenor (21:28): Exactly. And I think as physios and the evidence suggests that, we're very good at doing the early stage of the rehab because patients are probably more compliant at that point as well. But there's evidence actually coming out of Australia that less than 5% of people who have had an ACL reconstruction, so less than 5% actually go through a period of rehab beyond six months and include and return to sport type training. So I think whether it be a lack of understanding from a clinician standpoint, or also that, you know, financial and motivational points of view from the patient after six months of like, I've had enough, I'm out, I've good enough. I don't need that extra, you know, icing on the cake to get back to sport. They tend to drop off. And that's when not having that really high level agility capacity returned to school at top training, you increase the risk of re rupture. And that obviously is a devastating impact for these patients and increases the risk of longer term negative outcomes as well. Karen Litzy (22:27): Yeah. And I know here in the United States, not so much in other parts of the world, but insurance will oftentimes cut people off at three or four months. Adam Culvenor (22:36): Okay. So it's different everywhere. Yeah. Karen Litzy (22:38): So it's like, okay, so the person can walk and run and then, then what do they do? You know what I mean? So it kind of depends on your clinic model and things like that. But I mean, I've been lucky enough that I've been able to stay with my patients for 12, 13 months and upward. So it's been really great to be there the week they are out of the OR to getting them on the field and actually doing things that are going to, you know, mimic their soccer, their football place. So, but it's, yeah, there's so many obstacles. It seems. Adam Culvenor (23:25): Totally. And I think there's some really great evidence coming from Scandinavia that for every month that you delay the return to sport up to nine months, it actually reduces your injury risk by 50% that's mind blowing for me. So not only, you know, it was it from a rehab point of view, but actually from a range, point of view, having that nine months will actually you know, reduce your risk substantially of re rupturing when you do go back to sport. And I think that is why it's so heavily on people's minds when they're first going back to sport. That fear that's a huge impact psychologically for these types of patients. And I think often an ACL injury can happen. So innocuously, like you've done this movement a thousand times at training before, so why this time and that fear of, Oh, it wasn't a major blow when I first did it, like it wasn't someone running across and really hitting my knee. It was, I was on my own. And so what's stopping that from happening again. And that's that, I think that feeds into the fear of what could happen anytime again. Yeah. So I think I often try and say to patients while you injured your ACL, initially let's get your knee back to better than it was before you injured it, to prevent it from happening again. Because once we know once you have one injury, the biggest risk factor. So the biggest risk factor for a second injury is having a first. Karen Litzy (24:51): Exactly, exactly. And I've quoted that that study of that nine months reducing 50%, especially when you're working with kids who think I'm fine. Now I can walk. And I was like, listen, this, and you have to have that conversation with the child and with the parents. And once the parents hear that, they're like, okay, like we get it. Even though her physician was onboard, like you're not playing until you're one year out from surgery. I mean, wherever it is on the same page, but it's hard to keep. It's hard to keep everyone on the same page, but being able to use the literature and say, listen, I'll send you the study here it is. Adam Culvenor (25:34): When actually pulling it's actually for some people it's not in needing to encourage them, it's actually needing them to pull them back. That's where your education and clinical reasoning and discussions with patients will differ quite a bit is that some people are so gung ho in their rehab and they just want to get back to sport. You actually have to, as I said, pull them back, whereas the opposite might be true for some alpha people. So it's really interesting how different people respond differently to this type of quite devastating injury. Karen Litzy (26:03): Right. And how they respond, how you can use, like you mentioned the study of Scandinavia, how we can use that study with both of those extremes of people, right? So the people who are afraid and the people who are gung ho, so again, it's having this good rapport with your patient and their other stakeholders to kind of get them through safely through their rehab. But now we talked about it earlier on and that's osteoarthritis. So 50% of people will develop some sort of osteoarthritic changes in their knee. So what do we do about that? Are there prevention strategies? What can we do? Adam Culvenor (26:54): So this is something that we've been looking at for a few years now and obviously you know, we'd love to be able to have a treatment to stop this from happening, but we're not actually there yet. There's a lot of really nice longitudinal studies investigating risk factors for the increase prevalence of osteoarthritis in this population. And there's a number of risk factors that we can start informing how we might treat these people initially as well. So the number one risk factor is having a combined injury with a meniscus tear or a cartilage lesion. So if you have not only an ACL injury and very rarely, is it just an ACL injury, it can often be combined with a meniscus tear, cartilage lesion, bone marrow lesion, et cetera. So that more severe sort of type of injury will automatically put you at risk longer term of having osteoarthritis. Adam Culvenor (27:46): That's not that exciting because as clinicians, we can't do much about that. It's not really modifiable. So we're really trying to identify some factors that might be modifiable that we can address. So things like BMI being overweight, we know increases the risk of osteoarthritis longer term not only after injury, but in people of older age who have the traumatic type of osteoarthritis what's coming emerging from the literature more and more is the quadriceps weakness. So quadriceps in particular the muscle weakness in that muscle and also the functional impairments. So we talked about hop tests and in a balance in your muscle control a little bit earlier. So they're actually starting to become more and more prominent as risk factors for the medium and longterm outcomes for osteoarthritis. So we've just published a paper in the British journal of sports medicine, which looked at this exact question. Adam Culvenor (28:44): So do functional outcomes. So typical tests, we might use to clear someone to return to sports, a hop tests and strength tests. Do these actually have a relationship with future osteoarthritis? And what we found is, so this is a one year we tested them. And then at five years we measured their osteoarthritis on MRI. So quite sensitive measure of osteoarthritis, but also an X ray. And what we found is we combine a lot of these tests together into a test battery. So side to side hop test, single leg forward hop test. If you have a poor outcome at one year in these tests, then you're more likely to develop osteoarthritis at five years down the track. And so there's other studies that show quite similar findings in this space as well, which is really, I mean, it's upsetting because they're more at risk of osteoarthritis, but it's quite encouraging as clinicians. Adam Culvenor (29:34): This is our forte. We can actually do something about it in the initial stages of rehab. And again, this can be a great education motivational tool to say on this test, you're not achieving at a level that you need to achieve. This is not only going to put you at risk of reinjury. The research shows that this is actually going to increase your risk of developing arthritis. And we need to be a little bit careful about how we inform our patients about this. Cause as I said, some people can be really fearful and terrified about reinjuring and worried about what it is going to look like. And so presenting them with, Oh, you're going to be, you're going to have arthritis in 10 years as well. Might not be quite the right moves to allay that fear at that point in that patient. Adam Culvenor (30:16): Whereas other people having a knowing that information can be really motivating to try and get them feedback to the best possible condition that it can be. So again, it's very personalized how we educate our patients, but I think it's really important to educate them along the journey about that increased risk of OA and encouragingly. There's some, some really positive signs that we might start to be able to modify that risk with some really great rehab, getting back to the strengths, getting back to improving function in our clinical work as well. So I think that's really, really exciting moving forward. Karen Litzy (30:50): And that's great news for physical therapists because this is where we live, so wow. We can really make a difference in someone's life by good comprehensive rehab within that first year after ACL injury. And again, that's, regardless of whether they have surgery or not, is that correct? Adam Culvenor (31:08): Exactly. Yep, exactly. And as I said earlier about the return to sports, so we've also done some research which should be published shortly, hopefully looking at the fact that again, encouragingly, if you have an ACL injury or reconstruction and then decide to go back to these pivoting type sports, some people say, well, you shouldn't go back to that. You know, the high impact sport, because that's going to put your knee at undue stress and you're going to have more arthritis longer term, is that what we've found is actually that's not the case. So we can be confident that we can give these people you know, the advice to go back to sport. If that's what they really want to, for their quality of life and mental health, they do drive a lot of social pleasure from playing sport. The good thing is, is if you have a great functional and strong knee, then that's not going to put your knee at further risk by going back to sport. Sure. It's going to perhaps increase your risk of re injury compared to sitting on the couch at home. I heard that from a lot of mental health and also physical health being physically active and involved in sport has so many more benefits to our general health as well. Karen Litzy (32:11): Absolutely. And now can we, if you don't mind talk about the patient that I think a lot of physiotherapists are going to see, and it's like the patient that you saw 15, 20 years after their ACL. So we're not, we're not seeing them one to five years, but now we're seeing them 10 to 15 to 20 years later. That's when a lot of people are going to come to us with knee pain. So what can we do for these patients? Do we want to look at these hop tests in these patients? Does that make a difference? What happens then? Cause that's a big bulk of our population. Adam Culvenor (32:54): You're exactly right. And it varies about again what their goals are, but often if they're 10 to 20 years down the track and they've got osteoarthritis, we can look to the literature in the osteopath writers field. And in that space, it's very, very compelling evidence that exercise therapy and education provides the strongest effect for pain and symptoms and function in this population. And so that's almost reassuring that it's quite similar to what we're seeing in the early post-operative or post-injury stage is that whatever level on the spectrum you are post-injury and the development of osteoarthritis, essentially your treatment's going to be quite similar where you're developing the strength that underlies everything that we do in day to day activities. And indeed, if we want to get back to sport and also the functional capacity, so ask for the, what they want to do, what they can't do because of their pain and symptoms and make it a really goal oriented treatment. Adam Culvenor (33:54): And I think it's really important to also ask them what physical therapy have they actually done. A lot of those people come to us and they've seen five different surgeons and they've got different opinions. And when you actually question them and interrogate them, they've actually never had a gym program or they've never done any strength training. And it's like, well, of course you're having a few problems. So let's start you from the very basics. And not, you know, not flare them up by going too hard, too fast, but actually educate them around the importance of strength and functional control that the knee will benefit a lot from that. As well as from a function symptomatic point of view and start building on their strength, capacity and functional capacity to be able to meet whatever goal that they want to get back to. So I don't see it as being a totally separate patient from the post-injury one to the osteoarthritic, it's on a spectrum. And a lot of the treatments going to be very similar in principle depending on what their goals and their goals might change over time. So the treatment can as well. Karen Litzy (34:58): Yeah. Yeah. Well, thank you for that. That's great. Now, can we talk about the study that you are currently undertaking at La Trobe University. So can you tell us a little bit more about that? What is it and what are your goals for it? Adam Culvenor (35:18): We're super excited. Pardon the pun. So this is a project that's really stemmed from over the last 10 years of our work. Looking at identifying those risk factors, as I've talked about earlier to then be able to get some funding. So we've got some funding from the Australian government health and medical research council to perform this really world first randomized control trial, to see if we can actually prevent early osteoarthritis and improve symptoms and function through an exercise therapy intervention. So in essence, we're going to get a whole lot of people, about 200 people who are one or two years following there ACL reconstruction. So they've had that initial period of rehab to get better. Cause some people do really well. We need to remember that, that some people do great following the injury and surgery and don't need more intervention longer term. Adam Culvenor (36:14): So we want to try and capture the ones that have some ongoing symptoms and functional impairments. Haven't got back to doing what they want to do at one year post op to two postop at a point where they should be able to do those things and because they are going in out by some of the research, that's just, those people are more at risk of developing longer term problems. So we want to capture those at high risk and we're going to separate them into two different groups. In our clinical trial. One group will get a really intensive physio therapist, led exercise therapy program. So a lot of strengthening, agility, neuromuscular control, education, around physical activity you know, loading of the knee return to sport. And then that's over a period of four months initially. And then the other group gets what we're trying to say is usual care. Adam Culvenor (37:06): So very little intervention, they get a little bit of education and some booklets with the types of exercises I could do if they want to essentially, which is what they'd probably get it from their GP or their surgeon. Similarly, am I going to then assess their needs and their general health and symptoms and function from baseline and that changes over four months. And then also look at the changes up to 18 months as well because the MRI is one of our main outcomes looking at early collagen changes, which is our osteoarthritis marker. And some of these can take a little while to show up. So if you have an MRI on one day and then go and have an MRI the next week, chances are, you're probably not going to see much difference. So we need that period of, you know, 12 to 18 months to be able to see an effect of our exercise therapy intervention. Adam Culvenor (37:56): Whereas the symptoms of function we're expecting to be able to improve quite a bit within the first four months, which is going to be the most intensive period. And so yeah, our hypothesis is yeah, is that there's really strong, intensive, progressive rehab program strengthening, getting nice knees back to better than what they were before is going to be beneficial for their symptoms, function, general health quality of life, but also hopefully be able to show that that's actually preventing the early changes that we see on MRI or indeed maybe slowing the changes. So we know that cartilage thickness decreases. So we have a loss of cartilage, bone marrow lesions can start developing also for small osteophytes and bony spurs can start developing over a course of one or two years. And so we want to see if there's a difference in the development of those features in the two different groups. So we are ready to hit, hit, go on this study and a little bit delighted with COVID effecting us at the moment as well. So we're really excited to get going on this study and hopefully be a really impactful research project, moving the field forward and empowering clinicians to say, we actually can make a difference in this space for these patients. Karen Litzy (39:07): Yeah. I love it. Well, I look forward to when you guys can actually get started and maybe 12 to 18 months from then. So it sounds like a great study. And like you said, it's something that can be so empowering for physical therapists or physiotherapists to then pass on to their patients and kind of transfer that power from the physio to the patient to give them a greater sense of wellbeing, which is exactly that's what we do, right. That's why we became PTs or physios. So before we sign off, I have a couple other things. Number one. What are your biggest sort of takeaway messages for the listeners? Adam Culvenor (39:55): So I think the biggest thing is probably when you first see the patient, whose had an acute ACL injury in front of you and they're devastated. They often might come into your rooms and have heard particularly here in Australia. Our media is very centric on if you've had an injury, you need reconstruction because the elite athletes tend to have the reconstruction and I want the best treatment. And therefore I need a reconstruction is actually having a conversation with them and saying, presenting them with the evidence as I spoke about earlier. And there's no problem trialing a period of non-operative management for a couple of months, because that's going to be a great help if you do go down and have surgery afterwards. And it's, I think the reality is that a lot of people given the opportunity to do is to not pretty, very happy, actually can change their mind over the course. Adam Culvenor (40:45): And I realized actually, my knees gone really well. I actually don't need to have surgery where I was. I thought I would. So that's instead of just going gung ho into surgery, I think the evidence is very clear that a period of non-operative management is beneficial. Most patients almost all. And then the second key take home for me is, is during a postoperative or post-injury rehabilitation is actually working these patients intensively and progressively, I think we tend to shy on the side of being a little bit cautious, particularly after they've had a reconstruction, we worry about the graft rupturing. And of course we have to respect the surgeons requests of what we need to do with the patient from a restriction standpoint. But I think there's evidence growing now that we can be a lot more intensive early on and progressive with our exercises and looking to the strengths and conditioning research like these guys are trained specifically to develop strength and conditioning programs. Adam Culvenor (41:46): And I think as physios where we're pretty good at it, some better than others. And I think meeting the American college of sports medicine, you know, criteria for strength gains is actually, you need to work really hard. You need to get sweaty, you need to actually be working at an intense level. And so unless we put our patients through that, those sort of levels of intensity, we're not going to see the best outcomes that these patients can then can achieve. So there my two take homes is I think try non-operative period of rehab initially and revisit that along the course of the program. And then don't be afraid to actually build a lot of strength in those people because that's going to be beneficial. So they short term prevent re injury and the longterm of preventing arthritis, likely down the track as well. Karen Litzy (42:31): Awesome. And then number two, next question is, and it's something I ask everyone knowing where you are now in your life and in your career, what advice would you give to yourself right out of a physiotherapy school? Adam Culvenor (42:51): Ooh, good question. I'd say don't worry so much about things. Things will work out. I think in the research I'll probably have my research hat on a little bit, is often clinicians who want to start in research or even researchers who want to continue in research is that the funding can be really you know, tricky and really competitive and can often make and break careers. But I think some general, you know, I'd tell myself is don't worry too much about that. Just link up with good people and strong mentors. So, and I think finding, I'm sure you've had other guests say this as well, but finding good people who can mentor you really well and put your interests or your goals in your career sort of forward to their collaborators. So you can meet new people and open doors. Adam Culvenor (43:46): I think I was always worried that it wasn't gonna be enough doors opening, but I've been really lucky in my career that I've been surrounded by a great team throughout and doors have inevitably even though I don't expect them to keep opening. And so having the being in the right place at the right time is important, but you can, you can help to create more instances of being in the right place and more instances of being in the right time by putting yourself out there and meeting new people and surrounding yourself with really good mentors. Karen Litzy (44:20): Great advice. And number three, last question. Where can people find you? Adam Culvenor (44:25): Peak pool can find me in my lantern at the moment I'm up? No. So I'm have a Twitter account @agculvenor. My profile's on the Latrobe sport and exercise medicine research center page at Latrobe university. So we have a blog at our research center with a lot of really nice impactful easy to digest, short blogs, short videos, infographics designed for clinicians designed for patients. So you can take them off the blog and give them to your patients so I can not recommend that resource highly enough. And then my email, feel free to email me. You can find that email address on the La Trobe website page as well. Karen Litzy (45:13): And, we'll have all the links to that at the show notes for this podcast over at podcast.healthywealthysmart.com. So we'll have a link to your Twitter and to your page at Latrobe and also to the blog. So people want to get those resources, they can, and we'll also put in links to the papers that we spoke about today so that people can go and kind of read those papers as well. So we can link up to all of that. So, Adam, thank you so much was a great conversation. I appreciate your time. Adam Culvenor (45:44): That's been fantastic. Thanks Karen. Karen Litzy (45:46): You're welcome. And everyone, thanks so much for listening. Have a great couple of days and stay healthy, wealthy and smart.   Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Michael Greiwe on the show to discuss telemedicine.  Dr. Michael Greiwe is a practicing orthopaedic surgeon with OrthoCincy, near Cincinnati, Ohio, and the founder of the OrthoLive and SpringHealthLive telemedicine platforms. The platforms allow medical practices to deliver telemedicine visits through real-time HIPAA compliant video conferencing between provider and patient increasing practice revenue, efficiency and patient satisfaction. In this episode, we discuss: -The benefits of telemedicine for both the patient and provider -Choosing the right telemedicine platform for your practice -How to meet patient privacy and compliance requirements -Practical tips for a seamless telehealth visit -And so much more!   Resources: Ortho Live Website Michael Greiwe LinkedIn Michael Greiwe Twitter Email: mikegreiwe@ortholive.com   A big thank you to Net Health for sponsoring this episode!  Learn more about the Redoc Patient Portal here.    For more information on Dr. Greiwe: Dr. Michael Greiwe, M.D., is a surgeon by day and tech guru by night. He is a practicing orthopaedic surgeon with OrthoCincy, near Cincinnati, Ohio, and the founder of the OrthoLive and SpringHealthLive telemedicine platforms. The platforms allow medical practices to deliver telemedicine visits through real-time HIPAA compliant video conferencing between provider and patient increasing practice revenue, efficiency and patient satisfaction. Dr. Greiwe is a nationally recognized expert on how telemedicine technology is changing the practice of medicine. TV news stations and podcasts across America have interviewed him about the future of telemedicine and how to use it to improve the patient experience. He attended the University of Notre Dame, where he won the prestigious Knute Rockne Award for excellence in academics and athletics. He completed his Founder and CEO of OrthoLive orthopaedic surgery training at the University of Cincinnati Department of and SpringHealthLive Orthopaedic Surgery and Sports Medicine. In 2010, Dr. Greiwe completed his fellowship in shoulder, elbow and sports medicine at Columbia University, training with the head team physician for the New York Yankees, Dr. Christopher Ahmad.   