Healthy Wealthy & Smart

Keaton Ray and Scott McAfee, co-founders of MovementX, are on a mission to revolutionize physical therapy. They discuss the importance of effective communication in partnerships and how identifying team strengths can drive success. The pair share their journey in healthcare innovation and the concept of the '11-star experience' for patients. Emphasizing the power of vulnerability, they reveal how authenticity can foster a supportive company culture. Tune in for insights on aligning passion with purpose in business!

LIVE on the Healthy, Wealthy and Smart Podcast Facebook page, I welcome Chris Napier on the show to discuss the science of running. Chris Napier is a Sport Physiotherapist with a PhD in running biomechanics and injury prevention. He has an appointment as Clinical Assistant Professor in the Department of Physical Therapy at the University of British Columbia. In this episode, we discuss: -How to bring a wearable to market for running retraining and injury risk reduction -What to look for when investing in wearable technology -The importance of translating the research to both the clinician and athlete -Science of Running: Analyze your Technique, Prevent Injury, Revolutionize your Training -And so much more! Resources: Science of Running: Analyze your Technique, Prevent Injury, Revolutionize your Training Chris Napier Twitter Email: chris.napier@ubc.ca Chris Napier Research Gate A big thank you to Net Health for sponsoring this episode! Check out Optima's Top Trends For Outpatient Therapy In 2020! For more information on Chris: Chris Napier is a Sport Physiotherapist with a PhD in running biomechanics and injury prevention. He has an appointment as Clinical Assistant Professor in the Department of Physical Therapy at the University of British Columbia. In addition to working on research projects, Chris continues to be a practicing physiotherapist with Restore Physiotherapy and Athletics Canada. He has competed at the national level as a successful middle-distance runner, earning medals at the Canadian Track & Field Championships in 1996 and 1997. He is also an accomplished marathon runner with a personal best time of 2 hours, 33 mins. Read the full transcript below: Karen Litzy: 00:01 So welcome everyone. So for those of you who are watching live, thank you so much for taking the time out of your day and coming on to watch and learn. Oh good. I'm just making sure that it works. So I just had to check on my iPad to make sure we're live and we are. So thanks so much for taking the time out. As we go along. I may ask you just to kind of write in the comment section where you're listening from. If you have any questions, by all means, definitely, definitely ask. Now is your chance, I'm sitting here with Dr Chris Napier. He is an expert. He is a new author. We'll be talking about his book, the science of running in just a little bit, but Chris, just to kind of allow people to get to know you a little bit more. Why don't you kind of give the listeners and the viewers here a little bit more about you. Chris Napier: 01:05 Sure. well thanks again for having me on Karen. I feel like I've really made it big time. Now. I'm on the Karen Litzy podcast. It's huge. So thanks again for having me on. So I'm a sport physiotherapist. I've been practicing for almost 20 years now. And, I've worked with a range of sports. But I sort of ended up coming back to the sport I'm most passionate about. The one I love which is running. About 10 years ago I started really focusing more on running and it was basically because I'm a runner myself. Out in the community running with the various sort of recreational races training with different clubs and so then and talking to people who are running all the time. So it really sort of just made sense for me to kind of work a bit more clinically in that field. Chris Napier: 02:00 And at the same time I was getting interested in pursuing more research. And so I started my PhD in about 2012, 2013. And I focused on running and I was really interested in being able to quantify aspects of running in terms of running form and biomechanics. So my PhD was on running biomechanics and sort of clinical interventions using gait retraining to prevent injury. And so I finished that in 2018 and I've moved now more out of the lab so to speak out of the biomechanics lab but still interested very much in the mechanics of how we run. And I'm now working with a group of engineers at Simon Fraser university doing my postdoctoral fellowship there where they actually develop a wearable. And so we're doing some really cool stuff there in terms of actually developing potentially products that will be available to clinicians and to runners to measure their gait. Karen Litzy: 03:13 Very cool. And I will also add that you are sort of at the helm of the third annual world conference of sport physiotherapy in Vancouver this year. It was an amazing event. You and the team you guys did such an amazing job and I'm sure that's the feedback that you've have probably got from the conference, from the people who attended. So I just wanted to give you guys some more accolades and a nice shout out cause it was a really, really well run conference with some great info. Chris Napier: 03:48 Yeah, that is the feedback we've had, which was fantastic to hear from across the board. And, I'm really looking forward to our continued support for your therapy candidate conferences, which will be a biannual event and as well the next world Congress, which will be excellent, I'm sure as it's being hosted in Denmark. Karen Litzy: 04:08 Yeah. Yeah. That'll be fun. And that's in 2021. So that'll be a good time. And again, if you're watching live, I know I saw a couple of viewers watching live at the end of this, hopefully we're going to give away Chris's book. It doesn't come out until February 4th, but if you write your name or a comment or where you're watching from in the comment section, you're automatically in the running for a free copy of the science of running by Chris Napier, which is very exciting. So Chris, let's talk about wearables. So when I think of wearables, to me it makes me think of like a Fitbit or maybe an Apple watch or something like that. So in your introduction, you'd said that you're working with a lab as a postdoc. So when you say wearables, is that what you mean or are you talking about something else? Chris Napier: 05:11 Yeah, so I mean a wearable is really a broad category. And you know, for anyone who follows the consumer electronics show, which was just recently in Las Vegas you know, I think that area is huge right now across the board. And, we think of it very much in the health lens. But really a wearable, wearables, anything you can wear on your body that tracks something whether it's, you know, your heart rate or your breathing rate or your pulse or your blood pressure or skin temperature or joint angles, impact forces. I mean, it goes on and on. Really anything we can measure through something we can wear. So, you know, by nature it's something that's portable often, you know, connect with some sort of app either on a Bluetooth device or we'll sort of record onto the actual hardware itself or download later. Chris Napier: 06:15 But you know, that's the other side of it is, you know, beyond the wearable, the actual interpretation of the data and the visualization of that and that sort of thing. That's a whole other field as well. But the lab I'm in is looking at wearables that can measure health-related metrics. And so some of the projects we have going on there are looking at recovery from stroke or looking at you know, more fine motor function, that sort of thing. And my area specifically is looking at an application to running. Karen Litzy: 06:53 And so when, you know, I think about application to running and you think about, you know, perhaps using a wearable to enhance someone's running, whether it be their running gait, their endurance, their times. And what I think of right off the bat is a running analysis where you've got someone on a treadmill and you've got multiple cameras and they've got dots all over them and all their joints, which is not something that every clinic has the ability to do because those setups can be quite expensive. So what are you doing within your research that might be a little different and offer clinicians something that might be more practical? Chris Napier: 07:40 Yeah, so what you described there that sort of motion capture 3d motion capture analysis which is sometimes done on an instrument, a treadmill, which will give you force information as well as the joint position movements. But that was my PhD. So that's what I did. I looked at basically a snapshot of people running and then assume that that's how they ran when they left the lab. Which is a big assumption, right? And so what we're doing is we're trying to get those same measurements but in something that can be worn outside of the lab and in the natural environment which gives us it opens a whole other world to what we can measure. We can measure things where, you know, rather than on a treadmill, which might be unnatural for a lot of people, we can measure them running on the road or through trails or uphill or downhill. Chris Napier: 08:40 We can measure how their mechanics changed throughout the course of a run. You know, so we can see what happened when they start to get fatigued. We can measure in a race situation you know, when people perhaps run differently cause they're pushing themselves to their limits. And we can also measure over time, over a weeks or training blocks so we can see what happens to people's mechanics. As a more chronic sort of fatigue sets in. So there's a lot of stuff that we can study. And, in our lab we have sort of the ability to embed some of these wearables into garments. And so essentially we're developing smart garments. And we published a recent paper looking at using a set of running plates to measure hip, knee and ankle kinematics during running. And, we developed this and I think it compared to the gold standard, which is still the three D motion capture and these tights do very well at measuring that movement. Which is exciting cause then, you know, we can start to produce these and runners can start collecting data wherever they run. Karen Litzy: 10:01 Yeah. Which obviously seems a little bit more practical than, like you said, just being on a treadmill. We know running on a treadmill is definitely different than running on the road or the track or real life situations. And is that something that a, let's say your average physical therapist practicing PT like myself, if someone comes to me with a running related injury and I mean, I don't have access to a three D running analysis, is this something that I would be able to say to this potential patient he lives in? I have some wearable technology that you can use that might give us a better picture as to what's happening when you're running. Chris Napier: 10:49 Yeah, I mean, we're not there yet, but that's certainly where we're going. So, you know, I guess potentially we could, we could put this pair of tights on a runner and we could track their hip, knee and ankle kinematics while they run either on the treadmill in the clinic or we could send them outside and have them go for a run and come back. And or you know, these could be something that the clinic can loan out or rent out and maybe patients keep them for a week so we can track their running mechanics over the course of a week. And then that could potentially be uploaded to a cloud or brought back to the clinic and downloaded so that you can look at their data over time. And what we're using our strain sensors to be able to measure kinematics. Karen Litzy: 11:38 And what does that mean? What's a strain sensor? Chris Napier: 11:40 Well, essentially these are thread like sensors that the amount of strain produced can give us an idea of how much movement is occurring. Karen Litzy: 11:52 That's sort sewn into the fabric. Chris Napier: 11:54 Exactly. And we've done, you know, a lot of the research we do is looking at where we need to place these and how many sensors we need and that sort of thing. And so that was the big work sorta involved in developing these tights is to figure out how many, you know, can we get away with just having three or four sensors which reduces the you know, the cost of energy and also the amount of processing involved and where can we put those to optimize you know, the metrics we're looking at. But you can also then add inertial measurement units or I am use which have accelerometers and gyroscopes in them, which can then add a whole other layer so we can look at you know, impact. We can look at angular philosophy and things like that. So, you know, we're looking at integrating those things right now as well. Karen Litzy: 12:53 And all of that can be so knit fabric of a pair of tights. Chris Napier: 12:57 Yeah, yeah. We're talking about pretty small. Karen Litzy: 13:01 That's wild. And so, you know, you did a study kind of taking these tights and looking at, well, how many sensors do we need and where do they need to be placed? And was this sort of a preliminary study, cause I can understand the need for knowing how many sensors you need and where to place them and then kind of recruiting a larger amount of runners to kind of study to see does this do what it says it's going to do it in a nutshell. So right now, just so that the viewer isn't, so that I myself get a better idea. So right now you're sort of in that developmental stage where you're looking at where to place them and how many, and do they work? Chris Napier: 13:48 Yeah, we've done that. So basically this study was that, so we were happy with where they are and the number for what we want to measure. And so now what we're doing is can we use these to give us information about you know, the fatigue state that runners are in. So, you know, when we're getting into machine learning and that sort of thing as well with this. So you know, can we classify a runner as being fatigued or not? For instance, based on the information we're getting from these tights or, you know, and then as I said before, like, can we get these out now and actually get people using them so we can start collecting large data sets. You know, that's where it gets interesting. Can we get these out to hundreds and thousands of people to be able to start collecting data on those numbers and really start to refine the technology and perhaps see some interesting patterns. Chris Napier: 14:49 And you know, there's some of the studies coming out of refurbish lab in Calgary have been doing that. They use the now defunct Lumo device, which I am used situated on the waste. And they've done some really interesting work with Christine Claremont leading that and Learn Benson looking at sort of classifying situations or types of runners based on the data they've gotten from those devices. So we'd be looking at maybe doing some similar work with ours. Karen Litzy: 15:30 Yeah, I mean, very cool. And, I guess the next question is why should we care? So as physical therapists or even as runners, like, yes, this technology is cool, it has the potential to give us a lot of data and a lot of information, but why do we care about that? Chris Napier: 15:54 Yeah, exactly. So, you know, I think first of all, we have to figure out, is this going to give us information? That is I think we can be happy that it would be reliable, but really we're looking at the validity. Are we getting information where we're going to see patterns that lead to injury. And that's again, that's kind of where we're going with this. But at this point we can't say that that's where we need those large numbers. And hopefully I think that's what we will find is that we can kind of see trends. I mean, there may be a time where, you know, these are sold in running stores and people just wear them and then, you know, they get injured and they come in and say, Hey, yeah, here's my data. Chris Napier: 16:41 Check it out and, you know, see if you can figure out why I got injured. You know, maybe we'll get to that point. But I think for now it offers the clinician a chance to be able to analyze someone's running gait. So you get that kind of objective information. And then maybe they can use that over sort of repeated visits if they're looking at trying to retrain someone's gait or if they're looking for you know, some changes due to the intervention that they're applying, whether it's strengthening or gait retraining or something else. So I think that it gives us another tool really to measure something dynamically that, you know, until now we could only really do in a specialized biomechanics lab, which as he said, is very expensive and time consuming and really maybe only giving us a snapshot. Karen Litzy: 17:40 Right. Right. Versus being able to see the bigger picture of a runner. Yeah. Yeah. Very cool. Chris Napier: 17:49 And also, you know, maybe some of the work I'm doing is looking at monitoring, training load and you know, if you're kind of familiar with the training load research there's this sort of concept of internal and external load. And you know, the external load might be the number of kilometers or miles that you run in a week or the number of minutes that you run in a week. And the internal load would be some sort of intensity measure or rate of perceived exertion. And so, you know, my interest is, can we get a bit more specific perhaps about that external load. So we're not just looking at minutes or miles, but we're looking at you know, cumulative impact and that actually got a paper in review right now where we looked at that using the run scribe sensors, which are little pods you put on your laces on your shoes and they can measure shock, which is sort of a result of impact force results in acceleration when you hit the ground. Chris Napier: 18:56 And we looked at whether there's a difference between looking at just a cumulative minutes, you know, run versus number of steps versus cumulative shock. And we found differences and with the cumulative shock we're going to know a deeper analysis. I'm not sure where we're looking for, are there changes depending on the type of run that the person did. So is it more specific measure? When someone is changing the terrain they're running on or changing their intensity on a regular basis? If someone goes and runs the same route every day at the same pace, then we're probably not going to get more information by a cumulative shock. But if they're running in trails one day and roads the next day and then they're doing interval workout or then they're doing a long run we might get more information out of cumulative shock or some similar measure as opposed to just the minutes or miles that they run. Karen Litzy: 19:56 Right. Yeah. So just adding another element to, again, the overall picture of that runner. So like for example, like you said, you could have someone who says, Oh, I ran, I run 10 miles, I'm just making this up 10 miles every week and I haven't changed how many miles I run. But yet they're coming to see you for patellofemoral pain. Or maybe they're coming to see you with anterior shin pain. But what you're not getting is, well, I run the same amount, but this time I did on a trail and this time I did it on concrete and this was on a rubberized track or something like that. So I would assume that with that shock, you would be able to kind of see the difference and then as a therapist say, Hey, I don't want you to stop running, but maybe let's stop doing X, Y, Z. Chris Napier: 20:52 Yeah. It allows us not only to look at what has happened, but also to prescribe in the future. Right. So potentially we can then say, okay, we need to keep that cumulative shock below a certain level or, you know, increase it gradually. And so if that's something that they can monitor on their own outside the clinic. Great. and I've done that a little bit with some people just more experimentally at the moment. But I've had people who are really interested in sort of tracking that. They've done that and it's actually been quite successful so far. Karen Litzy: 21:24 Yeah, no, it sounds very reasonable to me as a therapist and certainly as I would think for the runner because, you know, oftentimes when runners get injured and first of all, they're told to not run. That doesn't go over very well. Chris Napier: 21:42 No, no. Karen Litzy: 21:46 And it's also not just the running, but it's part of stress-relief. It's part of what makes them happy. And so to be able to say, Hey, listen, we're collecting all this data on you and this is what we found. This is what you can do. I feel like it gives control back to the patient or to the runner so that we're not spinning. Right. Chris Napier: 22:07 Yeah. There was a great paper just published last month that essentially looked at what their runners do when they can't run. Right. So if they're injured and they can't run, what do they do? And the answer was, Oh no, they didn't do other activities. They just say they just want to run. And that sort of, I think validated your feelings. You know, when you talk about cross training and, you know, go get on the bike or go on a full run or a swim. But I mean, the greatest thing about running is you can put on some running shoes and head out the door and you can fit it in anywhere, anytime. So it becomes much harder to fit in that exercise when you have to go to a pool or go to a gym, get it done. Karen Litzy: 22:51 Yeah. And then I would think it must be even harder for some, not all, but some runners to get back to running after an injury. You know, there's fear involved there. They don't want to get injured again. They may sort of taper back to the point where maybe now they're not even happy with their running. Chris Napier: 23:16 Yup. Yeah. And often, you know, we prescribed like a walk run program to get someone back in because it's sort of graded impacts. Right. So again, looking at that key middle of shock is what we're trying to do there is gradually someone back in to doing that. Even if they've kept the fitness even if they have been on the bike or something like that when you get back after prolonged period off of running, it's still, it can hurt, right. Of the impacts you don't get in other activities. And so again, that's where, if we can measure that and monitor it, I think that's a big advantage. Karen Litzy: 23:53 Absolutely. Now before we get to the book, which I want to get to in a second, are there any other cool tech things when it comes to runners that may be you've worked with or that you've seen? Maybe not, you know, in the lab that you are in, but that might be coming down the pipeline that we can as runners or as healthcare providers we can kind of get excited about. And the answer might be a lot, but you can just pick. Chris Napier: 24:26 Let's say a lot of the kind of more research grade or maybe not a lot, but some of the more research grade companies are starting to shift I think a bit more to a clinician or consumer level products. And one reason for that is the hardware is just getting cheaper. So, it's possible. And then also I think you know, the ability to fit these into or integrate these into apps where you have the visualization side and you can actually easy interpretation of the data. I think that's you know, we're going to start to see more and more of these devices available in clinical settings and consumer settings. And I think one that comes to mind is I measure you, is basically an IMU inertial measurement unit that now owned by VI con, but you know, they're starting to I think offer products that are a bit more clinician friendly where you can get real time feedback. Chris Napier: 25:40 You can stop these on someone's tibia and have them run in the clinic and get some real time feedback and visualize it and give feedback if they're reaching certain thresholds. So if you're trying to keep them and you're trying to get them to run softly, for instance, you can get them to run. And this'll give you feedback when they're going over a certain threshold. Another, a Vancouver based company that I'm doing some research with. It's called plant Tika. This is actually their product here. It's just an insole. So you can just pop this into your shoe lacing. So on your shoe and in the bottom of it, I don't know if you can see here, but there's an IMU here. So it's very thin. Obviously it fits right into the insole and you don't really feel it when you're in there. Chris Napier: 26:30 But it's a very strong piece of hardware and you can pop that into your shoe. And I say, well, that it's actually measuring that it measuring accelerations so it's got an accelerometer, but it's measuring that impact at that point where it's hitting your body so it's right underneath your heel. You know, and so we're doing some interesting work where we're looking at different footwear and how that changes the impact at that point, because today a lot of the research is using ground reaction forces, which are measured underneath the shoe, right? That's the shoe round interaction. Or they're using to bill accelerometers, which are, you know, measuring that force once it's gone through the foot and the ankle complex and is reaching the tibia. Karen Litzy: 27:21 Some of those courses have already been disordered right through the ankle or through the shoe. Chris Napier: 27:30 Yeah. So this is a cool tool and I think they're really keen to start using this. They're targeting clinicians because I think this is an easy one that you know what, I'm using it in the clinic right now where people come in. And when we did the gait analysis, I just slipped these into their shoes and just cause it's that much more information. It visualizes asymmetries really nicely as well. And, and they're also looking at beyond running. They're looking at you know, ACL rehab and that sort of thing as well. Karen Litzy: 28:02 And are there any things you can think of that let's say your average physical therapist needs to watch out for? Right. So you have a lot of, cause I know you had mentioned more research based consumer products. I'm assuming that there are products out there that might not be the best things that we as consumers, you know, without naming names obviously, but things that we look at when we're looking at a company that's selling one of these like wearables and what their claims are. Chris Napier: 28:35 Yeah. So I think first of all, the hardware has to be good. And when I say that, I mean you need to have a high enough sampling rate to be able to measure what you want to measure. So, you know if you have an accelerometer, that's a sampling it 60 Hertz for instance. If you're trying to, we capture that and you're gonna miss peaks of data and steps. And so it's just not going to be something that's reliable. You know, if you're measuring it at up at the waist crowds, then it's okay because we don't need high as high frequencies at the waist. So no for that we need to how you need to have a product that can sample at a high enough rate and there's papers out there that have looked at that, you know for kinetic and kinematic information, that sort of minimum requirement you would need. Karen Litzy: 29:36 And what would that be? Do you know, off the top? Chris Napier: 29:38 Perfectly genetic information and it's about a, you need like 500 Hertz for it could be more like 200 Hertz, you know, for the kinetics is going to depend on the placement for sure. But typically you want to aim for something that's about 500 Hertz, you know, a lot of consumer level products wouldn't have. Chris Napier: 30:00 And then also something like the dynamic range would be important. And that's just essentially how many Gs they can measure. And so if your using a something that only measures up to 10 G then when you put that on your shoe and you're trying to, and, and there's impacts that are up around 20 G, then you're really not going to be capturing sleep. Right. It's missing that information again. So that, I mean, that's something to be wary of thought of it outside of the hardware would be looking at the output you get. And so some of these outputs you get are very general. You know, typically you'll have like a, you know, I put on my Garmin watch and go for a run and at the end of it it tells me I need to rest for, you know, 36 hours before my next effort or something like that. Chris Napier: 31:00 And you know, I never really sort of regard that it doesn't really doesn't make sense. I can interpret that much better myself than relying on my watch. It also spits out a bunch of other metrics. You know, some of them might be useful. Others I would just sort of disregard and I think that's where, you know, probably clinical decision making comes into it. And having a knowledge of the activity and the person in front of you don't overly reliant on just sort of what the metric is outputting. Karen Litzy: 31:40 So if you have, let's say a certain wearable on and it gives you again, making something up like 10 different kinds of outputs. I don't even know if that's possible, but you want to kind of take, is it sort of like you're taking what you need as it relates to what the patient's going through? Or are you buying something that says, Oh, it can give me all this information, so I'm just going to use all of it. Chris Napier: 32:11 So, I mean, someone like me, I like raw data because I can play around with it and I can plug it into things. I can graph it and I can do whatever I want. And it's that raw data is, you know, the highest frequency and so the best data I can get, so that's what I want. But most clinicians don't want that because they won't know what to do with that data. Right. So it's gotta be processed somehow. And so that processing you can lose data and you can lose focus and you can have misinterpretations along the way. And so it can be something is it can be processed down to the point of where something might give you an efficiency score, right. Which is, you know, unit and listen in essentially meaningless where it says, you know, your efficiency on that run was good, average or bad. Chris Napier: 33:08 Yeah. I mean that's something completely processed down to the end where it gives you this kind of, you know three categories. I mean, what does that really tell you? Probably not, or it could be somewhere in between. And so I think that's the hardest part here. And you know, what would be appropriate for a clinician isn't necessarily going to be appropriate for a consumer. So I think again, we're going to start to see products that are aimed more at clinicians and at more consumers as the