Read the full transcript below: Karen Litzy (00:01): Hey Dr. Greiwe, welcome to the podcast. I am so happy to have you on today to talk all about telemedicine. Michael Greiwe (00:08): Oh, thanks so much, Karen. I'm glad to be here. I really appreciate you having me on the show. Karen Litzy (00:11): Yeah. So for any of the long time listeners of this podcast, you know that back in March and April, when the covid pandemic hit, we talked a lot about tele-health. But I think it's great to sort of revisit that now that we're a couple of months in and perhaps more people are using telehealth at this time, then were back then. But what I want to know is Dr. Greiwe, did you just start using telehealth when the pandemic hit or were you more of an early adopter? Michael Greiwe (00:42): Yeah, thanks for the question. I kind of carrying out with sort of like an early adopter. You know, I started using telemedicine back when it really wasn't cool, I guess. It was like back in the 2016 time period. And I knew it was great for my patients cause they live pretty far away. I had patients that live like two or three hours away and they would drive and try to meet me. And then you know, I'd only see them for 15 minutes. I felt really bad about that. So I started using telemedicine and it's been a great thing for my practice. And then of course, you know, recent things changed everything and it's now exploded. Karen Litzy (01:16): Right. And like I said, in your bio is that you're an orthopedic surgeon. So one question that I think is probably good that you probably get asked all the time is how in the heck do you see someone for an orthopedic condition when you can't put your hands on them and kind of feel what's going on? Michael Greiwe (01:37): Yeah, that's a great question. I get it all the time. And it's one of those things where, you know, for me, and I'm sure for you as a physical therapist, you know, so much when you hear about the history of that patient. So like the history gives you probably 80 to 90% of what you need. And then the rest is sort of verifying things through, you know, a physical exam and there's certain things on video that you can kind of catch. So like if I have somebody with the rotator cuff problem, I can watch their arm move. And I just know that the rotator cuff is bothering them. And then I'll maybe order like an MRI or something along those lines sort of confirm. But ultimately for me, it's more about like, you know, I may have to see this patient in the office at a certain point in time, but I don't always have to do that. It's kind of like depends on what the history gives me. Karen Litzy (02:22): Yeah. And I agreed from a physical therapy standpoint. I get that question all the time is, well, how can you do physical therapy on someone if you can't, if you're not in the same room. And again, it comes down to listening to the patient. Like they will tell you everything you need to help treat them to help diagnose them. If you just listen in the beginning and then you can tailor your program accordingly. Now of course, like you said, there are times where you have to see the person in person, right. And sometimes that's the same with PT. So I think oftentimes when people think about tele-health, they just paint with a very broad stroke and they think, well, how can you do that? So what do you say to people who sort of have that mentality of all or nothing? Michael Greiwe (03:13): Yeah. I think if they experience it for their, you know, themselves, they can sort of see that, okay. You know, this really works and it works because, you know, if you have somebody on the other side that's engaging you and asking the right questions, you're going to eventually come to the right answer. You know, I've had patients with a frozen shoulder and I'm sure you've treated patients with frozen shoulder. It sort of have classic signs and symptoms. Sometimes the history isn't like exactly, they're just sort of out, well, you know, my shoulder has been hurting and it kind of came on over the last several months and now I can't really move my arm as well as I used to. Or maybe you might not hear that. You just hear like, well, it hurts all over all the time, but if you kind of ask some leading questions, you have the right examiner, you can find out the answer. And so I think that's really, the key is having the right person on the other side of the screen, you know, asking the right questions. I'm sure you do the same in your practice with physical therapy. Karen Litzy (04:06): Yeah, absolutely. And you know, when we're talking about our different practices and our businesses because of the COVID pandemic, a lot of places had to shut down there in person I'm in New York city. So talk about being shut down. So we were shut down quite early. Now other parts of the country are flaring up and there's a lot of uncertainty here. So when it comes to tele-health and our business, how can tele-health help our practices grow and help our businesses grow? Michael Greiwe (04:41): That's a great question. I think it's something that people are sort of finding out more and more about right now. I mean, there's so many ways to be able to utilize telemedicine in our practices to help it grow. I mean, first of all right now as an orthopedic surgeon, I see patients from around my area because of COVID in the situation we're in right now, they don't want to come into the office, you know, so they're looking online and they find, Oh, Dr. Greiwe has got an open slot to be able to be seen via telemedicine. So we're kind of advertising that at ortho Cinc, where I practice to say, Hey, anybody that might want to come in for telemedicine appointment, you can. And it just gives me access a lot better than it normally would to be able to see patients. And then I think there's other ways too. Michael Greiwe (05:25): So for instance you know, for physical therapists, you might work with employers for instance, or workplaces that need a physical therapist and you put like an iPad there to say, if you need a physical therapist, here's how I can help you, you know, call me or whatever through this device. And so there's just so many ways for us to do that inside ortho, specifically postoperative recheck appointments, they open up slots of time that, you know, you typically wouldn't have because it's a lot more efficient to see someone via telemedicine than it is in person. And you know, also there's a lot of downtime kind of between surgeries for us too, so that downtime can be utilized for telemedicine too. So there's a lot of ways we can sort of generate you know, revenue through that and kind of open up our practice a little bit more. Karen Litzy (06:13): And, what I found is I can actually help more people. Michael Greiwe (06:17): Oh yeah, absolutely. Because you could probably have group visits too. Right. You could have you know, on those group visits or are you talking about just sort of more you know, area? Yeah. Karen Litzy (06:29): Like you were saying before we went on is sometimes you have people have to drive two to three hours to see you. Right. You know, that's really, that can be really difficult. So imagine if you have, you know, this really aching shoulder pain and you have to drive two hours. Michael Greiwe (06:45): Right. Absolutely. You're absolutely right. I think what helps, what helps you is, you know, with telemedicine, you've got the reach to be able to see somebody that's five hours away or even across the country that's heard about you or, you know, maybe they know that you have certain techniques that they like. I sort of developed like a posterior shoulder replacement where it's kind of a muscle sparing approach to the shoulder. And so I have people come from like California, Texas, Montana, you know, and now I can kind of see them postoperatively and preoperatively with telemedicine. So it's a really nice, it's a nice tool from that standpoint too. Karen Litzy (07:19): Yeah. That's great. Yeah. So you could see them preoperatively, if they're across the country, they come in, you do the surgery and then you can then see them postoperative. So they don't have to stick around by you for six weeks. Michael Greiwe (07:33): Right. So I'll have him stay for the first week and then we'll have the incision to make sure everything's looking good. Take x-rays and then they'll go back home and then I'll check in with them every four or five weeks, they'll be doing physical therapy kind of in their local area. Or of course I could refer them to you to remote therapy, but yeah. So that's how they do it currently is they go back home, they work and they get their motion back. And then we'll check in again, virtual. Karen Litzy (07:57): Now how about prescribing medications? Is that something that you can do via tele? How does that work? Michael Greiwe (08:03): Yeah, it still works pretty well via telemedicine, but I don't really do any like schedule three narcotics, you know, things like that. We don't do, but you know, anti-inflammatories, you know you know, if somebody has had some nausea like Zofran or, you know, things of that nature are pretty easy to prescribe and we still prescribe and have the same prescribing practice that we do in person, it's just, I get a little bit more wary and I think it's prudent to be more wary about, you know, narcotic prescriptions and things like that, especially in the world that we live in right now. We've gotta be very careful about that. So, we're super careful with that, but I think most of the other prescriptions are totally they're okay to do. Karen Litzy (08:46): And how about this is a question that I get sometimes is what about privacy and compliance and making sure that meeting all those standards. So how can we ensure that we're doing that as a healthcare practitioner on tele-health? Michael Greiwe (09:04): That's a great question. I think, you know, it is very important, obviously. So HIPAA compliance is what it's sort of called as you know, and it's what everybody's sort of, doesn't like to have to worry about, but it's very important for our patients, right? I mean, it's, people are very much in tune with their privacy. Data privacy is becoming like a really big thing right now, but really people's healthcare privacy and their you know, their medical privacy is very, very important. So the telehealth platform that you choose, you have to make sure that that is HIPAA compliant. And that means end to end encryption. That means like the data that starts out, you know, it's carried through the internet and it's encrypted and then wherever it's housed, it's also encrypted there too, so that no one can sort of get to that information. I think that's really critical, very important for our patients and most of the platforms they will advertise whether or not they're HIPAA compliant. And you want to know kind of how many you know, what type of bit encryption they are and things like that when you look at platforms. Karen Litzy (10:06): What was that last thing you said? Michael Greiwe (10:09): Yeah, it's sort of like, as the information is traveling across the internet there's sort of, you know, bytes of information, right? And so the amount of encryption can be sort of leveled up so that, you know, basically you can have like 64 bit encryption, or you could have 264 bit encryption there's certain levels. And so it takes, it's like a string of numbers. And so that string of numbers is how much it would take to crack the code essentially. So 256 bit encryption is like, you know, a massive amount of code breaking has to happen to catch that while it's traveling through, you know, the inner web. Karen Litzy (10:50): Well, no, that's really good because I think that's something that if people are choosing a platform, it's definitely something that as a provider you want to be looking at. Michael Greiwe (11:00): Absolutely. It's very important, you know, and most providers are pretty in tune with that, but right now, like, you know, they're allowing telemedicine to occur on FaceTime and some other platforms. Karen Litzy (11:12): Now FaceTime is not HIPAA compliant. Michael Greiwe (11:17): Yeah. So we don't want to really be using that right now. And there are some providers out there that are doing it, maybe just for ease of use and because the pandemic it's happened. But ultimately what we really need to make sure is that we don't use those platforms. Those platforms are not safe, not secure. Karen Litzy (11:35): Are there any other sort of things that you want to watch out for when you're let's say, well, first we'll start with looking at different tele-health platforms. So what are the things that you want to be looking for? And if you have any advice on a do's and don'ts, while you're actually in your tele-health session, I know some of them seem like, should be common sense, but you never know. So let's go with, what should you look at first? What should you be looking at in your telehealth platform? Michael Greiwe (12:11): It's a great question. I think the first thing that's really important for patients is making sure that, you know, the HIPAA compliance there, we covered that, right? So HIPAA compliance, probably number one, number two is, does this platform allow you to, you know, keep a schedule? So one of the most frustrating things as a provider of telemedicine is, and this is what I found out many, many years ago is that there is no schedule. You know, you have to send the invitation to the patient. The patient sort of says, yes, I'd like to do this. And then, you know, they link up eventually, but what you really want us to be able to schedule the appointments, that way you can move from one person to the next, and you're not really leaving a screen and trying to come back and forth just from an efficiency standpoint. Michael Greiwe (12:53): It's not very efficient to do that. Another thing that's important, I think is being able to chat with your patient. Sometimes it's important to be able to have a conversation. And it's also important to answer questions. And so being able to have kind of a text based chat that's secure as well, that might be, you know, maybe they can send you a picture. Maybe you can send them a video. Maybe you can send them sort of a document that gives them some exercises or what have you. And that's really important too. But I think one of the other things I was gonna mention is consenting. A lot of platforms don't have consent and of course that's part of the law. You have to consent that patient for telemedicine before you have a visit in most of the States, I think 45 of the States, you have to have a consent. So very important for the consent process to happen also. And that allows you to have a legal telemedicine appointment. Karen Litzy (13:44): And that consent process. Can that be in your initial paperwork? So if you're onboarding someone and, you have, I mean, we've all been to the doctor's office, you have to fill out a million different forms, right? So same thing with PT. So can that consent to tele-health be in that onboarding or does it have to be every time you connect for a telehealth visit, do they have to consent every single time? Michael Greiwe (14:11): That's a great question. And it's really just a onetime consent, so it doesn't have to be, you know, every time. So if they just come to your office first time, you're going to maybe have him sign some paperwork that says consent to telemedicine, and that's fine. You're good to go. But in the case where you have a new patient, it's very important to make sure that you have that consent process. And so for us and what we do at ortho live and spring health live, we just have them sign off one time that they agree to telemedicine. And then we assume every time they visit the platform, they know what they're doing and they've already agreed to it. Karen Litzy (14:44): Yeah. Yeah. Cause I have woo. You just gave me a little sigh of relief cause I have it again as part of my onboarding paperwork that people are consenting to their telehealth visits, but I don't do it every single time for each visit. Michael Greiwe (15:00): Right. Then I think it's just sorta like the billing practices in your practice too. And that people sign off that they're okay with billing and that they just do it once they're not signing it every time that they come back, it applies similarly to telemedicine. Karen Litzy (15:12): Got it. Got it. Okay. So those are the things you want to look at when you're kind of shopping around for a platform. Now let's talk about some things that you want to have in mind as the healthcare practitioner during your telehealth visit with your patient on the other end. Michael Greiwe (15:30): Yeah. It's a really good question. So the first thing is if you're going to use a phone, you know, and sometimes you're using a phone because you might be on the go or maybe your platform only allows you to have a phone it's really important to make sure that you don't like hold the phone, like right underneath your nose. Because it sort of gives you like kind of the up the nose shot a little bit. So I always tell people, you know, prop your phone up in front of you, like on your keyboard, maybe that's a really good place for it. Or if you're using a laptop, obviously like your face is kind of directly in front of that camera. And it just gives you more of a conversational type of appearance to your patient rather than you're not like talking straight down to them. Michael Greiwe (16:06): I think that's important. The other thing to sort of test out is just make sure that like, you know, when you move your right arm, like your right arm is like going up in the correct location in the camera. So you're not off to the side, you know of the camera when you're trying to show them kind of what you expect, I imagine for physical therapy and you can answer this, you know, too, I imagine for physical therapy that you may have to be seen, like your full body may need to be seen at some point in time. Karen Litzy (16:33): Yeah. Yeah. You definitely need like a decent amount of space so that you can lay down on the ground. You can come up to kneeling, you're standing you're so yeah, for physical therapy, you do need a good amount of space. So it comes down to finding those spaces, whether it's in your home or your office, where you can kind of get the right angle and good lighting. Michael Greiwe (16:54): Right. That's great. I think that's really important. You know, for your listeners on the physical therapy and for us, it's also being able to screen share too. If you can screen share, then you can show x-rays MRIs, things like that. And just getting tests sent out. Like I know for my practice, you know, we had a lot of physicians go live as soon as COVID hit and nobody had practiced. And so it was disaster on the first day, it was like, you know, it was like Groundhog day. And like no one knew what they were doing. And I was running around different pods trying to help everybody. But it's important to practice just like we would never go to surgery, not practicing what we're doing, you know, you practice to on your side to make sure that everything's working properly, your camera, your audio and all of that. Karen Litzy (17:36): Yeah. Do a couple dry runs with friends and family, make sure it's working well. Yeah, that's excellent advice. And now what do let's say, physicians or therapists what do they need to do now to kind of quickly adapt to this telehealth? Because from like, I look at, it's such old hat now, but I've been doing it since March. So now you have other parts of the country who are sort of trailed behind New York city. So they're in lockdown maybe for the first time and they really need to start adapting quickly. So what advice do you give to those practitioners? Michael Greiwe (18:12): Well, you know, providers of medical services always have a hard time with change, right? I think that's like one of the tenants of being a type a personality, the personality that ends up getting into medical practices or, you know, we're very particular. So we don't like to change. That's the first thing to recognize. And, and so there's going to be bumps in the road and they're just going to be hurdles. And I think it's really important to just understand like, Hey, you got to sort of roll with the punches a little bit, understand is not usually too difficult. We just need to kind of figure out what your plan of attack is going to be. Are you going to see tele-health patients in the morning and then see your regular, you know business in the afternoon, if you're completely shut down, how are you going to adapt to that? How are you going to get the word out? Are you going to be able to market this really, really important for you to make sure you kind of figure all that out on paper before just sorta like saying, yeah, I'm going to buy this telehealth cloud from when we get rolling, you know, it's like let's plan an attack and how we're going to be seen and how we're going to be able to see patients. I think that's really, really important. Karen Litzy (19:12): Yeah. Makes sense. And now let's talk about the platforms. Let's talk about the platforms that you're involved with and how you got involved. So there's ortho live and spring health live, right? So how are you an orthopedic surgeon with all of the work that surrounds that and then sort of this tech person entrepreneur on the side. So you must have some spectacular time management skills. Michael Greiwe (19:44): Well, I've got a very forgiving wife. I know that that's number one. But you know, it is like a it's a wonderful thing for me because I really enjoy doing kind of creative things. Things that might help my patients and telemedicine was one of those things I think really was, was a great thing for my patients ultimately. But for me, telemedicine was a way for my patients to be helped in a way that we couldn't really help them through anything else. And so there wasn't a great solution. So I decided to found ortho live about three years ago, that was 2016. And it was only because I was looking around to try to find a solution for patients and for providers that was really efficient and that worked really smoothly. But what I found was that really didn't exist and it was really hard to find the right solution. Michael Greiwe (20:32): And so I decided to create it after speaking with a CEO of a telemedicine company out in the California area, he kind of runs a lot of the video for MD live and some of the other larger companies. And he said, Mike, you know, this is a great idea. You ought to kind of through on your vision to do this for orthopedics. And so I did that with ortho live and it's been really successful and I kind of knew what we needed. We just, you know, we didn't have the efficiency in a way to be able to see patients in a streamlined fashion. So we created that within orthopedics, which I knew very well. And then we kind of branched out and now we're offering services to other specialties and subspecialties as well with spring health live. Karen Litzy (21:11): And within these platforms, do you have ways to do objective measurements within these platforms? Cause I know some do some don't so how does this, how does this work let's say from an orthopedic standpoint. Michael Greiwe (21:27): Yeah. So I mean, if you want true objective measurements we have to kind of integrate with braces and things like that. So, you know, we're like a smartphone application. And so we do have API APIs that can integrate and take in information like that. It's not something that, you know, orthopedic surgeons really use on a daily basis. I would see that more for physical therapists. So we kind of have the ability to integrate with you know, applications that give you range of motion and actual discrete data. I think that's really important because it does give you some actual feedback on a day to day basis, how a patient's doing. But from an ortho standpoint, we don't really need those, like the discrete data points we just sorta need to see, okay, well, how was that patient performing? Michael Greiwe (22:09): Are they having difficulties still, you know, moving their knee, let's see you bend your knee. And if it's not really going as well as we want, we know we need to up the physical therapy, we need some more intensity there. And it's more of a good stall for us. Less on the discrete hard numbers, but with therapy, I feel like it is really important to have that feedback to say on a day to day basis that patient's not doing well, how can we help them? Do we need to intervene sooner? So maybe that's what you're getting at, but, but yeah, we have the ability to kind of feed that information back into our platform. Karen Litzy (22:39): Yeah. Yeah. That's cool. Because a lot of times it's, you know, you could say, well, if 180 degrees of shoulder elevation is considered full, it looks like maybe they're at 75% or they're at 50%. So, but it's hard to get those, like you said, very discrete numbers because we can't measure it. Right. So having the ability to kind of integrate applications to be able to do that, I think is it can be really helpful. Although I, yeah, I guess sort of postsurgical when the patient is perhaps limited to X amount of degrees of movement, I think is where that comes in really handy. Michael Greiwe (23:21): Right. Right. And we have them sort of stand kind of at the side and like watch for inflection and things like that. So I think we get, you know, to within probably five to 10 degrees, but if you're looking for exact degrees, that's where those programs, which, you know, you can strap like an iPhone to your leg now and like move your knee. And it measures range of motion through like some little track pads and things like that. And there's ways to, to really effectively get that, that motion and understand what's happening with the patient and recovery, which is nice. And so we've allowed the ability to integrate those types of applications to our platform, which is cool. Karen Litzy (23:56): Yeah. That's really cool. I was working with some developers based in Israel who have an app for gait. And so you put it in your pocket and what it does is it can tell you the excursion of your hip range of motion from flexion through extension pairing side to side, your stance time steps per minute all sorts of stuff. I think there's up to like seven or eight discrete measurements, which is super cool. So again, in times like this, this is where the technology 10 years ago didn't exist. Michael Greiwe (24:33): Yes. A hundred percent. Karen Litzy (24:36): Having that now is allowing healthcare professionals to continue to help their patients during this pandemic. Michael Greiwe (24:46): No question. I was speaking with a group that has some special socks that like will measure stride length and things like that. So they know when a person may be like, you know, unsteady with their gait when they might be a fall risk which I think is a great, it's a great thing. And so, you know, understanding when patients may need some therapy to try to help with balance is critical. I mean, falls are a multibillion dollar issue in the United States today. And if we kind of cut down on falls, it's a great, great opportunity. And so we're, I think we're leveraging little things like, you know, from a data standpoint to be able to improve population health. I think it's great. Yeah. Karen Litzy (25:26): And where do you see telemedicine moving in the future? The pandemics over is everybody just gonna wrap it up and call it quits? Or what, where do you see that moving towards in the future? Michael Greiwe (25:39): No, I think telemedicine is here to stay Karen, I think you know, so-called genies out of the bottle, you know, there's a lot of great things that have happened with telemedicine recently. I think it's here to stay. We're gonna end up seeing telemedicine continue to spike. It was on the rise. Even before the pandemic, we were seeing multi millions of patients that were being seen every year. It was doubling every year. And now it's like, I mean, I think it's gone up by 10 X. So there's going to be a lot more telemedicine, I think, in people's future. Karen Litzy (26:10): Yeah. And as we were discussing before we came on the air hopefully the providers of insurance will also agree with that and say, we are going to continue paying for these because look at the advantages it's giving look at the money we're saving because of this. Cause like you said, if you can have a telemedicine visit with someone and it prevents a fall, which is a multibillion dollar industry, would you rather pay the $2-300? Whatever it, I don't know how much it is or have that person hospitalized for hundreds of thousands. Michael Greiwe (26:48): You're absolutely right. And so if there's any, you know, any of the insurance industry listening is very, very critical that we continue with telemedicine for their patients. And it's so beneficial, not only in protecting them during this time period, you know, we definitely don't want to let them go out of the house or 70 year old patients that are potentially sick and I'll really you know, it's for their safety and it's also for the benefit of the patient. I mean, it's way more convenient for them. And so I think without a doubt, it is so important to make sure that our legislature continues to support telemedicine and telemedicine billing. Karen Litzy (27:25): Absolutely fingers crossed fingers crossed that that happened. So I'm with you on that. Alright. Now, before we start to wrap things up, is there anything that we didn't cover or anything that you want the listeners to sort of walk away with from our discussion on telemedicine? Michael Greiwe (27:43): Oh, I think the main thing is, is that, you know, there's a lot of great people out there trying to provide health care. And many of them are trying this, you know, as a new you know, thing for them in their practices. And I think supporting them in that is important. I think everybody inside their local community is really trying to do things via telemedicine now and they weren't doing that before. And so being flexible, I think with those providers, I think is important, but I also think that telemedicine is here to stay. It's one of these things where there's so much benefit on both the provider and the patient's end that it'll just continue to be here and be a part of society and medical care going forward. Karen Litzy (28:20): Yeah, absolutely. And now I have one question left and it's a question I ask everyone, and that's given where you are now in your life and in your career. What advice would you give to yourself as a fresh medical school graduate? Michael Greiwe (28:36): That's a good question. I love this question. I think for me, I was such a you know, a worrier, like I was, I was always worried about, you know, what was I going to be good enough? Was I going to be smart enough? And you know, I always knew that I believed in myself, but I didn't trust myself back in those days enough to know that I was going to be okay. And I think the thing to remember is like, you know, you went into this medical profession for a reason you want to take good care of patients. You got to believe that, you know, you're a hard worker and you're going to continue to do as best you can to take good care of people. And you're not, you know, even a few fail it's okay. I think failure is it's okay to fail. I think that's another thing that I would tell myself to, because I was so worried about failing that I wasn't willing to like branch out and take risks. But I've learned that now. And I think if I could go back, I'd tell myself, don't worry about failure. Just you're gonna be fine. Just keep working hard. Karen Litzy (29:36): Great, excellent advice. And now where can people find out more about you more about ortho and spring health live? Michael Greiwe (29:43): Great. Yeah. Well, they can actually look at our website. So our website is www.ortholive.com and then www.springhealthlive.com. So for me, I can be reached at mikegreiwe@ortholive.com. That's my email address and I'll be happy to respond. Karen Litzy (30:08): Perfect. And just so everyone knows, we'll have all of those links in the show notes under this episode at podcast.healthywealthysmart.com. So Dr. Greiwe, we thank you so much for coming on. And, and like I said, I've spoken about tele-health before, but it was way back when this started. So it's great to get more information out there for people to know that it's not just something that we're doing during the COVID pandemic, but that this is something that can be incorporated into your practice. It can help your business, help your patients. So thank you so much. Michael Greiwe (30:43): Oh, thank you, Karen. I was glad to be here. Appreciate it Karen Litzy (30:45): Anytime. And everyone. Thanks so much for tuning in, have a great couple of days and stay healthy, wealthy and smart.   Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