hardware gets cheaper and more widely available and people are going to kind of sort through and find things that work for them. Karen Litzy: 33:52 Right? Yeah. So I guess it's when it comes to the output, it's kind of like food. You don't want things to be overly processed it's not good for you. Okay. Cool. Well now let's get to the book. So I'm just going to read. So the book again for people watching the book is called the science of running and it will be available on February 4th, but you can go to anywhere books are sold, Amazon or what have you and you can preorder. But I'm just going to read a quick description. I won't read the whole thing, but I'll read a quick description. Science of running goes further than any other running book to intergrate the anatomy. And physiology of the runner showing how running in walls and affects every system of the body, including the effect of oxygen on the muscles. The book breaks down the runner's stride, scientifically showing what's going on under the skin at every stage of the running cycle. Highlighting common injury risk based on a readers natural gait and showing how to correct them, takes a head to toe approach to 30 key exercises for runners, annotating the muscles, ligaments and joints involved, and showing how to perfect precision in those exercises to optimize their benefits. Sounds great. Chris Napier: 35:12 I could have used more time. Karen Litzy: 35:15 He probably did that in a weekend, but I mean, this is a very involved book. It's not like just a pamphlet. Chris Napier: 35:24 No, no, it, it was a lot of work. I won't deny that. And it was a really interesting process for me. Essentially it's like what we just talked about sort of bullying down that kind of raw data or the raw science and being able to filter down to a level that's interpretable by kind of the general public or the, you know, the average runner. Cause that's essentially what this is. It's a handbook for runners about their bodies, right? Karen Litzy: 35:55 So this is for the average person runner and for the clinician, right? So not like overly overly technical, but technically simplified. Chris Napier: 36:08 Exactly. I mean it's not simple. There's a lot of information in there, right. And we've done our best you know, with the artwork and that sort of thing to be able to explain the science behind all of this. But there's a lot of information in there. I mean, it's not a textbook. And it's not an academic book, but it's very much for runners and clinicians, I think to have on hand. You know, whether it's in a clinical context, if you want to be able to explain, you know, an injury to a runner or you know, explain what you mean by you know, what's happening during running stride. There's a lot of you know, artwork and chunks of text in there that can kind of help to explain that. And for the average runner, I think it's sort of something that they can keep on hand and use you know, if they're training for a race or just in general or something to kind of, you know, refer back to over, over and over again. And there's also a whole chapter full of training plans. It was co-written by my coach Jerry Zack and again, that's a very comprehensive chapter there. Karen Litzy: 37:31 Fabulous. And so I'm going to say it again, so for the people that are watching if you leave a comment or a reaction, you're automatically in the running to win a copy of this book. So please, you know, give a thumbs up or a heart or throw in and whatever like where are your lists, where you're watching from or listening in from. Because we'll pick a winner and I'll contact you when we're done with the interview and everything. But so when you talk about a book like this is there ever sort of misinterpretation of by someone to say, Oh, it's a book on how not to get injured when you run? This is a book on preventing injuries? Chris Napier: 38:22 Yeah, I mean, yeah, I mean for anyone familiar with the research on running injuries, that's a pretty murky field at best anyway. I think what I tried to do in this book was present what the research does tell us and kind of show, you know, let's take foot strike for instance. Cause everyone knows about, you know, foot strike pattern and you know, we talked about, okay, what happens when you were first strike? What happens when you forefoot strike? And rather than taking the approach that one is inherently bad and we'll give you an injury we talk about, you know, how they affect your stride and where those forces go and that sort of thing. To be able to educate the runner on that rather than talk about, you know, this particular way of running will prevent injury. There's also a large section we've got about 30 different strengthening exercises in the book where you can you know, go through and again, it's a little visualize with artwork showing different stages of the exercises on specific running, strengthening exercises that you can do in the gym or at home. Karen Litzy: 39:42 Awesome. Well, it sounds like it's a great resource for clinicians and the runner alike and are you going to, after doing this, and this was, I'm sure an arduous task that took quite a while. Are you going to write a followup in the works or are you like, Oh my God, let's publish this book. Chris Napier: 40:02 I haven't really even opened this book yet. I got it. About three weeks ago, and I don't think I might've just opened at once to kind of flip through very briefly. So at this point I'm ready just to kind of keep it on the shelf and see what happens. But no, nothing in the works right now. I'm focusing on some other things right now and if that opportunity comes up, you know, down the line then perhaps a look at that then, but this was a very interesting process to go through. I have no regrets. I think it's pretty cool to see, you know. But I think I'll take a little break for awhile now. Karen Litzy: 40:47 I get it. For you, as now an author, what was the best part of writing this book for you? Might've been like, as a person, as a clinician, as a researcher, what was like the big positive for you? Chris Napier: 41:03 You know, in research we're always talking about knowledge translation, right? You have to kind of get that research to the end user. And how you do that. It's often very difficult for research. This gave me a lot of tools I think in my own field of how to get that research to the end user, whether it's a clinician or a runner themselves. So that's been really useful. Also I think working in the clinic it made me really think about what are the exercises I think are most valuable or what is the most useful thing that a clinician would get out of this book? You know, I'm often sort of pulling out a textbook to try and explain something to a patient who is in the clinic because they've got an injury and I'm talking about too much too soon or some of that. And I want to graphic where I can say, look, this is why too much, too soon is bad, or this is why, you know, running the way you're running might've led to this injury. And I'm often sort of ending up doing Stickman drawings or something to try and illustrate. Karen Litzy: 42:14 Well we all do that. Chris Napier: 42:16 Which is fine. But you know, this gives me a resource and hopefully others a resource in the clinic to be able to sort of say here like this is what I'm talking about and here's a nice sort of visualization and in some kind of bullet points as to what I'm talking about. Karen Litzy: 42:34 Yeah. That's great. So I feel like it, to me it sounds like it's made you maybe a little more present, a little more thoughtful about what you're doing with runners and why you're doing it. Great. And I'm assuming that's also the goal of the book is have people be a little bit more present, understand the way their body works. This is for the runner, the way their body works and why they're doing what they're doing. And for the clinician may be taking a larger analytical view in as to the person in front of them, the runner in front of them, and maybe why they're getting the injuries that they're getting. And some options on how to rectify that situation. Chris Napier: 43:16 Yeah, I mean, I think runners, runners are typically type a people, right? And they, you know, they get really into running and they want to know more and they want to learn like, okay, what's you should I have and what's, you know, what's the best way to run and what's the best way to train? And you know, so they're on Google and they're trying to get all this information. There's tons of conflicting information out there. Even from, you know, some of the top sources, right. Sort of the top sources for that. So again, hopefully this is something that kind of boils it down. It's very evidence-based and something that runners can rely on as a resource for all things running. Karen Litzy: 44:01 Sounds great. Now listen, before we wrap things up, I have one last question. It's one 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 yourself as a new grad right out of physio school? Chris Napier: 44:18 So I would right out of physio school, I think just get your hands dirty and see patients, try and get lots of different experiences. If you're interested in sports, volunteer with teams. You know, don't expect payment right away for those things. Get out and work with people and put in the time and you'll learn a lot and those will turn into opportunities in the future. I think getting out and I'm not saying no to things is a big, big thing. And I think that's how I kinda got involved in working with professionals and sort of national team athletics. It's because basically one opportunity led to another. And I didn't say no along the way and so it just, you know one thing snowballed into the next thing. So I think you know, that's probably my advice. Just get out, start getting your hands dirty and get the practical experience and don't say no. Karen Litzy: 45:26 Awesome, great advice. Now, where can people find you if they have questions and they want to find more info about you and about the book, where can they find you? Chris Napier: 45:35 Well, the best place is on Twitter. I'm fairly active on Twitter and they can find me @runnerphysio on Twitter and they can contact me through that. Also if people have, you know, wanting to access any of my papers, that sort of thing. They can reach me through my email address which is Chris.Napier@UBC.ca. I'm happy to send along papers or if you have any sort of specific questions, I'm happy to answer them if I can. Karen Litzy: 46:07 Awesome. And what we'll do is when this broadcast ends, I'll go back in and I'll put a link to your Twitter and to some of the papers that we spoke about today and a link to the book. So people want to preorder the book, go for it. For all the people who are on and who had some reactions or comments. I will pick a winner for someone to win Chris's book and you'll be hearing from me. I'll get in touch with you via Facebook. So, Chris, thank you so much for taking the time out and coming on to do a live and then it'll be on the podcast as well but to do a Facebook live. So thank you. Chris Napier: 46:45 Well, thank you. I've enjoyed it. It's been a good chat and thank you also for all your work in the lead up to the world Congress with all your Facebook live interviews with a lot of our speakers. Cause that was really great to be part of that. Karen Litzy: 47:02 Yeah, that was my pleasure. It was great. So everyone who's on and watching. Thank you so much and 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 TaVona Denise on the show to discuss burnout in physical therapy. Atlanta-based business accelerator, success coach and avid cyclist, TaVona Denise lives and breathes by the motto, "success is 80% mental, 20% skill." With certifications in life, weight and wellness coaching, her specialty is helping new entrepreneurs get past fear and overwhelm, get their business up and running, so they can help change the world. In this episode, we discuss: -Burnout in physical therapy and the tools you need to take the next steps in your career -Why a gratitude practice can help shift your mindset and elevate your to-do list -The importance of a coach that can identify your blind spots and keep you accountable -How to channel your fears and build confidence so you can tackle your biggest goals -And so much more! Resources: TaVona Denise LinkedIn TaVona Denise Facebook TaVona Denise Twitter TaVona Denise Instagram TaVona Denise Website A big thank you to Net Health for sponsoring this episode! Check out Net Health's 4 Ways to Increase Patient Engagement! For more information on TaVona: Atlanta-based business accelerator, success coach and avid cyclist, TaVona Denise lives and breathes by the motto, "success is 80% mental, 20% skill." With certifications in life, weight and wellness coaching, her specialty is helping new entrepreneurs get past fear and overwhelm, get their business up and running, so they can help change the world. Shortly after finishing college she started her first two businesses, but found herself burned out because they were not using her gifts. TaVona then used her skills as a physical therapist to start a physical therapy contracting company. Finally her own boss, the problem was, she basically created a job for herself, which was not the life she had envisioned. It wasn't until TaVona found the world of coaching, that she was not only able to successfully lose 80 pounds and keep it off, become an award-winning athlete, and build the business that would eventually provide the lifestyle she wanted. Speaker and author of, Unstoppable Success: How to Finally Create the Body, Business and Lifestyle You Want, TaVona teaches entrepreneurs the steps she used to create lasting success as a lifestyle, in weight loss and in business. She believes there would be less addiction in the world if people were courageous enough to walk in their purpose. She is on a mission to help people find their zone of genius and make money by making a difference. Read the full transcript below: Karen Litzy: 00:01 Hey TaVona, welcome to the podcast. I am so happy to be interviewing you live here in Nashville, Tennessee at Graham session. So welcome to the podcast. TaVona Denise: 00:10 Thank you for having me. Karen, I'm so excited to be here and to be speaking with you today. Karen Litzy: 00:15 Yeah, and I'm excited to have you because what we're going to talk about today is when a therapist, we'll stick to physical therapy, but this really could probably apply to most people in healthcare, let's say. But we'll stick with physical therapists because that's what we are. That's what we know. And we're going to talk about when, as a physical therapist, you kind of hit that crossroads in your career where you're not sure if what you're doing is what you want to continue to do. So TaVona, yourself as a physical therapist and as a coach, I'm sure you've seen this quite a bit. So can you talk to when therapists get to that crossroads and what you've learned from interviewing over a hundred different therapists? TaVona Denise: 01:03 Yeah. Well, it's a fascinating thing. I started to notice whenever I would remember to ask somebody, like, what year, how many years have you been in the game? What's going on with you? When they're coming to me for life coaching and they're thinking about making a change. The number 15 kept coming up. Every time I would write it down, they're like, yeah, I'm at year 15 I don't know if I was attracting them because that's about when I started to feel like, okay, I've been doing this 15 years. I know my job inside and out, backwards and forward, and I don't think I can do this for the rest of my life. And at that time I wasn't even 40 so I have plenty more work, work years left and I can't keep doing it. And so I just find that, especially for the women, either it's 15 years if they've gone straight through and sometimes it stretches to 20 if they have gone back into part time to rear their children. Karen Litzy: 01:56 Okay. And in talking with all of these therapists, have you found any common themes that they get to this 15 to 20 year Mark? And they're like, Ugh, now what? TaVona Denise: 02:09 Well, that's exactly what they say. It's like, now what? I know my job, I don't necessarily want to keep practicing in this way. I feel stuck. I don't know what to do next. And part of the problem is they do not have a passion for research, academia or management. And so many of them are thinking, well, should I leave the profession? And if so, what does that look like? What does that mean? Am I throwing my degree away? And so what are the options? There are several. I think one of the things that we have to do is take a look at, well, why did you get into the profession in the first place? And can you reconnect with that? Are there aspects outside of what you're doing that you can bring into what you do now to help judge it up and renew it? To me, some people have reinvented themselves and said, okay, well maybe I don't necessarily want to stay on the rehabilitation side, but maybe I want to practice prevention and wellness. So I think for some people that's an easier transition because they get the sense of I continue to use my degree and leverage it to do something that still helps people. Karen Litzy: 03:20 And if let's say I'm coming to you and I'm saying, Oh TaVona I just, I don't know what to do, I'm really stuck. I'm getting, you know, I'm starting to feel like I'm not making a difference anymore. So how would you, we can kind of go through a mock coaching session here. So what are some things that maybe you would want to ask me or want to know from me that maybe can help me figure out what to do next or what's your process like? TaVona Denise: 03:51 It really, really depends. Just like in an evaluation situation, like no two people are alike. So it depends on how they present, how they come to me. But I really want to know what do they enjoy at their job and what do they enjoy as a person working in a profession. Because sometimes there's an opportunity for a person to create a position for themselves or to create a program. And some of the clients that I've worked with have become what I call intrepreneurs. They have taken their skills, their expertise, their specialties, and then develop programs within the organizations that they work in, which it's a challenge. It's not as risky as being an entrepreneur and going off and doing it for themselves. They get to stay in that environment and not lose the years of service and PTO and all the perks and things. It's kind of like playing with the house's money so they get to do that. Sometimes it's a matter of just feeding the hobbies and things and taking time for themselves that they're not doing. Because we always hear the analogy of you have to put your own mask on first before you serve others. And so as caregivers, that's what we do. We care for others and sometimes we are forgetting to care for ourselves. So sometimes that's the approach we take. I find a lot of people, and this is also a strange one that I'm thinking about. A lot of people need to declutter their homes. Karen Litzy: 05:14 Yes. 100% yes. I'm just going to say yes to that. I'm Marie Kondo in my home like five years ago and I have to tell you, decluttering my home kind of decluttered everything else for me, even part my practice and my thought process and I was able to then expand and do things that I couldn't even imagine were possible. So proceed. TaVona Denise: 05:42 Yes, 100% it was interesting, I listened to a coach that specialized in a relationship. It was one time and she was like, you need to make space in your closet for the person that you want to come in and so if your closet is jam packed. There's no room for anybody else. And I think about that too. Now that we're talking about this, the decluttering process I think gives people space, like you said, expand space to think, to breathe. So that, that like every time they pulled into the garage and they see all the boxes in the junk, it's irritating them. And so that's just one more thing. If they can declutter that, that's something that they have control over where it doesn't have to do with the manager sucks, the coworker sucks, the patient's suck and all of this thing, we've got to go to all these meetings, we don't like you can control your space. So I think that's part of the empowerment process and having them have a sense of control over their lives and looking at how we do anything is how we do everything. TaVona Denise: 06:32 Yup. And so once we take a look at that, then they can use the skills that they learned to, to go into other things. And it really goes into thought process too. So a lot of people are holding on to things that they shouldn't be. It's beliefs that they shouldn't. Stories that they shouldn't, grudges that they shouldn't. And we literally unpack that stuff as they start to declutter their homes. And I also found that when I decluttered my home, I mean I have a garage, but when I decluttered my home, when I would come home after a busy day of seeing patients, I was coming home to a space that was calm and that was peaceful and comfortable. And so I wasn't adding stress of ah, God, I gotta go home, I gotta put this away, I have to do this, I have to, I didn't have to do anything when I got home except take the time for myself and relax a little bit. TaVona Denise: 07:30 And so for me, I felt like that was really helpful in almost like avoiding burnout, if you will, at that stage of my career, which is about the 15 year Mark. Karen Litzy: Yeah, I think you made an interesting point about the word have to, whenever I hear someone say I have to do something, my antenna goes up because it's a very disempowering thing to think I have to do something and whatever we have to do, we kind of resist. And so part of the resent and resent, right? So the burnout is coming from this resistance like, Oh, you can't tell me what to do. And so if we can just make that subtle shift to I get to do this thing, sometimes just that subtle shift of people thinking that they have to go to work. And this is really important for those who are considering building a business and they need to bridge, they can't just quit what they're doing in bridge, you know, it requires a lot of effort and energy to start a business as you know. TaVona Denise: 08:28 And so if we have that resistance and that resentment towards our job, that is actually paying the bills, right? We are exhausted at the end of the day and then there is no mental energy or emotional energy to put into our new baby over here. And so just one subtle shift. If listeners can think about anytime they say, I have to go to work, can you find the shift who I get to go to work and really be grateful and thankful. The things that go into work is providing you the opportunity to practice new skills, to make connections, to pay your bills without worrying about what it's doing to fund the software or the whatever that you need to in order to start this other venture. Karen Litzy: 09:09 Absolutely. And I think I'm so glad that you brought up the get to versus the have to, because I admit I'm a have to girl sometimes and so now I am going to remember to say I get to, because you're right, when you get to, you're coming from a place of appreciation and of gratitude and we all know there's a lot of research out there on how gratitude can make you happier and gratitude can make you successful, can contribute to making you successful. And so I think that's a really important shift. And now what, are there any other, let's say little shifts like that that the listeners can do if they get to that point where they're like, Ugh, work, I don't want to do it. TaVona Denise: 10:00 Well, one favorite exercise I like to give people, especially if people are just zonked at the end of the day and they like to carry work home with them. One thing I have people do is put a journal or notebook. It doesn't have to be fancy or expensive in the car. And so what it does is when you get into the car, you get the opportunity to let your brain have it. Say they get the fuss out, whoever they want to from the day they get to say everything that they didn't get to say. They want it to say they think they shouldn't have said and all of that on paper. And just that bit of detachment from it. They can more easily evaluated and see the truth or the lie of it. And when they do that one, the brain gets to say it and then let it be done. And I've found that many people have thanked me because in their relationships get better cause they don't go home complaining to the partner or the spouse. The other thing that it does is it gives a clear break from the day. So the brain can say, okay, we're done with work. I've said my say and I can go to the gym, I can go enjoy time with my honey, my children, my whatever. And there is that separation. Karen Litzy: 11:06 And in your experience in coaching, a lot of therapists, do they return to work? Do they switch gears? Would you, if you were to put a percentage on it, and I know that's probably tough and I'm making you do this on the spot here, but if you were to say, you know, after we came up with better strategies, they found the joy in their work again, or after coming up with better strategies, they were like, Oh, I think I want to do X, Y, Z. TaVona Denise: 11:34 I think it's so it's an interest in it, but it may be a 25 go back to work and they're excited and they're like, Oh, I'm renewed. 25% is like, thank you for those skills. I want to turn the page to the next chapter of my life and do my own thing. Whatever form comes in. And then there's this 50% that's kind of in the middle and they either don't move forward to practice the skills all the time. And we see this sometimes with fitness and anything in life, right? And I think, and here lately I've been wondering about that person, like what makes that person not move forward? And I've come to understand that that person is very much afraid. So we talked about those over 100 interviews I did last year. And in my note, taking some variation of the word fear came up in 90 something percent of those interviews. TaVona Denise: 12:34 And I thought to myself, well, what is really going on here? And what I've been thinking about here lately is how we in healthcare are taught to follow certain protocols and we're breaking out of that now, right? So people are not recipes and things like that, but there's still this underlying mentality that we need to have certifications that we need to follow rules that we need to play inside the lines and get it perfect and get it right. Because, I come from acute care background. So things that I do we do could literally kill a person. And so it can be very scary to make mistakes for the rest of us. It's very competitive to get into PT school. We were higher achievers, many of us athletes were used to getting stuff done and doing it well. After you've been in the profession for so long, it can be very difficult to be a beginner again and then be in something that nobody's written out. TaVona Denise: 13:28 A curriculum to tell you this is how to be an entrepreneur and be successful at it. And so people freeze. And I'm like, Whoa, I know the answer. Let's move forward. What? Why are we not moving forward? And it's something that I've come to understand is what I'm calling the confidence loop. So for example, a person may be uncomfortable in their situation and work, they want to make some kind of change is not really comfortable. They decide that they want to move to the next level. They're going to make some kind of change. The challenge is once they make that commitment, then the freak out occurs and it's like, well, I'm too old. I'm too young. I don't have this. I don't know what I'm doing. So and so failed. Right? So that's the freak out. What it requires is a bit of courage to take the first step and to keep on stepping. TaVona Denise: 14:18 That part, I call the gauntlet because it's very challenging mentally, emotionally, spiritually, sometimes, physically, depending on what the goal is. But if you can continue taking the moves forward and be consistent, what happens is you find clarity and you find competence. And from that clarity and competence where you know what to do and you know how to do it, people are confident. Like when you know what to do and you know how to do it, you're pretty confident. But when you don't know those things, you're not going to move forward. That can be paralyzing, very paralyzing. The problem is we're so used to knowing what to do. We won't keep invoking the courage to do enough of the things to be clear about what to do in house so that we can be confident. And the interesting thing that I realized about that was that when we were in PT school, that consistency was forced, right? TaVona Denise: 15:13 We had tests all the time that were given to us when we're in clinicals then should see, I would say go do that manipulation or mobilization or whatever, go take that as subjective like they forced us to do of it. If we decide to do something on our own, it's on us to keep moving through and to be courageous. And so that's what I call that pattern of the confidence loop that I've started to notice is why some people never get started in the first place. And the gauntlet part, that first part where it is where people get stuck. Karen Litzy: 15:44 Yeah. And that's why people need a coach sometimes to keep us consistent. Right? Like I interviewed Steve Anderson a couple of months ago, so Steve is one of the founders of the Graham sessions. Like I said before, we're in Nashville and he is now doing executive coaching, not necessarily with physical therapists but with different C suite executives. And he was talking about the need for a coach. And one of them is accountability, which leads to consistency, right? And he said there's a reason why Roger Federer, who is one of the best tennis players in the world. You think, what does he need a coach for? He's already great, but he has a coach because that coach keeps him perhaps motivated and consistent and accountable. Yeah. And it's like, you know, we talk about doing exercises and we tell our patients all the time, you have to do this daily. Every other day. You have to be consistent and yet consistent physically, but being consistent mentally still changes the brain. TaVona Denise: 16:47 Oh, 100% I think the other reason why coaches in the way that I coach people is in finding the blind spots, right? So one form of coaching is to hold a person accountable. Did you do what you say you were going to do? And that forces the consistency so that you can move