On this episode of the Healthy, Wealthy and Smart Podcast, Dr. Michael Weinper speaks with guest host Dr. Stephanie Weyrauch about the American Physical Therapy Association's Vision 2020. Passed by the House of Delegates in 2000, Vision 2020 was APTA's plan for the future of physical therapy. In his 2000 Dicus Award speech, Dr. Weinper discussed his predictions of where the profession would be in 2020. Dr. Weinper and Dr. Weyrauch revisit the elements of Vision 2020 and analyze whether our profession has accomplished a vision of the future set twenty years earlier. In this episode, we discuss: -How has the physical therapy profession evolved since the drafting of Vision 2020? -The student loan debt to income ratio -Advocacy efforts to achieve full direct access in all of the States -The importance of lifelong learning and evidence-based practice -And so much more!   Resources: Stephanie Weyrauch Instagram Stephanie Weyrauch Twitter Stephanie Weyrauch Facebook Email: sweyrauchpt@gmail.com APTA Website   A big thank you to Net Health for sponsoring this episode!  Learn more about Four Ways That Outpatient Therapy Providers Can Increase Patient Engagement in 2020!   For more information on Dr. Weinper: Michael Weinper, PT, DPT, MPH, cofounded the company in 1985 with his partner, Fred Rothenberg, a former executive at Blue Cross of California. A physical therapist with more than 40 years of experience in clinical practice, management consulting, administration, and program development, Weinper is also a principal in Progressive Physical Therapy, a private practice, with four locations in Southern California. Weinper received a Bachelor of Arts degree in Industrial Psychology and a Bachelor of Science degree in Health Science (physical therapy) from California State University, Northridge. He received a certificate in physical therapy from that institution in conjunction with UCLA Hospitals and Clinics. Weinper later received his Master of Public Health degree (M.P.H.) from UCLA in Health Services Administration and his Doctorate in Physical Therapy from the EIM Institute for Health Professions in Louisville, KY. Weinper has been active in the American Physical Therapy Association (APTA). He has served as a member of the APTA’s Task Force on Physician Ownership of Physical Therapy Services, as a member of its Committee on Physical Therapy Practice, as the association’s chairperson on its Task Force on Reimbursement, on the Board of Directors for APTA’s California Chapter and national Private Practice Section, and as trustee of the APTA Congressional Action Committee (now known as PT-PAC). Weinper received the prestigious Robert G. Dicus Award from the Private Practice Section of the APTA in 2000, and he received the Charles Harker Policy Maker Award from the APTA Health Policy and Administration Section in 2011. On behalf of the state of California, Weinper has served as a member of the Physical Therapy Subcommittee of the Division of Industrial Accidents, now known as the Division of Workers’ Compensation. He also has served as an expert to the Medical Board of California, where among his activities he has appeared on behalf of the People in insurance fraud trials. He has provided expert witness testimony on behalf of more than 20 insurance companies. A former associate professor of health science at California State University, Northridge, Weinper is a frequent presenter for various professional associations including the National Managed Healthcare Conference, the American Medical Care and Review Association, and the APTA. He has authored many articles for both physical therapy and insurance industry publications. For more information on Stephanie: Dr. Stephanie Weyrauch is employed as a physical therapist at Physical Therapy and Sports Medicine Centers in Orange, Connecticut. She received her Doctorate in Physical Therapy and Master of Science in Clinical Investigation from Washington University in St. Louis. Dr. Weyrauch has served as a consultant for a multi-billion dollar company to develop a workplace injury prevention program, which resulted in improved health outcomes, OSHA recordables, and decreased healthcare costs for the company’s workforce. She has served on multiple national task forces for the American Physical Therapy Association (APTA) and actively lobbies for healthcare policy issues at the local, state, and national levels of government. Currently, she serves as Vice President of the American Physical Therapy Association Connecticut Chapter and is a member of the American Congress for Rehabilitation Medicine. Dr. Weyrauch is also the co-host for The Healthcare Education Transformation Podcast, which focuses on innovations in healthcare education and delivery. Dr. Weyrauch has performed scientific research through grants from the National Institutes of Health and National Science Foundation at world-renowned institutions including Stanford University and Washington University in St. Louis. Her research examining movement patterns and outcomes in people with and without low back pain has led to numerous local, regional, and national presentations and a peer-reviewed publication in Archives of Physical Medicine and Rehabilitation, a top journal in rehabilitation.   Read the full transcript below: Stephanie Weyrauch (00:00:01): Hello everyone. And welcome to the healthy, wealthy and smart podcast. I'm your guest host Stephanie Weyrauch and I am interviewing Mike Weinper who's the president and CEO of physical therapy provider network or PTPN as it's better known and also a private practice owner for progressive physical therapy in California. The reason that I wanted to talk to Mike today, as he won the Robert G Dicus award for the private practice section back in 2000, and he has been an instrumental person in practice, leadership, innovation, legislative, and political issues, healthcare reform, and a number of other areas where he's really had the opportunity to champion innovation and leadership. And one of the things that, you know, we know it's 2020, and obviously vision 2020 has something that has happened in the APTA was written back in 2000 and in Mike's Dicus award speech, he talked a little bit about where he thought the profession would be in 2020, in 2000. And so I'm really interested in kind of his take on where we are today. So Mike, welcome to the healthy, wealthy and smart podcast. And tell us a little bit about yourself. Michael Weinper (00:01:21): Well, thanks Stephanie, for the very nice introduction and it's a pleasure and an honor to be with you today. At some level, I’m considered by some, to be a dinosaur, having gotten my Dicus ward 20 years ago, and now long in my career, I'm just celebrating my 50th anniversary as a PT. So I hope that some people won't tune out just because of that. Maybe if nothing else, they can see me as a history lesson, any event, I can tell you that back in 1992 the California chapter of APTA now called California PT association created a long range planning task force that I was honored to serve on. And in that task force where a lot of leaders in the profession in California names that were household names, then probably names and most people would not know now, but our plan was to draft a long range vision. Michael Weinper (00:02:21): If you will, a crystal ball of what things would look like some 18 years later in 2010, kind of looking back, it's interesting to look at and we created, I believe 18 different points that would be goals if you will, of the association and the primary aspects of that working document, which was called PT 2010 by the California association. I'm sure if you were interested, you could look it up or get a copy of it. Then later became the working document for APTA called PT 2020. And since we are now in 2020, I wish we would have known then what we know now, because things have dramatically changed in many ways, but in other ways they have not. And so I guess I could give you some of the ideas we envisioned back in 1992, if you'd like, and then we can take it from there. Michael Weinper (00:03:23): So in that document, we said that PTs would be able to evaluate and diagnose conditions that's true today, perform specialized treatment procedures and work in teams with physical therapists and PT assistants. So all that did come true. Next, the PTs would be able to initiate services subsequent to their own evaluation diagnosis without referral from or diagnosis by another practitioner. And that in 2000 that had not yet been accomplished, but we, now we know we have independence and practice almost every state with regard to our licensure. In most therapists are, would be in independent press configurations with other therapists, maybe who would work in a hospital. In other words, there would be an opportunity to be clinically specialized in it with a board certification, which we now know has really grown quite a bit. Michael Weinper (00:04:25): And they would be sought out. These specialists would be sought out by consuming public and third party payers. Not as much. I don't think our profession has reached to the public well enough to get the public, to understand what a board certification really means and what it takes to become a board certified specialist in our profession, but I'm progressing for a moment. Anyway. So then we said that PTs would be able to be involved in the continuum of care from the hospital to the home, to the private practice. In other words, PTs would have hospital-based privileges and they would be able to go there. And then if the patient were home, many of them would be able to then go to the patient's home and treat them there and then follow them up in the office. And so that was another kind of idea we had way back then. Michael Weinper (00:05:21): So it would be basically following the patient through the episode of care from beginning to discharge and obviously getting them ambulatory and functional. We also said that this is a good one that PTs would become diagnosticians. And more importantly that we would be at the entry point in healthcare which wasn't the case in 2000, but in now in some places, it is that therapists are in fact these musculoskeletal specialists would be a cause we can do it musculoskeletal evaluation or diagnosis many states now recognize that. And some insurance companies have recognized that we can be an entry point into the system, which I believe going forward, it's going to become much more prominent because of the higher cost of care. And actually Stephanie, the difficulty we all experienced when we try to refer a patient to a specialist, state, an orthopedist or a neurologist to do an evaluation so we can follow the patient. Michael Weinper (00:06:18): We find that it can take several weeks for that patient to get in, to see the physician, whereas they can usually get in to see us in a few days. So I think that's something that we will see more of in the future, but back then we had it as a dream, but not a reality. We also said that at that time, that instead of 24 weeks of internship that were experienced by PT graduates back in those years, we thought internships would last one year. Now that I don't think there's a, but we have in fact seen fellowships and other levels of work where therapists are really going into specialization so that they in fact can do things over a year's period of time and then becoming sort of like specialists. So those were sort of the, kind of, I think the basic things that would be of importance today. Michael Weinper (00:07:15): We did also, this was a very important one. We identified that in the year 2010 PT would be a doctorate profession. That was what our key points of doctorate and profession. And lo and behold now our entry level is what a DPT, a doctorate. I'm very proud to say that I went back and got my DPT a little over 10 years ago. I talked back in 1982, and I certainly wanted to walk the walk before 2010. So cause that was our benchmark was 2010. So with that in mind I think it's important to realize that we have become doctoral people. In other words, we are now at a level of sophistication with our education and hopefully some research that gives the PT of today a much broader view of a patient, their wellness or their disability, and gives them better tools, which the function do the evaluation or assessment of the patient, and then follow up with treatment compared to how things were back when I graduated in 1969. Michael Weinper (00:08:31): So and I found that when I got my DPT that I learned quite a bit. I learned some of the things I learned actually were more on how to think differently than I had thought previously. And I will tell you that some of the things that I learned that were most valuable to me was how other people think so studying with other transitional DPT candidates gave me an opportunity for me because I was the oldest person in my class. Gave me an opportunity to hear people think and how they process, how they analyze and how they come to the decisions they do. And then how do they communicate it? I like to think I'm a good communicator, but oftentimes I get really wrapped up or wound up and, you know, I go off on a tangent and I probably go down the rabbit hole and maybe other people in today's world are much more succinct. Michael Weinper (00:09:31): And to the point also I can tell you that I was privileged back in 1975 to get my MPH at UCLA and the school of public health there. And I learned a lot about things that are important today, including epidemiology, which we now know is at the forefront of everybody's thinking and infection control and making for safe environments, which was only very basically touched in my DPT program. But one of the things that I really enjoyed was the differential diagnosis courses I took and the radiological courses I took that gave me a much broader sense for things that I'd studied back previously, or maybe taken some content courses, but went into much more depth and listening to other people discuss those kinds of things. So that's how things were back then. I can tell you also that insurance companies were perceived to be able to give PTs a lot more latitude. And it's only been in recent years that many insurance coverage industry to pay for PT. That's independent of physician referral. We're still working with Medicare on that. You and I know all the snow and I think the day will come that the feds will start to get a little wiser and realize the cost benefit of the PT being an entry point into the system. Stephanie Weyrauch (00:10:58): I think that that's a really great overview of kind of what you guys envisioned back in the early nineties and kind of correlating that with vision 2020. So the APTA vision 2020 and a couple elements that made that basically encompassed a lot of what you said. So autonomous physical therapist practice was one of them, direct access, evidence based practice, doctor physical therapy and lifelong education PPS as practitioners of choice and professionalism. So those were when the house of delegates discussed this, those were the main themes that they were looking for. So keeping those themes in mind, let's maybe start by talking about the doctorate of physical therapy. I mean, that was something that you were obviously very proud of. You will talk the talk, you walk the walk. So what do you think? Well, studies have been shown the DPT student debt now varies between 85,000 and 150,000. Okay. Do you think based off of what we're seeing today, as far as student debt, do you think that today's DPT is a good return on investment? And do you think that the salary for the physical therapist has kept up with the increases in training and inflation? Michael Weinper (00:12:14): Well, I'm very happy to hear you raised this question because it's a question that I not only think about a lot. I talked about a lot with my colleagues and I also talked with students who are becoming PTs and people have gone into residencies for a year post-doctoral now for purposes of gaining a better outlook on things. And I must tell you that when we gave thought to the idea of PT being a doctoral profession, never in our wildest dreams, did we think about the cost benefit aspects of it as it relates to educational costs back then costs were not inexpensive. You should teach part time at USC and Cal state university Northridge. And I remember students used to complain about the cost of education back then, but it was nothing as compared to today. So to get to your point, I am sad to say that we have not grown our income levels for PT to the level that they should be given the doctoral training that we received. Michael Weinper (00:13:29): And the depth that usually goes with that, unless you've got some kind of a rich uncle or a greatness scholarship, having said that most PTs coming out with a lot of debt, and then they find themselves in jobs that they don't want to do. Let me just elaborate a little bit on that. PTs in private practice is considered by many to be the desired venue in which to work because patients are coming to you. You have all kinds of equipment and resources and hopefully a nice facility to work in. And the patients for all intents and purposes are ambulatory or said differently. You're not going to be ambulating a patient in a hospital hallway and have something happen to your shoe. If you can get my drift in any event, it seems that most PTs that come out of school today are struggling with where they want to work versus where they have to work and where they have to often work or those places that pay more because they're less desirable. Michael Weinper (00:14:35): So as the desirability quotient increases, the unfortunately the salary decreases because of in part supply and demand. And also to a greater extent because insurance companies are not reimbursing PTs in private setting, like they are in the hospital, for example. So if I go to work in the hospital, I can make a lot more right out of school than if I go to work for an independent therapist in the same community. On the same side, I can go to work for a home health agency, not have this desirable of a work environment. Have you seen changes from patient to patient, but make better money, but then again, have other costs of doing business. And I think at the end of the day, those who do home health, and I don't mean to criticize those of you who do, but if you look at your cost of doing business and take that away from your income, you find that your true income is much less than you thought it was going to be. Michael Weinper (00:15:30): Whether it's wear and tear on your car, gasoline insurance, you have to carry on your own, whatever it may be, equipment you might have to buy and so on. So it seems to me that the desirability of where you'd like to work and the pay ratio is a universally, but proportionate with that in mind, it's a function of insurance companies, and this is where I really go down a rabbit hole. And that is why are PTs and private practice paid less? And the answer is because PTs in private practice accept less, they have an, I am very secure, experienced on this. Having started PTPN 35 years ago, a managed care company for PTs in private practice. And we have always advocated for higher reimbursement. And in fact, we Protestant have been successful in getting a higher reimbursement for PT and practices that are in our organization. Michael Weinper (00:16:30): Then PTs were in the community who are not in our organization. However, because PTs are willing to accept whatever insurance company pays. In other words, they don't want to lose business. They accept fees. They're much lower than they should. And that has driven down the value of PT in the mind of the insurer and that's led to lower salaries. And so to get to the end of this thought, PTs coming out of school, don't get proportion of the kind of income they should with a doctorate. And let's contrast that for just a moment to a PA, a PA has less training than we do. They will usually get a master's degree. They work in a physician's office, but the way that they can bill under the physician's license gives them much better reimbursement. It makes them more valuable to the physician and therefore their income is oftentimes much greater even out of school, you know, apples to apples. Then we get as a PT out of school. Stephanie Weyrauch (00:17:31): Yeah. I think you make a lot of really great points there. I mean, the doctor, the DPT was obviously great as far as, you know, gaining direct access, being more autonomous, but you know, the cost of education has obviously sky rocketing it. So based on, you know, your ideas, what do you think that the private practice section can do to help guide new graduates through the uncertainties of student debt? Michael Weinper (00:17:57): Wow. there's a lot of things that come to mind. First of all, we, as a profession have to be better educated to know when to say, no, that's a K N O W and N O in the same sentence. Know when to say no. In other words, if insurance companies are offering rates that are below what it costs us to business or below what we think we should be reimbursed, we need to learn to say no to them and walk away from that business. Maybe it's better to see fewer patients and make more money and be able to compensate our staff better than to take every insurance contract that comes down the road that pays less than it costs you to run your business. Those in private practice who might be listening to this podcast are shaking their heads affirmatively I'm sure because they get it. Michael Weinper (00:18:47): Those who are not in private practice probably don't understand what I just said. I don't need that it was criticism, but I think that at the educational level, during your basic education it's therapists need to learn more about socioeconomics as it relates to our profession. Supply demand economics certainly, and cost of doing business are key points. In years past for APTA taught courses on economics made easy for PTs because many of us come out of school even today without very much in the way of business knowledge or knowing much about economics. And once you learn more about that, things become much clearer and it makes it easier to make decisions that are in the best interest of our profession. So I think the PPS can, it does from time to time try its best to educate us on how to be better managers, if you will. Michael Weinper (00:19:51): And that includes things like the economics. But I think we, as a profession need to be top of mind with economics and learn how to advocate more as a group, as a profession, not just individuals because insurance companies will not look, listen to individuals. They will disappear to larger groups. To that point, larger groups get better reimbursement. So that point hospitals being really affiliated with one another or powerful entity as an association get better reimbursement. So I think that getting PTs together to understand I know APTA has advocated for many years better reimbursement. I worked with APTA in different retreats for payers. So there was a way to bring together a summit, a payer summit, they call it where they bring together many insurance companies. Actually I did one in Connecticut where you are cause that's a sort of a hodgepodge or location of many insurance companies. Michael Weinper (00:20:55): So we had several speakers who knew a lot about reimbursement, including Helene furan, a dear friend of mine and others who would speak to insurers about what is PT? What does a PT do? How do we evaluate patients? What does it cost to run a business to give these payers a better understanding, but remind you be reminded. These were not big association meetings. We brought peers together. So we might have 25 or 30 people in a room, some of whom which were larger decision makers than others, but when it came right down to it, we didn't have the ability to follow up with them and push them down the road to where they would be accepting of what we do. So we today, the cost benefit of coming to PT, I'm sad to say is very disappointing. It takes you a long time to work off your debt. Hopefully in the future, our government will see fit that people in professions like ours need to have better forgiveness of their debt in return for doing public service for the public we serve. Stephanie Weyrauch (00:22:06): Yeah. I think that you make a great point about the fact that we as private practitioners need to walk away from some of these more measly reimbursement contracts. And you know, one of the things that we hear a lot with incoming graduates is that there are a lot of private practices that have very high volume. And one of the reasons that they have low job satisfaction is because they're seeing so many patients. So I think that you make a really great point in saying that, you know, maybe it's better that we take fewer insurance companies, see fewer patients, but get paid more because now you're eliminating that burnout and that poor job satisfaction and allowing that new professional, or, you know, even if it's a veteran physical therapist, make the money that they actually deserve with the training that they have. Michael Weinper (00:22:58): Exactly right. And that's why we need to really advocate politically. And that's why the PT PAC is a very important thing to be involved with because we, as a profession can be heard through advocacy many, many years ago, I was one of the early trustees of what we used to call APTCAC American physical therapy, congressional action committee, which now PTPAC. And I always used to say, and I consider you to say today, if every PT would just give $25 to political action, how much more strength we could have because we live in a world where legislators listen to those who support them, support them with votes and support them financially so they can get folks important that we do get to legislators. Michael Weinper (00:23:54): We have a lot of people in Congress who are friends and have been our friends for many years, but we need more. And when things come up like budgetary cuts of Medicare, where they talk about an 8% reduction in Medicare reimbursement coming in next January, which I hope goes away. I think it will go away. I pray it would go away. But if it doesn't, I mean, think about that. You're getting a reduction in your reimbursement, which is not that great today. And they're going to reduce it even more. What's that gonna do to salaries? It's not going to help the PTs in private practice. And this is something that I think many people who are not in private practice, the students podcast may or may not, may not believe, but it has to be true. Michael Weinper (00:24:40): I've spoken to hundreds of PTs in private practice over the years. And I think many people would be appalled or shocked at least to realize that many people who own private practices do not make a lot of money. I spoke to a PT just last week here in Southern California, who was impacted by the rallies that were going on with black lives matter. And unfortunately, during that time, there was some looting and pillage went on by some bad actors, if you will, not people who were affiliated with the rallies themselves, but people who took advantage of that and broke into places and solving fuel and burn places. We all heard about that here in Southern California was one of those places in other parts of the country, the same thing that held true, that PT, when I talked to them and was trying to do what I could do to help them rebuild their practice. Cause your practice had been broken into and everything taken. Michael Weinper (00:25:42): I asked this individual if they would be willing to share with me how much they make per year. This person said to me, under $80,000 Michael Weinper (00:25:58): And I pause for a second. And since not only for the problems they were experiencing because of the looting and stuffed up to their office, but for the fact that even under good times, they weren't making a lot of money and they were working hard. They're working 10, 12 hours a day, sometimes on weekends. That is because they were in a situation where their cost of doing business is almost as high as what they would receive in payment. Michael Weinper (00:26:24): And we know that owners of businesses get what's ever left over after paying all the other bills, including salaries and benefits and rent and all the other things that come to mind. And it's not uncommon to find people who own their own practices, who do not make a lot of money and you have to take a lot of risks. So it's one of these things that we need Congress to better understand that it's important to support physical therapy as a profession, because we are a very valid and important aspect of the health care continuum that if we aren't there the cost of care will go up because rehabilitation, I believe, and I'm sure you believe decreases overall cost of care. So getting Congress to vote that in and to budget more money for us and Medicare, and then hopefully getting insurance companies to understand that not every therapist is going to do things on the low ball side of it, but really are going to hold out for a higher compensation that they're entitled to. Michael Weinper (00:27:36): They're going to be more inclined more and as a parent more it's my idea that therapists should be able to own practices to be able to pay their staff more. I've always said, Stephanie, that I wish I could pay every therapist that works in our practice, $150,000. I think they're easily worth it, but it's a function of what we get paid. And I can tell you that, you know, my own practice, progressive PT my income hasn't gone up in over 10 years and I don't make, you know, I don't make a lot of money in it, but it's because I get what's left over after we pay everybody. I feel that we've got to give our employees reasonable compensation for what they do. And we don't use a lot of extenders. We don't do a lot of things that are in the realm of I'm doing it on the cheap side as many people do. Stephanie Weyrauch (00:28:31): Yeah. I think that your points about advocacy are really important because I know APTA has been working on that 8% cut. You haven't written to your Congressman. I definitely encourage those of you listening to this podcast today to log onto APTA’s website, whether you're a member or not and write a letter to your Congressman, it really only takes three seconds. Additionally, there has also been a legislation that has gone forward with trying to increase the loan forgiveness for DPT students. APTA is always trying to get us to have pay, be paid more so that advocacy piece is really important. So that kind of brings me into the next pillar or the next element of vision 2020 and that's full direct access. So we do have at the some form of direct access in all 50 States right now, however, there are three States where the direct access is extremely limited, where you basically can only do a wellness evaluation without a doctor's referral. And then there are about 27 States where you have direct access with basically limitations or rules attached to it. And a lot of those have to do with say diagnosis or with different interventions like dry needling or electrical stimulation. Those types of things. So kind of along that route, how can PPS ensure that we get full direct access in each state? What are some things that the association can do and that physical therapists can do? Michael Weinper (00:30:04): That's a wonderful question. And I think the answer is create stronger advocates in each state because what you're talking now is not about federal legislation, but state legislation. In other words, each licensing act is governed by the state legislature. So having a good group of PTs who can rally and lobby, if you will, or have a lobbyist, if there is a big enough state to meet with members of the state legislature to express how important it is in an effort to control costs in healthcare, to give therapists more clinical rights and abilities, that's where it starts. Once you get that, then you can get insurance companies to start to buy in because they realize that is legal in that given state. I have seen this happen throughout my career that has been slow to come. We've been shooting for direct access. And at the same time also trying to eliminate the need for there to be physician intervention in certain musculoskeletal situations where we now are trained as diagnosticians to be able to evaluate and treat these things. Michael Weinper (00:31:17): It's my hope in the future that we get the opportunity from a licensure standpoint to order x-rays, to order lab work and things like that, to where we can have more information at our fingertips, but then to have to refer out. But only where it's appropriate, where we're adequately trained to do that. You have to teach legislators what is PT and what is the benefits of PT and what are the cost savings that insurance companies, the public. And we all save by giving the opportunity for patients to be strong entry points into the healthcare field. It's certainly fond for us to evaluate patient. And in some States you can do, like you said, dry needling. I live in a state, California doesn't even allow dry needling. I have people in my practice who teach dry needling to therapists around the company because he used to do that where they worked in other States, very frustrating for them, extremely frustrating for me, but it takes legislation. Michael Weinper (00:32:25): It takes talks. It takes contributions to your local state PAC, and most of them have it now. And to be involved in APTA, I think is key that so many PTs I call nine to fivers. They come in and they do their nine to five and go home and they forget about their profession. People like you and others who are dedicated to making this a better profession for PTs of the future, not to mention the public that receives our care are the ones that make things happen. And so being more involved in our field through volunteerism obviously is key, I think, to change and too many of us look to the other guy to do it, whether it's writing a letter to your congressmen, or there's going to meeting with a state legislator, whether it's inviting your local state representatives into your practices, see who you are and what you do. Michael Weinper (00:33:27): All of the things bode well for growing our practice. And too few of us, unfortunately do that. We don't realize that it starts fortunately with regulations and what we can do and how we can do it. So the quest, if you will, or request, I should say would be that we as a profession, get more involved in our association because the association is the focal point for getting the information to legislators. It's our association that has the greatest credibility. And I can tell you that one of the reasons I went back and got my DPT was that I saw that when I would testify on a bill in Sacramento here, there would be people with a doctorate, not necessarily in our field, but just doctorates, so would speak against what we were doing it. And I would get up there and I would have 40 years of experience, and we have a master of public health degree then on my doctorate. Michael Weinper (00:34:26): And I were always, and I would like to think I had good presentation and good preparation and knew the facts. And yet it was those who had doctorates that were, or had the title doctor who were paid more attention to now, we as PTs have that title. And now we're sort of in a level playing field with other professions, from the term being entitled a doctor. And with that credibility, we need now to take more action, we need to spend more time trying to create change in my Dicus talk back in 2000, I said that people were afraid of change and it's true. And even today they're afraid of change and we all like the status quo, but the reality is we need as a profession to embrace change because with change comes progress and we need to progress as a field of profession. If you think about things it takes a village if say and certainly in our professional, it's no different, we have to be part of that village. We can't just be part of the tribe. We need to be active leaders of our village. Stephanie Weyrauch (00:35:43): Yeah. And I think, you know, if you look back at where we were with direct access 20 years ago, I mean, obviously we're in a much better state than where we were, but some of the resources that I know PPS has for people with their fighting, the direct access is they do offer grants to state associations if they're doing any type of lobbying. So if you haven't applied to one of those, it's a pretty hefty amount of money. It's like five or $10,000, which that goes a long way when you're paying the lobbyists to do the work for you. You know, they also have a key contacts program and they offer resources for practitioners that if you do invite a legislature in a legislator into your practice, or you are trying to advocate for a bill, like they provide all that information for you on their website and on the APTA action app. Stephanie Weyrauch (00:36:29): So, I mean, PPS does have resources out there that we can utilize to try to continue in our fight with direct access. And I mean, yes, we're in a much better place than where we were 20 years ago, but like you said, change takes time. And as a, you know, as a young professional, I definitely would love to see change happen even faster. So you know, the more people we can get together and build that village, the faster it's going to happen in your Dicus speech, you also talked about how you envisioned that physical therapist will be evaluating and diagnosing conditions, performing specialized treatment procedures and working with the PTA team. And then you also envision that there would be no referral needed by another practitioner. And I know you've kind of covered this a little bit, but give us an idea of where we are, where we're at with this prediction and what you think the future holds. Because as you know, a lot of these direct access bills that we have still restrict our ability to quote unquote diagnose conditions or even perform specific procedures. So kind of give us an idea of where we are compared to 2000 and where you see us going in the future. Michael Weinper (00:37:41): Well we are obviously light years ahead of where we were in 2000, just by hearing what you described to helping things in what I predicted. And I think from the standpoint of going forward, we need to be cognizant of the fact that we can change things if we put some effort to, and in other words, so many therapists don't do things because I think I hear people say, Oh, it doesn't make a difference, or they'll say somebody else will do it. And the truth is that we all need to be more involved. And I'm one of those key contacts and have been for many, many years. I can only tell you that how rewarding it is to invite a legislator or even somebody who works in their office, into your office, into your practice, to visit with you, see what you do, talk to you, the things that are your barriers to growth and barriers to doing for patients, what we should be doing and should have been doing for many years. Michael Weinper (00:38:46): And I think it's more important to understand what you can't do versus what you can do. And you only learn that by going to stage or talking to people in other States who have full privileges to do those things and have that true autonomy. So I think that by attending association meetings, for example, PPS is a great example or CSM when it comes back. And, and I say this, not just going to the meetings, but talking to people, not just your friends, but talking to people you don't know, but from other States where you might know there's a lot more progress, ask them what they did and how they did it, or talk to the leadership in those States, in those state associations and ask them, how did they accomplish what they accomplished? Because it takes a lot of work and there's a lot of resistance by other professions, physicians be it chiropractors, osteopaths, even dentists from time to time resist, having us grow to where we should grow. Michael Weinper (00:39:53): And the key again is educating the public, what we do. So when you're treating them, let them know what you can do, what you can't do all because of the laws, even though you might be trained to do these things. And sometimes the best advocacy doesn't come from ourselves. It comes from the people we serve our patients. So getting people to write letters to their members of the legislature is very important. But I think getting more people to stand up, write letters, attend hearings in your state Capitol become more involved, become more aware of the benefits you can create, not only for the professional, but certainly for yourselves as well. And that's one of the reasons that I've been very involved in APTA throughout my career was I felt that I had the ability to change things if I would only work at it. Michael Weinper (00:40:47): And I was very blessed. You haven't brought it up, but Bob Dicus for who the Dicus award is named obviously was one of my mentors. When I was a student, I got to meet Bob. He was already very deep in his ALS disease in Georgia. He was fully wheelchair bound and tied to a respirator, but that man had so much knowledge. He was one of the first private practitioners. And one should only go to the PPS website and learn more about Bob and what a great man he was and what a visionary he was for our profession. As a matter of fact, just to digress for a moment, he is the one who created the ALS society nationally. He was the inventor of that. He had a second professional. He was in, he was a motion picture producer in his later years when he couldn’t be a PT, he went into motion pictures. Michael Weinper (00:41:48): A lot of them had to do with rehabilitation and things that we do. They weren't necessarily featured like Sims, but he got involved in that kind of communication. So it always goes to the fact that I think some of the best PTs are the ones who are best able to communicate with their patients, with the public, with our legislator. Sure. Those are the PTs who really do the best, because if you're good with your patients in communicating, you're able to motivate them to do the right thing. Right. And communication is something that we need to study more perhaps in school. I teach a lecture on communicating with different generations because as I become part of the older generation and looking at the younger people, I see how you and others in your generation and younger generations communicate with one another as much different than what my experience is. Michael Weinper (00:42:43): I grew up with our computers. I remember the very first calculators. We were not what I was going through school in high school. We used an Abacus and a slide rule. And then going forward, we used a Texas instruments brand calculator, which was very expensive and very elementary looking back at it. That's an idea of technology when technology and communication are, I think are very interwoven. In other words, as technology increases, communication becomes dependent on that technology. And we tend to communicate less with one another or said differently. I can see my son-in-law and daughter at our house, sit on the couch, waiting for dinner, remake, and what are they doing? They're texting. And I said, who are you texting to talk to them? Wait, what answer? Just speaking with one another. And that's just the world we live in. And then all the little acronyms, all these simple things that you know are, are part of the lexicon today. Michael Weinper (00:43:56): Today's younger people, older people don't necessarily know. And when treating an older patient, it's key that you speak to them in a communication form that they're going to understand. And don't assume they understand. I mean, you're saying just because you're saying it, and the same is true for older therapists like myself, talking to younger people, you have to motivate them in a different way. Young people want it. Now they want things quickly. They're used to getting information quickly. You go with something up on Google and get an instant answer on something. Whereas back in my day an encyclopedia sales person used to knock on our door, trying to sell my family a big set of 30 books of encyclopedia. We were tell much to us what we needed for today's knowledge. And I don't think those people around anymore. If at all. If you wanted an encyclopedia, you've got it. Michael Weinper (00:44:50): Just look up something in Google or another search engine, and you've got instant. You got too many answers. Sometimes you get different answers for the same question, but with all that in mind, communication is key to success. And we as service need to communicate better, not only with our patients with one another, with our legislators and with the public in general, and to that point, having better PR public wise. And I think APTA is trying to do that. Now that we're into our hundredth year, starting there as your celebration or Centennial celebration. I think you're going to see a lot more information going out to the public, through electronic media and social media, to where we gain a higher visibility with the public. Michael Weinper (00:45:38): I had the TV on the other night, I was watching a game show and one of the contestants was a PT. And he was a young PTA until that. And he didn't want a whole bunch of them. I think it was, I believe the show was a wheel of fortune actually, which I don't watch too often, but it was on. And I've heard the word physical therapist. It's just like you, whatever you heard that word somewhere. Even as sitting in a restaurant, you hear somebody talking about their PT, your ears perk up and you sort of start to eavesdrop a bit. And we as a profession don't hear that word in the public as much as we hear about doctors or other things. So I think the public needs a better awareness of who we are and feel comfortable talking to us. And we need to feel comfortable talking to them and educating more about who we are for. They haven't needed to see us. Stephanie Weyrauch (00:46:26): I think you make some really good points about the communication aspect and that kind of leads into the next element of vision 2020, which is us being practitioners of choice. So in kind of going off of that with communication, it's too bad Bob Dicus, isn't around anymore to make the next hit healthcare drama on physical therapists. I mean, how many physical therapists and healthcare dramas do you see walking patients or stretching patients? You know, it's never really, they're never main characters in, you know, like Chicago med or Grey’s, you know. Michael Weinper (00:47:05): Anytime I see a PT portrayed in these situations. I cringe because first of all, they're wearing, and I hate to say this cause I'm going to probably, I'm going to take an issue with some of you they're wearing scrubs. I don't think I don't scrubs when I grew up were for people working in surgery. Now everybody wears scrubs. So you go to the grocery store. People were in scrubs. They, I think people not even in healthcare wear scrubs sometimes, but I think we should look more professional. We should be more professional and the public will respect us better if we act more professional. And so there are some times PTs who are brought in on dramas to be a technical advisor. I have been in that position before twice, and I have talked to directors and producers about what they need to show. Michael Weinper (00:48:05): And I can only tell you that what you tell them to do and what they end up doing sometimes is different because maybe they don't have the right equipment or the character. They thought they already lined up costumes for their characters. It becomes very frustrating, but getting in on the front end and getting the public to understand who we are, hopefully through drama and maybe through, you know, like I say, public service announcements or ads on TV where we're portrayed better or having the opportunity. Many of you are in smaller cities and towns, your local newspapers and television are hungry for local news. And you may be doing something you don't need to think second thought about, but it's newsworthy. Maybe you just purchased a very important piece of equipment to help with ambulation or suspension or something technical electronically to create new opportunities to treat patients your local TV stations would love to demonstrate, come to your clinic, film you doing that and have it as a segment on their TV show. Michael Weinper (00:49:21): And many of us don't even think about that. So and I, again, even in Los Angeles market, I've had the opportunity to do that a couple of times. And it can be a little bit overwhelming, a little bit scary, but you know, something at the end of the day, you feel really good about it and how you come across is much better than you perceived. You are going to come across when you're getting ready to do it. So don't be shy, but reach out to your local media and try to get them interested in what you do, because what you do, what I do is very newsworthy and very important for the public. Stephanie Weyrauch (00:49:52): Yeah. And you know, obviously people are following what the media says and listening to the media. So, I mean, the media is, has been a very powerful force that you can utilize to spread the gospel of physical therapy so that we can become the providers, the practitioners of choice, for the musculoskeletal system. And so the people actually know that PT means physical therapist and not like personal trainer or part time, people actually know what it means in your speech. You also stated that PTs would be recognized by payers as diagnosticians an entry point into the healthcare system. And I know you've talked, you you've touched on this a little bit, but how do payers recognize physical therapists and how do today's payers recognize us compared to back in 2000? Where are we at with that? Michael Weinper (00:50:43): Well, back in 2000, and even in day sense, payers felt we needed to be treating only under a physician's referral. If you looked at insurance policies that you might have, or if you spoke with payers, they would say that PT was a covered service when provided or the auspices of a physician referral or diagnosis today. Many of those policies from the same payers do not have that language. So because of the direct access laws and because of therapists and given States talking to their insurance companies, the payers they've educated them to where certain payers are starting to realize the benefits of PT first. And let's just take substance abuse and chronic pain. We know as musculoskeletal experts, there are lots of things that we can do for the patient to avoid surgery, to avoid downstream costs like expensive imaging that may be unnecessary. We can certainly get the patients treated properly and get them in a mindset to where pain is not top of their mind. I have a book sitting right behind me on my bookshelf. It's called explain pain. Are you familiar with this book? Stephanie Weyrauch (00:52:13): Oh yeah, that's a very familiar book. Michael Weinper (00:52:16): Okay. And this was a very good book for people to read. It's the authors are David Butler and Lorimer Moseley, and they're down in Australia, but they talk about dealing with the mental side of pain, the cognitive side of pain, if you will, and how to best creature patients in deemphasize of pain and emphasize wellness or health. And we need to do more of that as practitioners. And as we can educate our insurance companies, that by sending the patient to PT for four or five, six visits, we can avoid surgery, many cases, what is a cost benefit to the insurance company? Their insurance companies listen to money. And I know this from my experience for many years of working with many of them speak with probably too many insurance companies to not only remember, but to count. And they are driven by dollars and they do not put enough emphasis on times in their underwriting to allow PTs to do the things we do. Stephanie Weyrauch (00:53:26): Yeah. Michael Weinper (00:53:28): Shortsighted because they ended up then forcing patients to go to a physician first, wait, several days or weeks to see the physician where the patients only getting more deconditioned. And rather than just seeing us first, and we have the opportunity and the knowledge on doing things that get the patient out of the problem or fixing the problem, if you will, from a nonsurgical standpoint. So insurance companies in some cases have become much more enlightened and other cases are still in the dark ages. And those who allow us to treat without referral and pay us for what we're worth are the more enlightened ones, some insurance companies that I've dealt with now in recent years are paying for outcomes. There's concept of paper for pay for performance or P for P. I like to call P fro. It's really not what you do, the process of what you do, but really the outcome that you get. Michael Weinper (00:54:27): So if you can get a great outcome with fewer visits, then insurance company should be willing to pay you more because you reduce their costs. And, not only of what you did in terms of your crew cough, but in terms of what would otherwise cost them to treat the