into clarity, competence, and confidence. One of the things that I'm very good at and work on with my clients where you were talking about the mental exercise of, okay, the courage, where is the fear coming from and can I help shine a light in that blind spot so that you can see that it's not as bad as you thought it was. So the big example that I have is many times when we would do a total knee or total hip replacements, the moment I would open the door to the stairwell, people would freak out. TaVona Denise: 17:33 Oh yeah. Because the fear of the fear or the anticipation of pain is worse than actually doing the thing. And so part of my job as a coach is to help coach them around that fear of anticipation of pain and to understand where it's coming from so that they can unlock themselves. Karen Litzy: Yeah, I mean fear is a very powerful emotion and it can take many, many forms, which I'm sure you've seen, like not all fear is, Oh, I'm not going to do that. Sometimes fear could be self-destructive. We could be self destructive to ourselves or to others around us out of fear. And so if you were to give any advice for people who are at that point where they've got everything lined up but they're not taking the step because of fear, what do you say? Well that's a loaded question, right? TaVona Denise: 18:43 So going back to the journal is a very, very powerful tool if you're not working with a coach and you're trying to do this on your own. But the simple question of what am I afraid of? What am I afraid of? And if you will, after you asked that question, don't just ask it and just have like in your brain, like actually write it down because there is some power in the scene, the written word, and you giving yourself that distance because once it's on the page and out of your head, you can actually analyze it and see is that true and how can I mitigate the things that I'm afraid of happening? So Tim Ferriss calls it fear setting as opposed to goal setting. So what am I afraid of? What's the worst that can happen? And he borrowed some of this technique from stoicism and he asks you to answer those questions for yourself and see, okay, well I'll be out on the streets. TaVona Denise: 19:39 Well do I have family that I could stay with? He did. He actually went and did some couch surfing for a while before he took the leap. So he went and stayed on people's couches for a couple of weeks so that he could be in that space of is it actually that bad to have to sleep on somebody's couch or eat ramen noodles or something like that. So like what am I actually afraid of and write it down. Karen Litzy: So, if I'm getting this concept correctly, and you can correct me if I'm wrong, so you write, what am I afraid of? Kind of write those fears. And then what's the worst that can happen if that fear were realized? Is that what you're kind of writing? TaVona Denise: Okay, that's exactly right. So what am I afraid of? And what if this actually happened and how can I mitigate it? Got it. And he actually goes and practices it so that he can feel like, Oh, that's actually not that bad. Even if it does happen. And that you may even have more resources than you thought you did if your worst fear were realized. So again, I think it forces you to write things out and say, Oh well maybe isn't that bad. Karen Litzy: 20:48 Or maybe it is really bad. I don't know. I guess it could go both ways. I'm not sure. TaVona Denise: 20:54 Well, they could. So one of my mentors says, whenever you choose to do something or not to do something, make sure you like your reason. TaVona Denise: So, so many people are one, unclear about what they want in the first place. And two, if they know what they want, they're just not taking action, but they can't articulate why. So I just think if you can just start with that, those two simple questions that will give you a lot of information to get started with. You can find your why right. In some minuscule way in your life. Right? You can kind of find that why, which is often elusive to too many people. Yeah, I can because a lot of people, I think that's another thing that I've found is just the simple act of asking you what do you want? Many people are quick to tell me what they don't want and when they're very clear on what they don't want, but they can't tell me what they do want, they're also not going to make a move. Karen Litzy: 21:53 Got it. So all of these little tricks that we play in our minds can work against us in so many ways and we don't realize it until we either, like you said, journal it, write it down, have an external eye, take a look at what you're doing to kind of shine that blind spot right into your face so you know what's going on. And then also just, I think, like you said, decluttering and really getting to the bottom of why at this point in your career, are you feeling the way that you're feeling? Trying to recap a little bit here. Yeah. Is that good? Okay. All right. So now in before we kind of wrap things up, I have a couple other things to ask, those were the key takeaways from our conversation, but what do you want the listeners to really kind of take with them? TaVona Denise: 22:50 I think we hold ourselves back unnecessarily. So I think it would be, if I were to give you like a step-by-step, if you will, a rough step-by-step is to one, figure out what you want, understand why you wanted, because the understanding of why you want it will help you move in the face of fear. Just like when we went to PT school, we had, there was a lot of fear involved and we moved through it anyway because we had a reason, right? So know what you want, know why you want it. Understand that fear is allowed to drive, ride the bus ride side car, but not allowed to drive the bus. And it's really going to be okay if you think about that confidence loop and I can share a diagram with you so that people can actually see a visual of it. But if you think about it, if you just keep going, you will get there. If you just keep going, you'll get there. Karen Litzy: 23:53 Yeah. And I think to that point in a digital age where everything happens at the speed of light, that can be difficult because what if it takes longer than you think it should take? Right. So expectations, let's talk about that for a second. TaVona Denise: 24:14 Yeah. Because speed of light microwave society, here's something that I've been noodling over here lately. We want our business to take off like in 60 to 90 days. And Jen and I were talking about that today. Oh yes. And I was just thinking about this, like, why is that even fair? You need to learn marketing. You need to learn sales, you need to build an audience. I mean, there's so many pieces that you need to learn. If you would just flip the switch. So from have to versus get to right. Here's another little mental switch. What if it was just like going to PT school? So what's the average length of PT school now? Is it two and a half, three years? Yeah, so let's just say three years. What if you just said, I am going to learn what I need to learn all of these pieces of business and I'm going to not expect anything for three years and if I'm not as consistent as I was in PT school, which is full time, I don't think anybody can work and do PT school. If I am not putting in that amount of hours in that amount of effort that I did in PT school for three years, then I need to add a year for however much time and effort I didn't put in. If we can do that and give ourselves the mental space, time and grace, if we thought about how hard we worked and how long we worked in PT school and apply it to business, nobody should expect anything before three years of full time work and then it'd be great if it happens in a year. Karen Litzy: 25:45 Yes, I agree. I think oftentimes people are fed false hopes and expectations in marketing ploys and whatnot, and that's just not how it works. It just, it just doesn't work that way and you got to work at it. And I think I agree with you. I think your expectations have to be realistic and to have a successful business in 60 to 90 days is not realistic. It's just well put, it ain't going to happen. Not a chance. Yes. So expectations are huge. Thank you for touching on that. Okay. Did we miss anything? TaVona Denise: 26:25 Not that I can think of. Karen Litzy: 26:26 All right. Cool. Cool. All right, so then the last question before we get to how people can get in touch with you is knowing where you are now in your life and in your business, what advice would you give to your younger self as a graduate out of PT school? So this is advice to you from you, from future you, to past you from future. You got it? TaVona Denise: 26:57 Mmm. Don't be afraid to take risks. It's all going to be okay. The things that you think were for you that don't work out actually happened for you. Karen Litzy: 27:19 Excellent. Excellent. So again, going, looking back, you can say to yourself, man, I was so upset that X, Y, Z didn't work out. But look where I am now. TaVona Denise: 27:31 Oh yeah, yeah. If I didn't get that great management position that I thought I was going to get. I wouldn't have gone to Costa Rica to Spanish immersion school if I didn't. If I got the other management position that I thought I was going to get that I didn't get, I wouldn't have written a book. I wouldn't be here talking to you all today. Karen Litzy: 27:49 Amazing. What great advice. I love it. Now. Where can people find you and find out more about what you do? TaVona Denise: 27:55 Yeah. you can find me anywhere on the web at TaVona Denise. I'm most of the time on Facebook, sometimes Instagram and Tavonadenise.com. Karen Litzy: 28:11 Perfect. And just so for all the listeners, we'll have links to all of that under the show notes for this episode at podcast.healthywealthysmart.com one click will take you to everything that TaVona has an and can offer to you. So TaVona, thank you so much for coming on. This was great. All right, 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 Dr. Howard Luks on the show to discuss knee osteoarthritis. Dr. Howard Luks, MD is an Orthopedic Surgeon practicing in Westchester and Dutchess Counties in New York. He specializes in the management of complex knee and shoulder injuries with a focus on ACL injuries, Patella Dislocations and Shoulder Instability. In this episode, we discuss: -What is knee osteoarthritis and how is it diagnosed? -Modifiable risk factors for developing knee osteoarthritis -Indications for a total knee replacement -The importance of managing expectations for good patient outcomes -How to strengthen the physician therapist relationship for more patient centric care -And so much more! Resources: Howard Luks Website Howard Luks Twitter Howard Luks Facebook Howard Luks Youtube A big thank you to Net Health for sponsoring this episode! Check out Optima's Top Trends For Outpatient Therapy In 2020! For more information on Dr. Luks: Howard Luks, MD - @hjluks - is a patient centric, Orthopedic Surgeon who has been in clinical practice for 20 years. Dr Luks utilizes his passion for patient engagement and his expertise in medicine and social media to educate a global audience through his website, twitter, facebook page and YouTube channel. He serves as a consultant, board member and adviser to many companies in the mobile health, online health platform, and medical decision making start-up spaces. He served on the External Advisory Board of the Mayo Clinic for Social Media - a recognized leader in this space. "Technology is not about replacing physicians ... instead, we must remember, change brings opportunity — and we must use these changing times to scale great physician thought leaders." - Howard Luks Howard Luks, MD (@hjluks) is an Orthopedic Surgeon practicing in Westchester and Dutchess Counties in New York. He specializes in the management of complex knee and shoulder injuries with a focus on ACL injuries, Patella Dislocations and Shoulder Instability. As an early adopter of Twitter, Howard Luks MD also runs a blog (>100,000 unique monthly viewers), a Facebook Page, a YouTube channel and a personal site to educate, interact and engage a worldwide audience. Read the full transcript below: Karen Litzy: 00:01 Hi, Dr. Luks. Thank you so much for coming on the podcast and really looking forward to this today. Howard Luks: 00:06 My pleasure, Karen. I'm looking forward to it too. Karen Litzy: 00:09 Okay. So today we're going to be talking about osteoarthritis. You had a great tweet thread back in, I believe it was the end of June, beginning of July, 2019 on osteoarthritis and got a lot of positive responses from people and I really wanted to talk to you a little bit more about osteoarthritis. First thing is what it is and what it isn't. So I will hand it over to you. Howard Luks: 00:40 So the reason why I decided to put that thread up was based on the fact that I keep hearing people become worried thinking that their body is wearing out and that our arthritis is a mechanical process and wear and tear process. So they're going to stop walking. They're gonna stop riding, they're gonna stop running, they're gonna stop their exercise. So in other words, they're going to increase their risk of dementia, heart disease, hypertension, diabetes, and other metabolic disorders because they think they're saving the lifespan of their knee. So in order to get across that osteoarthritis is really a biological process where the articular cartilage is starting to degenerate for various reasons and that their activity actually, if anything is beneficial is what led me to write that whole series of tweets. And I followed up with another one a few months later. That then started to throw in all the exercise patterns and activities that people can in fact pursue, especially with respect to runners. See, since I seem to attract a lot of runners, I wanted to be known that running is not damaging for a knee that doesn't have any significant mechanical issue or is recovering from a fracture. Karen Litzy: 02:22 And when we talk about osteoarthritis, oftentimes people will come to us as physical therapists and they'll say, Oh, well, you know, it's bone on bone. That's what the x-ray shows bone on bone. So how do you respond to that? And how should a physical therapist respond to the patient in those scenarios? And in a way that doesn't undermine the physician that referred them to us, but being consistent with the evidence. Howard Luks: 02:51 It's quite a challenge, right? I mean, yeah. The interesting thing I always talk to our residents about is that, you know, I'm 56 now and I'm just starting to get really good at patient interactions and discussions and conversations in the office just in time for me to retire. And I talk about the fact that words harm, images, harm, and you really can't unsee your MRI or xray report. So it all comes back to communication and education. And that's one of the biggest problems in healthcare today, right? We're RVU driven. You guys are strapped if you're a network, you know, you can't make a living of $40 per hour. And so we're all seeing more people in less time and that really threatens our ability to have a good, actionable and meaningful conversation with people. Yet it's absolutely critical that we do so. Howard Luks: 04:02 So if I put an X Ray up showing bone on bone arthritis, I then immediately enter into a conversation about how you really treat people, not an image. And that even though they're bone on bone, you know, most likely I'm talking to someone who doesn't have severe quality of life limiting knee pain more often than not, and you know, a bone on bone knee that's relatively dry, meaning it doesn't have a significant effusion, it's really not going to be too terribly painful. You know, the bone itself isn't what hurts, you know, bone marrow edema hurts, synovitis, hurts. But not the bone itself. So I explained that I've run with people that I know have bone on bone arthrosis yet. I explained that I've also replaced knees in those with less severe arthritis because they had severe synovitis or bone marrow lesions that just wouldn't go away. Howard Luks: 05:16 So it's important to talk about the fact that the xray has only one small part of the overall evaluation and a very small part in determining what the treatment or treatments could be or should be. And that it really it's their story. It's their history, it's what they're telling us. And you know, when it hurts, how often it hurts and how severe that pain is. That's more important in terms of how we craft our treatment plan. And when, you know, I had a patient today actually asked me, well, when, when do you know, as the patient, when do you know that you need to have a joint replacement surgery and we'll stick with the knee. Karen Litzy: 05:58 So when your patients come in and they asked you that question or you talk to them about the possibility of a total knee replacement or a partial knee replacement, what do you say and how does the patient know? Howard Luks: 06:23 Huh, that's a great question. And it's one that I'll get probably 15 times tomorrow so the discussion usually goes as follows. It's, you will know you're going to wake up one day and say, I just can't take this anymore. I've tried X, Y, and Z. I've done my exercises, I've lost weight, I have adjusted my diet. I've tried over the counter medications, Savage's bombs, ointments, suction cups, tape and everything else that their friends have told them to try and their pain is limiting their quality of life. So that's, you know, a very important part of the decision making process is you have to dive into their goals, right? You can run into a lot of trouble with people between 40 and 65, 40 and even 70, depending on how active they were, because you might have someone who's miserable, but it's simply because they can't play singles tennis anymore. Howard Luks: 07:37 Right? It's like having someone with shoulder pain in your office because they can't hit a second lob as like they used to. You know, that person who's going to be really unhappy with the results of surgery. Same with the knee replacement in someone who can't play a second set of tennis but could easily finish, you know, a three set doubles match. So we have to determine when the patient feels that their quality of life has suffered long enough that they wish to move forward. Then we need to dive into what their goals are. It should be simply that they want to get through their day without this horrible knee pain. Because if it's anything other than that they may not be all that satisfied with the end results of the surgery. Karen Litzy: 08:33 Yeah, that makes a lot of sense. There's a big difference between the person who's having trouble walking from, you know, their bedroom to the bathroom or like you said, the person who can't get in another set of singles tennis. They're very, very huge quality of life differences there. Although that second set of tennis might be disappointing. It's different than not being able to walk a block. Howard Luks: 08:57 Correct. And we know, you know, both of us know there are significant number of knee replacement patients who have persistent pain after surgery and who are not happy with the overall results. And many times that might trace back to false expectations. So it's a really important discussion to have. And we also know there are many different patients out there. You know, there are some who have achiness and pain when they roll out of bed, but by the time they're done with their morning shower, they feel fine. Yet those people, some of those people might tell you that they want to have their knee replaced. So again, it's really important to dive deep into the reason why these people want to move forward and what their goals are. Karen Litzy: 09:54 Yeah, I think that's a great point. Thank you for that. And now I just want to go back to one thing. When we were talking about osteoarthritis, one thing we didn't talk about were factors that may lead people to be at risk for osteoarthritis. Do we know what some of those factors are? And if so, are they modifiable? Howard Luks: 10:14 Sure. So first, you know, the, the big category now that requires everyone's attention is our metabolism. You know, we are bombarded daily now, especially on Twitter with all the ELA facts associated with a typical or standard American diet full of ultra processed foods. I'm not gonna get close to the Quito vegan world and subdivided. However, it's really important that people start to read this literature about the dangers of ultra processed foods. It's very clear that a calorie is not a calorie and that a hundred calories of ultra processed foods versus a hundred calories of real food is going to have very different metabolic affects on us. And we're finding that people with high homocysteine levels have a higher incidence of heart disease, cardio metabolic issues as well as joint related issues. We're finding the same with uric acid levels, which will my car lay with your fructose intake. Howard Luks: 11:38 So high fructose corn syrup, we find a correlation with lipid disorders and the prevalence of osteoarthritis people's weight will certainly have an impact. A lot of people don't know that what each step you take, you're putting, you know, five to seven times your body weight across the knee with each step. If you're achieving 10,000 steps a day, you weigh 250 pounds, you have an extra 60 pounds on your knee across 10,000 steps. That's a lot of an added weight across that knee. Now for those who do not have osteoarthritis already, that might not initiate the process for those in whom the process has started. An MRI studies on asymptomatic people show that the process has started in a majority of us over 50, then that excess weight and force or stress burden is certainly going to increase the risk of developing a more rapidly progressive arthrosis. Howard Luks: 12:50 Now by far the most common causes are genetics and people with structural issues. So a varus or Bodine or valgus or knock kneed that will set you up for unit compartmental changes or changes in either the middle or the lateral compartments. Why we seem to see a pretty severe patellofemoral disease and in some middle aged women, I'm not exactly sure, perhaps it's some degree of underlying map tracking. But in terms of the modifiable risk factors, without a doubt, our weight, our activity level, it turns out as we, as we just said, that's right. This is less common in runners. Cartilage likes that cyclical loading and likes to be exposed to force in a cyclical manner. I think we hit on many of them. Karen Litzy: 13:54 Yeah. And then the only other thing I can think of is previous surgeries. So we know like ACL having an ACL surgery or ACL disruption, the majority of those people do develop osteoarthritis later in life. Especially if you're, you know, most of them happen when you're younger, usually. Howard Luks: 14:13 True. So you're absolutely correct. So upwards of 50% of people who have had an ACL tear will go on to develop arthritic changes. Even having just one Hema arthrosis, you know, blood in your joint elevates your risk of developing osteoarthritis because it changes the chemical compounds that's present in the knee. Once that has happened, now you'd go ahead and you add a mechanical issues such as a meniscus tear and your risks really start to go up dramatically. Karen Litzy: 14:54 Yeah. And, I mean I have seen patients in their forties you know, who have had multiple ACL reconstructions on their knees cause they were high level athletes in their younger years. And those are people who, you know, we were talking about the people who can't play tennis versus the ones who are having trouble walking down the street. Those are the people that are having trouble walking down the street and they know it, but they're doing everything they can to not have the surgery as well. So it's, it's an interesting group. Howard Luks: 15:25 Correct. And they're not harming themselves. I don't care if you're limping if you can get away without having your knee replaced, you should do so. Karen Litzy: 15:37 Absolutely. Absolutely. Certainly, certainly I think, you know, oftentimes people will hear, Oh, it's knee replacements are not that bad. It's not like it was years ago, but I mean, it's not great. Howard Luks: 15:49 Huh? Yeah. So there's, you know, the only surgery without risk is a surgery on somebody else. Yeah. If you're assuming an infection after a knee replacement has a low incidence, right. A 0.7 0.8%, but it's a life altering permanent problem. You know, you're going to need one to three operations to try and eradicate that infection. And if it's a nasty bug, it's going to end in an amputation. So, you know, are there a lot of amputations that happen each year because of knee replacement infection? No, but there are not zero. And there are a significant number of people who have persistent pain. I've looked, I perform a lot of knee replacements and I think it's a great operation for the right person. So there are significant upsides to a well functioning knee replacement and the vast majority of people are not going to get infected. However, when you start to push indications and you start to stretch them if you get into trouble with one of those people, that's an awful place for them to be. Karen Litzy: 17:06 Yeah. Yeah. No question. No question. And now what I'd like to do is we've got a couple of questions from listeners that some of them are about you in particular and the way that you practice others. Again, continuing on the osteoarthritis subject. So one was from physical therapy and they're all from physical therapists. Gina Kim said, how do you set expectations for patients, especially for active busy ones, that conditions such as osteoarthritis, frozen shoulder can take months to resolve or can be something that you're managing, let's say. Because I would say osteoarthritis is something that you're managing. Howard Luks: 17:49 Correct. And sometimes the frozen shoulders too. So any of our patients with these longterm chronic conditions can get into trouble, especially when they're used to being high level weekend warrior as an athlete. The, you know, my goal is to keep that runner running. And most runners, if you sit down and say, look, we don't think that arthritis, we know that arthritis is most likely not caused by running. We really don't think that you know, running five miles at a reasonable pace is going to cause her arthritis to worsen more than it already has and more than the normal disease course will worse than that. So we think it's okay for you to keep running. 