patient going forward. So I like to pay to pay for outcomes Peterborough, and that's why we, as a profession, need to do more in the way of outcome measurement, whatever tool we use and be able to communicate to the payment payer community, the benefits of what I do. So I'm going to go back now to the mid seventies again, when I got my master's degree we learned even back then that the definition of quality in healthcare was composed of three things. And the author of that was a fellow who's no longer with us. Michael Weinper (00:55:22): His name was Avitas Donabedin. He was a physician. He was very involved with the new England journal of medicine, D O N A B E D I N, if you want to look it up and Donabedinn even back then said that quality health healthcare was three things structure, which is where you do it and what you use in terms of equipment process, what you do okay. And outcome, or the results. So we all have been able to measure it structure, and we were able to mission measure the process where you, but not enough of us over my career have been able to truly prove that what they did was a benefit. And I think that that's one of those things that we have to focus more on proving the benefit of PT two outcomes or said differently because of what we do, patients get better quicker. Stephanie Weyrauch (00:56:16): And that leads us really nicely into the next element of vision 2020, and that's evidence based practice. So obviously APTA has done a lot over the years to try to improve how we're measuring outcomes. So you have the outcomes registry CoStar was created. If you look at how much the literature has been put out for, if you search, if you search up physical therapy, even in Google, it's, you know, an exponential growth since even 2000 and even the larger growth. If you think about it from even the 1970s, when outcomes were first described. So, I mean, this is something that, you know, we've been working on for a long time. I think that obviously it's come a long ways, but we still have confirmation bias in our literature. We still have group practice that people are practicing. We have treatment fads that really don't have a lot of evidence behind them. And we have practice variation that continues to affect our outcomes and affect our profession. How can PPS help offset this? How can we continue to go forward to mitigate some of these things that are occurring? Michael Weinper (00:57:24): Well, that's a $64 question, as we used to say my hero. I think it's important that we need to, you talked earlier about one of the goals of PT, 2020 is lifelong learning. And I see too many people in our profession who don't come to meetings of the profession, whether it's a local meeting in your area, whether it's a state conference whether it's CSM or PPS meetings, too many of our colleagues never go, or maybe they went as a student cause their school paid for them or somehow or another they're were to go. And they never ever go. If you think about people, you went to school with Stephanie, you never see them again. And you wonder, how are they getting their education? One of the things that has occurred a dream the last 15 years I would say is the requirement by States that each PT in order to continue, their licensure must have continuing education, a certain amount. Michael Weinper (00:58:35): And it varies state by state, as we know, and what things have to be parts of that, continuing education, again, vary by state by state, but at least we're being forced now as a profession to continue our learning. Having said that, and having taught in different venues in different ways. I can tell you, there are people who are serious learners, and there are people who we call lazy learners. The lazy learners are those who will buy the cheap level CEU kind of stuff, and do a quick read on something and take a test and not really spend the time to investigate what was being offered. And maybe some of the quality of that they're learning is really not up to date either. Versus those of us who will go to con ed meetings, we'll do things online. Now there's a lot of opportunity. PBS shows a lot of things out ABQ has a lot of things. Michael Weinper (00:59:35): I'm a member of the orthopedic session section and the oncology section. They have lots of stuff going on that, yeah, there's too much of it. There's just like there's like education overload. So you have to be selective, but do choose things that I think will be beneficial to you. And that are evidence-based. So it brings back to the evidence based part because too often I've heard people get up at meetings and start to talk about things. And then when challenged on what's the word, what's the basis of your comments? They sort of stammered. And they said they gave answers that weren't really appropriate. So we do need more focus on, on lifelong, which we’re mandated to do, but some people take the easy way out. You know, people, we all have people we know who will take the high road and others who take the low road and the low road may be the easier road that may not be the get to the right end. Michael Weinper (01:00:29): So we want to challenge ourselves to learn more each day. And I can tell you that when I went back and got my DPT, I thought it would be fairly easy. And some of the things that I was exposed to, I'd already learned in my master's level, but I can tell you a lot of things that I learned were new concepts that I had never even thought about. And that goes to the idea of this lifelong learning and evidence based practice you learn, most of you learned in school all about evidence-based theory and practice, and some of you embraced it very well and other views sort of gone a different path. So I would say, take a step back and look at the research that's coming out. There's all kinds of journals. And that's another thing that I have to digress on a moment. Michael Weinper (01:01:17): And that is, here's a question for each of you, how many journals or publications that are healthcare oriented, do you read or subscribed to, if you say only PT, then I think you're making a big mistake because there's so much literature and so many things that are appropriate for what we do in our field. And to validate what we do in other journals and research is being done that we miss the boat by not looking at it at other professional journals or other modes of information, or even attending meetings for physicians and so on. I used to specialize in the treatment of hand injuries. And so I would go to the society for hand search and they actually had a PT sub, a PTO to see subset of that that my friend, dr. Susan Mike Clovis, was very involved in and she got me involved and I would listen to physicians. Michael Weinper (01:02:18): We collegial meetings where PTs and physicians would interact to try and come up with the best ideas. And many of us don't really have any contact with physicians, except when we're talking to them in the halls of the hospital or when we're going out to market them, or we're trying to take lunch to them. We don't talk really about concepts and about theory. And what do you base this upon? And what can we do to learn more about the benefits of what we do? And that gets us to the idea of each of us having the challenge to do some research, research is fascinating. It doesn't pay a lot, but you can still do research in your clinic. You can be parts of research projects. If you just look for them, is they're out there to take advantage of. And if you do that, it opens your eyes so much more. Stephanie Weyrauch (01:03:09): And I think a lot of the things that you've touched on kind of goes with the last element of vision 2020 and that's professionalism. So when the house of delegates originally defined what professionalism means in vision 2020, it's that we as physical therapists and physical therapist assistants are consistently demonstrating core values by aspiring to and wisely applying principles of altruism, excellence, caring, ethics, respect, communication, and accountability by working with other professionals to optimize health and wellness in individuals and in communities. So obviously one of the bigger focus is of APTA has been this optimizing society or optimizing movement to impact society. And we've been kind of taking more of a population health kind of perspective, trying to get out of the silo, physical therapy and move more into the interdisciplinary healthcare, healthcare, professional realm. Where would you say we are? As far as our professionalism goes in 2020, compared to where we were in 2000? Michael Weinper (01:04:15): Oh boy, I think many of us have because of our increased education, gotten more credibility with the medical profession. They tend to listen to us more rather than just seeing us as a technical entity or a technician versus a professional. Although I can tell you still today, physicians oftentimes don't see the benefit that we do even orthopedist. And we have come a long way in some with so many physicians, but we've missed the boat with others. I think it's critical than medical stuff, schools, especially if you're doing an orthopedic residency, that's a resident spend time with a PT. I was in a well known physician, internationally known physicians office recently with my wife who, when she had her shoulder surgery. And he has no to fellows at all times. And occasionally a PT will visit and come in and, and be there not to get paid, but just to talk and work with the physicians, educate the physicians and the younger ones, the fellows who are going to be out there real soon in their own practice. Michael Weinper (01:05:34): We need to do a better job of educating physicians. I said that a little bit earlier, but I really mean it. We can do it when they're in school, when they're doing their fellowships, we can invite them into our practices. We can go to doctor's offices and shadow them much more than we do. We can go into surgery with physicians and talk to them while they're there doing their procedure, learning why they're doing their procedure. And sometimes a light bulb will go on in your head say, Oh, I get that. And that's, I think there's something I could do a little bit differently with like, with your patients when I'm treating them by seeing what you're doing surgically and listening to what your concepts are. So I think there's a lot more collegial realism of that goes to being a professional. And to that point, if you don't see yourself as a professional others, aren't going to see you as fun and too many of us lose track of the fact that we are in it. Michael Weinper (01:06:27): When you say it's a profession, a profession requires one of the key points of any profession is that you learn, you keep current and you give back to society. And giving back to society means more than just treating people. It means educating the population, doing things from a wellness standpoint or avoidance of injury. I guess going back to my public health days where one of the key things is getting people not to have to see you clinically as a post op or whatever, but helping people to avoid surgery and do things the proper way. Ergonomics for example, is a good, good use of our skills and what we've learned as I sit up in my chair properly. And we doing things that people just don't think about. And when we break away from just being the PT, treating person and branch out to media with other professions, talking to them about what are their challenges, what can we do to help though, or thinking about things we can do to help them communicating better in collegially at different levels. Then we go a long way towards not only building those relationships, but most importantly, helping the patients we serve. So it's one thing to say your profession. That's another thing to give back to society and find different ways to give back Stephanie Weyrauch (01:07:55): What, you know, from this conversation. Obviously we've come a long way since 2000, we've achieved many things that vision 2020 set out to achieve, but we still have a lot that we yet need to achieve. So kind of on that note, Mike, you know, what is a clinical Pearl that you can kind of leave all of us with? What is some advice you could give a young graduate or somebody new in the profession that maybe you wish you would've known when you were coming out of school? Michael Weinper (01:08:29): Oh, that that's an easy question to answer because I oftentimes get asked by younger PTs, how did I become successful? I say very simply through volunteerism, volunteering your time to help your profession and help those we serve, whether it's going to a health fair and educating the public, you ever done that fascinating what they don't know and how the aha moments you see in the public. When you spend two minutes with them screening students preseason athletic screening, another great opportunity to follow tourism positions you're working with, Oh, that's how you do that. That's how you measure that. I didn't realize that. And that's another idea, again, of getting involved, getting I talked earlier about legislation, getting involved in legislation, getting involved in your association is what I think makes you successful. And to that point, I think that the best jobs of PTs get are not the ones they see through a Craigslist or three C on the association. Michael Weinper (01:09:41): Advertisements is from talking to other therapists, word of mouth learning, where are the best jobs to be had. And the only way to do that is not staying in your little house if you will, but getting out and talking to the PTs. That's like I said earlier, getting to know other PTs there's this PT pub nights that I see around the country, what a great idea I've gone to them. And they're actually fun. I stood out in the rain. They had an outdoor one here in Southern California, and you don't get a lot of rain here, but that particular night, we all were standing outside of this venue drinking our beverages of choice, getting soaked, but having a good time. And it's very memorable and getting to know other people and volunteering just goes a long, long way. I think, to learning more and learning what needs to be done, if you could learn what needs to be done and then not put it on somebody else, but say, I'm going to take responsibility again, getting back to I'm a professional. Michael Weinper (01:10:43): I need to be professionally responsible. I need to be the one who does this. I know you're one of those people. I'm preaching to the choir. Stephanie, when I say this and you know exactly what I'm talking about, but so many people who might be listening to a podcast like this, don't quite follow it. So my challenge to each of you would be get involved in your profession and spend a little time here and there, away from family away from work away from your social activities and back to your profession. That's part of being a professional. And as you give back, the more time you give the more you get. And I like to leave this thought with people. And that is for all the thousands of hours, I guess, at this stage of my career, I have given to my profession, whether it was the local district or my chapter or the national association or the private practice section or other sections I've been involved with or doing things in the public realm, getting involved in I was involved in a college board. So people got to know me as a PT and as an individual and get to know more about PT, getting involved in society, rather than just going home at night, turning on the TV, or turn on your computer or playing games, getting more involved with people and trying to do good things for the public benefits you directly. Stephanie Weyrauch (01:12:11): There were some wise words spoken by a true visionary of our profession. So thank you so much. And thank you for all of those who listened to this episode of the healthy, wealthy, and smart podcast and I'm your guest host Stephanie Weyrauch. And I hope that you stay healthy, wealthy, and smart.     Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Jamey Schrier on the show to discuss how to develop your dream private practice.  Jamey Schrier, P.T. is the Founder and Chief Executive Officer of Practice Freedom U, a business coaching and training company. He’s an executive business coach and leadership trainer. In this episode, we discuss: -Jamey’s entrepreneurial journey -The importance of vision and giving yourself permission to imagine your dream practice -How to generate revenue even during unprecedented times -Why building a team of experts is necessary for you to grow your practice -And so much more!   Resources: Jamey Schrier Twitter Jamey Schrier Instagram The Practice Freedom Method Facebook FREE GIFT Practice Freedom Method Website   A big thank you to Net Health for sponsoring this episode!  Learn more about the Redoc Patient Portal here.     For more information on Jamey: Jamey Schrier, P.T. is the Founder and Chief Executive Officer of Practice Freedom U, a business coaching and training company. He’s an executive business coach and leadership trainer. Founder of Lighthouse Leader®, Jamey helps physical therapy owners create self-managing practices that allows them the freedom they want and the income they deserve. He is the best-selling author of The Practice Freedom Method: The Practice Owner’s Guide to Work Less, Earn More, and Live Your Passion A graduate of The University of Maryland Physical Therapy School, Jamey specialized in orthopedics and manual therapy. He was the sole owner of a multi-clinic practice for more than 15 years. Jamey’s passions are basketball, tennis, golfing, and reading. He and his wife, Colleen, and there 2 kids live in Rockville, Maryland.   Read the full transcript below: Karen Litzy (00:00): Hey, Jamey, welcome back to the podcast. I'm happy to have you on again. Jamey Schrier (00:05): Karen. It's lovely to be here. Karen Litzy (00:07): Yes, no stranger to the podcast. That is for sure. And that's because we love having you on because you always give such good information to us PT business owners. So thanks for coming back now, you were a PT business owner yourself. People can go back and kind of listen to the past podcast that you did with us to get even a dive in a little bit deeper to your history and how you kind of went from a business owner to now coaching and mentoring in a training business. But can you give the cliff notes version for us now? Jamey Schrier (00:45): The cliff notes. That's how I got through school. Yes. Be happy to give the cliff notes. So I always wanted to have my own business ever since I was younger and went with my dad to his store. I thought it was the greatest thing. So when I got the opportunity to open up and put up my shingle, I went all for it. And I had my fiancé Colleen at the time. Now my wife who you have met, she was, yeah, she was my fabulous front desk. So it was a perfect scenario. Right? I was the quote, the doctor doing the treatments. It was the happy go lucky front desk. And it was a perfect scenario. And that lasted for a couple of years until we started to hire people until I said, honey, do you want to get married? Jamey Schrier (01:35): And she said, sure, boom. She left. She got 35 books on weddings. And she was like, not really there that much. So we had to actually grow a real business. Well, I really didn't know how to hire. I just assume everyone worked like I did everyone thought like I did. Everyone just did quote the right thing. And that's when a whole lot of stress and a whole lot of struggle started to happen, which caused me to create this sense of anxiety that I really didn't experience before. Definitely not as an employee, but I didn't experience for the first couple of years in business. So my hours started to increase. So not only that I have to do the treating and some of the other duties that I had to, but I also had to oversee them and all their stuff. So I took half of their job as well. Jamey Schrier (02:23): And about four years into it, a crazy thing happened, which I've shared before, but I will quickly share. It is my place burned down. We had a fire and it burned down and I was caught with these weird feelings of feeling relieved. Great. I don't have to go to work on Monday and feeling scared to death and feeling, Oh my God, what do I do now? Not just similar to what has happened with, COVID like, Oh my God, I wasn't prepared for this. What do I do now? Jamey Schrier (03:00): So after some soul searching, I realized, I don't know anything about how to build a business. I was a very good clinician. I thought being a good clinician was enough. It was not. So I spent the next nine years learning, trying, failing, learning again, trying and failing of how to build a business that can literally operate with a little bit of maintenance, but not me. They're doing all of it. And fortunately I figured it out and in January of 2013, I removed myself scared to death, but I did it anyways. Remove myself from the schedule no longer I was treating my team was handling it and my business shot up. So I got more time and I made more money and my team was great and my patients were happy and I was like, Oh my God. So I went on a webinar. I believe it was the private practice section webinars that they do. And I just shared my story. People reached out. And next thing you know, I was in the coaching business because they were asking me how I did it. And I've been doing that and being on a mission to help other practice owners try to build, grow their business for the last seven years. Karen Litzy (04:11): Awesome. And the name of your courses? Jamey Schrier (04:19): So the name of the company is Practice Freedom U, the letter U kind of playing off the university thing. And it is a really a business training and coaching firm. So we help the practice owners and we help their teams and grow and build the kind of business they like. So they can have the kind of life that they want. Karen Litzy (04:40): Awesome. And now you had mentioned in your story about when your practice burned down, you kind of weren't prepared for it. It's like kick in the guts. So the country, the world continues, not has been, but continues to live through the COVID-19 pandemic. A lot of clinics had to close. Some may still be closed as we tape this. I am in New York city. We are just reopening now. So as owners begin to reopen and restart, delivering their patient care, what are some of the not so obvious things that they should be aware of? Jamey Schrier (05:23): Yeah, that's a great question, Karen. What I learned in my experience when the place burned down and literally I had nothing to go back to, what was difficult about that was I was the only person going through that everyone else was just business as usual. And my initial instinct, because I am a high achiever because I am a doer was to do more like, okay, what do I got to do? What are we going to do? And it wasn't until maybe a couple days into it that I began to learn that, you know what me trying to do more me trying to be busy and filling up my day with just stuff. Even though I had no patience at all. And there was, by the way, there was no tele-health right. I mean, there wouldn't be telehealth right now if there wasn't a whole country, if it was just one person, the insurance companies wouldn't be changing all their rules. Jamey Schrier (06:26): So, but we didn't even have the technology for that. So what I did was I just started to sit and think and just sit with, well, okay, I'm going to rebuild this. If I'm going to rebuild this, what is it that I really want from this business? What wasn't working well. And I started to write out this, this idea, this outline of what I wanted the business to be. Now, mind you, I didn't know how I was going to get there. Right? I didn't know that, but the more I ask questions, the more I said, what would my business have to look like for me not to work 70 hours a week, which is what I was working, what would happen? What would my business have to be? If I didn't work the weekends, who would I need to hire ultimately to perhaps not have to treat or choose the people I want to treat. Jamey Schrier (07:26): So, as I started asking these questions and gave myself permission, love that word, I gave myself permission to imagine what it would look like. It started to create the outline. And this is exactly what I did and what I shared with other practice owners, what to do during this time. First of all, pause, acknowledge what the hell was going on right now, because it is unprecedented. I hate that word because everyone's saying it, but it is something that you are not prepared for. And it is something that everyone is going through. The people that are going to get through this and be better than they were before, or the people that are not trying to go back to where they were. It's the people that are pausing and saying what an opportunity to fix the things that were broken and to ultimately create what I want. Jamey Schrier (08:21): It doesn't mean it's going to happen today or even in a week, or even in a month, or even in six months. But it's something that can start to help you create the outcome you're looking for, which then causes you to focus on where do I work today, this week? Who should I keep? Who should possibly, I keep furloughed, right? If you're like me at the time I was treating for, you know, 12, 14 years, I was like, maybe you want to reduce your schedule. What would that have to look like to reduce your schedule? Because now's a great time to start searching for therapists. Cause they're out there. And then maybe you weren't as keen on some of the metrics you weren't as clear. Well, what a great time to start getting really organized. So I tell people the not so obvious things is for you to pause, reflect, and start to ask the question. Jamey Schrier (09:21): I love questions better than statements, but start to ask the questions. What would it look like in order to blank? What would it have to be? Who would I have to have in place? What technology we would have to be. You don't have to answer the questions. And that's the mistake that people make. They put all the pressure to have to answer them today because we are doers. We are problem solvers, give yourself a break, give yourself permission, just put them out there. And something interesting is going to happen. I know you and I have talked about this in the past. It's amazing how things start to happen. How people start to show up people that are like, wait a minute, fall into place. They start to fall in place. And it seems like this voodoo magic. It isn't, your mind will start to look for your subconscious mind will start to look for these and it could be right in front of you, but you never saw it before. It's kind of like, where's the salt honey, where's the darn salt. Then she comes in just right in front of you, your mind, wasn't seeing that. So that's kind of the things that I would initially suggest, and then that kind of guides you to. So what are the key elements that you have to do now, which I'm sure we can dive in. Karen Litzy (10:34): Yeah. So let's talk about that. So aside from the obvious safety of your staff and of your patients, that's clearly number one, right? And we want to make sure that when places reopened that that is number one priority. So putting that to the side, because that is hopefully a given for all physical therapy practice owners, right. If it's not, I think you need to go back and ask yourself some questions, but so that should be number one. I think the other thing that a lot of owners are struggling with is the lack of money, lack of revenue that you missed from your business, let's say over the past three months or so. So do you have any thoughts on how owners can build back that revenue? Jamey Schrier (11:22): Yeah. And that is from the people that I've spoken with the surveys we've done, I mean, that is the number one stressor. I mean, you would want to think it's safety it's to protection. Well, the thing that stresses us out is if we don't have any money, we don't have security and stability and we can't take care of our own family. And that stresses the living daylights out of us. Cause for many people, that's why we went into business to be able to have that control and freedom to create the lifestyle we want. So we know that the biggest stressor Jamey Schrier (11:54): Now, for many people, you have a PPP loan, you have maybe a EDIL loan. So it's important to get clear on what options you have find eventually. So some people are kind of coming out of that PPP loan, like the money's gone, they just reacted, they got the loan and they thought they were doing a good job by keeping their staff, even though their staff didn't do anything, except write some blogs and send out some YouTube videos, but it didn't generate anything. So you know, you have to look at what you have available. So that's number one, get your financials in check. So you know, for our business we brought in accountants, we brought in attorneys, I'm sure you know, Paul well so we brought in people and I know for me personally, when this happened, I reached out to experts in this area. I reached out to my accountant, to my financial advisor. Karen Litzy (12:55): Are you kidding me? I was on the phone with my accountant, like literally, almost every single day and emailing him several times a day and thank God for accountants, what gems. Jamey Schrier (13:08): Yeah. But you know, what's interesting, Karen, not everyone thinks like that. You see, we are rugged individualist at heart. What is this business? We struggled. We sacrificed, we studied, we got A's and that is not how you build your business. You need to be. Karen Litzy (13:25): Yeah. That's how I used to be. Now. I'm like could you help me with this, this, this, and this? I mean, because I don't, I'm not an account. I've never filled out. Like I got a PPP loan. I didn't know what I was doing. So I would take screenshots of everything, send it to him. And then he was like, put this number here, put this number here, put this number here. And I was like, did it digit to do? And guess what? It was approved. If I didn't have his help, I wouldn't have been able to do that. I have learned, I've seen the light. Jamey Schrier (13:54): Don't tell anyone. I did the same thing. I call my accountant very calmly. I said, Hey Greg, what should I do? He said, well, it makes no sense not to get the PPP loan. I mean, it's more or less going to be free money. Who knows what's going to end up happening with it. But go ahead and apply that. I said, great, can you have someone help me with that? Because if I don't feel like doing it and he's like, sure, yeah. So everyone's talking about PPP loan. Everyone's freaking out. I've had, I can't tell you how many dozens and dozens and dozens of conversations I've had with business owners. Because I asked him, I go, so who's on your team. Do you have an accountant, financial advisor, someone that understands this and they went, well, I have a friend or a neighbor that does my taxes. And I'm like, see there lies the problem because you don't look at your business as a team of people that are experts in different areas. Jamey Schrier (14:52): So if you're going to learn from this whole COVID thing, start building the experts in your business. So it doesn't fall on you to try to be the expert that you're not. And give yourself permission, Karen, like you did. And I did. I'm not the expert nor do I want to be. However, I do know enough to know that I need to talk to the accountant about this particular problem. Yeah. So talking to someone, even if it's your bookkeeper and start to design what you have available, because that is going to determine if you have literally no money available, then bringing back all your staff isn't feasible, right? It's just not going to happen. But if you have some money available, if you have some other loans, maybe you have equity in your house. Maybe you have some things, not that you're going to use it, but you have it there. Jamey Schrier (15:46): Then the next thing is, start to create the plan, have a plan. Now I typically teach what's called a 90 day sprint, right? 90 day sprint is what is the outcome? The number one outcome you want in the next 90 days, once you're clear on that outcome, let's say the outcome is I want to be a lot of outcomes for people. I know I want to be back up running the way we were before at the same level, it doesn't mean they're going to do it, but it's amazing how many people have believe it or not. It's amazing how many people have that. They are literally 80, 85% pre COVID and they just, you know, kind of reef officially grew up in a, you know, for six weeks ago. So it's amazing what happens when you put that scary goal out there. But the purpose of it is to just reverse engineer down to, so what has to happen this week? Jamey Schrier (16:46): What are the two or three things that have to happen this week for you to start moving towards that? So once you get clear on your financials, you got to start making decisions about your staff. The one thing I would be very weary of is diving back in. If you weren't that before, if you were not treating 40 hours a week, I would not knee jerk reaction to go back to that. The reason is this, I know it seems. Yeah, but if I do it, it's like free money because I'm not paying myself. Yes. That would seem to be the case, but it's not. It's actually going to cost you more money because your mind, your creative energy is all taken up by taking care of the patients in a very emotional setting, dealing with the notes and the insurances and all that. And you're not taking a step back and a 30,000 foot view and really seeing the different components of the business. Jamey Schrier (17:50): And if that happens, your natural response is going to be quick, impulsive decisions. Even you think you're a hundred percent sure of the decisions you can't trust yourself because of the emotional state that you're in. So if you've been a treater before, okay, if you want to go back to that fine, cause you still need to remove yourself at some point, even if it's cutting your schedule down, cause you need to look at things to run your business. So, but if you're not, take a survey of your staff, who's essential. Well, you need people that can generate money. I would choose the people that were the most productive before. COVID sounds obvious, but sometimes you kind of like so and so more, but even though they weren't a great therapist or not a producer and you make decisions like that, or you haven't really had numbers, you're not even sure what your metrics are. Jamey Schrier (18:45): We never really tracked productivity. I think this person was good. So look back at that. Or when, in doubt, who was sought after bring those people back. Now, if you're deciding on will Jamey, should it be full time or part time there's other models out there. I just got off a conversation with a guy that has a business around employment payment models. And he was talking about, you know, this model of shared risk is becoming more and more popular. So perhaps you do an hourly model. Perhaps you explore a shared risk model where the person gets maybe one third or 40% of their income and then they get targets and they make money based on that. You don't have to know what that is. You just have to know that someone is out there that knows what those options are. Your job is to go out there and find out about it and then share it with your staff. Jamey Schrier (19:48): So really getting clear on your team and who you need. I would absolutely bring a front desk back, obviously your billing and all that can be done from anywhere. And then the biggest thing is if you don't have patients in the door, none of this is going to matter. Your money will eventually run out. So I am a simple person, you know my stuff isn't rocket surgery. As one person once said it isn't rocket surgery. What was working before COVID hit? Like, what were you doing? I know most people will answer. I don't know. It was kind of word of mouth. I was kind of doing this. Like they weren't really clear on that. Well, first of all, moving forward, let's be really clear on that. What's working. What strategy was working. One of the most basic strategies you can use. Jamey Schrier (20:39): That's a human strategy is reach out to your people. If you haven't already, most people have reach out to your patients, reach out to the list of people, check in with them, see how they're doing. And they've been cooped up for months. I don't know about you, but I got problems all over the place. Cause I haven't been able to exercise the way I want I'm stress. Of course, stress goes to my back and my head shoulders, these people, it's not like COVID took their health. I mean, they still are human beings. They still have the same problems they did. If not worse, how can you help them? So approach it from, Hey, how are you feeling with all this? Well, my shoulder hurting, Hey, you know what? And then you just offered maybe a free consult. Then you do it either in person or through tele medicine. Jamey Schrier (21:30): Yeah. If you do that and you approach it genuinely like you want to help them, man, I've had people generate dozens and dozens of patients quickly. And I would put the people that are best on the phone that had the highest level of communication. Don't put someone that doesn't really like people that much, you know, like don't put that person on the phone. They're not going to like having that conversation. Same thing for your referral sources, same thing for your referral sources. And you know, can I share one strategy, marketing strategy, eight marketing strategy. And you and I were just talking about it right before this, you said, you know, I couldn't get half these people on my podcast and now what else are they doing? They're like, sure, I'll come and share all this stuff. Well, we have a simple strategy that is called an interview spotlight strategy. Jamey Schrier (22:27): And all you do, same thing. What we're doing here. You just reach out to a rep. We call them referral partners. But someone that oversees and has influence of your target audience, right? If you're going to do this, do it with someone that as you build a relationship can send you the kind of people you want and you offered to interview them and you choose the topic. That would be interesting to your audience, to your list of people. So do you specialize back pain? Are you a vestibular person? Are you pediatrics? Women's health doesn't really matter? And you say, Hey, I was you know, I was thinking we're starting in an interview. Spotlight interview love to interview you. It's all through zoom, 20 minutes, 30 minutes, whatever it is, we'll promote it to all of our people. So I'm sure you'll get some recognition and business out of it. And if you'd like, you could promote it to your people as well. And then you end up with marketing term leads, prospects as well. But what really happens is you start building a connection, a deeper connection with the referral source, who obviously is, you're going to be top of mind with them because you reached out and helped them. You weren't the person sucking on the teat did, give me, give me, you were actually providing something first. Jamey Schrier (23:46): One of my clients did this and he generated 50 cases, 50 in a very short period of time in New Hampshire, like massive town. And he said, this is like, I think it was like 52 people. Exactly. But he said, Jamey, this was easy. And it was fun. It was really a lot of fun. And because we're all used to zoom now, the technology is so easy to use. You just record it. Doesn't have to be video. You can do audio and you just save it and slap it in an email. Karen Litzy (24:18): Yeah. Yeah. That's a great marketing tip. Thank you for that. And just so people know it doesn't, you don't have to have a podcast to do that. You could just, like you said, save it, send it out to your list. Even if your list is five people or if it's 500 people just, you're just creating good content that people want to hear. Jamey Schrier (24:40): And you're meeting people, who's a great marketing, same and it can be used for anything. Always meet people where they are not where you want them to be. So if I was going to do this in New York and let's say reach out to some docs or reach out to some other people that may I'm like if you do with personal trainers or CrossFit or whatever your audience is, my approach in New York would be different than my approach in the Midwest. Of course, right now, the template's the same, but how you're going to do it, how you're going to, I mean, what you're going to talk about the content has to meet your people where they are. If you start talking about, Oh my God, we're opening up. Things are great. And all that. That's not going to land on a lot of people in New York. Jamey Schrier (25:31): So meet people where they are meet the doctor, meet the people, meet the other referral partners where they are and see how you can help start cultivating these relationships. And as your town opens up more and more and things get back to quote normal, whatever that is that bonding is what separates you. That's what keeps giving again. And again and again. So how many of these can you do? I mean, I know some people are doing like twice a month and they said, this is just fun and it's easy. And by the way, it does lead to other opportunities. Karen Litzy (26:07): Sure. Tell me about it. Jamey Schrier (26:09): I mean, your whole business is built on, you started this. You're like, I'm trying to figure this out and all of a sudden you've done. I don't know thousands of episodes. You've met all kinds of people. I know you used to travel around the world. So  this is a formula. And it's a really powerful formula. I'll tell you the hardest part about the whole thing. Karen Litzy (26:31): Yes, absolutely. Jamey Schrier (26:35): Passion. Don't let the little critic on your shoulder go, but you can’t do it. I think you need to be, you need to learn more about zoom. Just do it, just do it. Karen Litzy (26:37): Yeah. So yeah, it doesn't have to be perfect. Jamey Schrier (26:49): It better not be, if it's perfect. It's too late. You're not doing something that's rusty, not rusty, but like just rough around the edges and stuff. You've waited too long. You need to get what is called the minimum viable product up running and out. Then you learn from it and your fourth interview will be a hundred times better than your first. And there's nothing you can do about it. Yeah. So true. So how quickly can you get to the fourth interview? Karen Litzy (27:19): Yeah, that's great advice. And now as we kind of wrap things up here I know that as we were going through this conversation, one thing that struck out as like, you just can't do all of this stuff on your own. It's what I should say. You can, but it's really, really hard, right? Why would you, so having a mentor coach, is something that can be so helpful. So where can people get in contact with you if they feel like, okay, I've got this business, I'm ready for it to grow. I don't know what the hell I'm doing. So where can people find you and learn a little bit more about what you're doing and if you've got any free resources and things like that for people that would be helpful. Jamey Schrier (28:12): Sure. So I want to just real quick, I know we're coming up on time here, but I want to address real quick with the idea of the coach or a mentor. You know, a coach isn't the end all be all it. Isn't the person that has all the answers and all the solutions to your problem. The way I got into coaching was I resisted it because I was a rugged individualist. Who's smarter than most people who could figure it out. And eventually I started looking at my bank account, looking at the amount of stress I was dealing with and looking at how many hours I put in. And I said, these aren't the results I want. So whatever I think I am doing, it's not getting the results. So can I just swallow my pride and my ego and go ask for help. Jamey Schrier (28:55): And that is so hard for high-achieving individuals like ourselves. So if you are at the place where you're like, you know what, I want some guidance because to me, a coach is guiding you. It's a co collaborative effort. It's strategic thinking partners. If you want that person go and find the person that connects to at practice freedom U I built our company based in part of providing people that kind of business coach, that kind of guide that helped them through some of these problems. Cause it's hard to think of it. I've had a coach for over 14 years. I'll never not have a coach because I don't trust my own thinking because I don't know what, I don't know. So if you're interested in that, you can certainly reach out. You can check out our site, practicefreedomu.com. Jamey Schrier (29:50): You you can get my email from Karen, but one of the things that I thought would be a great thing for your audience is to give them a little insight on some of the things we talked about today and a lot more other things that I think are very appropriate in how to restart, rebuild, and build your business the right way. I did write a book called the practice freedom method and it's 12 chapters of various things from marketing to hiring, to financials a lot with my story and all the struggles I went through. I share all the crap that I went through. So you can learn from it and I wanted to give it to your people for free. You can download it immediately. It's the entire book, but feel free to just go through the chapters it's in digital form. Jamey Schrier (30:42): You just go to practicefreedomu.com/healthywealthysmart-podcast, and you'll just get it immediately. So that would probably be the first place that I would go. And if some of my stuff resonates and you want to have a conversation happy to do so, if not, I would just seriously, you know, consider getting a mentor, finding someone or even maybe a small mastermind group, just people you resonate that can think differently than you to help you through things that alone will take you down a better path, regardless of the specific strategy or tactic that you use. Karen Litzy (31:21): Right. Excellent advice. And thanks for the free book. And that'll also be on the podcast at podcast.healthywealthysmart.com under this episode. So one click and we'll take everybody right to that site. And now last question, knowing where you are now in your life and in your career, what advice would you give to your younger self? Say a young pup, right out of PT school? Jamey Schrier (31:49): Young Jamey Schrier that's scary. Cause I was one cocky son of a bitch. God, I knew it all. Fear is a part of this fear is a part of growth and it is never the right time. You will never feel like you're enough. And if I had to talk to myself before I would've told myself, swallow your frickin pride and start hanging around people that you want to be like, that you're in that you're impressed by something of what they're doing. Just be there, just be with them. And just soak up some of that. I didn't do that a ton. I had a little bit of an attitude towards that. I don't know why. I don't know where it came from, probably because I wanted to feel improved to myself. I wanted to do it on my own. And the reality I look back and I was like, God, that was the stupidest thing I ever did. So whatever your passion is, whether it's business and you want to do your own thing, whether it's side hustle, I know that. Or whether you just want to be the greatest therapist or clinician or researcher, just connect with other people. People are so awesome in giving and providing, but they're not going to do it without you coming to them. Karen Litzy (33:10): Yeah. They're usually not knocking on your door while you're on your couch watching TV. Jamey Schrier (33:15): They're not going to come to you and what the successful people out in the world. I don't just mean financial success. I mean success and happiness success and just who you are as a person, just your own wellbeing. All of those people have these groups, these connections, these people, they reach out to, they all do. They might not talk about it, but they all do. They all have coaches. They all have mentors. They all have people they connect with. And when you do that, it just makes this so much easier and so much more fun. Karen Litzy (33:48): Yeah, absolutely great advice. So Jamey, thank you so much for coming on and everyone again you could go to a podcast.healthywealthysmart.com to get the book or go to freedom practice U the letter freedompracticeu.com/healthywealthysmart-podcast for the book. And you can also find out more about Jamey, what Jamey's doing to help so many physical therapy business owners around the country. So Jamey, thanks so much for coming on again. I appreciate it. Jamey Schrier (34:25): Oh, thank you, Karen. Enjoyed it. Karen Litzy (34:28): Great. And everyone, thanks so much for tuning in. Have a great couple of days and stay healthy, wealthy and smart.     Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Erica Ballard on the show to discuss how to optimize your health and performance through nutrition.  Erica is the founder of Erica Ballard Health – a wellness company that optimizes individuals’ energy through food. Erica started her company after realizing health looks way different than what she thought, bought into, and sold for decades. Now, an evangelical about helping people do better, Erica teaches working professions how to truly take care of themselves despite their busy schedules. In this episode, we discuss: -The impact of optimal nutrition on performance -How to detect and remedy vitamin and mineral imbalances in your body -Mindfulness strategies to cope with quarantine stressors -And so much more!   Resources: Erica Ballard Website Erica Ballard Instagram Erica Ballard LinkedIn Pantry Essentials Playbook The Lies We've Been Fed Podcast   A big thank you to Net Health for sponsoring this episode!  Learn more about the Redoc Patient Portal here.     For more information on Erica: Erica is the founder of Erica Ballard Health – a wellness company that optimizes individuals’ energy through food. Erica started her company after realizing health looks way different than what she thought, bought into, and sold for decades. Now, an evangelical about helping people do better, Erica teaches working professions how to truly take care of themselves despite their busy schedules. Erica has her MS from Tufts University School of Medicine, got her CHC through the Institute for Integrative Nutrition, is a regular contributor to WTHR 13, and has been featured by Women’s Health, Lululemon, and the Young President’s Organization.   Read the full transcript below: Karen Litzy (00:01): Hey, Erica, welcome to the podcast. I'm so happy to have you on. And now, before we get into the meat of our discussion, I would love for you to talk a little bit more about you so that the listeners kind of know how you got from point a to point B to where you are now.   Erica Ballard: Sure. So for most of my life, I have been a public health practitioner. People pleasing go getting type of gal. And so because of that, I thought I knew what healthy was. And so I was always trying to get there through the traditional means of, you know drinking the shakes, eating the bars, following the guidelines. But the thing about it was I never actually looked or felt the way I wanted to, which was again, so confusing because rule following people, please are working in public health. Erica Ballard (01:02): You think that I would look the way that I wanted to given that I knew quote, unquote, exactly what to do because I had these huge desires to not only have the body I wanted and look like the women I saw on TV or magazines, but I also had this like deep desire to be happy. And I thought that health or fitness, because I equated the two at the time was the linchpin for me because externally I had everything that one would desire, but internally I felt unfulfilled. And so the only piece that was missing in my exterior, you know, look was my weight. And so I was like, okay, that's it. So I did what everyone does, who tries to get healthy? I like, I count calories. I followed all the rules. I tried to outrun every French fry or glass of wine that I would have, and I just couldn't get there. Erica Ballard (01:57): And that all changed though, when I moved from East coast to Indianapolis, which is where I'm originally from, I moved here and I went to the Institute for integrative nutrition, even though everyone said, don't do it because I got my master's at Tufts medical. I had still student loans, all those things. I was like, no, this is the thing. And it was like, it was the thing. It actually taught me that, you know, food sleep, stress. Those are the drivers of health. And when I figured that out, I went out and I tried to share this information with people. And when I did, they were like, no, that's not right. And so while I started to get results, I would hear them or I would hear society saying girl, no. And so then I would stop doing the thing that made me feel better. Erica Ballard (02:46): And it was this weird up thing that would happen until finally I decided now I'm the expert on me actually. And I'm going to let feeling good lead the way. And when that happened, it's like weight dropped. I was able to hold conversations and happy. My mom likes me again. Right? Like I wasn't the worst human being who was like constantly snapping and more. So I just figured out that, like I was in charge of my happiness. I was in charge of my health and I knew best. And so doing that journey is what has brought me here today to help not only continue to help myself, cause you never just arrive at health. Right. But also to help others who are really desperate to get healthy, do it because most of the people that I help are high performers are people that are willing to do the work and are just like, I am doing it, but I can't. And I'm like, I got you. I've been there. And so walk them through the things that they can do in order to really enjoy their lives while being healthy. Karen Litzy (03:49): That's incredible. And now let's talk about that. Cause I love that you work with kind of high performance people, high achievers, high performers feel like I'm the same way in New York. I don't know a lot of people in New York who aren't that way. I think that's part of living in that might be a requirement for living in New York city. But let's talk about how we can optimize our performance through food, right? I'm a physical therapist. So we're used to optimizing performance through strength, training, stretching, pro programs, plyometrics, but as a physical therapist, I also know that just what you said, sleep food are paramount to when it comes to being able to optimize your performance. So I'm just going to throw it over to you. And I would love to hear your take on what that means. Erica Ballard (04:42): Sure. So it was up to two things when I have this conversation because so many people will tell me all the time, Hey, I get so much done. Even though I don't eat the way I should or I'm drinking these Cokes or whatever it is. So like screw you Erica. And I'm like, listen, you're only in second gear. Like think about that. Like you're only in second gear, you get to fifth, you have to get your food. Right. And the first reason I think that I think it's so clear that we need to get our food right for this is Maslow's hierarchy of needs. So at the bottom of Maslow's hierarchy of needs is psychological and within psychological is food. So that means in order to get the self actualization, the top that, you know, essentially self fulfillment, you have to get the base, right? So without it, you just can't be. And if that's not enough, cause social science, isn't always enough for people. The hard data is starting to show that our brain and gut aren't connected. So we know that if what you put in your gut is not good, your brain will not function. And if your brain will not function appropriately or to the best of its ability, you can't optimize because a lot of your decisions are made with