90% of real runners are going to take that and run with it, so to speak. They are not going to stop. And there's really no reason for them to stop, cut, stop. Howard Luks: 18:54 Cause a runner that stops running is not a whole person anymore. It's really embedded in our psyche. They're very unique people to deal with. So oftentimes we're seeing a runner with a little swelling after a run, we're seeing them a little, a little achiness and pain the next day. Perhaps they can't run as fast as they used to or they have pain going down Hill. So they will very readily work with you. So what I will immediately start doing is dive in to their typical week. How many miles are they running? What pace are they running, what zone are they running in? Are they Hills or are they technical trails and the carriage are they road? I don't necessarily push people onto trails or onto roads but I might pull them off a technical trail or off of steep Hills. And I'll try to work with them. Craft a workout pattern and running strategy with them that will lead to very much acceptable or tolerable levels of knee pain. And then once they understand that the etiology of a cause of their arthritis and they understand you really didn't do anything wrong, it's not the running that led them to this point, most are okay and most will fight through again, a reasonable level of discomfort in order to allow them to run. Karen Litzy: 20:35 Yeah, and I think that's the last thing you said is so important because oftentimes when people have more persistent pain, and I can say this from my own experience is when, when we, I guess I can say we, I'm part of that group. Oftentimes when we do things and it results in pain, we think that we're causing more damage. And I think it's really important that last point that you made that, Hey, listen, you might have a little bit of pain, a little bit of swelling, but from what we can tell, we know this isn't doing further damage. It isn't sort of creating more wear and tear. And I think that's really important to get across to the patient. Howard Luks: 21:16 I agree. I mean, if I start to get stress fractures and stress reactions and book painful bone marrow edema, lesions, you know, I'm going to change. But as I alluded to earlier, you know, imagine a runner who stops running out of fear not because of the level of pain. You know, they're now increasing their risk of any number of chronic diseases, right? Alzheimer's and heart disease and hypertension, diabetes and on in the, you know, in the hope that maybe they're going to save their knee and save the knee from what? So if, you know, a lot of them, even if, even if we knew that running caused it, they would sacrifice their need to keep, you know, their head clear from the benefit that they derive from their weekly run. Karen Litzy: 22:21 Yeah, they're a motivated bunch, that's for sure. And, and motivated because like you said, it's the running. So when you're a runner, it's your running that allows you to do the rest of the things in your life. That may be work. It may be dealing with family, it may be dealing with colleagues that keeps your head clear. It could be meditative. So you're taking all of that away by saying you just have to rest. You don't, you shouldn't run anymore. Howard Luks: 22:46 Correct. Karen Litzy: 22:47 Dangerous. Okay. Dangerous stuff. So let's go onto another question, Miranda Henry, and I think this is a nice question is how do you see the evolution of the patient doctor physiotherapist role in the care of osteoarthritis? Cause we know we've got baby boomers getting older, osteoarthritis is most likely going to be more prevalent. So how do you see that evolution of care from those roles? Howard Luks: 23:15 Sadly, in this environment I see it dwindling, which is really unfortunate, right? Because it should be increasing. There should be a direct electronic or otherwise communication between our offices. You know, we both have these five page electronic medical record nightmares that our office produced that we fax to each other, you know, for signatures to send back. Yet it doesn't have much actionable, useful and meaningful information. I have a number of a number of therapists who are my go to people in my region. And you know, we're on the phone a lot. Trying to share details about certain people in terms of progress yeah. Or roadblocks or other issues and what and why they're sending them back or why they're not. And it's, you know, an open channel of communications is just so critical. And we just have to keep in mind regardless of how busy and crazy our lives get as healthcare providers, that it really is a patient's life and wellbeing that's sitting at the end of these phone calls and things that are easily perceived as nuisance irritation. And so yeah, it is worth it in the end to go the extra mile and make that phone call. Karen Litzy: 24:51 Yeah. And I think you just answered that with that answer. The next question is what do you see as the best way for that PT doctor patient to align themselves for best patient outcomes? Which I think you just answered. Just having good communication channels and being able to keep in mind that the patient is at the center. Howard Luks: 25:13 Correct. Yeah. Can't forget that. Karen Litzy: 25:15 No, that makes perfect sense. I think you just answered it. And then finally, this is from Mark Rubinstein said what or who inspired you in your holistic approach to promoting health? Combining traditional orthopedic medicine with sort of lifestyle medicine? Howard Luks: 25:32 Ha. Good one. As I alluded to, as I said before, you know, you start to get much better at determining talking to people, listening to people asking the right questions. You know, my exam starts when I watch them walking in the hallway, you know, before you sit down on your stool, you know more about that patient. Then half the words they're going to say are going to tell you and you learn how to craft your messages and craft your, you know, your treatment plans accordingly and you find out that non-surgical management is often really effective. Then you realize, okay, you're 56, you know, what are you doing to change your life? So, you know, probably about six years ago I started to optimize my own lifestyle for my, not only longevity but health span, right? I want to go to the very end, hopefully running and then just drop off. I don't want to spend my last 10 years on cane's going to doctor's offices, being hobbled, being frail, et cetera. So as I started, you know, a lot of the more recent blog posts that I've written, I've just done in an effort to help me learn the topics. Karen Litzy: 27:12 That's a great way to, it's a great way to learn. Howard Luks: 27:14 Right? Because I'm pulling all these papers and I'm doing all this reading. I might as well write it down on my website and share it. And so it started with my diet and then it started with a sleep. I read Matthew Walker's book and then it started to, it was exercise and muscle mass and atrophy, sarcopenia and everything else written about. And then you start to dive into the metabolic literature and you realize, Hey, you know, this is really important for our patients. And that's another motivation to get it up and get it on the website. And as we all know, it's really hard to change many people's habits, but if they have actionable information, if they have a thorough understanding of why they need to do this I'm getting a lot further with people in terms of committing them to dietary change, lifestyle changes, activity changes than I ever had in terms of success before in my career. And I think maybe it's just cause I'm communicating it better and perhaps cause I'm leaving it up on my website for them afterwards to revisit and share it amongst their family. Karen Litzy: 28:48 Yeah. And they can kind of take a deeper dive into it after they leave the office and say to themselves, Oh, okay, now I think this is making more sense. Cause like we've all been to doctors. I mean sometimes you go in and you're like, Oh man, I really wanted to ask this question and I didn't. Or Oh he said this thing but I forgot. And so to have that backup on your website I think is probably really helpful. And like you said, is most likely helping you get some greater buy in from your patients do I think is fantastic. And I think it's also important to note that when you're writing that you're, at least, this is what I get from your writing style, is it's very relatable and approachable and it's so, it's very, I think patient forward. Howard Luks: 29:33 You'd be amazed at the comments that I get from editors editors or publishers or writers through channels, how unhappy they are with my writing style. I'm like, just, you just have to leave it alone. It is what it is. Karen Litzy: 29:50 Yeah. And if it's relating, if it's relatable to your patient population, great. Correct. Great. All right. So before we wrap up, what are the big takeaways you want people to leave with this discussion today? Howard Luks: 30:06 So yeah, in an effort to save your knee, don't throw the rest of your health under the bus. You're not gonna save your knee. You can't stop arthritis from progressing. You can't cure it. You're not gonna waste your money on $10,000 in STEM cells cause that isn't going to work. You will know the day that you need your knee replaced. And hopefully your surgeon or therapist will help you better define what your goals can and should be following a knee replacement. Don't forget how important our entire lifestyle is in shaping how much pain we are going to have, how long we're going to have that pain and how long we're going to suffer with it. Our sleep matters. Our diet matters, what we stick in our mouth matters and our activity levels matter. If you don't optimize for your wellness today, you're gonna end up preparing for your illness and frailty later. So there's no better time to get moving. Karen Litzy: 31:18 Great advice. And now last question I ask everyone is knowing where you are now in your life and in your career, what advice would you give yourself as a newly minted doctor? A new graduate from medical school. Howard Luks: 31:34 Yeah. you're not as good as you think you are. Right? You know, all these young docs on Twitter, I get a kick out of them, you know, they're great, but, and I wasn't any different. You know, the world is far more black and white when you're younger then as you get older but yeah, pay more attention to your elders. Pay more attention to your patients. You don't always have the right answer, you know, and just be willing to admit sometimes you don't know. And then look for the person with the knowledge and experience who can help you. Karen Litzy: 32:22 Great advice. Now, where can people find you if they want to read your blogs and find you on social media? Very important. Howard Luks: 32:28 Just put my name on Google. I think I own the first 10 pages. Karen Litzy: 32:33 Perfect. And we'll also have links under this episode at podcast.healthywealthysmart.com So if you want to get all of Dr. Luks' info, it'll be right on the website here as well. Awesome. All right, well thank you so much for taking the time out. This is a great conversation and I hope you have a great start to your 2020. 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 Ryan Burklo on the show to discuss financial planning for small business owners. Ryan Burklo, RICP® is a financial planner, host of the podcast Holistic Finance, and co-owner of Quantified Financial Partners. Through his work as a financial planner, he works with medical practice owners to protect their practice, keep them financially efficient and assist with their eventual exit. In this episode, we discuss: -How to manage debt financing and make it work for you -What is tax efficient cash flow planning? -Retirement options for small business owners -The conversations you need to bring up with your financial advisor -And so much more! Resources: Quantified Financial Website Holistic Finance Podcast Ryan Burklo Twitter A big thank you to Net Health for sponsoring this episode! Check out Optima's Top Trends For Outpatient Therapy In 2020! For more information on Ryan: Ryan Burklo, RICP® is a financial planner, host of the podcast Holistic Finance, and co-owner of Quantified Financial Partners. He lives in Seattle, Washington with his wife and two kids. After learning his son had a stroke while in utero he became an avid volunteer for Pediatric Stroke Warriors. He learned much about the medical professionals who cared for his son and truly enjoyed working with them both on a personal and a professional level. Through his work as a financial planner, he works with medical practice owners to protect their practice, keep them financially efficient and assist with their eventual exit. His firm and his personal mission is to simplify finances so that you can focus on what you enjoy most. Read the full transcript below: Karen Litzy: 00:01 Hey Ryan, welcome to the podcast. I'm happy to have you on. Ryan Burklo: 00:06 Thanks for having me. Appreciate the invite. Karen Litzy: 00:08 Yeah. And you know we're getting onto the end of the year and people are starting to think, look back on the year, look forward to next year talking about their businesses and maybe how they can move forward, expand, stay the same. Lots of stuff. But today we're going to talk about kind of the business side of things. And I absolutely love having people like you on the program because I didn't go to school to be a financial planner. I don't, I don't know what I, you know, this is not my specialty. So I love having folks like you on because I feel like I learned so much from you guys, plants and seeds in me that make me think, Hmm, maybe I need to make some changes in my practice. So thank you for coming on. Cause I'm definitely excited. Ryan Burklo: 01:06 Yeah, I again appreciate being on. I actually started laughing when you said you didn't go to school to be a financial planner cause I was about to say neither did I. I think very few of us actually go to school to officially become a financial planner. I think it just kind of molds it's weighing falls into our lap. You know, life's events occur in the next, you know, you're, you know, you're in the industry and so it's very interesting. Had you told me that I would be a financial planner when I got out of college, I would have said you're drunk. I love what I do. Karen Litzy: 01:41 Yeah. And here you are helping and I should mention that you do work with a lot of medical practices. Ryan Burklo: 01:50 Yeah, that's really a majority of our focus is helping medical practices on the business side and merging that with the person side. Cause eventually we all exit our practice in some way, shape or form. And it turns into the personal side. So, you know, the two are married, yet business owners tend to only focus, they focus more on the business side because you know that that's the fun side. That's what they do every day. Karen Litzy: 02:19 Exactly. Exactly. And so it's great to have people like you guys to help guide us through that. And now, you know, I've been taught, this has been in the news quite a bit. I had, you know interviewed someone a couple of weeks ago about debt and we hear debt a lot in the news. Mainly the focus is student loan debt, but there's all kinds of debt, right? And when you're a business owner, you may be in debt, you may not be in debt. But my question is, can debt work for you? Can it be a good thing sometimes. Ryan Burklo: 02:56 Yeah. Yeah. I mean the quick answer is absolutely yes. You know, you brought up the media and everything we're hearing in the news and right now it's a lot of student loans. But you know, oftentimes there's also, you know, just debt is bad is the mantra and you should pay it off as fast as possible. And in some scenarios that makes sense in other scenarios that doesn't, you know, really depends on what kind of debt it is. You know, credit card debt for the most part isn't the best that I have because it tends to be high interest rate, right? You're getting in the double digits, 16, 17, 20% or so. But then there's other debts. Student loans can be one of them. You know, mortgages on real estate and other debts that are lower interest rates and you have to look at it at, if I'm going to put a dollar towards that debt, if I put my dollar elsewhere, how would that act? Ryan Burklo: 03:52 How would that do differently? Right? And so the simple example of that is, you know, right now you can get a mortgage really, really inexpensive, you know, 3.8% or something like that on a 30 year mortgage. And so if your dollar can be put back into the business or put elsewhere and beat 3.8 at a relatively low low risk, well then you'd be better off putting your dollar elsewhere. Cause then you'd be making money on your money so you're leveraging that debt so your money can work harder. Whereas the credit card debt that I mentioned, you know it's a 20% interest rate. Well now I used to be 20% that's a lot harder and the risk is a lot higher. Karen Litzy: 04:38 Got it. So, so for instance, if you take on the debt of a mortgage, whether that be, you know, let's say you bought a building for your practice or you bought space for your practice and like you said, the interest rate is 3.8% then that might be a good thing for your business because you're putting that money to better use for you or the equity is in the building is good. Is that kind of what you mean? Ryan Burklo: 05:07 Well, to put it in another way, if you had $1 million of cash or $1 million sitting somewhere and you went to buy real estate and real estate was worth $1 million, we get to put the whole thing down, the million dollars sitting wherever it's sitting versus getting a debt and having to pay interest on that debt. You have to analyze what could that million dollars would be doing for you, and if that million dollars could be doing something better than a 3.8% yeah, we were just talking about why would you give the full million dollars to the bank. Got it, got it. And then you have the flexibility between it. All, right? Even if you're, maybe if you're just breaking even some people will get nervous about that too. We'll, again, you've got $1 million. How much more can you do with other stuff in your business because you've got that rather than just giving it to the bank, what type of flexibility do you possibly lose? Karen Litzy: 06:15 Got it. Got it. Ryan Burklo: 06:16 So that's just a simple example that I like to use. And that's not to say that you shouldn't pay off some debts. It does go by case by case, but you have to look at what your dollar could be doing elsewhere. And does that make more sense rather than only looking at it, well, Ryan, I'm going to pay more interest over 30 years. That's 100% true. And what could that dollar the other dollars be doing over the next 30 years? Karen Litzy: 06:42 Got it, got it. So it could mean the difference between investing it into something that's going to give you a higher return or putting it to use elsewhere instead of hiring another doctor. Ryan Burklo: 06:54 Well, another position that's going to grow revenue by X percent, that might be the better solution. Karen Litzy: 07:04 Got it. Got it. See, this is why, you know, my brain does not work this way. This is why I need someone to kind of break it down and explain it to me as if you were explaining it to like a fourth grader. Ryan Burklo: 07:18 Yeah. Well, my industry doesn't like to do that, but we like to confuse people. I try to make it as simple as possible because that annoys the crap out of me. Karen Litzy: 07:25 Yeah. I appreciate that. All right, so that's a great way that we can kind of make debt work for us. If you have, are there other ways, I guess that you can make debt work for you? Any other easy, simple examples? Ryan Burklo: 07:48 I threw a couple of examples just in that one. It's really about, again, it's just leveraging what you currently have. And so if you can get a loan, well, you know, let's just say we have a bit of a widget maker, right? And the widget maker needs to buy a machine to make more widgets. And they've got, they can go get a loan on it for X percent or they can just buy it in full. Well, what makes the most sense for your business? How are you leveraging your money to make it work as hard as possible for you? So it's a constant analysis of leveraging where the leverage is. Does it make more sense, can your money work harder outside of giving it to the bank? Karen Litzy: 08:43 Got it. Yeah. So if you were to pay in full and you can make more widgets and sell more widgets to make more money, that might make more sense than making payments on that piece of equipment. Ryan Burklo: 08:54 Exactly. Karen Litzy: 08:55 Got it. All right. Excellent. Now I got it. Thank you so much. Sorry for being a little slow on the uptake there. Now the other thing that I really wanted to talk about is this idea of tax efficiency, cashflow. So in going through your website, I saw this and I thought, hmmm. Karen Litzy: 09:16 This is really interesting to me because I don't know that I'm being as efficient as possible. So can you explain what tax efficiency cashflow means under the lens of, you know, your small business owner? Ryan Burklo: 09:31 Yeah. So there's two sides of taxes, right? There's the taxes that you're going to pay now, right. Where the income that came in the door minus the deductions and everything that we can take as a business owner, what's leftover and what we're going to pay on taxes from that on the business side as well as from the income side and that's based on the rules and laws that are in place this year, 2019 then there's the tax side of what am I going to get taxed on 15 years from now, 10 years from now, 30 years from now, depending on where my money and my assets are sitting. That's the side that most people don't really consider because what they're only considered is I want to pay as little money in taxes this year. Karen Litzy: 10:21 Yes, yes. Right. Ryan Burklo: 10:24 So the next question you have to ask yourself, okay, 10 years from now or five years from now or whatever time period that is, where do I think taxes are going to go? And obviously we can't predict this. Oftentimes it depends on who's in office and what's going on in the economy, all that kind of fun stuff. But if you're of the opinion that taxes are going up, should you have a lot of money and assets where you have not paid taxes on yet? Karen Litzy: 10:54 Yes. All right. I got it right. Ryan Burklo: 10:56 Yeah, exactly. Because you've deferred the tax. So essentially if it taxes went up, now you're gonna pay more in taxes. Conversely, it taxes go down within, you wanted to defer the tax. And the problem is, is we don't know. And so much of this is, Karen Litzy: 11:11 It's a gamble. Ryan Burklo: 11:13 It's a balance is what I put in. So we talked about financial balance quite a bit and it's because we don't want all of our eggs in one basket, right? We don't want all of our assets to be tax deferred because what happens if tax go up? Conversely, like I just said, if taxes go down. Whereas we have our assets in different buckets now we can actually control what tax bracket we're in five, 10 20, 30 years from now. Just like kind of what we're doing right now in terms of lowering our tax bill this year. Karen Litzy: 11:47 And so when you're looking at balancing and not having all your eggs in one basket, where would those eggs be? Ryan Burklo: 11:57 Yeah, so it depends on what you're building in your medical practice or in your business. If your plan is, you know, take a solo practice, you know, at one doc and you know, the chances of a one doc practice being able to sell it is not very high, especially they're required. They're the ones that bring in the money anyways, right? You can't sell something if you're the person that you're trying to sell. So oftentimes those types of practices, they have to build side retirement accounts. Okay. Right? These are your traditional IRAs, your simple IRAs, your standard retirement accounts. And so you could be putting a bunch of money into those accounts where you deferred the taxes. So that's one asset. But we could be talking about, it's also an event. Conversely, if you've got the multiple doc practice, we've had a couple of partners and maybe it's an inside, say on, you're actually transitioning one doc out. Well, how do you consider the taxation of the business? What's the cost basis, and then how are we going to sell it? Oftentimes in insider sales, what they call that, oftentimes no one writes a lump sum check and says, here you go, doc, you're gone. It's normally let me pay you in installments over the next 10 years. I see. Okay, so now you have more taxes going on there. Karen Litzy: 13:27 Oh, cause you, yeah. So you, if you are the doc that left the practice, you're paying taxes on that money that is coming to you in installments. Ryan Burklo: 13:37 Correct. And if you're the doctor bought them out to pay that doctor, you need the revenue of your practice to be doing a certain amount. So there's taxations on both sides of that equation. Karen Litzy: 13:50 Right, right. Oh my gosh. These are things like, I really thought you got bought out in one lump sum. That's why when you said that I started laughing, I'm like, Oh, okay. Yeah. I guess installments does make more sense. Ryan Burklo: 14:04 Yeah. Do lump sum sales occur. Absolutely. That's not, that's not what normally occurs. What normally occurs is here's a 10 year buyout plan. Karen Litzy: 14:15 Got it. That does actually make a lot more sense. Ryan Burklo: 14:20 So yeah, the steps that I have our clients consider is, you know, which type of practice or which type of business are you, are you wanting to build for one? Are you building the business where you're at? And essentially you just kind of run off into the sunset and business kind of goes with you or you trying to build a practice or a business that you can actually sell. And early on it's kind of hard to know that, but as you're growing, you start to picture, you start to build towards one of those. And once you know that now you can get more efficient with your money and what's going on and where to put it, how to get after it. While it's taking into considerations, obviously we don't want to pay a lot of taxes right now, so how does this all come together in one cohesive plan? That's the conversation that people should be having with their advisors. Karen Litzy: 15:14 Great. No, this is great. Yeah. And you know, we, you sort of mentioned the 401ks and setting up for retirement and things like that. And you know, I think we're, like I said, we're going into a new year, we're going into 2020, and maybe there are some listeners out there who are newer practice owners or perhaps they have not thought about their own retirement at the moment because they're building up their business. But can we talk a little bit about how one goes about setting up a retirement plan again, under that lens of a small business? Ryan Burklo: 15:55 Yeah. So, you know, really depends on, you know, how many employees we've got. What type of plan do we have any employees that are what we would call a key employee. And so what I mean by key employee, if you have an employee that if they quit or left and it either cost you a lot of money because they were the customer service side of the business or they were the office managers. So now you've got to go train and hire someone else and go do their work. So you can build in a retirement plan that, that helps keep that employee active and engaged in yours. And you're a business. And that can also be part of that transition that we were just talking about as well. And so, so, so much of it is what is it we're trying to build? Ryan Burklo: 16:47 If we're looking with a starter business that you were just talking about and if you've got a couple employees, you know, it's looking at something like a simple IRA. That way it's low cost, easy to set up. You can set up matching type of contributions for your employees. You know, you can do like a 3% type match where you can go as low as 1% in the simple that allows your employees to be able to contribute and you match. Now they don't contribute, then you don't have to match. Right. And it's low cost. The 401K side of things is more, it's better for when you have a lot more employees, like 20 plus because there's more costs involved and it gets a little bit more intricate. That's when you can start to design it and really mess with a bunch of different things. And because you can mess with a bunch of different things, it costs money. Karen Litzy: 17:40 Got it. So if you have a couple of employees, I like this simple IRA, a 401k for a larger company. How about if it's just you, you're a solo practitioner. How do you set up, what is your retirement plan look like? Ryan Burklo: 17:58 Yeah. Yeah. So you could do a set by IRA if it's just you and you don't plan on hiring any employees you can do the traditional IRA route as well. Then there's Roth IRA, so you can still do that, that standard stuff. The SEP has more, has a higher contribution limit than say the traditional Karen Litzy: 18:16 And what does SEP mean? So for people who aren't familiar with what that is exactly. Ryan Burklo: 18:27 Yeah. So the simple IRA, well, I'm sorry, you mentioned the SEP IRA, sorry about that. So if you're looking at the SEP IRA, we're looking at a simplified employment. I'm sorry, I've got that all backwards now. The simplified employment pension is what that stands for. So SEP, S E P simplified employee pension. Okay. And the reason they call it that is, is just for yourself. And you're kind of setting yourself up for your own retirement plan, which is why the word pension is in there. It gets a little confusing. It's pension. Most people think of a pension has guarantees. It's not necessarily guaranteed, it's just setting yourself up with a plan for retirement. Karen Litzy: 19:10 Got it, got it. So as a solo practitioner, you've got a couple of different options, and again, this is where sort of you're taxed now or taxed then, is that right? Depending on like a traditional versus a Roth. Ryan Burklo: 19:28 Correct. So the traditional side is what they would call qualified money. That's tax deferred. You're deferring paying the taxes this year, you'll pay it when you start to pull the money out. The Roth IRA is you're paying the taxes this year on your money, it grows tax deferred and you can pull the money out, tax free passed age 59 and a half. Karen Litzy: 19:54 But with the Roth IRA, if you make a certain amount of money, you can't contribute to it. Is that correct? Ryan Burklo: 20:02 Yes, there are limitations. There are what they would call a backdoor roth IRA option where you can do, you can kind of go round that rule and there's a bunch of implications there depending on from taxation standpoint. But in general, there are some income limitations to do a direct contribution to a Roth IRA Karen Litzy: 20:26 Yeah. And again, does that matter what state you live in or is that a federal thing? Ryan Burklo: 20:32 That's a federal thing Ryan Burklo: 20:38 IRA's contribution is $6,000 contribution limit below the age of 50. Karen Litzy: 20:46 Right, right. Okay. Awesome. And like I have sort of a mix of all of these things, but I've been, you know, kind of contributing to this for many years. So let's say your in your thirties and you don't have any of this setup yet, are you done? Ryan Burklo: 21:08 Not at all. No, not at all. I mean, unless, unless you're planning on retiring when you're age 31 then maybe. Karen Litzy: 21:17 Right, right, right, right. Ryan Burklo: 21:19 You know, step one, have a conversation with a professional that understands what you're building for. And I know we're talking about retirement plans, but you know, I'm really of the opinion of what, what do you have set up for yourself prior to a retirement plan? Like if you don't have, say an emergency fund set up, start there. Like you don't have to contribute to a retirement plan. The retirement plan is not the savior for your financial status. It really isn't like you can have all of your money outside of retirement plan and actually still retire. Ryan Burklo: 21:57 There's this misnomer out there that when you have to put everything into a retirement plan and you know, for retirement only purposes, yeah, that's a good place to put money. But what can happen to a 30 year old prior to retirement over the next 10, 20, 30 years? A lot. A lot, right? Practice, growth opportunities, buying a house, selling a house, a bunch of different things. So having your money in what we would call a liquid type of asset where you can actually get after it without having to pay a bunch of taxes and penalties is something to really consider first prior to a retirement plan. Karen Litzy: 22:41 Yeah, that makes sense. Because like you said, a lot can happen between your thirties to retirement at 70 or 75. Got it. So setting up that emergency fund and looking at your, kind of what we spoke about earlier, looking at your debt ratios and how can you make that work for you and look at what taxes you're paying now and how you're paying them. And then finally then looking at, well, what do I need for retirement? What do I need to do for retirement that makes sense for me right now because I can put money elsewhere. Like you said, maybe it's into real estate buying a home or something like that. Oh my gosh. There's so much to think about. Ryan Burklo: 23:23 Yeah. The biggest thing, I've already said this once, I'll say it again. You know, I was talking about taxes. It's also where your money sitting. Again, don't put all your eggs in one basket. If you have your money in different sovereign account, you know, some in retirement plans, some in just a straight investment, some in real estate, some in savings. When you have that kind of diversification of where your money's sitting, how much more flexible is your life just from a financial standpoint? Karen Litzy: 23:52 Yeah, I would think much more flexible. Ryan Burklo: 23:55 A ton more flexible because of everything sending or retirement plan and you want to pull some money out to put into the practice. That might be the best thing to do, but you probably didn't pay taxes and penalties. Right, Karen Litzy: 24:07 Right. So then you're kind of losing money there. Exactly. Karen Litzy: 24:12 No, that makes a lot of sense. Lots of sense. This is really good stuff. Thank you so much for sharing all of this. Now, something that I know you guys do is you look at people's sort of financial wellbeing, if you will, but you also look at the person themselves, right? And so what are some things that maybe we can look