your brain. Karen Litzy (05:47): Right? Absolutely. Yeah. And, and you know, when we talk about that brain gut connection and you can correct me if I'm wrong, but we are really one of the bigger there is that Vagus, Am I correct? In that a hundred percent? Do you want to talk a little bit about that? Erica Ballard (05:58): Well, I think it's one. So for me, when I work with clients, I can, but where I always find it being interesting is that when I talk with people about how to get healthy every single time, I don't know, this is what happens to you when I get into the nuances. They're not, they're like, yeah, the Vagus nerve that matters, but I'm like, yeah. Breathing, putting things in making sure that like the fibers in your gut, they're all going up to your brain, making sure that that's, they're talking matters, but the nuances I have found people don't care as much about. Karen Litzy (06:36): I can definitely relate to that because I deal with a lot of people who have pain, more chronic pain. And so when I sort of go into kind of the neurophysiology behind pain, people like get it for a little bit, but then they just don't want to go that much deeper into the weeds with it. Like you said, like the nuances, but for the purposes of our discussion, I would like to, so let's pretend I'm like your ideal client and I'm like, Erica, tell me what does all this mean? Erica Ballard (07:10): So for me, when I look at our nervous systems and how they're connected, right, we have this nerve that literally runs through our body that connects these two entities and for it to be functioning appropriately, to make sure that the fibers around it actually work to make sure that it, all of the things that it's also then connected to work appropriately. It's really important that we put in foods and fibers and vitamins that our body need for those things to communicate and talk. And so what we typically do, right, is we're like, we'll put whatever it's in and it doesn't matter. And if I just drop weight, I'm going to be the healthiest version of myself. And it's like, no, you have, you have the Vagus nerve, you have your entire nervous system. You have your gut lining. Erica Ballard (07:58): You have these, like you have these different pieces within your body that need to appropriately absorb all of the nutrients in order to make sure that everything is communicating the way that they should. And so when I think about how to optimize and when I think about food and Vagus nerve and all of those pieces is I like where my head often goes is in order for these things to function appropriately, we need the right amount of nutrients and we need our body to be able to absorb them so that these things can talk. But we were like, we think that supplements work by themselves. And we think that vitamins and minerals work by themselves, but it's a payer to make sure the communication is appropriate. Karen Litzy (08:45): Okay. That makes sense. Yeah. And I think you do see a lot, I don't know about you, but I see a lot of people Hawking different kinds of supplements and vitamins and this and that. And then you hear research on none of it matters, right? Like, Oh, why take this? Why take that? Why take a multivitamin or take a plethora cocktail of vitamins that doesn't work. You should get it all from food anyway. So what do you say to that? Erica Ballard (09:11): So I think there is, I can understand where they're coming from. And I think that from a health perspective, if you're at the beginning and you're like, I'm trying to get healthy, I can't quite figure it out. Start with food nine times out of 10, or I would, should say eight times out of 10, start with food, making sure that you have of the highest quality items. But when I think about the importance, I used to really agree with that. But now I'm starting to understand the importance of supplementation or I have fully grasp it of supplementation because the soil in which our food grows does not have all the nutrients necessary for our body, for the plant to grow to the best of its ability and for our body then to take in all the nutrients that exist. Like as a society, we are magnesium deficient as a society. We are vitamin D deficient. And as a society, we tend to be omega-3 deficient and you can't often get enough magnesium through your food, especially if you're trying to make up and provide them in D like if you're in a Chicago or Boston or in New York, it is listen, it's cold outside. Like it is hard. Erica Ballard (10:22): To get those things in. So while I believe that food is medicine, I do believe often food is the first line of defense. If your thyroid isn't working appropriately, if you're in a lot of muscle pain, if you're not sleeping so well, those are, they're probably supplementations that you need to bring into your body to make sure that it's optimized. But, before going to experiment, I would always say consult with a practitioner or like PT health coach, like certified health coach doctor nurse practitioner, because you can't like you can't really OD per se, but you can get the wrong results from these supplements. Karen Litzy (11:04): And do you suggest people take blood work? Like if you're working with someone, do you suggest they get blood work taken so that you have a clearer picture or to see like, Oh wow, you really are deficient and XYZ. And then here's a way I can plan this. Erica Ballard (11:19): So when I work with people, what I always recommend is first start with your diet. So straight up, like most people are not eating enough vegetables. You know, if you're listening to you are like eat vegetables, try to also clean up your diet, take out where you can. And if you can organics pasture, raised grass fed really just up that quality and see what happens. But if you do that and in a month, you're not moving towards the results you want. Blood work, I think is, can be extremely helpful because like, for instance, going to like to the thyroid, the amount of hypothyroidism underdiagnosed in this country is, is pretty high. And when you also look at inflammation markers, even though you're eating a clean diet, like if we're having food, like we're eating things that we're intolerant to, maybe you can't get that exact number in, or that exact food item in the blood work. Erica Ballard (12:14): But I do think it helps really show same with magnesium, vitamin D cause there's different protocols, right? Based on different deficiencies that you have. And so to be able to task, versus just to think I provides a piece of mind that a lot of people want, especially going back to the high-performer piece, like your mind is always going, like you're going a thousand miles a minute, but if you can get paperwork that will show you what's happening and different ways to track, it can feel really nice. And it also can feel like an accomplishment.   Karen Litzy: Yeah, I agree. And I think that it gives you, like you said, a goal to work for, to work towards maybe like, I know I'm like a big numbers person, so I really like to see the numbers. So for me, if I had like a blood test, let's say I was vitamin D deficient, which I am by the way. And then I was like, okay, well let me change my diet or let me take this supplement. And then I got another blood test in six months and it was better than I would be like, okay, this is a little bit more proof for me. This is what I needed. And it would encourage me to stay on that healthy path. Erica Ballard (13:09): Yeah. And I think there's nothing wrong with that. I think that that's why there's such beautiful things with all the tracking devices and blood work and the availability of multiple different types of blood work now to test all these different things, because what I always find, and this is neither good or bad, it just is. It's not a lot of folks are sicker than they know that they are. And because they're so used to feeling a certain way, they don't even know that they're in deficient levels or dysfunction. Erica Ballard (14:00): And so that blood work can also, as a practitioner help us show that there are different ways to feel better. Because going back to the vitamin D example, I mean, vitamin D was all the rage. And then it was then were told it was a crock of, you know, stuff. And then now it's coming back in and it's like, if we could just show here's where it should be, that was conventionally what we said. Right. And here's where we need to be. It just fosters an easier conversation. Karen Litzy (14:53): Yeah. I think you get better buy in, you get people like, Oh boy, I don't think it's, and I don't think it's meant to scare people, but it's just meant to be like, Hey, you know, something may be some of your symptoms. Maybe they're correlated with this. You know, it may not be causative, but maybe it can correlate and let's see if we can change some and see, Do you feel different? And then retest, it's just a test retest, right? Erica Ballard (15:03): It's yeah. And if one scientific method, if you will, I'm all for that. And I think when it comes to supplier minerals, nutrition, like nutrients, things like that, it's really helpful. I think the only place I would say, and I would be interested in what you think that it's not as wonderful as doing the test on yourself is food intolerance. Because I find that the best model or the best testing out there is 85% accurate. Whereas the gold standard I have historically found is to pull it from your diet for three to four weeks and then systematically add it back in. Which you can do anything for three weeks. Karen Litzy (15:40): Yeah. Yeah. And I've done that in the past. And it was definitely very, very helpful. Like I took things out of my diet for a month and it's felt a huge difference. I had some autoimmune issues after getting the flu shot. So I had an auto immune reaction to that and it was quite painful and it lasted nine months. Yeah, it's called erythema nodosum it looked like somebody kicked me in the shins 500 times of the steel toed boots. Like it was swollen and red and purple. And I remember I was at the time dating this guy that lived in Baltimore and it was on one leg and it was like over Christmas. So it was in between Christmas and new year's and it was on one leg. I was like, what? And I remember I showed his mom like, what, what do you think this is? Karen Litzy (16:28): And she's like, she used to be an EMT. And she was like, I feel like you should just see a doctor. I'm like, why? And she's like now. And so I just went to like a ready care place, you know, like a city MD. And they thought it was like a staph infection, which I was like, this is I've seen or cellulitis. I was like, listen, I've seen cellulitis this ain't it. And then the next day I woke up and was on the other leg and I'm in Baltimore. And I said to my boyfriend, like, we gotta go to the ER. He's like, I don't know where to go in Baltimore, Johns Hopkins, Johns Hopkins immediately. And I went in and the doctor said, I'm in the ER. And he looked and he's like, it's erythema nodosum. I was like, what he's like, did you have any, like, do you get any shots lately? Karen Litzy (17:08): I'm like, well, I got a flu shot a week ago. He's like, yeah, it's the flu shot. Don't ever get a flu shot again. I was like, okay. So that was over Christmas. And then it finally, all of the symptoms went away in September. And, what I changed in September is I did an elimination diet and took a whole bunch of stuff out. So I don't know what it was, but I mean, I mean, I stopped sugar, gluten caffeine, which I didn't drink anyway. Dairy, everything, like just took it all out. Yeah. And then within a month I was like, and even like my boyfriend, he's like, you're so much brighter and you're back yourself again. And so that auto-immune really like knocked me out quite a bit. And so I do agree there is something to that pulling stuff out of your diet and just see what happens. I mean, it's the easiest thing you can do, right. Doesn't cost any money. Erica Ballard (18:06): I mean, there's so many now alternatives and just the auto immune piece of it. I work with a lot of folks who have auto immune disorders and gluten. I mean, whether or not you have an intolerance or not gluten, for some reason always seems to aggravate these autoimmune diseases. And so we're disorders. And so when you pull that out for a few months, it doesn't mean it has to be gone forever, taking it out and then allowing yourself to see if it works or doesn't is huge. And like you, like, it's the sugar and the caffeine. I know it can be really tough for people, but the rest of the stuff there are alternatives for all. Karen Litzy (18:39): Yeah, absolutely. And I mean, I don't really have a lot of sugar and I don't drink caffeine anyway. So that was easy. The other thing was no alcohol also fine. I can handle that. You know, the gluten was a little hard in the beginning, but then like you said, like I just had gluten free bread and gluten-free POS I mean, it's so easy. It's not like I was like Jones and for tea, like a loaf of French bread or anything, you know? So for me, I felt like, Oh, this was super helpful. And I have not had the flu shot since. Erica Ballard (19:09): I wouldn't either if I had to. Karen Litzy (19:11): Horrible. Anyway, so we're talking about optimizing performance through food, right? And so I think the listeners can now get an appreciation for how food should be the first line of defense. Then move into if you need vitamins or supplementation or minerals and nutrients and when these work together, your brighter you're quicker. Like you said, you're moving from second gear to fifth gear. Erica Ballard (19:37): Yeah. And the thing that always it's interesting for people when they do this is they never knew that they could feel this good. And now it's what makes continuing it so much easier. It's both a mix of like, I feel this good. And then being quite honest is when you start to eat better, like take supplements, do those types of things. When you put in things that your body doesn't like, man, does it fight back? Like you just feel the pain, you feel the grogginess, you feel the lethargy and you don't do it anymore. Because a lot of times people will say, well, you're healthy. It's easy for you. And it's like, Oh, it's either I feel horrible. Or I take care of myself because I've done enough. I find that the body always is trying to talk with you. It's always communicating and it will slap you in the face. If it does, if you do something, it does not like, and most of us can't feel it because we've put it in such a stressed out state. So that it's always feeling so bad that like, it's just hanging on because we're in survival mode. But when you get into that parasympathetic nervous system, when you get into thriving, it will literally have as many communications and conversations as it can that you move in the best direction for you. Karen Litzy (20:53): Yeah. And it sounds to me like what you're saying is the body would prefer not to feel like shit. Erica Ballard (21:03): Yeah. That's exactly in a nutshell. Karen Litzy (21:05): Okay. All right. That's what I thought. Okay. So you brought up briefly, they're talking about stress. So let's talk about stress. I mean, we're still as we're recording this, I'm in New York city, we're still on lockdown. We're in the middle of a COVID pandemic. So stress is a real thing right now. And when we're stressed, I think that's when people are like, I'll take that piece of chocolate, I'll take this, you know, so what can we do to help overcome the stress without falling back on those cravings if you will. Erica Ballard (21:39): That's a really good question. And I heard something this morning that I think was brilliant. So I'm going to share it here is when we think about stress, the idea is just, how do you get back into the present moment and how do you get back in to finding joy? I mean, it sounds a little corny, but that is that's it. And so in quarantine, what can be really helpful is identifying things that you could do that you would do on your vacation at your house. So whether you take naps on vacations or you take long walks, or you listen to music in the morning, instead of a podcast, doing those things that transport you into a state of calm is really helpful. And we can do those things in our house. We just completely forgot that we could, because we're so used to only doing them when we're out there. Erica Ballard (22:36): So that's the first thing that just came to top of mind when you were, when you asked that question. And I think the other pieces are just looking for moments of not solitude seems like the wrong word right now. But moments of peace, because while some people are not at the office, we're there were so available now. And at least we had these cutoffs, right? You go into the office, you leave the office like, and that was that. Now everyone knows we're not going anywhere. So we're getting the emails, we're getting the texts, we're getting those things. And if we could work our way in defining moments where we can shut down, whether it's the walk without the phone, whether it's actually closing your computer and not opening it back up, putting your phone away for half an hour, those things are really gonna help bring you down. Even though we don't think that they do like you feel it in your body, like 15 and another phone, you kind of, you're able to sink down into that couch wherever you're at and just be. Karen Litzy (23:40): Yeah. And you know, I've been hearing that from a lot of my clients who I normally see patients in their homes. And so at this, right. Nobody wants somebody coming into their home and I don't blame them. But they're also working from home and what everyone's saying, they're like, you know, when I'm at work and we have a meeting, I get up from my desk, I walk to a boardroom, I sit down, I go to the bathroom, I talked to other people. I come back, I walk to work. I walk home from work. I go out for lunch. I come back in or at least I go to the kitchen and I come back to my office. And now I said, you know, I'll have a meeting from two to three. And they're like, Oh, you're available at three. We're gonna have another meeting from three to four. Karen Litzy (24:20): Oh, you're available from four to five. She's like, so all of a sudden my patient, she was like, I'm not leaving my computer. Whereas when I'm at work, I do. And I also have the opportunity to get fresh air, but now I'm 12 hours. I barely have time for lunch. And I'm just, and I heard that again and again and again, so you're right. It's that, that feeling of, we all have availability and for some people, their only option might be a five minute break, you know? Like they might not be able to take that half hour break if they've got people sort of like breathing down their throat. So do you have any advice for those people to do like a five minute break or a three minutes something to help at least ground them a little bit. Erica Ballard (25:04): Yeah. So there's two ways to do it depending on who you are as a person. So I think standing up planting your feet from on the ground and just breathing in and out in a really calm, amazing fashion and like feeling the breath go through you is just such a great way to literally move yourself into a very present state. The other way is to move your body, right. It depends on who you are and what you need. When I have five minutes between meetings, I'm not even going to hide it. Like I, right now, I'm here for the Jonas brothers. You can judge me all you want. I turn on the Jonas brothers and I like dance in my house. Cause those songs are only like three and a half minutes. So I will literally put it on and I will just dance around my house because a music makes me happy. But also it like moves. My body moves. My energy moves like that stagnation. And so whether it's squats for you going up and down the stairs dancing, whatever it is, it's just shaking off what was for what is. And I find that that is very helpful when you're chained to your desk for 12 hours on end. Karen Litzy (26:10): Great advice. Thank you so much. So now before we wrap things up, is there anything that we didn't touch upon or anything like, what is the thing that you want the listeners to leave this discussion with? Erica Ballard (26:24): I would say that if you want to get healthier and you're not where you want to be really taking a look at your food and at your stress and seeing which one is holding you back. Cause I pretty much guarantee it's probably one of the two and then make a few decisions and change as necessary. Karen Litzy (26:49): Excellent. And again, the good thing about this is that doesn't take a lot of money, may take some time, but it certainly is not something that's going to break the bank. And, and again, because we're in these uncertain times right now, you know, people might be a little less wary of like, Oh, do I have to, you know, go and leave my apartment or my home and go and do this and go and do that. But if there are easy ways, like you said, look at your food, look at your stress easy. Now, if you are the kind of person that needs someone to help walk you through it, that's where someone like you Erica would come in, you know, at being a health coach, like that's where you would come in to kind of not hold their hand, but be their coach and give them the game plan. Erica Ballard (27:41): Yeah. And, that is why if you do need help, I'm so huge on working with a practitioner because like at the beginning, it's an N of one, you are actually the unique snowflake you think you are. And so helping you figure out the right things for you in a safe space is really important because health is so personal and you get a lot of feels when he's searching to move, try to move in the direction you want to move. And so I do really believe people can do it on their own with a little bit of support from online programs and things like that. But if you can't, asking for help is the best thing you can do. Karen Litzy (28:26): Yeah. And I know you have a free resource for the listeners. It's the pantry playbook. Is that right? So do you want to talk a little bit about that? And just everyone knows, we'll have a link to that in the show notes at podcast.healthywealthysmart.com, but talk a little bit about it and where people could get. Erica Ballard (28:43): Sure. So I heard from clients all the time, I want meal prep, I want meal prep. I want meal prep. And I was like, no, you don't, they don't want it. But it's what they kept saying that they wanted. What they really wanted though, was they wanted it to be able to make really quick meals on the fly that tasted good because three days into the meal prep, if throughout all of their foods, they're sick of it. So I said enough, that's like, yeah. I mean, I don't like five day old food either. So I get it. And so what I did is, I was like, well, I don't ever meal prep. I don't. And so I was like, why don't I meal prep? Oh, cause I have everything I always need on hand all of the time. Erica Ballard (29:25): And so I went to my pantry and started to look at, and then think about all what my clients do and me, and they're there, the special needs that go on and was like, Oh, I can create a list that if you always have on hand, it's going to be faster to make healthy meals than it is to go out and get takeout, because these are our options, right? We meal prep, we get take out or we make it home. And if I can help you make a fast healthy meal at home that cuts the meal prep and cuts the time it would take to get takeout. It works. So I have that resource for them and it'll be at https://www.ericaballardhealth.com/pantry-essentials-playbook. Karen Litzy (29:59): Thank you so much. And now onto the last question that I ask everyone, knowing where you are now in your life and in your career, what advice would you give to yourself after college? Let's say grad school Erica Ballard (30:12): That I love this question and I really, really wish I knew this, that you can do it your way. Karen Litzy (30:22): Mm, powerful. Erica Ballard (30:24): It's just with health. Like you go into people's homes. Like I go into people's homes via camp, like what, like, you know, zoom, you can do this thing. You were away. So don't follow someone else's rules. If it doesn't feel good inside. Karen Litzy (30:41): Excellent advice. And where can people find you social media website? Erica Ballard (30:47): Okay. So I play a lot on Instagram. So it's at Erica Ballard health. I'm actually on LinkedIn quite a bit. Website is EricaBallardhealth.com. And I had a new podcast that's actually dropping on June 2nd called the lies we've been fed. And it's an eight part series that walks people through the lies that we have been fed about food to give them a path forward. Karen Litzy (31:12): Awesome. It sounds great. I look forward to listening and thank you so much for coming on. This was wonderful. Thank you and everyone. Thanks so much for listening. Have a great couple of days and stay healthy, wealthy and smart.   Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Kameelah Phillips on the show to discuss optimizing health during pregnancy.  Dr. Kameelah Phillips is a board certified Obstetrician and Gynecologist, wife, mother, and lifelong women’s health advocate.  Since high school, she has been involved in local, national, and international organizations aimed at advancing women’s health care issues through advocacy and direct patient care. In this episode, we discuss: -The impacts of COVID-19 on pregnancy and post-partum -Factors that impact the United States’ maternal mortality rates -Six ways to optimize your health during pregnancy -The importance of interprofessional collaboration -And so much more!   Resources: Calla Women's Health Website Dr. Kameelah Phillips Instagram Calla Women's Health Instagram   A big thank you to Net Health for sponsoring this episode!  Learn more about the Redoc Patient Portal here.     For more information on Dr. Phillips: Dr. Kameelah Phillips is a board certified Obstetrician and Gynecologist, wife, mother, and lifelong women’s health advocate.  Since high school, she has been involved in local, national, and international organizations aimed at advancing women’s health care issues through advocacy and direct patient care. Dr. Phillips graduated from Stanford University with a degree in Human Biology with an emphasis in Women’s Health and Human Sexuality. After graduation, she worked at the San Francisco Department of Public Health in the AIDS office as a Research Assistant on HIV vaccine studies.  She relocated to Los Angeles to attend the University of Southern California Keck School of Medicine. During medical school, she received numerous community service awards. She was privileged to travel to Ghana, Cuba, and Tanzania on health missions during this time. Upon completion of medical school, she attended a competitive OB/GYN residency at the New York University School of Medicine. She also served on an emergency medical mission in Port-au-Prince, Haiti to provide women’s health care during the 2010 earthquake.  Dr. Phillips is an educator, mentor, and expert in women’s health issues.   She loves to help women and girls feel comfortable with their bodies, so that they can be aware of changes or new developments.  Her interests include Minority Women's Health and health care disparities, lactation, sexual and menopause medicine.  Dr. Phillips is a member of the International Board of Lactation Consultants and speaks Spanish. She enjoys teaching residents and medical students. Her guilty pleasures include reality T.V.   As a Real World Alumnae, she has used this platform to travel nationwide to discuss domestic violence, smoking cessation, and other health-related issues.  