at as ourselves at our business kind of reflect upon for next year? Like what, you know, cause I know that your process is a little bit different. You're really looking at not, like I said, not just the business or the cashflow, but you're looking at the person and their goals and visions and things like that. So how do you, what advice do you have for listeners out there who kind of want to get their financial house in order? But I'm sure there are some things to think about before you even have that discussion. Ryan Burklo: 25:13 You know, there's maybe two or three things I'll say to you, to your question. The first and foremost, and this is often not spoke about, and this is going to sound probably kind of weird, is what is your philosophy with your finances? What is your value? Right? So in my family, when we'd look at money, right? It's not about, especially in medical practice and naturopath, some physical therapists, right? Like typically you're not getting into the industry to make a ton of money, although that might be a byproduct you're getting into it to help a bunch of people, right? So the value of the money oftentimes when asked that question is, well, I want to help as many people. Well, to do that, my practice has to be very successful. Ryan Burklo: 26:02 Like without the cashflow coming into the practice and building that growth in the practice. How are you helping more and more people, maybe it's a different way, but what does that philosophy, what that does that that alone will have you direct where your money's going. Okay. And then step after you have that kind of philosophy. Step two is going to be more around where is it you are currently at? Like, how do we, how would like, you could do a quick net worth equation, right? Like add up all of your assets, checking accounts, savings accounts, retirement accounts, real estate, add up all your liabilities, student loans, cards, mortgages, and then so track the two numbers. That's your networth as it is today. And if you did exactly what I just said, we actually listed out your assets in one column, listed out your liabilities on the other column. You just got a lot of your balance, your balance sheet on one page. How many people I've ever seen that even though that's a simple activity to do. Karen Litzy: 27:09 Yeah. Yeah. Great. Ryan Burklo: 27:12 And then you can look at what you're building next year. Okay. If your plan is to hire another doctor or buy real estate or invest in your practice more, what's your plan? How are you currently sitting and how could you possibly do that if you don't have liquid cash and liquidity to do that? Well now you're first, you know, your first step next year. It's actually having some money set aside that's liquid or accessible to do that. Karen Litzy: 27:41 Yeah. So really like you said, having your philosophy, your values, and your goals. Look at what you have and what you don't have and see if you can help make a plan for 2020 I think that's great advice. Ryan Burklo: 27:57 Yeah, it's, you know, money in America's taboo, right. It's a taboo topic to talk about it. We don't like talking about it. We don't even know half the time we don't even talk to our children about it. Right. And it's a taboo factor. It's a business factor. It's all this wrapped in one and for someone to take, especially as business owners, you know, we're wearing what sturdy different hats. One of those hats needs to be CFO. Right. So in your, hopefully we're taking a day out of the business to look at how the business is financially and that could be an exercise for that. Karen Litzy: 28:33 Yeah. I like that. Taking a financial business day. Ryan Burklo: 28:39 Yeah. Karen Litzy: 28:40 I really love it. I'm going to start doing that. I have to put it into my calendar cause you know, if it's not in the calendar it doesn't get done. Ryan Burklo: 28:48 Yup. I'm like you, I get it. Karen Litzy: 28:51 Yeah. Yeah. This is great. Thank you so much. Is there anything that we kind of didn't touch upon that you're like, Ooh, I really wanted your listeners to get this info? Ryan Burklo: 29:02 You know, the biggest piece that I want your listeners to get and really anyone to get is have conversations about money with someone you know and trust. Karen Litzy: 29:14 Yep. That's great advice. Ryan Burklo: 29:15 It really is that simple because it starts there. Karen Litzy: 29:21 Yeah, you're right. It does. And we don't talk about it enough. I know I'd have, I probably don't talk about it enough and need, probably need a little more guidance and things like that. So I think that's great advice. So have more conversations about money with people you trust is great advice. And now my question that I always ask everyone, speaking of advice is knowing where you are now in your practice and in life, what advice would you give to yourself right out of college? Especially knowing that what you said at the beginning of the podcast here, but as someone said, you'd be a financial advisor. You'd be like, what? Ryan Burklo: 30:03 I think it would have been slow down. Mmm Hmm. Karen Litzy: 30:08 Yeah. Ryan Burklo: 30:09 I was your traditional person that got out of college and said, I want to retire early. And so I hit the ground running and I started just grinding away. And not that that's a bad thing, but you know, as I've gotten married and have kids, I look back at that time and I'm like, you know, I could have done a couple of different things. I'd just slowed down and it wouldn't have affected me in a negative way the way I thought. And even if it affected me in a negative way, it might've been worth it. Karen Litzy: 30:37 Right. Yeah. A lot of people say that same thing and it's always kind of slowed down and you know, enjoy where you are in the moment and you are not alone in that train of thought. For sure. Well, Ryan, thanks so much. Where can people find you? Ryan Burklo: 30:55 Yeah. So if you want to go to quantifiedfinancial.com and you can find all the information you could possibly want about me, whether you like it or not. Karen Litzy: 31:07 Perfect. And of course we'll have a link to the website at podcast.healthywealthysmart.com under this episode. So one click will take you all to Ryan's info about his company and their philosophy and how they work. And I highly suggest you click on over there. So Ryan, thank you so much for coming on. I really appreciate it. And we did a nice podcast swap, which I always love to do. So thanks so much. Ryan Burklo: 31:35 Absolutely. I appreciate being on. Karen Litzy: 31:37 And everyone, thanks so much for listening. Have a great a 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 Joseph Reinke on the show to discuss student loan debt solutions. Joseph Reinke is the CEO and founder of FitBUX, Inc which is introducing innovative finance products and technology to the student lending industry with a specific focus on physical therapists. In this episode, we discuss: -How family, work and financial goals effect your loan repayment options -Why refinancing public loans may not be an optimal strategy -Practical examples of loan forgiveness strategies -The personal and societal importance of financial literacy -And so much more! Resources: FitBUX Website FitBUX Courses A big thank you to Net Health for sponsoring this episode! Check out Optima's Top Trends For Outpatient Therapy In 2020! For more information on Joe: Joseph Reinke is the CEO and founder of Fitbux, Inc. FitBUX is introducing innovative finance products and technology to the student lending industry with a specific focus on physical therapists. Thus far in FitBUX's beta test, they have helped PTs develop financial strategies on over $11mn in student loans. Joe has been in the finance industry for over a decade and is one of the few CFA Charterholders in the world who has experience in both wealth management and business valuation (globally, there are only 120,000 CFA Charterholders). He has hosted numerous live chats about student loans with SPTs across the country, presented at the California Student Conclave, appeared on podcasts, and written numerous financial blogs. Read the full transcript below: Karen Litzy: 00:01 Hey Joe, welcome back to the podcast. I am happy to have you back. Joe Reinke: 00:07 Glad to be here. It's been a few years. I know that we see each other at different conclaves and different events and stuff, but it's been a few years since I've been on the podcast. Karen Litzy: 00:16 It has. I know, I'm happy to have you. And, we'll talk a little bit about what a difference a couple of years make in a second. But the first thing I want to get to is student loans. So let's talk about first, cause I know you have a lot of data on this. You have a huge data set within fit box. So what is the average debt? And we'll stick with physical therapists. We don't have to go across the board, but the average debt for physical therapists loan debt. Joe Reinke: 00:45 Yeah. So PTs or student loan debt. So we now have about 7,400 students and our platform, it comes out to about $900 million of student loan debt. The average is about $144,000 for PTs. We have some other graduate students that we also work with too. Before PTs, it's about $144,000 in debt. And like you just said too, it's like a moral, I know when we first came on the podcast years ago, we had like $30 million or something like that on the platform. And when I tell people we have like 850 $900 million down there, like, you know, congratulations like you know all the growth that you've had. And I look at it, I'm like, that's disgusting. Like the fact that there's graduates and it's like, okay, $900 million of debt, that must be a lot of people. It's like, no, that's only 7,400 people. Karen Litzy: 01:35 Yeah, it's criminal, it's criminal. So let's say you've got 900 million in loans, the average of $144,000 which is mind blowing. So what are the options for these students coming out to help repay that loan? Joe Reinke: 01:54 And the first challenge is trying to figure out how these things even play a role in the bigger picture. But then the government doesn't do us any favors. So right now there's nine different student loan repayment options and it's a minefield trying to figure out which one you should use. How does it play a role? Like what happens if I do this? What happens to my retirement, what happens to family planning? Can I get a mortgage? All these different things. And instead of just being like, okay, I'll pay back my loans, here's the answer. You've got gotta dig through all these things and that's where people get lost. So what we've done is simplify that into two strategies. Either you're going to pay off your loans, or B, you're going to go on some type of loan forgiveness strategies. And the pay off loans is really dominated by the headlines of refinancing because that's what we get bombarded by in terms of advertisements. Karen Litzy: 02:38 And what exactly does that mean when someone says they're going to refinance? Joe Reinke: 02:43 Yeah. So refinancing means you go to a brand new lender and they offer you a brand new rate and a brand new loan and you're literally replacing your old loans with a brand new loan to get a lower interest rate. Okay, so like I know PTs they get bombarded by low road, which is one of our partners, but they get bombarded by a low road because a low road has a partnership with a PTA. So they just get bombarded. So we get everybody, everybody comes to us and like, well, I'm thinking about refinancing. I was like, well, why? It's like, well, I've got these things. That's what I see in my mailbox. And on the other side of that, they hear all these headline news articles about loan forgiveness and public service loan forgiveness and whatnot. So those two things dominate the headlines. But really it's even upload from that is either you're going to do a payoff strategy or loan forgiveness strategy. Joe Reinke: 03:34 And what I mean by a payoff strategy is what we typically think about when we get a loan. Like you get a mortgage or a car loan, you make payments over a certain amount of time after that, it's over. You could do different things to be strategic with that. Like instead of doing a 10 year plan, you can do a 25 year plan. So you can make prepayment strategically and save money. You can do refinancing, you can see if refinancing is right for you. And those are the big things with the payoff strategies is just figuring out what's the most effecient way to make my payments. Now, unfortunately, one of the problems is that the loan servicers don't always apply your prepayments correctly, so you got to stay on them and make sure they're doing the right thing. But that's, that's a whole nother topic on that. Karen Litzy: So quick question. When you say making prepayments, can you define what that is? Joe Reinke: 04:16 Yeah. So when you have a payoff strategy so most of us on average, so like when a DPT graduates, they actually have between 10 and 20 loans. So when I say $144,000 in debt, it's not just one loan, it's like 10 to 20 loans. They're all different sizes, they're all different interest rates. And so what a required payment is the payments. They add up every payment on those loans and then say here's your required payments. So they might say it's $1,000 a month. So on that required payment, you don't have any say on that. You have to make that payment every single month. And then you don't have a say where it goes. They just throw it across all your loans equally. Okay. A prepayment is like the complete opposite. Joe Reinke: 05:06 You have a hundred percent control of it, meaning you determine the dollar amount, you determine when you do it, but most importantly you can determine which loan that you want to go towards. So like if you wanted to pay your higher interest rate loans faster because that would save you the most money, you can do that. So the trick with payoff strategies is just knowing that general idea of the difference between a repayment, a PR, a required payment. And a prepayment is, well, how can I drop my required payment so I can increase my prepayment? Right? And so that's a lot of the tricks that we go through and mix and match the different plans to allow people to do that. And then you throw a refinancing on top of that and you can save even more. So that's really the payoff strategies. Karen Litzy: 05:58 Yeah, it would seem to me that everyone should refinance to a lower percentage but like why wouldn't someone do that? Joe Reinke: 06:03 It really depends. I'll give you a few examples. We might work with a travel PT for example, and with travel PTs. First of all it's harder because of the stipend. This is for OTs and nurses as well. It's a stipend, so it's actually hard to get qualified because they don't qualify that as income. So like we have nine lending partners, only three of them will do travelers first of all. So that makes it a little bit harder. But in that situation you're traveling so you don't know the cost of living when you're moving from place to place. You don't know how long it's going to be between contracts and you don't know, most importantly what your income's going to be when you stop traveling. So it's really hard to lock yourself into a refinance loan, even though you can always refinance again later, you might not qualify later to refinance. Joe Reinke: 06:54 So oftentimes we do do refinancing with that, those types of individuals, but it's more strategic. So instead of doing like a 10 year loan, we might do a 20 year loan and instead of doing all their federal loan debt and refinancing, it might only be three or four of their higher interest rate loans. So just in case there's something there that they can't do they're not obligated to this huge monster payment every single month. So that's one example. Another example we see often times is, I'll give you an example. I just actually talked to somebody today. She had about $210,000 in student loan debt and she's paying it off. Mmm. And my thing was the tail are like, look, you know, slow down. Because when you do your budget and you're doing paper and pencil, all the numbers always looked like they make sense. But this individual just started working. Joe Reinke: 07:49 They've never had a budget in their life. They've never had like real expenses in their life. It's like wait three or four months because you might decide that you can't make those payments. You rather do a loan forgiveness strategy and if you refinance, you can't do a loan forgiveness strategy anymore because private loans don't qualify for loan forgiveness strategies anymore. So just different situations will dictate. Does it make sense? And then sometimes the refinance rates are just not that good. So it just doesn't matter. Yeah, exactly. It's like stay there and just chip away at your loans. And I'll give you one more example, Karen. When you refinance, you also consolidate your loans. What that means is you merge your loans into one big, big, big loan. Karen Litzy: 08:37 Got it. So for instance, if you took a loan from a bank or a federal loan or whatever, when you refinance did, so let's say you have a federal loan, does that federal loan is no longer a federal loan, it becomes a private loan. Joe Reinke: 08:54 That is correct. And instead of having like 10 you might only have one big, big, big loan. So sometimes what happens, you have to understand how federal loans work though too. Like I said earlier, you have 10 to 20 loans, so every time you pay off one of those loans, your required payment actually drops. With the refinance loan, it won't drop because you have one monster loan, you never pay it off until the whole balance is zero. So sometimes people come to us and say, look, what am I goals is to buy a house in five years? And so if that's the case, we might turn around and say, okay, we'll stick in your federal loan. Because if you keep making prepayments and you pay these specific loans off, your required payment would go from $1,000 down to like $500 when you want to buy your house. Joe Reinke: 09:37 Why is that a big deal? They use the required payment in the ratios for qualifying for a mortgage. So a lower lower required payment on your student loans, the easier it is to qualify for a mortgage. So that's some of the analysis that we would do to say, okay, well how much does a refi actually save you versus are you better off just trying to drop your monthly payment over time so you can qualify for your number one goal buying a house? And so that's what I meant earlier when I said these things. It is more than just the student loan strategy. Karen Litzy: You've got to look at how does this thing play a role in the bigger overarching strategy, right? Because oftentimes I would think the student loan debt isn't the only debt. So can you explain how maybe you have to work around other debt as well and how to navigate all of that? Joe Reinke: 10:27 Yeah. And I'll give you an example. We just did a poll and we also took some of the data from our members as well. And it was something like 68% have more than one form of debt. So that could be cars, mortgages, credit cards. And again, another example, I just talked to somebody today, and actually we get this probably four or five times a week where somebody calls us to talk about their student loan debt and we noticed that they have credit card debt. Okay. And we're like, look, you want to do this strategically with your student loans to drop your required payment as low as you can and focus on paying off your credit card debt. And it's like, I didn't even think about that. It's like, yeah, credit card debt, socks, get all of that stuff like as fast as you can and use the flexibility of refrigerator loans. Joe Reinke: 11:10 That's another reason why you might not run a refinance is because the federal loans are more flexible. There's more options of what you can do. So if you have other debt, it may be allow you to pay that off faster. And that's why sometimes people go into the student loan forgiveness plans also in the short run is the drop that lower payment focus on something else and then go back to their student loan strategy and say, okay, now I'm going to go focus on that. What do I need to do to focus on my student loans now. Karen Litzy: Got it. So it's all part of a bigger plan. So let's talk about quickly the student loan forgiveness because that's been in the news lately. I feel like there's been rumblings of that. It may not exist anymore, Betsy Devoss may cut it or what's the story? Joe Reinke: 11:51 Yeah, so there's actually two different forms of forgiveness. Okay. And this is where people get confused. The actual repayment plan you're on is called an income driven repayment plan. And the government also says that these are things our student loan forgiveness plans. Long story short on these plans, your payment is based as a percentage of your income. And the payments really low is like 300 $400 a month. But for most of us, that means that we're not paying the interest that's being charged on loans, which means the balance of your loan Rose. And that actually will happen for about 20 or 25 years. And then under normal loan forgiveness at that 20 year Mark or your loans are forgiven, but you have to claim it as income and pay taxes on it. Joe Reinke: 12:44 So your balance of what you owe will grow because they just add the interest of your balance, just like in your differing interests cause you're not making payments. Happens in these plans. Okay. So then you worked for 10 years or 20 years or whatever, and then your loan is forgiven. So in these plans loan forgiveness, they last for 20 or 25 years. Department of education forgives them. Okay. However, in this country, it doesn't matter what type of loan it is, it can be an auto loan, a mortgage, student loan. If it's forgiven, you have to claim that as income. Yeah, so like let's just use that example. $144,000 is the average person on our platform. If, you're single for those full 20 years, just working, whatever it is, your loan balance might grow, does being worth $200,000 in 20 years? Joe Reinke: 13:44 So at that 20th year, the $200,000 is wiped out. You don't have to pay it anymore. But you have to claim that $200,000 as income, which means your ordinary income that you made that year. It's just here it is. You got to pay it. And so the goal on these plans is like the complete opposite. You're not trying to pay it off as fast as you can. You're trying to save for that tax liability as fast as you can. Cause like what we always tell people the number one risk on those plans, you don't know what the tax rate is going to be. That's right. It could be 35% it could be 80% it could be 60% now you also factor in like we just moved from California, so if you had $200,000 plus you made 120 grand because you're, you know, 20 years in as a PT in California and federal taxes, you're going to be in a 35 and 40% federal tax bracket. As of right now, plus a 12% tax bracket in California doubled on top of that. You should definitely move to Texas. Joe Reinke: 14:50 But that's a big thing there. So that's normal loan forgiveness. Now there's another form of loan forgiveness. And this is the part that's been dominating the headlines where if you're on one of these plans, but you work for a nonprofit hospital, a hospital, it could be a full time teaching job. I mean you can say I don't even want to be a PT, OT, whatever anymore and I want to go work at Goodwill full time. I mean it just has to be at a nonprofit full time. And if you're on one of these plans working full time and you make 120 payments, your loans are forgiven in 10 years cause that's 120 payments and you owe nothing in taxes. Okay. And so those have been dominating the news recently because there's been 110,000 people that applied and only about a thousand people have gotten it actually approved. Joe Reinke: 15:40 And people are like, Oh well that's less than 1% so that's like the big headline. You know, Loan forgiveness is failing. But when you actually dig into the numbers, over 90% of the people that have applied for that, it should never have even applied. Meaning, they don't even work in a nonprofit or they do work at a nonprofit, but they haven't worked for 10 years. Mmm. So they're finding the people for forgiveness and that they shouldn't even been filing it yet. And so that's where the news kind of distorts that stuff. But then at the same time, you have that percentage, two, three, 4% that is told the wrong thing by fed loan servicing. That's the company that, that does this. They're told the wrong monthly payments. They're told that their payments are qualifying even though they're not there. We're told that their employment qualified even though it's not. Joe Reinke: 16:26 And so that's where the mass confusion comes in on that. I'm actually shameless plug. We just rolled out a new technology that actually tracks all that for you to make sure if you're on public service loan forgiveness, you're actually doing everything you need to do to get it forgiven. And we rolled that out. We rolled that out specifically because of all the headline news of all this stuff. People getting this stuff forgiven. They have nowhere to go to get the answer. So it's like well we can build this pretty easily. And it took us about three months to ramp it up and build it and it's like here it is and we're actually going to release that. We just got done testing it. It's going to be out in about a week or two. So yeah I'm excited about, it's given me a lot of gray hairs and a lot of sleep aside. I'm excited for it. Karen Litzy: 17:07 Well I mean that's such a gift though. That's such a gift for people because there are a lot of physical therapists who work in hospital systems that would be considered nonprofits and so if they can just sign up for that and have something else, keep track of it for you. Like automation is so much easier in our lives. So this is a way to kind of automate your student loan forgiveness programs so that you don't have to keep track cause we've got a million other things that you have to keep track on. Because like you said before, you've got student loan debt, but then you may have credit card debt, you may have mortgage debt or you have a car loan. And so there's so much that kind of goes into this puzzle. I mean to say I did not realize that it was so, all this is so complicated because I graduated like in the stone age, you know, so I didn't really have all, I didn't have $144,000 in loans. Joe Reinke: 18:01 Yeah, I mean it's amazing. And, that's why the big thing that I'm excited about. So like the average person that's gotten their loans forgiven so far has basically saved $62,000 okay. That's a lot. We're rolling this plan out for $5 a month and when we roll it out for the full 10 years, we're just charging a one lump sum fee of $300 if you just want us to track it for all 10 years. And it's like, you know, and we did that cause it's like guys, yeah cause somebody has, some of the people that signed up to beta test it for us. They're like dude we pay like a thousand dollars a year for this. I'm like no, no, no, no, no, no. Like the technology doesn't cost us that much to run like this stuff needs to be out there because again it plays a role in a bigger picture and fast forward, we haven't really disclaim this to very many people cause I don't know when it's going to actually roll out but it's supposed to come out next year. Joe Reinke: 18:50 Like you said, all this stuff plays a role in the bigger picture. We're developing a technology where instead of just tracking the student loans, we track everything. Like, we help you set up the plan and as your 401k your retirement, your budget, your student loan plan, everything. And so to me, like when we say, Hey look, we're only charging, you know, $5 a month for this thing, it's making sure that it works. So when we roll out that bigger plan, it's like we got this piece checked off. We don't have to worry about it anymore. Cause again, I bring up those gray hairs. It gives me something else to worry about. Karen Litzy: 19:25 There's always something else to worry about. So just one little part of it. So now, so let's talk about something that you had mentioned before we went on the air and it's, people don't really understand money. Karen Litzy: 19:42 Tell me why you said that and tell me what people can do to better understand it. And on that note, we're going to take a quick break to hear from our sponsor and be right back. Karen Litzy: 19:57 This episode is brought to you by Optima, a net health company. Optima therapy for outpatient is a software solution enabling therapists and staff to do their jobs efficiently and accurately. Their software provides anytime, anywhere access to documentation, even while disconnected and workflows that streamline patient care and save valuable time. You can check out, optimize new on demand video to learn what's in store for outpatient therapy practices in 2020 with some of the biggest industry trends along with tips and best practices to successfully navigate these changes. Learn about these trends for the new year at go OptimaHCs.com/healthywealthy2020 Joe Reinke: 20:36 Yeah, so we have this big thing that like if you watch our courses that we released or go on the new website that we just released, we talk about our method and it's understand, plan, implement those like the big three things. You've got to understand, you've got to have a plan, you've got to have a way to implement that plan. And there's been a lot of chatter because it's political season and we've seen all the stuff about, Oh, this politician is gonna forgive X amount of student loan debt. And then another politician wants to one up and then say, well we're gonna forgive X amount and another politician wants to one up them and say we're going to forgive everything. And so it's like, well, you know, went up in each other to see who can get the most votes for this. And you know, I get the question all the time is what do you think about these policies? Joe Reinke: 21:18 And I just turn around and say to people, it doesn't really matter because they're missing the root of the problem. You can forgive all the student loan debt. But like I brought this statistic earlier, over 60% of the people on our platform have more than one form of debt is not just doing loan debt. And it's not like these things like money problems didn't exist before. Student loan debt. I mean just before this we had the mortgage crisis. Okay. Like before that we had savings crisis. We still have people savings crisis, like retirement savings. I mean we talked about baby boomers and stuff like baby boomers. Like it's something that I saw a report the other day that 65% of them don't have enough to last like more than five years. Karen Litzy: 21:58 Yeah. And they don't have student loans. And then isn't it true that the majority of Americans don't even have like a retirement plan or don't have that savings? Joe Reinke: 22:12 They don't have anything and that they're dependent on social security, which the social security was never meant to be a retirement plan. It's supposed to be a supplement to retirement. But for a lot of retirement age individuals, that is their retirement. And I'll give you even more. I discussed the statistic I was about to write an article about this. Is something like 43%. It's somewhere in the forties, I want to say the low forties. I've got to look at the article again. It's in the low forties, that the super, that percentage of people in this country don't have enough money in their bank account to cover a $400 expense. Okay. So when we sit there and we talk about, Oh, well, you know, if we just forgave student loans, the problems of the world would be over. Joe Reinke: 23:03 And it's like, well, no, no, no, no. You know, like, I give this example in a workshop all the time. I used to work a lot with athletes and statistically 60, the 70% go bankrupt within three years of being out of league that's in the NBA and NFL. Well, in those three years that they work and play football or basketball, they will make more money than the average American makes their entire working life span. Yep. They go bankrupt. Within three years, they had the complete opposite problem. They had all the money in the world and they still went bankrupt. So it goes back to that fundamental root of not understanding. And that's actually one of the reasons why, like we used to do, or actually we still, I shouldn't say used to, we do workshops. Oh, it's the last time I came on the podcast, like it was, I don't think we had any workshops before that. Joe Reinke: 23:55 And then we started doing them. I've done over 120 workshops at different DPT programs and conclaves different conferences. And that was one of the big things that like, everyone's like, we love his workshops. Well, where can we learn more? And it's like, how, how do you explain this? Understand, plan implementing? And I couldn't find anything. So I was like, well, we're just gonna roll out our own courses. So we rolled those out about two months ago kind of in a soft launch type of beta test. And the feedback that we've gotten off of them is fantastic. So that's like our new thing that we just rolled out was the courses. The next new thing is that that public service loan forgiveness solution and the next year is like the big solution that we're coming out with. So it's exciting. But yeah, those courses, it's fun to see people taking them and being like, Oh my God, like this stuff is, makes so much more sense now. And it's, it's actually simple. That's my big thing. Keep it simple. Don't make it complicated. So, that's the bigger thing when I see the student loan forgiveness hype and all these political things, like it doesn't matter what happens there. You got to get that understanding. You've got to develop your plan, you've got a whole way, have a way to implement it. Karen Litzy: 25:02 Yeah. And just so if people want to learn more about it, if you go to the fitbux website, it's under monies. Joe Reinke: 25:10 Yeah. That is cool. Yup. Karen Litzy: 25:13 What would you say in your opinion and in your work with people, what are maybe one or two fundamental misunderstandings about money that people have? Joe Reinke: 25:18 I don't even know. No, I will narrow it down. This is one of the big things and this how we start off our workshops now when we start explaining some of this stuff. So, you know, and this is about a minute or two explanation on this, but then when I was back in wealth management, I would ask people what are your goals? And I started bucking those into three main groups. They would basically say my family goals, I have my work goal and then financial security. And what I mean by like family is like, okay, I want to do this. I wanna be able to buy a house because I want to provide for my family, my daughter, whatever it is. My work, my work, I want to have my work, have a meaning on life and an impact. Joe Reinke: 26:07 People like I joke around with all the time. No, none of you went to school because you couldn't wait to have student loan debt. You went to school because you wanted to help people. That's what I mean by career goals or life goals. And then the third one was financial security. And when I started asking people, yeah, rank these, it was always in that order, family, their work and then financial security. But when I would ask him, where do you spend the most of your time? They'd be like, well, I spend about 90% of my time on financial security. I'm like, well, that doesn't make any sense. That's like your third goal. Like that. And then I would ask them, here's like, when you say a misconception, I would say, what is financial security? And they kept telling me a lot of money and I'm like, wait, wait a second. Joe Reinke: 26:47 I just gave you that example of NBA players and NFL players. Lottery winners are the same statistics. They all go bankrupt. They have all the money in the world and they can't manage it. I used to manage people money that had millions and they were financial train wrecks. I know guys on wall street that were making million dollar bonuses every year that are financial train wrecks, so that can't be the case. So then I started looking at it and saying, well, what is it? And that's where we came up with the understand plan implements. Like those things is you've got to have a simple understanding. I mean I give examples of people that I know that are, have been barbers for 40 years. I mean they have no college education, they have none of this stuff and they live in San Jose, California, the most expensive place in the country. Joe Reinke: 27:30 And they're millionaires, like they had an understanding, a simple understanding of money. They had a simple plan, you know, and I joke around all the time about my dad. Like when I was 22 years old, like I come home from college thinking I'm like this big investment guru guy, right? Cause I'm a 22 year old punk kid and I'm just like, Oh I'm going to tell my dad. I'm like dad, you know, his strategy was always just, you know, he started a business when he's 18. Yesterday, he started, he bought it from my grandma and you're just put money in the bank and they would buy a piece of property and that's all he did. He never did the stock market anything. I'm like, dad, dad, dad, check this out. Like, if you would have done it, you know, in the stock market it would've been worth like $10 million. Joe Reinke: 28:09 And he's just like, I don't give a shit. Like I don't know anything about the stock market. All right. That was his plan. It was simple and it works for him. Great. And then you had a simple way of implementing it. That was a thing that really lacked Mmm. Is everybody that I knew that had an understanding it and had a simple plan, it would taking them hours to implement it because it would have to do their own Excel sheets or they had these files all over the place. I've got gotta do it all by hand, but they did that. But those are the three big things. And so actually that's why people always ask like what's the technology behind FITbux and why do we do this stuff for free? Like why do we actually have people call us? And if we walk through their plan for free because we say the understanding and part is free and then the technology that we're building, especially for next year is going to be the part that helps them implement it. So they have to spend hours and 90% of their time doing that and they can spend that time doing something else. You asked about the biggest misconception that is the biggest misconception is what is financial security? It's not having a lot of money. It's those three things. Understanding, planning and implementing. Karen Litzy: 29:13 And if someone, let's say someone were like me, so I don't have any student loan debt or credit card debt or any debt really. So if I wanted to use this technology, like does it apply to someone like me who's like, well, I don't have any debt, but I definitely want to try and buy an apartment in New York city, which we know is like not cheap. I mean, in all seriousness, to buy an apartment in New York city to get a decent apartment is $650,000. Yeah. And that's a lot of money. If I want to get an apartment with two bedrooms, it's like over a million dollars. Joe Reinke: 29:43 Yeah. I was going to sell our apartment in San Jose and they got appraised that $900,000. And instead I was like, I'm just going to rent it and it's like $3,000. And then like I tell people, so I moved to Texas cause really I wanted to have a backyard for my daughter. And we bought like, it's like 0.3 acres and it's almost a 4,000 square foot house. It was a way too ridiculous. Like I don't use half the house and it's just ridiculous. And it was like 300 grand but yeah they like the technology but really on the next year. Joe Reinke: 30:37 Yeah, definitely for people like you, it's actually for anything, and this is why so many people, we talk about the student loan stuff, but we already have a piece of the technology out to help people plan. And this actually leads to like the number two misconception that I would have to say when we sit down and people talk about budgeting. They used to always come to me and they still come to me and say, Hey Joe, I spend like $1,200 a month on my student loans. Is that a lot? And it's like I have no idea. Right? Because $1,200 for one person might be nothing for somebody else. Okay. And so what that means is when it comes to money, absolute numbers mean absolutely nothing. It all has to be relative. And the way we do that as percentages, so like when people sit down and look at their budget, they always look at absolute numbers. Joe Reinke: 31:23 So if you go onto these budgeting apps and all this stuff, it's all absolute numbers and it's like, Oh well I'm going to cut, stop drinking coffee, you know, and boil and make my own coffee. It's like, great, you save $2 you know, a day or $50 a month. Like that might be 0.04% of your budget, but you don't want to learn something about retirement savings and taxes. I can save you like 10% like learn the learn. And so when you start looking at percentages, you start seeing where you should focus your time on. And so that's number one thing. But the number two thing would that allows you to do is then we could sit there and say, look we break this down very easily here, right? So we say the first formula is income minus expenses equals discretionary income. With that discretionary income, you can then do two basic things. Joe Reinke: 32:09 You can either build assets or pay off debt and before you even decide what to do with that, we can upload it and say, okay, on average, a new grad PT for example, can take 30% of their gross income and put it to those two groups, assets or debt. You just got to figure out how you want to do that. And so if you have no student loan debt like yourself, Karen, you'd be like, okay, well can I do 30% can I do 35% can I do 40% once you figured that out, then it's, well, now what do I do? Do I do my 401K you know, do I have self-employed income? So can I do a SEP IRA? What about a Roth IRA? What about HSA? What about just brokerage accounts? Oh, well I also want to say for a down payment for the apartment, what do I need to start saving for that? Joe Reinke: 32:50 What do I prioritize first? And then that, so that's the part that we'll have the technology that we have built now what we're building for next year is where we can say once you say, okay, this percentage is going here, this percentage is going here, this percentage is going here, implement link all your accounts into the profile. And they would automatically track to make sure you're moving those percentages and that you're doing it correctly. And so yeah, right now we only help anybody with student loans. And then we track the student loan strategy to make sure they're doing it the efficient way. And then next year we're going to roll out the bigger piece of the technology. And that was part of the preview with the courses is the courses talk about all that stuff. And that was like the first phase of what we're launching for next year. Joe Reinke: 33:35 We just got the courses down early and we're like, let's get 'em out. Like people are asking for them. So happy to get those out. But yeah, next year if you want to sit down and talk, let me know. Karen Litzy: I think I might have, I'm thinking about a lot here. So is there anything else that we didn't cover that you're like, Oh, I definitely want to talk about this. I wanted to get this in. Joe Reinke: Like we've talked about the percentages. The reason why I'm so adamant on that is because then it makes life easy. And what I mean by that is if you say, look, I know 5% is going here, 10% is going to here, percent going there. Joe Reinke: 34:21 Well guess what? You get a raise every year, so all you have to do is calculate and say, okay, well no, I just have to increase how much I'm going into those, those different areas. It's automatic discipline. You don't have to think about it anymore. And not only that, but like if you get a bonus or a commission or a tax return. Yeah, you already know the percentages. Take this here, take this here, take this here, put it here, the rest I can go use on vacation. Hell have fun with it and you don't have to think about it anymore. Instead, I see a lot of people being like, Joe, I just got this $5,000 bonus. Like I'm stressing about, do I put it in my investments? Do I pay off my student loan debt? It's like, well, if he's had those percentages that you don't have to think about anymore, you already know what you're doing with it. Joe Reinke: 35:00 So that's, you know, one more like they played it was one last thing to add. That's one of the big things is those percentages I strongly recommended. It doesn't matter who you are, where you're at, if you have student loan debt or not. If you're saving for a wedding, saving for college, saving for you know, kids. By the way, if you do have kids and you're saving for college for them, don't do it. Save for your retirement first please. They can fund college other ways. But make sure you fund your own retirement first before you can fund your kids. That's one of the biggest mistakes I see parents make. They want to fund their, call it kids' college education and their retirement is lacking. It's like no on your retirement first on their stuff later. So those are the big takeaways. Karen Litzy: 35:42 Awesome. I mean, such good information. I really appreciate all of this. And now this question I been asking everyone lately who come on the podcast and it's given where you are now with your life, your business, what advice would you give to yourself as that 22 year old punk going home to his dad more than he does? Joe Reinke: 36:03 I wish I would draw my ego level way before. That was, I was an athlete at that time too. So you get once, yeah, once you stopped playing sports and reality starts hitting then and all of a sudden it's like Mmm, well not on this pedestal anymore. You get shot down a little bit. But no, actually at that time for me, my big thing was I grew up around, you know, the rule of finance because that's what my degree was and everything. I was around wall street guys. Joe Reinke: 36:41 I had a plan for money coming out of school, but it was simply just to make a lot of money. And you quickly find out that if your motivation is money, you're going to end up burning out. It doesn't matter what you do. If that could be going to take a certain PT job simply because it pays more because you need to pay off student loans. So I guarantee you, you didn't go to school for student loans. You went to school to be a PT. So if you're going for income and that's your only reason you're going to burn out. Okay. And like I said earlier, I've seen guys making half a million dollar bonuses on wall street that don't even work in finance anymore because they're so burned out off of it. And it took me a long time to realize that you're not money that shouldn't motivate you. Joe Reinke: 37:28 It's whatever you're trying to accomplish, that it'd be building a technology that'd be treating patients. And if all you do is strive to be the best at building that, that certain thing or focusing on those first two goals, I talked about your family and your work and you're really focusing on those, that the monetary side will take care of itself in the long run. Like stuff will happen and take care of itself if that's what your main focus is. And like, I mean, fitbux is the living proof of that. I've said it from day one to our investors and everything. Don't ask me about revenue. Don't ask me about shiny objects. Like we talk about business owners all the time. It's one of the hardest things to do because you see so many opportunities out there. You're like, Oh, if I just do that, just a little shiny object, it's going to make me a couple extra thousand dollars, but it's going to be a distraction. Joe Reinke: 38:18 It is not part of your main thing. Now you're chasing money instead of being focused on why you are doing what you're doing. And so that was one of the big things that I had to learn was, you know, it's not about making a million dollars or $5 million or $10 million. It's focusing on what you love doing and the recipe, it will come true. I mean like Karen and you're, you're a perfect example of that. You love doing the podcast, you love getting out there doing that stuff and helping people and guess what you've been successful at doing it. You've been successful as your PT career, all that stuff falls in line. If you're focusing on the right things and money's not the right thing to focus on is the bigger picture. What does money actually represent to you? What does it mean to you? Why do you want it? Because you can have all the money in the world. Do you want it to do something? Focus on that. Do something first and then the money will come from that because you're going to be the best at what you do. Karen Litzy: 39:10 Great advice. I love it. And now where can people find more information about you? Contact you find more about Fitbux. Joe Reinke: 39:20 https://www.fitbux.com/ As the website. As you said with the courses, it's just underneath money school. If you drop down the header underneath solutions, there'll be money school on there. That talks about our courses. If you want to come on and, you already know for example, that you want to do the student loan forgiveness strategy and you just want to sign up for our $5 a month tracking solution. You just go into solutions and sign up. We have a payoff strategy. We also had the loan forgiveness strategy. If you want to go in and use our refinance service, it's free. All you got to do is build your profile and schedule a call. We'll walk through making sure that refinancing is right for you and then go shop nine lenders. And if you have no idea what you're doing Joe Reinke: 39:59 And don't feel ashamed, about 70% of the people that come on our platform don't have a clue where to even start. And that's statistically true cause we asked them have you looked at anything? And they say, I have no idea. And so we, that's all free too. We'll have you come on, you build your profile, we go through the payoff options, we go through the loan forgiveness options. And then depending on which one you feel more comfortable with, we'd go deeper and deeper into how to actually implement that strategy. I mean that's all free too. You just go to the website and click join now and sign up, schedule a call and we'll be talking soon. Karen Litzy: 40:30 Perfect. And just so if people aren't familiar, it's fitbux.com. So Joe, thank you so much for coming on. This was great info. I learned, I learned a lot. So thank you so much. Glad that we can teach and it's always fun and hopefully we'll see you at another conference or conclave or something soon and I'm sure talk more. And everyone, thanks so much for listening. Have a great, 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!

Happy holidays to the Healthy, Wealthy and Smart family! This is a special episode where all the amazing women behind the show come together to discuss 2019 and what's to come in 2020. Thank you for supporting us and we hope to continue to provide great conversations in the new year! In this episode, we discuss: -Why you should enlist a team to help grow your business -How to gracefully ride the ebbs and flows of entrepreneurship -Prioritizing your mental health to avoid burnout -New year intentions from the team -And so much more! Resources: A big thank you to Net Health for sponsoring this episode! Check out Optima's Top Trends For Outpatient Therapy In 2020! For more information on Jenna: Jenna Kantor, PT, DPT, is a bubbly and energetic woman who was born and raised in Petaluma, California. She trained intensively at Petaluma City Ballet, Houston Ballet, BalletMet, Central Pennsylvania Youth Ballet, RDA Choreography Conference, and Regional Dance America. Over time, the injuries added up and she knew she would not have a lasting career in ballet. This lead her to the University of California, Irvine, where she discovered a passion for musical theatre. Upon graduating, Jenna Kantor worked professionally in musical theatre for 15+ years then found herself ready to move onto a new chapter in her life. Jenna was teaching ballet to kids ages 4 through 17 and group fitness classes to adults. Through teaching, she discovered she had a deep interest in the human body and a desire to help others on a higher level. She was fortunate to get accepted into the DPT program at Columbia. During her education, she co-founded Fairytale Physical Therapy which brings musical theatre shows to children in hospitals, started a podcast titled Physiotherapy Performance Perspectives, was the NYPTA SSIG Advocacy Chair, was part of the NYC Conclave 2017 committee, and co-founded the NYPTA SSIG. In 2017, Jenna was the NYPTA Public Policy Student Liaison, a candidate for the APTASA Communications Chair, won the APTA PPS Business Concept Contest, and made the top 40 List for an Up and Coming Physical Therapy with UpDoc Media. Jenna Kantor currently holds the position of the NYPTA Social Media Committee, APTA PPS Key Contact, and NYPTA Legislative Task Force. She provides complimentary, regularly online content that advocates for the physical therapy profession. Jenna runs her own private practice, Jenna Kantor Physical Therapy, PLLC, and an online course for performing artists called Powerful Performer that will launch late 2019. Jenna continues to perform in musical theatre and lives in Queens, New York with her husband and two cats. For more information on Julie: Dr. Julie Sias, PT, DPT is the Producer of the Healthy, Wealthy and Smart Podcast. Julie received her Doctor of Physical Therapy degree from Chapman University. Julie loves to gain new insights and inspiration from the guests of the show in order to enhance her physical therapy private practice in Newport Beach, California. For more information on Lex: Alexis Lancaster is a student intern on the Healthy Wealthy and Smart podcast. She earned her Bachelor of Science degree in Biology, a Graduate Certificate in Healthcare Advocacy and Navigation, and is currently in her final year of the Doctor of Physical Therapy program at Utica College in Utica, NY. Lex would love to begin her career as a traveling physical therapist and hopes to eventually settle down in New Hampshire, where she aspires to open her own gym-based clinic and become a professor at a local college. She loves working with the pediatric population and has a passion for prevention and wellness across the lifespan. Lex also enjoys hiking, CrossFit, photography, traveling, and spending time with her close family and friends. She recently started her own graphic design business and would love to work with you if you have any design needs. Visit www.lexlancaster.com to connect with Lex. For more information on Shannon: Dr Shannon Sepulveda, DPT, M.Ed., CSCS, WCS is the owner and Physical Therapist at Shannon Sepulveda, DPT, PLLC. She is an Orthopedic and Women's Health Physical Therapist and is currently the only Board-Certified Women's Health Physical Therapist (WCS) in Montana. Shannon received her undergraduate degree from Dartmouth College, Masters in Education from Harvard University (M.Ed.) and Doctorate of Physical Therapy (DPT) from the University of Montana. She is also a Certified Strength and Conditioning Specialist (CSCS). She has been a practicing Physical Therapist in Bozeman, Montana for over 6 years. In her free time, she enjoys running, biking, skiing, hunting and spending time with her husband, son and daughter. Read the full transcript below: Karen Litzy: 00:00:07 Hey everybody. Welcome to the last live podcast of 2019 I am your host, Karen. Let's see, and today's episode is brought to you by Optima, a net health company. Optima therapy for outpatient is a software solution enabling therapists and staff to do their jobs efficiently and accurately. Their software provides anytime, anywhere access to documentation, even while disconnected, which is huge, and workflows that streamline patient care and save valuable time. You can check out Optima's new on demand video to learn what's in store for outpatient therapy practices in 2020 with some of the biggest industry trends along with tips and best practices to successfully navigate these changes. Karen Litzy: 00:01:14 Learn about these trends for the new year at go.Optimahcs.com/healthywealthy2020 and we will of course have a link to this in the show notes under today's episode. And I also want to thank net health not only for today, but for being such an amazing sponsor to this podcast. We couldn't do what we do every week without their help. So a huge thanks to net health. So definitely check them out. And notice I said we now it's because of course I cannot do this podcast alone by any means. And today I am so excited to have the powerhouse team behind this podcast for amazing physical therapy entrepreneurs for strong, amazing women who help bring this podcast to life every single week. So in this episode, I'm happy to have on doctors. So they're all doctors, Julie Sias, Jenna Kantor, Shannon Sepulveda, and Lex Lancaster. And what we did was I had a conversation with Jenna and Julia. Karen Litzy: 00:02:18 You'll hear that in the first half of the podcast. And then in the second half of the podcast with Lex and Shannon and we talked about what our sort of our year in review, what 2019 did for us as people and as women and as entrepreneurs and physical therapists. And one theme that came across was that we're all doing things that make us happy and that in 2020 we want to continue that and we want to sort of construct the life that we want to see us leading. So that's in our personal lives and also in our life as physical therapists. So the amazing thing is Lex, Jenna and Julie are new grad physical therapists. Jenna and Julie have started their own practices. Lex has her own business outside of physical therapy, helping people with websites and graphics. Shannon, has an amazing practice in Bozeman, Montana. Karen Litzy: 00:03:20 She has started her practice about two years ago. It has grown exponentially. So she talks about how she did that. And it's amazing. We talk about what I have coming up in 2020 including an online course to help all those physical therapists or occupational therapists out there who want to start their own practice in a way that feels good to them in a way that's going to make them happy, bring them joy. And also the most important thing as physical therapists is our job is to get people better. And in our conversations in this podcast, we talk about how what we do as individuals not only affects us, but it's exponential. It affects everyone around us, our communities, our friends, our families, and of course the patients that we serve. And we're so grateful to that. And of course, as the host of the podcast and creator of the podcast, I just want to thank all of these women because without them I wouldn't be able to do this. Karen Litzy: 00:04:14 There's no way I can do this on my own. Like one of my guests said, Stephanie Nickolich and we mentioned this in the podcast is if you try and do it all, it'll keep you small. And when I was trying to do it all with this podcast, it was keeping me small. I wasn't able to upcycle this as much as I have with the help of these four women. So I just want to tell all of them and I say it in the podcast as well as that I appreciate them. I think they're amazing and I wouldn't be able to do what I do without them. And I just want them to know that my gratitude for this past year of 2019 is so immense and looking forward into 2020. I'm so excited to see what we all come up with. So I hope you guys really take in this episode because I think it's really special and of course to the audience thank you so much for another great year of listening and interacting with the podcast and being able to meet so many listeners all over the world has been a real joy to me in this past year. So everyone, thank you so much. Have a very, very happy new year and we'll be back with brand new episodes in 2020. Karen Litzy: 00:05:24 Hey Jenna and Julie, welcome to the podcast. Welcome back to the podcast. Since you've both been on several times. The reason being is because we all work together on the podcast to make it what it is. So well, welcome, welcome. So we're wrapping things up for 2019 and I thought, well, what better way to do that then with the people who make this podcast happen every year and who I'm eternally grateful for and appreciate so much for all of your hard work and your dedication and your fun and your being you. So, thank you guys for everything that you do. And now let's talk about 2019. Right? So we have January, 2019 to now. So a lot of things have happened within that year. So Jenna, we'll start with you. What are some highlights for you that's happened over the past year that you can kind of share with all the listeners? Jenna Kantor: 00:06:34 Why hello listeners! Good, good evening and sun salutations. For me, I started my own practice literally on January 1st and we were driving back and I got my first patient that day. So literally my practice started this year. That was a big one for me. I also very quickly left all my PRN for those who don't know, that's working as needed, like a substitute teacher at a bunch of mills and I very quickly left all of them and I have been working for myself and it was the best decision I ever made. I have that musical theater background, which I'm sure listeners are quite familiar with, but if you don't know not, you know, and I was really not meant as a physical therapist to be sitting in one spot from nine to five. I really am not built that way and I love that I can make my own schedule, my own life and not feel like I'm really stuck in a location. It's a very, very big deal for me. That was something that was very concerned about as a performer. So I'm grateful to have made that move for myself. Karen Litzy: 00:07:49 Awesome. And Julie, how about you? So what's happened from January till now? Julie Sias: 00:07:54 So having been kind of mentored by Karen for the past three years, it was nice cause I also actually started my own practice and Karen was helping me along the way and everything. And January 1st yes, had my first patient and everything and it's been going really well, I haven't left my PRN jobs, but I do manage my concierge outpatient practice. And then I also see kiddos as like a consultation kind of gig. And then I work at a skilled nursing facility, PRN right now to supplement all that. But it's been a really exciting year because I finally have had a lot of control over all of my hours and it's been nice being out of school as a new grad. Karen Litzy: 00:08:44 Yeah. And Julie, when did you graduate? What was your graduation? Julie Sias: 00:08:49 So I graduated in the summer last year and then I took the licensing exam in November. Karen Litzy: 00:08:56 Right, cause you had to wait that extra long time to take your licensing exam. Julie Sias: 00:09:01 Yeah, so that was when I was just like a licensed applicant in California and I was working at the skilled nursing facility that I did a clinical rotation at. And then after I finally got my license, I was able to do all the paperwork to get a corporation and everything. Karen Litzy: 00:09:16 Right, right. And Jenna, when did you graduate? Jenna Kantor: 00:09:19 That is so cool, Julie. I graduated in May 2018, took my boards in August and then I had a baby. No idea. I felt like, I think it was the rule of threes and I didn't have a three so I made up one. Karen Litzy: 00:09:48 That's so funny. Can you imagine now people probably be like, Oh my God, if they get like just a little clip. Julie Sias: 00:09:54 That's Jenna's one liner for the episode. We should make a graphic. I had a baby. Karen Litzy: 00:10:06 So great that the two of you were able to have a good idea of what you wanted to do and then we're able to execute on that and take action on that because it's certainly not an easy thing to do, especially when you've just graduated and you're trying to, you know, sort of make your Mark and kind of find your way. So to be able to know that before you even graduated I think is is amazing. And do you have any advice? Let's say there are some new grads listening or some students who are getting ready to graduate on what they can do to get some clarity around maybe where they would want to start their career at. And I'll have either one of you can jump in. Julie, do you want to jump in? Julie Sias: 00:10:56 Yeah, I'm ready to rock. So it was good to have accountability from you Karen because I kept telling you every year that I was going to do this. So then when it finally came to the time I couldn't really back down. So that was good. Cause then I had told everybody so if I ended up backing down that wasn't really going to look very good. And then I was also really clear with how I wanted my life to be. And going this route is definitely more of like a, it's tough, it's been tough kind of cause it's feast or famine sometimes and that's kind of like the ugly side of being an entrepreneur. But I have to like pause and just be grateful when I think about like my day and I just go, you know what, this is actually my ideal day. I got to go for a walk in the morning. Julie Sias: 00:11:54 I saw two patients. Maybe it's not like whether I want to be for like a full time job eventually, but I just have to like take a second and just be grateful. So it's good to have a clear vision about what you want your days to look like and then just know that when you put in the hard work eventually it will pay off. Jenna Kantor: 00:12:41 Yes. Amen, this is Jenna. I could not agree with you more. I think that is such a good point with any new practice owner is to stop and essentially smell the roses because it's easy to be, Oh my God, this is where I'm at. Oh my gosh. You know, living sometimes paycheck by paycheck and yes, you're not going to be rolling in the dough right away. It takes time. It takes patience, it takes persistence, all that stuff. But exactly what you said I think is a great way to approach it. I think a big thing, well there's a lot of big things for somebody. Big things when you graduate and you're trying to find a job, but there really is, from what I have seen, I know there's always an exception to the rule. There's really no help with the idea of graduating and getting a job from your school. They are focusing on teaching you what you need to know. You've got to pass those boards, boom, bada Bing. So if you're not going to continue and try to teach at the school that you were just at, you're not going to really get that guidance. The big thing now unfortunately as most of the jobs are at mills, there are places where people don't want to work for a long period of time. That's why they're always hiring. It just is what it is. And you could have this idea similar to me where you want to work with performing artists or say you want to work with tennis players. Say you want to work with geriatric patients only, but not by the hair of the chinny chin, Medicare, chin. So you have a different vision on how you want to treat your patients. It's not easy to fully see that through when you graduate because you see this number of what you owe. Jenna Kantor: 00:13:50 So you're in this like fantasy world. You're in school, you're learning like, Oh that's what I'm going to do. You graduate, you see your debt, that number and that number changes everything for everyone you've finished. You're like I need to get a job now. And it's just ah, and then you start work and then I've heard from some people, cause I spoke to a lot of new grads since then, I'm coming to me and I've only been out for a year and four months, you know, since taking the boards and then coming to me, just so fearful of Jenna Kantor: 00:14:26 what if I quit? And that makes me look like a bad physical therapist. I always say the same thing. I don't care if it's your fourth, your fifth or 10th job that you're quitting. This is your life. None of us are living your life. So you got to make sure you are happy every time. You may get promises that, that they may not keep. And you need to keep track of that so you're not putting it on yourself. When you're not enjoying the job and you feel like you need to suck it up, you're not supposed to suck up life you're supposed to enjoy life. You can't find that working for someone. You might be happy working at a mill. I'm not saying you wouldn't be, you wouldn't be, but most people aren't, unfortunately. So you're going to go through a journey most likely, unfortunately as a new grad of really having a hard time finding that fully right place for you to work long term. Karen Litzy: 00:15:14 And I usually tell people to kind of when you're trying to figure out, well what do I want to do or where might I fit? I usually have people do a couple of different exercises and I mentioned this on the podcast before, but one is like, just make three columns. I'm a big column person, right? So you make three columns in the first, just put like what you love to do and the second column is what you're good at because they could be two different things. Just cause you'd love to do something doesn't mean you're good at it. Like I love to do graphics doesn't mean I'm good at it, but I love to do it but I'm not good at it. And then the third is what will someone pay you for? So if you can kind of find a through line there, I think it helps you to sort of drill into maybe what are your strengths, what are you good at? What do you love? What will someone pay you for? So I always say like, I'm really good at crocheting. I really love crocheting, but no one's going to pay me for it. So it's a hobby. See the difference, right? So you want to make sure that Karen Litzy: 00:16:30 you're excluding your hobbies as being your full time job. But you know, for me, I some examples of what I'm good. Like I love curiosity, I love asking questions. I love, you know, networking and being with people and meeting new people. Those are things I really love and those are also things I'm good at. And so I was able to parlay that into a podcast and then parlay that into, through the podcasts and through networking into public speaking and into being asked to different conferences and stuff like that. So just know that not everything has to come from one singular job. You know like, and I think we can all say that here cause we've all got a couple of different things in the fire, stokes in the fire. Is that how you say it? I'm not really sure. Karen Litzy: 00:17:22 At any rate I would say to new grads is to certainly find the job that's going to put food on your table and feed your family and feed yourself and feed your pets and feed your kids and feed whoever else is depending on you. But don't discount that this one thing is the only thing you're allowed to do. You're allowed to do a whole bunch of other stuff, you have to give yourself that permission to do that and then you never know where that's going to lead you. Because if I only stuck just to patient care, well I wouldn't have this podcast and I wouldn't be going all over the world speaking and I wouldn't be asked to coordinate social media for conferences around the world. I mean just wouldn't be a thing. But instead I just decided to do what I love and do it well and get paid for it. It's awesome. Julie Sias: 00:18:28 Actually I have like a counter to that and that sometimes it's also good not to do what you love as a job cause it can be something that is your me time sort of thing. Oh that's like another counter to that. I was thinking about that maybe if you monetize something, it takes away the fun from it and then it becomes something where like I have to do this to make money versus I get to do this because I want to do it. Karen Litzy: 00:18:59 Right. And I think when you reach that point, Jenna Kantor: 00:19:03 Yeah, I agree. Cut the cord if you don't like it's for me with performing I did. That was before me professionally for many years in musical theater. And I started to, I got into an eating disorder and I had to take a backstep cause it felt like a nine to five job going to these different States and I started doing community theater again to refine and which I did. And then I started working professionally again. So really was just, I realized I was just working at the wrong places. It's not that they were bad places, just not right for me. So yeah, I definitely agree with it's just assigned to cut the cord Karen Litzy: 00:19:41 Like Julie said, when you get to that point where I love doing this thing, but now it feels like a chore. I think you have to really do some self reflection and kind of see like, boy this is not, maybe, maybe I made a misstep here, so I need to take a step back and reexamine what I'm doing and let it go. Or you can see are there ways that I can make it even better if I give up some of the controls. Hmm, nice. Right? So I felt what Julie just said is what I felt about the podcast a couple of years ago. This very podcast, I was like, Aw man, I have to do another podcast. But then, and I was like pissed about it cause I was like, Oh, but I have to do this and this and this and Oh now I have to make time for this. Karen Litzy: 00:20:37 And I thought, all right, let me take a step back and kind of re-examine what I'm doing here. Cause there's gotta be a way that I can make this better and that I can make it bigger. And the thing for me was asking for help. So once I ask for help and let the control go, now all of a sudden it's, you know, more enjoyable and it's something that I continue to be very proud of, but that I'm not like, Oh no, not again, damn you podcast. You know, so it's instead of cutting the cord, I just tried, I took a step back and tried to look at ways that I can improve upon it and the improvement came with bringing people on board. So that's, you know, another all very valid kind of ways to look at things. Julie Sias: 00:21:49 Yeah. Another way to look at it too is that when you were under a lot of pressure, that allowed you to kind of be more creative too, to look for solutions and sometimes you go in directions that you wouldn't have thought you were going to go just because you were under that pressure and boom. That's where sometimes magic happens too. Karen Litzy: 00:22:09 That's right. Yeah. I think what Ryan Estis who was on the podcast a couple of weeks ago, what did he say? Like, when you're comfortable it breeds laziness or something like that, I'm really butchering his statement. I was like, boy, I really butchered that one up pretty well. But I remember when you said that, I was like, yes, that's so true. And yeah, it was something to the effect of like if he was looking at it from the point of view of an entrepreneur, that when you get to the level where you know you're consistently making money and you're consistently successful and then does that then breed complacency and does that take away your creativity a little bit? Julie Sias: 00:22:58 Yeah. That's not really the magic zone for growing. Karen Litzy: 00:23:01 Right, right, right. Yeah. And that's when you need some outside eyes to kind of take a look and see, and like Steve Anderson said last week, what is the role of a coach? And he said to give you those external eyes and ears that opens you up to things that you're just not seeing. And that's for everyone. Julie Sias: 00:23:27 Yeah. I actually have a perfect example of this and it was when I was just graduated and I was a licensed applicant and I had gone to all of my clinicals and asked for a job because I needed to make money while I was studying for the boards and stuff. And so ended calling Karen up and I was just like, you know, this one job offer, I got sure, like I'll have guaranteed money and guaranteed hours and stuff, but I just, it's not sitting with me well, I didn't really enjoy that experience as much as I could have. And then you were just like, Oh well maybe that's not the right fit for you. And then I got really creative and asked for referral for another clinic and ended up getting a job that better suited me at that time. So it was kind of nice having you there cause I was in the trenches like, Oh I need to make money right now. And you were just like, no, just take a step back. And then I had all these other opportunities present themselves. Karen Litzy: 00:24:24 Right. Right. And Jenna, that's kind of what you were saying. Right. When you graduate, like you said, all you're seeing is like, I've got debt, I need to make money. So you just take what you can. And so, you know, we don't always want to take just what we can, but you know, we want in an ideal world, we want to take what fits from all perspectives, what fits for the employer, what fits for you as a potential employee, what fits for you, whether you want to be an entrepreneur or you know, a part time entrepreneur, full time, whatever. But I think as a healthcare provider, if you find that job that fits, it just allows you to help more people. Karen Litzy: 00:25:19 Right? And in the end, we're in the business of making people better. And if you're not in the job that allows you to do that or you're not in the head space that allows you to do that, then the people who ultimately suffer are not you. I mean, you do a little bit, but it's the people that we're out there to help. We're there to help people. That's what our job title is. And so if you can't, you're not in a good head space to do that or in a good physical space to do that. Then I think it becomes very difficult. Like Julie said, well, I had a great day. I was able to do the things I want to do that keep me sane. So that when you show up for your patients, your clients, you're showing up fully for them. That's where I think the PT profession can Excel for sure. Jenna Kantor: 00:26:24 When I was filling in for PRN work, I would come in energized, positive. I would walk in and go, let's do some physical therapy. We're going to heal. And like people loved me, or at least I believe they did. I had the patients even though I was a substitute teacher, which is how I introduce myself. Jenna Kantor: 00:26:45 Like I really bonded with these people, you know, and I have that energy, but Oh yeah. If I had one full day or Oh my gosh, forgot it, two or three, Oh, can maybe have at once. Oh my God. Full days in a row, I would need days to recover, days to recover. Like I was like, I was gone, I was gone. I was like sleeping, like just feeling so tired throughout the day and it really made it so apparent to me that everyone else is doing this six days a week, maybe five, you know, I don't know, depending on there schedule, but I was just, Oh my God, I can't, you know, hence here we are a private practice owners on this call. Yeah, exactly. Karen Litzy: Now let's talk about what's in store for 2020 new decade. New year. Jenna Kantor: 00:27:44 It's my birthday. I'm turning 40 years old. That means I'm going to be so mature. February 16th. I like flowers, see's candies and cats and Disney for anyone who wants to know. Yeah, we're getting a dog. But like I'm more of a cat person so, but it has to be cute cats cause there are those presents. But 2020 is going to be awesome. I'm sorry, I just jumped in. But I'm theater people love talking about themselves being the center of attention. It's great. So I am so excited about fairytale physical therapy. For those who don't know, Fairytale Physical therapy is where we bring musical theater shows to children in hospitals and teach choreography that's secretly composed of therapeutic exercises. This whole past year we've been working on paperwork back and forth with the lawyers to get it done right. Jenna Kantor: 00:28:42 And we're like almost there every time. Like people ask, it was just us liberal almost there. Right now we're trying to get the right legal name because it's not as simple as you would think. So we're trying to figure out that legal name where they're not straying too far from what we are. And so that's going to exciting. And then for me, I am doing a lot of one-on-one beta tests with performers, for one course an online course for performers to essentially, those are going to be mini courses like say you have, hip tendonitis. All right? Now the majority of non-union musical theater performers do not have health insurance. And if they do, they have extremely high deductibles. So they usually just don't get help. So this is creating a wellness program that will be on that boundary of like, Oh my God, you doing like physical therapy stuff, but y'all do. Jenna Kantor: 00:29:42 It's about the patients. So I'm creating this for them. The people who don't have that access, they don't have the money, they don't have all that, where it's a program and right now I'm just testing it on people cause it's physical therapy. You have to test on people and see if it works, if they stick with it. And so that's really cool. So I'm literally doing it, I'm doing three different types of injuries, right? No, five injuries right now. And taking different people. They're essentially like patients where I'm talking to them every week and like upping the game and figuring out symptoms. So that's great. Move that over. Now I'm also starting next week, just walking into the new year one on one work with physical therapists who want to work with dancers and figuring out what they want to know to make them the confident, accessible and go to dance PT in their area. Jenna Kantor: 00:30:35 So I am working with now five, it was originally three 50 minutes ago, became five. I'm working with five and figuring out what they learned and basically giving, creating a course from this. So I'm very excited about two things cause it's where I want my energy to go. I love doing, like we were saying, find what you like doing. I like doing the creation of online stuff. And I've just encountered so many people with limited access to performing arts, physical therapists who specifically know that. And if they do know that our hearts, they don't have the insurance. You know, there's a lot, a lot of people in this world who don't get it. So I'm very excited to be bringing that help to performers at large. Whether it be giving that education to physical therapists or providing a program to them directly so that is exciting! Julie Sias: 00:31:36 Jenna, I was like, I'm going to bring like some California chill into the conversation because when I think about 2020 it's more just like, okay, I got my income streams and their proportioned a certain way. I want my business to grow more than the other ones and slowly phase those out. So that's like my intention for 2020 but then every other intention has nothing to do with physical therapy. Karen Litzy: 00:32:12 I love it. That's good. Julie Sias: 00:32:16 I've just been spending too much time thinking about physical therapy this year too much time, so next year I'm just thinking about more time with family, more time exploring hobbies and stuff. Maybe then I'll feel refreshed and have some inspiration to do more online type services and stuff like that, but just going into 2020, I have I don't want to say low expectations, but just I don't want to set too many things, just see where it goes. Karen Litzy: 00:32:40 You have sort of more relaxed expectations, so not that they're low. I think phasing out your PRN jobs and increasing your income that's a big job. And it's awesome. So I think that's a great thing to focus on. That'd be fabulous. Julie Sias: Karen, you haven't told us about your 2020. Karen Litzy: 00:34:09 Why I am going to do nothing? No, I'm just kidding. I'm just stepping back and I'm going to live the life of Riley for the whole year. No, no, no. I am going to continue obviously with my concierge practice because I love it. I would like to take on another independent contractor onto the practice as well. Just to, even if it's just one or two patients a week, you know, just something to kind of help offset the amount of time I'm spending with patients, which I love. But, it's a lot. So oftentimes I get caught up working in the business instead of on the business. So that's something that I'd like to kind of get a better balance of. And I am also in the final stages of putting together an online program. I know I said I was going to do this year, and I did it because I was too fearful and just was too afraid of like, no one's gonna buy it. I'm going to look so stupid. And with that, you know, it's clear that has been holding me back. But I've been working with Adrian Miranda also. So he helped me with some videos and worked with Joe Tata, to help me come up with a great plan. And I've been working with copywriters throughout the year and some business coaches. And so I have a program that I was calling strictly business mastermind, but now I think we're might change it to the private practice mastermind, but that might be changed. I think someone else has a name that's pretty similar. Jenna Kantor: 00:35:20 You could do PP mastermind, so you could say pee pee like professionally, which would be funny. He'd be mad. Karen Litzy: Oh boy. I didn't even think of that. Now that private practice mastermind PPM, I may need to rethink this. But we're hoping for like an end of January launch and it's not just me, there's myself, there's lawyers, there's accountants, there's PR professionals, marketing professionals, investment professionals, you know, investment 101 for entrepreneurs kind of thing. Got other successful physical therapists are going to come in and that's just the six week part of the course. So six modules over three months, but then it's a year long program. So each month I have new mentors coming into the group to talk about whatever the group is looking for. Whether that be, you know, practice succession or tax stuff, student loan stuff, whatever. Karen Litzy: 00:36:38 So we'll have monthly webinars for the whole year. And then the best part is I'm doing the Marie Forleo model. So Marie Forleo started a B school, which is an online kind of business school, like abbreviated business school that she started several years ago. And once you purchase it once, that's it. So if we do it again and there are things added to it, you're always in the Facebook group. You don't get shut out of the Facebook group after a year. You don't have to pay for upgrades and all that kind of bullshit cause I think that's so stupid. So I'm going with the Marie Forleo model and it seemed to serve her well since she's made millions and millions of dollars and she's just helped so many people. And I think they just know that like, Hey, this is the deal. And so once you buy the program, once you're in it for life and you'll get the benefits of that for as long as you need or want said benefits. Karen Litzy: 00:37:41 So I love it. I kind of liked that model. I just think it's, I dunno, it just fits my personality a little bit better, you know? So, we'll come up with a name, and then we'll unroll it hopefully at the end of January. Jenna Kantor: Karen Litzy's LIT program. Karen Litzy's Master class cause you could do lit in LITzy. So that'll be like the fire. Oh, I see what you mean. That's a topless pizza delivery man. I dunno. I just, I was thinking lit. That's red fire color and nothing. What else is fire color? Oh, pepperoni. And then I went to pizza and that's where we got. Karen Litzy: Well, I thought it was because I am from the pizza capital of the world, which I guess would make sense. That would be amazing. I love that. Yeah. Yeah. Old forge, Pennsylvania. Plug for my hometown, pizza capital of the world. But yeah, so, but that's pretty much. And then, I also am going to take a vacation. Julie Sias: Where are you going? Karen Litzy: 00:39:08 I don't care, but I'm doing it. I don't know where I'm going yet, Julie Sias: You should go to Hawaii. Karen Litzy: I love Hawaii. It's so nice. Jenna Kantor: This morning you, I don't know what it is, but one, I have a friend that's gone on vacation that is when I decided to contact you. So it's not on purpose. It's just so when I'm contacting you I'll be like, wait a second. She's probably obvious. She's in Hawaii. She's in Hawaii. Karen Litzy: So we'll see. I don't know, but 2020. I am definitely, cause I have not had like proper vacation in a long time. So my goal, one of my biggest goals, and this is not PT related, kind of like what Julie said, but is take a vacation and love that with Brett. He just doesn't know it yet. Karen Litzy: 00:40:03 We just have to be after June. He worked for a state Senator in New York, so he's in session until in Albany, you know, you gotta, you gotta do what you gotta do. And then the other thing that I want to do, and Jenna can probably help me with this, is get a little more involved on the legislative side of things. Jenna Kantor: Love that stuff, man. You want, it's that be the change you want to see in the world. Karen Litzy: 00:40:50 That's another thing that I'd like to do, whether it's PT related or not PT related, but just try and push for things that I believe in that should be happening. Jenna Kantor: So I think this has been the best podcast ever. I think for all of us were overjoyed to have us have cats. Julie, where's your pet? Julie Sias: She's outside. Jenna Kantor: There's that dog, a dog and two cats walk into a bar. Thank you so much for having us on Karen. Karen Litzy: Yeah, this was great. And I'm just so happy to wrap up the year and I'm looking forward to lots of great stuff from everyone and with the podcasts and just kind of keep moving forward and trying to innovate and do some fun stuff. So that's the goal and I thank both of you. So Jenna, Julie, thank you again. Like I said in the beginning, I appreciate you guys so much for all of your hard work and help and making the podcast much better than it ever was. So thank you so much. And everyone we're going to take a quick break to hear from our sponsor and we'll be right back. Karen Litzy: 00:42:20 This episode is brought to you by Optima, a net health company. Optima therapy for outpatient is a software solution enabling therapists and staff to do their jobs efficiently and accurately. Their software provides anytime, anywhere access to documentation, even while disconnected and workflows that streamline patient care and save valuable time. You can check out, optimize new on demand video to learn what's in store for outpatient therapy practices in 2020 with some of the biggest industry trends along with tips and best practices to successfully navigate these changes. Learn about these trends for the new year at gooptimahcs.com/healthywealthy2020. Karen Litzy: 00:43:00 Hey Lex and Shannon, welcome to the podcast for our year end wrap up our year in review. So thank you so much for coming on and being on the other end of things for Shannon and the other end of things for Lex too. So thanks so much. So I spoke with Jenna and Julie the other day and now I have you guys here and I'll say the same thing to you guys that I said to them is that I'm so thankful and appreciative of both of you for being part of the podcast and really elevating it to a new level this year. Cause I really do feel like without your help and without your contributions that it just wouldn't have been what it was. So I just want to thank both of you and know that I appreciate both of you for your work in front and behind the scenes. So thank you so much. And now let's talk about 2019 because now is the time of year that everyone looks back on the year. So I'll ask the same question of both of you. Karen Litzy: 00:44:14 Where were you at January of 2019 versus kind of where you are now. So Lex, why don't I have you start kind of what big things happened in your year? Where are you now? So it's way different than where you were in January. Lex Lancaster: 00:44:32 Yeah. It's pretty crazy to be honest. I was thinking about it last night. This time last year, I was preparing for my last clinical physical therapy school, so I was actually going to New Hampshire. Mmm. I was going to be in an outpatient clinic for 13 weeks. I was super excited because it was my last one, but I was also getting that full 13 weeks in outpatient clinics. I was like my powerful clinical, so super pumped. So I finished that and then I went to graduation and I actually got engaged on white coat night. So that was really, it was awesome. Kyle did a really good job. And then I graduated PT school, it was so awesome. I was so happy. And then the NPTE came around and that was a different experience altogether. I will say that I underestimated that completely. Just the preparation for it as a whole, but then I passed. So that was great. And then now, so I had this dream of being a travel PT. Lex Lancaster: 00:45:42 So, this past year, you know, I decided I was going to explore that. So right after I passed the NPTE, I accepted a contract with my fiance in Alaska. So we moved 3,500 miles away from home to an Island of 1200 people in Alaska. So now we're in Ketchikan where it's like the rain capital of the world. So I don't look at rain as like, let's keep me inside anymore. It's okay. It's always raining. It's never not raining. And it's pretty dark here. It's pitch black still right now. So we're currently in Alaska and an outpatient clinic. And to be honest, it's been a whirlwind transitioning from student to kind of a PT, but you're just studying for your exam to a full blown PT. It's been hard just because I didn't expect it. You know, I've done clinicals, I'm like, Oh, it's no big deal. It's totally different when you're the person. So I've spent a lot of time in the last 13 weeks just kind of getting used to that and getting the groove and I'm excited. I'm excited to see what the next year will bring because this year was just really, really awesome and I'm really excited for, you know, to see what's next. Karen Litzy: 00:46:52 And you also, not to, I don't want to leave this out, but you also have an entrepreneurial streak in you. You have a company that you started this year as well. Am I correct? Lex Lancaster: 00:47:05 Yeah, yeah. And I shouldn't, you're right. So I guess I initially launched it in like the end of 2018 but this past year has just skyrocketed. I just went from, I mean, I guess word of mouth is kind of the way that it really worked out. And I get to design websites and graphics and I am a virtual assistant, so I get to work with people all over the country and all different professions. I have so much fun doing that and I started it in PT school as I admit. I used to do it when I was bored in class. And then, you know, it got to the point where that was how I took study breaks. So that was the way I decompressed and I found that that was a big stress reliever for me. Lex Lancaster: 00:47:56 So I explored that option and then I was kind of talking to Shante, movement Maestro and she was like, you know, you could really do something with this because I approached her at RockTape course and I was like, Hey, do you need an assistant? And that was right after I started working for you Karen. So like I was feeling pretty good. I was like, this is fun. I love doing this. And then I decided to do the whole web design business too and big changes for that coming next year. So yeah, it's been, it's been really, really cool. I've learned a lot about a lot of different people and I get to explore that all the time and I love it. Karen Litzy: Yeah, I think that's great. What would you say to a physical therapy student right now? Who is set to graduate in, whether it be, maybe they're graduating now or maybe it's spring of 2020 given the huge changes that happened in your life over the past year. What would you say to them as they prepare to graduate or maybe they just graduated? Lex Lancaster: 00:48:48 A couple things I would say I would say really explore your mental health. I think that I didn't take that route when, as I was graduating, preparing for the NPTE and I feel like I truly drained myself to the point where if I could go back, I would invest in, you know, even a coach just to get me out of that sympathetic drive because I feel like my life just kind of, I just devoted all of my time and energy to the NPTE and it really did drain me. And, it was just a lot to manage. So let's say explore your mental health, get that in check and you know, really be prepared to learn a lot and find yourself in whether you're in your last clinical or just starting your job, you know, if you're the smartest person in the room, try not, you know, try not to be that. Lex Lancaster: 00:49:50 Like there's always something to learn and it's hard to go back to be in the clinic and be by yourself and not have someone to bounce ideas off of that's in your room. Like your CI. It's hard. And I truthfully would say get involved in Twitter. I've found that I've met the most incredible PTs on Twitter and I get so much good advice from them and I'm able to contact, you know, people have specialties that come into the clinic and I'm just like, wow, they could use some opinions on, you know, the vascular aspect and I'll find somebody on Twitter and they are more than willing to help me. I would say just reach out if you have any questions about patients because there are so many PTs on Twitter and social media in general that would help you. So I would say just keep your network huge. Karen Litzy: 00:50:36 That's great advice. And you know, I feel like this, the first time I heard someone say take care of your mental health. I mean Shannon, like we've been the NPTE or the boards and on through to our career. Have you ever gotten that? I never got that advice to kind of take care of your mental health. I think it's great. Shannon Sepulveda: 00:51:00 Yeah. I mean I think it's super important. I mean, one thing like when I was a runner and an athlete and so I always made sure that like I worked out every day cause that really helped. But I remember like, just wait until you take your specialized board exam because then you don't get your results for three months. So it's like three months of like, okay, like is it June yet? You know? And so you don't even like, and like when I took my women's health board exams also I was postpartum so that like added a whole new mental health aspect to it. But I mean I studied for, you know, probably six months, probably pretty intensely for three months. And then you take the exam and it's very similar to the NPTE where you're like, I don't know if I pass this because the questions are similar where you're just like, ah, yeah, I don't really know. Shannon Sepulveda: 00:51:55 And then you have to wait three months to know if you pass. And so that's really hard. Lex Lancaster: I'll say a week was really hard. So I give you a lot of credit. Yeah, I know it was a hard, and you walk out and you're like, then I have never felt like I have completely bombed a test, but I feel like I just bombed that and then everyone's like, don't worry, this is normal. Shannon Sepulveda: Oh, it was sort of like, even with like my women's health exam and then I was like, I think I failed that. And then I ended up getting like in the top 10 or 25 it was something like I did really well on it, but I thought I failed it. Lex Lancaster: It's so odd that our brains do that, that all we remember all of the negative questions. We forget how many good ones there were and then we just kind of wrap around that. Karen Litzy: 00:52:51 Yeah. And that's life, right? That's why people always say to like, keep a gratitude journal at night. So then you remember the good things that happen to you every day and you don't get wrapped up in the negative because I think that's, like you said, it's kind of where our brains tend to go. We remember those negative aspects before we'll remember the positive ones. It is amazing. Shannon Sepulveda: 00:53:15 Yeah. It's the same thing with patients. Like who do you go home and think about the one patient that didn't get better, not the six that you made better. Karen Litzy: 00:53:27 Totally. And now, Shannon, speaking of changing lives, so going from January till now, what's been going on? What were your highs and lows and just so everyone knows, I mean they can go on the website, but you're a business owner. You're in Bozeman, Montana. And one of the only women health specialists in the state of Montana? Shannon Sepulveda: 00:53:53 I'm the only one that's taking the board exam. A couple women in Montana who have done the Herman and Wallace pelvic floor and they're super highly trained and there's other people in Bozeman that are women's health physical therapists, but I'm the only one that's taken the plunge to take the exam. But yeah, so 2018 so I know, I was thinking about this question. So I've been in my own practice for a little over two years. And so I was thinking, I'm like, where was I in January? And so since I take insurance, January is always like dead pretty much, but December is always nuts. I think I was still building my business like last January. I didn't really like have a full schedule. I had been in business for a little over a year. Shannon Sepulveda: 00:54:45 I changed my last name when I left my old clinic, just kind of to make a clean break with insurance and everything. And so I was still trying to get like name recognition and I do women's health also getting into like the Perinatal community in Montana. And so this year I'm finally like, like doctors know who I am and patients come in, they're like, I got referred by, you're like so-and-so. They said you're awesome. And so I'm getting like all of these women, especially postpartum women, that's generally who I see, who were like, Hey, so and so like saw you, you changed their lives and I'm here. And so I would say like probably well over 50% if not 80% of my patients are direct access word of mouth. And I'm just like, Oh, this is so nice because I don't have to like network anymore. Shannon Sepulveda: 00:55:49 I don't have to like spend my nights at like local networking events and which I was doing just to get some name recognition and now I feel like I can, I don't want to like totally rely on word of mouth. I still think I need to get out into the community but it's really nice just to like check my phone. I do online scheduling and be like someone's requesting an appointment and another person's requesting an appointment and know that like the patients are coming without me having to like really go out and spend a lot of time, which, and I think doing that really helped me now. I think I had to do that but now it's nice where like it's almost like an exponential growth cause moms tend to talk, which is really nice. And so the word of mouth has gotten really great for me. Karen Litzy: 00:56:37 That's awesome. And you know, I think you bring up a really good point that you were in business for a year and you had a patient flow but it wasn't like you were overwhelmed and you know, you didn't have this full, full schedule. And I think for people starting out in business that is so important to realize that you don't start your business and in two months, it's rare it could happen. Yes. You're not usually on a full schedule within a month or two. Shannon Sepulveda: 00:57:09 No. And I think what was really important was like the time that I wasn't seeing patients, like I took that time to either like have lunch with somebody, like have lunch with a prenatal yoga instructor or like have lunch with, you know, really anybody, a doula and midwife, like whatever. And so I really like had a lot of lunches and coffees just to like meet people. So when I wasn't seeing patients, I was trying to meet people in the community. And I feel like those like one-on-one rather than like the big networking events were really important. And I sent like, it was great for me too because like I want to know who to send to for prenatal and postnatal yoga and I want to know who the good doulas are and who the good midwives and OBs are because I send people their way and who the good like trainers are that understand pregnancy and postpartum because I'm not a trainer. Like I get people to not pee their pants so they can go to the gym and see the trainer. Karen Litzy: 00:58:10 Correct. It could be your slogan. And you know something that would work. Shannon Sepulveda: 00:58:19 Yeah, it was funny cause Shayla, the one that I did the podcast on with the hats she wanted, I got a bunch of my hats embroidered and she wanted me to put on the back leak-free thanks to my PT and I was like, that's awesome. You know, I don't know if people will wear that, but that's a really good slogan. Karen Litzy: 00:58:39 That's great. I mean, you're really good at what you do. No, I mean that's great because what do people want? They don't, like you said, like I get them to not pee their pants so they can do other things. It's that simple. You don't have to overcomplicate things. Yeah, but I love that you're still kind of doing business. I call it like business generating activities, you're not getting paid for it, but it's business generating activities, so it's still like a moneymaking activity. And you're right, the bigger, like Lex said, the bigger network you have, whether that be virtual in your case, because your business is in Bozeman, the bigger network you have a Bozeman, the more people are going to come your way. And so you did all of that work and now you're really starting to see the benefits of it and it's really exciting. Shannon Sepulveda: 00:59:28 Yeah. Karen Litzy: 00:59:29 It's also good that you know the cycles of your business. So you know there's going to be really bit busy but January, not so much. You'd be like, okay, so January I'm going to set aside this time to do X, Y, and Z for my business. And if you know that those are the ebbs and flows because every business has an ebb and flow, then you know you can rely on that. And like I remember for me, my downtime is now around Christmas, new years, not a lot of people around. So that this would be the time where I would take a vacation or I would work on business plans for next year or I would, you know, just get things together. So, so to speak. So I think it's great that you brought up all those points. And Shannon, what would you tell a new business owner, regardless of what kind of PT business you have, whether it's a cash based business or your insurance or a hybrid, what have you learned that you're like, Oh man, I would tell everyone this. Shannon Sepulveda: 01:00:29 Yeah, I've learned that if you're good at what you do and you get patients better, they will tell other people. And so I don't want to say think of every patient as a referral source, cause that sounds like you're, you know, it sounds like you're categorizing them. But think of every patient as like, this person is very important. It's very important for me to get them better because that's what I do and what I'm good at. But it's also very important for my business because if you get them better and you treat them well with respect and you do everything, they're going to tell other people, especially in a small town. And so like I am very, like sometimes I come home and like after seeing like patients for an hour, so like I see like seven patients and that's a big day for me. Shannon Sepulveda: 01:01:22 And I am just like compassion fatigue is like full on set in because like I am so engaged for that period of time and with my population it's really important because it's really important for, they just need someone to listen to them. But if you think of every patient that way, it pays back. And every word that you use with the patient is very important. Because they come from like sometimes doctors that say things that I wouldn't necessarily say to a patient and they come in with, you know, thought viruses. Thank you Lorimer Mosley and you know, just talking to them but being really compassionate, you know, with all for your patients. Yes. Really in the end. And sometimes it's hard at like four o'clock at the end of the day, but it's really important. Karen Litzy: 01:02:16 Yeah. And I always think of your patients instead of like you said, referral source, cause that is a little, that's, I don't know how to like how would you, I described them as ambassadors. Karen Litzy: 01:02:30 So they become ambassadors for my practice. And that's the way that I don't treat them as a referral source. I treat them as an ambassador. So someone who chose because of the care you gave to them, you know, I would love for you to see this friend of mine or my daughter or my cousin or my, you know, X, Y, Z person, my coworker. Because like you said, you're listening to them, you're treating them with respect and kindness and compassion. And so to reduce that to a referral source is, I don't know, I agree with you. I like to use ambassador because they're new, that they want to be part of what you're doing. You pulling them in and saying, Hey, I'll give you a free X, Y, Z. If you refer me to five of your friends. Shannon Sepulveda: 01:03:24 But because they're choosing to represent you and they're so excited to tell people like that's what is so awesome about what I do is like, like I'll see people and be like, thank you so much for referring your friend. They're like, Oh my gosh, I am telling everybody because like we don't have to pee our pants anymore and we don't have to have painful sex anymore and this is just so great. And I'm like, yeah, it's great. Karen Litzy: And Lex, you'll get more of that as you practice more, you know, you'll get people coming to the clinic you're in specifically to see you, which you might've already gotten so far is you're in this small town, right? Lex Lancaster: 01:04:07 Yeah. I actually wanted to say that because you used a word Shannon, you said, or a phrase, compassion fatigue. And I find that as a new grad, I'm learning how, cause that's me every day I do that. And you know, my patients come in and on the Island we don't, there's not a lot of doctors. The practitioners here, you know, they have to go down to Washington to see a specialist. So oftentimes people will come in with, you know, a lot of comorbid conditions and we have to sift through all of that and make sure they've seen the correct people. So there's nothing I love more than getting on the phone with four doctors for one patient. So, and I've found that like, that's caring about them and I'm like, Hey, look, I'm going to reach out to your doctor. And they love that. And, but I do find at the end of the day that I'm exhausted. And so I'm trying to find that balance where I'm giving, giving, giving, but also saving a little bit for myself at the end of the day. But yeah, there's been patients that are like that, Karen, they just, they're like, Oh, I've told my friend. And then that friend comes in and then they come see me and it's just like, this is amazing. And that's why I could see why having your own business, why that's so important. Because that word of mouth aspect, you really can't replace that. Karen Litzy: 01:05:24 Yeah. Yeah. And you know, I think most PTs have that kind of compassion fatigue. And one thing that has helped me is, I remember it was at, Oh, I dunno, it might've been Jason silvernail might've mentioned it on Twitter. I'm not a hundred percent sure, but I remember. So I think it was him saying that the thing that helped him the most and he's in the army, the thing that helped him the most is, is finally realizing that somewhat he is not responsible for a patient's outcome, that the patient's responsible for their outcome. So and that's hard because you're investing your time and your compassion and your emotions into this patient and your skills. But once I realized once I was able to kind of separate myself from like I am not the fixer, I'm there to guide and to coach and to diagnose and treat but not to fix and can separate the fact that I'm not responsible for this person's outcomes, that the person needs to embody that. Karen Litzy: 01:06:32 Then the compassion fatigue is less, it's still there because we're all humans, but it's much, much less. And when you instill that into your patients, it's really fun. Like I had a patient who had chronic neck pain for five plus years and came in and he had stopped running, working out, doing this, doing good, going to CrossFit, doing everything. And I said, well, why, why, why do you think that is? And I understand I was the same way. And so we got him back to doing things and I would see him once a week, once every other week now, just once a month. And he's like, yeah, so I had like a week. I was like, I really didn't have any pain. He's like, and you know, it's because he's like, I work out like almost every day now. He's like, so you're here but it's not like what you're doing to me. He's like, I'm working out and that's what's making me feel better. I'm like, yeah, exactly. He was like, what? You gave me permission to work out again? I was like, yeah, I can do this. And I was like, I was like, you got like, that's exactly what you hope to hear is like, yeah, got it. It clicked. And you can tell it like clicked for him at some point that week. Like, I'm helping myself get better. Oh, I see how it works. Got it. Shannon Sepulveda: 01:07:51 Yeah. And that's, I think really like, it's hard. Like I try really hard not to make my patients dependent on me. Like I try really hard. I was like, my job is to empower you to get yourself better. Like I give you the tools to get yourself better and I don't tend to do a lot of like if someone's in like acute pain, I'll do some manual therapy, but I don't tend to do a lot of manual therapy because aye I can see like sometimes they'll become dependent and my job is to be like, no, you can do this. Like you, you can do this. It's all you. Karen Litzy: 01:08:29 Yeah. And all the research that like Lex, I feel like, and I don't know Shannon, you could probably agree with me here, but I feel like Lex and like you guys and your new grads, like you guys are starting out on like second base. I started out, I didn't even start out in the dugout. Like when I started, I feel like I started out in like the showers. Like I didn't even get to the dug out yet. Karen Litzy: 01:08:50 You know, with all of this sort of patient forward care and you know, the science behind pain and all this stuff that's this new research that has come out in the last 10 to 15 years. I feel like as a physical therapist it really gives us a headstart if you're keeping up with it. So like you're light years ahead of where I was. Lex Lancaster: 01:09:14 And I would say a lot of it too is because of people that share things. Because you know, even like on social media, you see something and someone shares, whether it's at a snippet of an article or something, you're like, where did they see that? And then you go read that and you're like, Oh wow, that was awesome. So you know, people post the books that Lorimer Moseley's books and you know, you see those posts, you're like, Oh, I should read that. And you read it and you just gain all this knowledge. And like I said, I feel like a lot of it is dependent on people that share things. So, you know, all the podcasts that are out, especially, I mean, especially yours, Karen, to be honest, I'll say, I look at all yours and I'm like, Oh my God, that's so amazing. So yeah, I feel like we do have an advantage, I would say, especially with the pain science literature, new curriculums like that, that like just the education piece that I give for pain, people just are like, Oh, okay. And then it's like immediate buy-in and it's so easy to just get people to, like you said, get ready to help themselves Lex Lancaster: 01:10:13 We're very ahead of the pain science literature. Karen Litzy: 01:10:19 I know I looked back and I'm like, Oh man, I'm grateful. I'm so grateful. I'm better with these people. Shannon Sepulveda: 01:10:22 Oh yeah. I mean, I graduated in 2011 and there was nothing really, Oh yeah. I mean, well, in my PT education there was, yeah. I started learning some stuff after that, but there was nothing in my PT education about pain sciences and that was like, so I would have had like didactic until about 2010 early, you know, so I know it's like 10 years ago. Karen Litzy: 01:10:59 I know. And like David Butler first published on sort of pain science stuff in 1996. Wow. You guys look it up. It was 96 or 97. And so, you know, we have, they say research to practice takes like 15 years. Shannon Sepulveda: 01:11:18 There it is. There it is. Karen Litzy: 01:11:20 It's amazing. It's astounding to me. And, I find that if you stay engaged as a newer grad, that you really do have such an advantage, and advantage with your patients and I hope that people really no that and can appreciate that. Then new, newer ish grads can really appreciate how lucky they are coming up. As far as information, the information pipeline is so much easier. Now. I won't even tell you, like I had to do the Dewey decimals system. I'm so old. Shannon Sepulveda: 01:11:56 We were cleaning my house and I had all of my PT books and like my husband, so he works for the US geological survey and he has a PhD and I had all my PT books, what are you doing with these? I was like, he's like, have you looked at these in 10 years? And I was like, no. And he's like, everything's online now Shannon, you can get rid of these. Yeah, yeah. And like everything. Karen Litzy: I got rid of my mind a couple of years ago. I'm like, what did I doing? And even if it's all these journals, like physical journals in my apartment, I'm limited space here in New York. I'm like, I gotta get rid of these journals. They're taking too much space. Karen Litzy: 01:12:52 So let's talk about what's coming up in 2020. So what are you looking forward to? Do you have any goals or expectations or plans, whether Lex, I'm assuming you're going to get married. Lex Lancaster: 01:13:07 Yeah. So we finally set a date. The wedding has been interesting. So I didn't really want a wedding just because it is, it's overwhelming. It's a lot of stuff to plan. But then, you know, family, they're like, Oh, well you're the only girl. You really should do it. So we set a date for October 17th of next year, so we're going to get married in New York. I've done minimal stuff. I've gotten the venue, really making very slow progress. Lex Lancaster: 01:13:36 So working on that and then you know, for 2020, you know, I'm really looking at bringing, I just applied for a trade name for my business so I could take my name off it and just make it a new name. So I'm really excited to launch that eventually once I get that all set in stone and really trying to bump that side gig up just because I have found the value in the last couple months of doing things you like to do more often. So Kyle and I were actually talking the other day and you know, we're seeing the value of providers that have their cash based or insurance businesses and these small towns in their hometown. And we're seeing the value here. Like you get to know people, you get to know doctors. I love travel PT, I do, but I'm very far from home so I'm hoping I get closer back to home and we kind of want to land in a spot where we can kind of start our own thing. Lex Lancaster: 01:14:34 We were those people like we care, we want to reach out to people out. People know us back home. And we really wanted to start our own thing. So we're trying to get back toward, well and try to do that just because I see people, you know, as they have their own business, they make so many decisions that they get to see patients when they want to see for how long they want to see them. And sometimes, you know, I'm very jealous of that right now. You know, there are patients that I'd love to spend an hour and a half way, then I just can't. And so I think that's a major goal right now. It's just to get to that spot. And I understand as a new grad it's very hard. Yeah. I mean, I don't, and Julie did it, so I should probably reach out to her because, you know, everyone says like, it's really hard to do a business on your own as a new grad. Lex Lancaster: 01:15:21 I should reach out to her because that's what we want to do. And you know, we understand that will probably be hard, especially with student loans and whatnot, but at the same rate, like we're trying to define, you know, what's your happiness worth? And we just kind of find that right now the quality of care that we want to provide is sometimes limited by you know, whether it's because of insurance, a lot of dancers and we're finding it hard to justify their care even though they need it with insurance and people can't afford to do X, Y, and Z out of pocket. So we're trying to find, navigate all of that. So, I dunno, trying to, that's a goal just to get to a place where we can build our own, you know, set of patients. Karen Litzy: 01:16:04 Awesome. And you're in upstate New York? Lex Lancaster: 01:16:08 That's where I'm originally from, but we're probably going to end up back in New Hampshire. Yeah, we both really love it there. And I don't think my parents will be in New York forever, so I think we're just going to go back to New Hampshire area. So we're close to Boston. Karen Litzy: 01:16:23 Yeah, I think that's a great goal. And you should definitely talk to Julie about that. And the good thing is you have each other to give each other support. You and Kyle have each other so you can, you have that support from each other. And I think being able to do that with the two of you I think would be really exciting. Karen Litzy: 01:16:42 If you build up your side gig, then you can slowly build up your practice. You know, you just to know where you have those income streams coming from. But I think that's cool. Lex Lancaster: 01:16:52 I'll say after reading Danny McTay's book, it kind of gave us both a little hope of just that you can do it. It's just you have to decide if you're going to burn the ship or do it as a side gig for a little bit. And I think we're more or less thinking side gig for a little bit, even if it's just something, something to let us treat, you know, the high level athletes that we can't justify insurance-based for right now. Karen Litzy: 01:17:18 Yeah. Basically. Yeah. You should talk to Julie cause that's what she's doing. She's sort of building it up slowly. We talked about it for this podcast. So. Perfect. And how about you Shannon? What's coming up for 2020? Shannon Sepulveda: 01:17:31 I was thinking about this, I'm like, what are my goals? So business is really good, which is awesome