She loves a good bargain, flowers, and deep-tissue massages. You can follow her on Instagram @drkameelahsays   Read the full transcript below: Karen Litzy (00:01): Hi, Dr. Phillips, welcome to the podcast. I'm excited to have you on. And this is the first time I'm having an OB GYN on the program. I've had lots of physical therapists who work with women's health and pelvic health. So this is really exciting to get a different point of view on women's health and on pelvic health. And now, before we get into the meat of the interview, we are still living in a pandemic, COVID-19 is still here. It has not mysteriously disappeared or vanished. And so there are a lot of women who are getting pregnant, who are living through pregnancy at this time and who might be a little nervous, a little concerned about what can happen during their pregnancy is COVID affected. So what I would love for you is any advice for those pregnant women in the time of COVID? Kameelah Phillips (00:58): Yeah, absolutely. You know, one thing I really try and impress on patients that is absolutely unique to OB GYN is despite what's going on in the world, whatever chaos is going on, women still have babies women still go into labor. Women still take healthy babies home. So for us in particular we've made some minor, not, I shouldn't say minor there there's significant, we've made some changes in how we deliver care and the hospital setting, but for us, it's really been, you know, not so huge of a change because you know, hurricane Sandy earthquakes in Haiti, I've been through both of those, we still deliver excellent care to women. So one thing I would ask them to do is just really take a deep breath and while things are going on around us remember that their primary concern is to take care of themselves so that they can take care of their baby. Kameelah Phillips (02:11): I have told patients that a little bit of their OB care is changing. So we might have fewer visits, but really the important things we will always make sure that we hit the important time points and hallmarks of a pregnancy. So you won't miss anything. I've been telling them that labor and delivery has changed a little bit. And I think this changes pretty much coming across country, but whereas it used to be a time where, you know, extended family was welcome. It's important that they recognize now that only one or maybe two people will be allowed to be present for labor and delivery. And our hospital in particular, both moms and support family are being asked to wear a mask. We do check moms for coronavirus. We use the nasal swab. The extended family is not tested, but they're expected to keep their mask on. Kameelah Phillips (03:16): And most of the time our moms are coming back negative, but if they do come back positive, you know, we have a discussion and education with them as to what it's going to be like, knowing that they're now corona virus positive and going to be taking home a newborn. So we talk about those things. But for all intents and purposes, women are coming in. They're having healthy, safe deliveries, both C-sections and vaginal deliveries. Their hospital stay we've shortened a little bit in New York, we're going back to keeping women two days or four days, but other places in the country are, are shortening. The hospital stays in an effort to get women home safely and so that they can use hospital resources for the people that need them. But we're having healthy and safe deliveries. There was a panic, I think, amongst the pregnant community at the beginning of the pandemic, and everyone wanted to have a home delivery that still continues to not be the best response to this. Kameelah Phillips (04:28): It is still safest to deliver in a hospital or birthing center, certainly not at home to have best outcomes. We still recommend that women breastfeed that's the best way to feed your baby despite Corona virus, even if you were previously infected. And when women go home, I just ask them to be considerate of the new immune system in their house, right? So limiting visitors, washing their hands. If people come over, keeping them not being afraid to say, Hey, keep your face mask on while you're with the baby or around the baby. And really using the technology that we have to their benefit. So while it's not what we're used to, the grandparents meet their babies over FaceTime or zoom now. And that's not going to be forever, but you know, if you have people who are unable to quarantine and can guarantee that they're negative, I asked them to defer visiting. Karen Litzy (05:29): Yeah. Thank you. That's all really great advice. And I should have mentioned in the beginning that we are both located in New York city. And so right now it's different.   Kameelah Phillips: Yeah. So obviously New York was the epicenter of the pandemic, certainly in the United States, if not the world at one point we have now our numbers have gone down, but the safety for the pregnant and new moms have, has not is right. Yeah. Right. So we are still on top of new infections, preventing infections in the hospital, the doctors, the nurses, the people who clean your rooms, we're all washing our hands, wearing gloves, keeping our mask on because it is our priority that you come in healthy and that you leave healthy. Karen Litzy (06:33): Yeah. Perfect. All right. Well, thank you for that. And hopefully if there's any pregnant moms or other healthcare practitioners that are working with pregnant women kind of give them a little bit more information to pass along or to kind of keep in their heads. So now let's switch gears slightly here. I'd love to talk about maternal mortality rates in the United States now in the United States. We know, unfortunately that we do have a very high maternal mortality rate amongst advanced countries, or what's the best word for that advanced countries? Is that the right developed countries, industrialized countries, like we know what you're talking about, you get it right. So the questions that I have are what populations are most effected. And then what, in your opinion, do you feel like needs to be done to improve those maternal mortality rates? Kameelah Phillips (07:32): I am firmly under the belief that we can as a nation, as a country walk and chew gum at the same time to make these rates better. So to answer your first part of your question we have plenty of data that show that black women, African American women in particular are most vulnerable during pregnancy labor and delivery. And postpartum times the rates of increased death can be anywhere from five to seven times higher than their white counterpart. And these rates are abysmal for a developed country to have such a discrepancy in healthcare is really saddening and frankly just discussing it's unacceptable. But there are other ethnic groups that are also at risk that, you know, we always talk about black and white and really this country is so diverse, but our native American population is also significantly affected by maternal mortality rates that are poor as well as Alaska. Kameelah Phillips (08:57): We always forget about Alaska. So African American women, native American women and Alaska women, and it's complicated. It is a combination of access to care. It's unfortunate that we seem like we're talking about the same things over and over, but access is a big issue. We live in the biggest city in the United States, but you know, Manhattan alone, what the Island of Manhattan has four hospitals there used to be more, there used to be more can you imagine? But some of our outlying communities that are more ethnically diverse or Latino or African American have far fewer hospitals. And certainly in those hospitals, the resources aren't comparable to anything that you would see in Manhattan. So along with, you know, access there's hospitals, there's doctors there's birthing centers, all of these are less often found in lower resource places. Kameelah Phillips (10:06): So access is a big one education both on the part of the health field and of patients themselves is a problem. I think we're starting to really get some traction on the African American population, helping them understand that this is a very critical time in their life. And so they have to be hypervigilant about blood pressure, weight gain, diabetes, all of things, all the things that can be triggers for issues in pregnancy. Those are the big things that stand out access and education.   Karen Litzy: And do you also find that, and I find this in other aspects of healthcare especially when it comes to feeling pain that oftentimes women are not believed as much as men are. And, that is in other parts of healthcare, certainly true. Do you find that women maybe during pregnancy or even post pregnancy, like maybe that the day they gave birth, if they're there trying to explain things that are going on and perhaps they're not being believed and are just yeah brushed to the side so that I think is absolutely the case for a lot of the issues that women experience around the maternal period. Kameelah Phillips (11:22): And it's not limited to women. It also crosses ethnic and socioeconomic boundaries. We have a real issue and I'm part of the establishment, right? I'm part of the medical community. So I feel free to air up our dirty laundry, that we have a real issue with bias and medicine and we talk about racial bias and how that can impact black people. But we have a bias against women. We have a bias against women and, you know, she's being hysterical, she's being dramatic or pain's really not that big women in our discomfort in our needs are routinely downplayed and even by other women, because we've sort of ingrained in our head that, you know, women tend to be more dramatic, whatever. Kameelah Phillips (12:30): We downplay the needs of poor patients who come in, Oh, you know, she's just being loud for no reason or, Oh, that's just how they're. So this isn't just an issue of women. It goes across class, it goes across ethnicities. But for us, when we're pregnant, it has to be addressed and highlighted because when a woman is saying something isn't right. Something isn't right. And that should be taken seriously because in the postpartum period we get lucky a lot of times because women are generally young and healthy, but when things go bad in obstetrics, they happen quickly and then its big. So for example, if a woman was like, my bleeding is kind of heavy and say, maybe she just delivered a baby, a woman could easily lose one to two liters of blood in like a few minutes. So we had a really bad postpartum hemorrhage the other day. And I was like, this is impressive when you see what the body can do. Especially in labor, it happens quickly. And so it's incumbent upon us as healthcare providers to take women seriously. Karen Litzy (13:27): And then I would also think there is, and again, I don't know if this is true or not, but I know kind of where I come from more looking at the pain world and from my own experiences, as I personally would downplay my own pain. So as not to bother someone. Right. And do you feel like in the world of OB GYN, if you're going for pregnancy, like, do you have to kind of really educate those patients to say, listen, if you're feeling something doesn't feel right, like you need to speak up, right. Well, like you're bothering us. Have you encountered that?   Kameelah Phillips: I have encountered that. And it's really incumbent upon all of us to relearn these narratives that we've picked up just growing up in the United States of like not being the complainer or not being the squeaky wheel, not rocking the boat. Like those all have negative connotations right. Kameelah Phillips (14:47): In the obstetric space. When you don't speak up, we can have really negative, horrible outcomes. So part of my experience with patients is to listen to what they're saying really repeat back what they're saying, like, okay, I hear you're having X, Y, and Z. Did I get that right? And if it's something that is quote unquote normal in the space of a, you know, a growing uterus or a growing body part of my job is to really provide education, to help them manage their expectations for what they should expect. Growing uterus, growing weight gain, swelling, what they should expect from their body. If it's the first time they've been pregnant or the sixth time they've been pregnant, you know, all the pregnancies are different. And if we have a clear understanding her giving me her complaint, me giving her feedback on what I think she's saying, and then giving her the anticipatory guidance, I think she needs, and we still have an issue. Then it's incumbent on me to escalate it and really make sure that there's nothing there that's going to hurt her. Karen Litzy (16:01): Yeah. Great. That's perfect. And I love the kind of handling of expectations and monitoring expectations because that goes such a long way when, especially if it's your first time or not, like you said, your first or your six times, but kind of knowing what to expect at certain times is very comforting. And so then as if you're the patient, then you can say, Oh, you know, she said, this might happen, but I'm not, you know, it's not happening or it's going above and beyond what she said. So maybe this is time that I reach out and contact my physician on this, there are times where you may need to reach out to your doctor. And so knowing when those times might be, is really helpful. Kameelah Phillips (16:53): Exactly. So when a woman leaves the office and you know, it'll be maybe a month before I see her again, I tell her, you know, this is what I think might happen. It's okay. If it doesn't happen to you, but in the next four weeks, you might expect, you know, your pants size to change general discomfort in this area. You might feel something fluttering in your belly, like giving her those points to look out for. And again, managing those expectations and I'll get a phone call, Hey, this is maybe more I'm having this. Plus this is this in the realm of normal. No, it's not come in. You know, we can really help women out by giving them education cause it's empowering. And it helps us do a better job taking care of you.   Karen Litzy: Yeah. And it also keeps people away I would think from dr. Google or far down the rabbit hole of how many doctor Googles do you get? Kameelah Phillips (18:17): You know what, I can't anymore. Just so many doctor Google's with doctor said, I can't even more. Or my Facebook friend Sally said, Stay off. And it's funny cause when their partner comes with them, the partner inevitably just looks at him and like glares at them because they know that they're on Google or they're on these, you know, small chat rooms where everyone is on the T level 10 when the patient's issue is actually maybe a one or zero. And so it freaks her out. Yeah. I encourage patients to stay off of Google. Because yes, there are some times when it might answer your question, but really we're aiming for individualized personalized care and Google doesn't offer that to you. And so I really ask my patients to stay off of it. That's what their visits are for to write down the questions as they go. And honestly, it's so funny. They'll come in with like, say there's five questions just in the scope of time, given them the anticipatory guidance. Kameelah Phillips (19:17): Like by the time they actually get to the appointment, they may only have two questions because they're like, Oh yeah, she said that was going to happen. They know exactly, exactly. It helps to stay off Google.   Karen Litzy: Yes, yes, yes, yes. And now I think we've touched a little bit, I think on this, but let's see if we can delve into this more and that are what are ways women can stay healthy throughout their pregnancy so that maybe it can contribute to a decrease in the maternal mortality rate, even if it's just chinking away at the tiny little bit, because like you said, it's a big bucket with a lot of stuff going into it. But if there are ways that women can, like you said, empower themselves to stay healthy and give themselves the best chance, what advice do you give to women to stay healthy? Kameelah Phillips (20:04): Yeah. So in thinking about this, I have six points that I usually share with patients. So I'll go over them really quickly. But my first point is to find a doctor that you trust. I'm really big on that. I'm really big on that. I tell people to find someone that they trust because inevitably, you know, most pregnancies are fine, but if we get into some mess, I need to know that you know that I am your advocate and I am on your side. And if you hesitate or you don't feel like you can trust me a hundred percent, I'm going to ask that you explore other op, find another doctor because I want you to the best experience possible. And I even say this with my GYN patients, like if I tell a patient, you know, I really think you need surgery for this. Kameelah Phillips (20:56): I don't sign them up for surgery that day. I've let them go into the world, do their due diligence, meet with three other doctors. And I promise you, I have not had a patient not come back because they trust me. So that's a big thing. Find someone you trust. I think it's really important that patients meet with their doctor frequently, meaning that you come to your visits, you got to show up, right? So we can get data from you like your blood pressure, your weight how you're feeling, checking the baby regularly, blood work, this data that we're collecting at every visit. And it might not sound like a lot 15 minutes, but it actually gives us a picture of where we're going with your health. So that's important. I asked my patients also to stay active and exercise. I am not sure why there's this misconception that you should be sedentary during pregnancy first trimester. Kameelah Phillips (21:55): I get it that progesterone knocks everyone out there on the couch. They can't, you know, they're nauseous. They don't want to, I get that. But for the most part, when you feel healthy in pregnancy, I need you take care of yourself. And that means exercise and eating healthy and patients are, Oh no, but the baby really wanted the chili cheese fries. No, no she didn't the baby requests. Yeah. Did she send you a text message to get that? So really encouraging, like if you would feed your six month old, you know, a Coke and chili cheese fries for lunch, that's a separate conversation, but you know, trying to do as best they can. In terms of staying active and eating healthy education is a big piece for me. Every time they leave, I'm like, okay, we're entering this phase. These are the major risks for this phase. Kameelah Phillips (22:53): So I need you to go home and look at this website and read two minutes about diabetes, cause you're doing your diabetic test and this is why it's important. Being flexible is huge. Patients, I think often have the misconception that physicians or that I control their pregnancy. And really, I see myself as just like a tour guide, ushering your baby safely into this world. And so it's important that they're flexible to whatever the results come back as whatever the ultrasounds tell us, however, the baby is behaving in labor, that they're flexible. In my industry, I'm not sure what the corollary will be with physical therapy, but people who come in with very strict demands as to how they expect their process to be are the main people who have complications as opposed to just letting us do our job, to get you guys to the finish line. Kameelah Phillips (24:02): So being flexible is really important. And then my last one is to not refuse life saving treatments. We were, it was in the, I told you the other day I had a postpartum hemorrhage and I might back of my head. I was like, this woman's going to bleed. So as we were pushing or when she got admitted, I was like, you know, this is the type of situation where I see XYZ happening and when XYZ happens and she lost all that blood. When I came to her about needing a blood transfusion, she was already on board to not refuse treatment that could possibly save her life. So not refusing like blood products or blood pressure management, those are increased surveillance. Those are the big things that hurt and cause women to lose their life. So really not refusing important treatment. Karen Litzy (24:58): Yeah. And I think thank you, those are great ways that women can stay healthy. And you know, as you were saying, they need to be flexible. And I always go back to movies where they show the woman going in and she's got a birth plan and it has to be this and it has to be this. And there's no flexibility around that. So I could see how that could be really dangerous if you're going in with that kind of a mindset of, you know, I have to have this baby without any drugs and have to have it vaginally. When in fact there might be some complications where that's just not possible and it's just not possible. And, or advised or safe. Kameelah Phillips (26:00): And again, we don't decide that, right. The baby's position, the mom's uterus, the pelvis, like all of these things that are outside of our control decide that we're just here to make sure you both come out on the other side. Okay. And I can't underscore that. Cannot underscore that. Like I don't have anywhere to be there's this misconception that doctors always have like tickets. So like I have to be at the opera tonight. No, we don't have anywhere to be we're here for your baby, but you know, we have to have some flexibility, like let us just do our job and we'll get you through this.   Karen Litzy: Yeah. I think that's great. And then of course, I always love the third point, which is stay active and exercise and move during your pregnancy. And I think I'll give a quick plug for physical therapists. I think this is where physical therapists and women there are a lot of physical therapists who are pelvic health specialists and who work specifically with pregnant and postpartum women. And this is where I think we can actually maybe make an impact in that maternal mortality rate as physical therapists. Kameelah Phillips (26:54): Yeah. Yeah. I spent the first part of my career in a group dynamic and it was very hard for us to think outside the box with complimentary specialties that can help make this process of pregnancy, which is physically mindblowing. Like people, if you haven't necessarily been pregnant before or been in an intimate relationship with someone who's going through pregnancy, you can not imagine how physically difficult it is to have a baby. And so when I was bringing up the options of like physical therapy, no, no, no, she's fine. The body heals itself. I'm like, but it's not like, look at her walk. You know, I'm looking at her. Diane is like, like, let's think outside the box. So in my new practice, I'm making much more of an effort and actively establishing relationships with people that, okay, you're having this issue. Kameelah Phillips (28:07): Now let's connect with the physical therapist because you know, the hips give women the most trouble, the hips, maintaining flexibility labor and delivery, the act of pushing literally separates your pelvis. You know, it's not, of course you have issues with your pelvis afterwards. Lacerations, you know, women who undergo episiotomies that pelvic floor has literally hit the wall and back. So to not expect that pregnancy is a hundred percent, the most physical activity you can do with your body just really undermines and belittles the whole process. And so part of my process now is to send women to physical therapy, postpartum, even if it's just for one visit so they can have an idea of how to improve their core, how to keep their pelvic girdle in shape and engaged because most women have more than one kid. Kameelah Phillips (29:11): So that's a lot of, you know, trauma to the body. And we can do better. We know that it works, we know that it's available, but it's up to us to provide the education and the next steps for them to heal.   Karen Litzy: Yeah. Well said, well said I love it. And now as we wind things up here what would be, what would you like the audience to take away from our discussion today? Kameelah Phillips (30:29): I think that it would be helpful to really understand that most doctors do their best to provide women with excellent obstetrical and Gynecological care. I think that a good doctor is really open to receiving information from other specialties in this case PT, physical therapy as modalities that can compliment what we offer. That's not in opposition to what we do so that if we could somehow strengthen the relationship between obstetrics and physical therapists, everyone would win. Like it's for all of us, the patient the obstetrician, the physical therapist the patient's family. It's, you know, pregnancy is the deal. It affects literally you physically, emotionally, psychologically, and sometimes the physical impact of sometimes a lot of times the physical impacts the emotional and the psychological and your sense of wellbeing and health is so impacted by like how you physically look and feel. And you guys have a direct, you know, you have the keys to helping us, you know, improve women physically. So if we could strengthen that relationship and not see it as so oppositional, I think it's a triple win for everyone.   Karen Litzy: Yeah, I agree. And the last question I have is one that I ask everyone. And given where you are now in your life and in your career, what advice would you give to your younger self? Kameelah Phillips (31:41): So I'm out of residency 10 years, and I'm just starting my first private practice venture. And looking back, I probably should have done this five years ago. And yet I had a lot of other things going on. I was like birthing my own children and that kind of thing. But at the root of it, honestly, I was scared. I was scared of failing. I was scared of the unknown. I was scared of doing things that I'd never been taught before. Like formally I didn't consider myself an entrepreneur, all these like negatives, right? Negative, negative, never didn't have it. Shouldn't wouldn't, couldn't like, and I would give my younger self, like a kick in the butt to like, just get out there and you know, unless it seems so cliche, but you don't know unless you try. And when you're young, there's nothing to lose. Kameelah Phillips (32:53): Except the fear that's like this imaginary fear that's holding you back. It's a time to be brave and courageous and adventurous. And so I would probably give my younger self like the little push off the ledge the encouragement that I needed to have started this venture and experience earlier. And I would just tell her to be fearless. What do you got to lose? You can always, you know, move back in with your parents. That's what we're doing these days. Right. So like, why be afraid to fail like that just now it's so funny. Cause I think about it cause I'm in it now, but what did I have to lose? Nothing. Nothing. Yeah. Like time, but that would have been a learning, you know, you would have learned so willing to learn. Kameelah Phillips (33:52): So yeah, I would have jumped sooner.   Karen Litzy: Excellent advice. Thank you for that. And now where can people find out about you about your new practice? Where are you on social media? Where can we find you? Kameelah Phillips (34:57): So on social media? My main page is drKameelahsays, my practice page is Callawomenshealth, like the flower. I love the like beautiful erotic nature of the calla lily. So that's my practice Calla women's health. I'm on the upper East side of Manhattan, but also available for telehealth visits, physical visits throughout coronavirus. I've been on the grind in this office. So taking new patients of course also happy to see them.   Karen Litzy: And for everyone listening, we will have all of this information, one click straight to all of the practice and the social media at the podcast.healthywealthysmart.com. Under this episode, it'll all be in the show notes. So if you didn't get it, don't worry, you can get it that way. So thank you so much for coming on. This was a great episode and I think you've given a lot of wonderful advice to healthcare providers and to women who may be pregnant or want to be pregnant or maybe has already been pregnant. There's a lot of stuff here. So thank you so much. I appreciate it. And everyone, thank you so much for listening. Have a great couple of days and stay healthy, wealthy and smart.   Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts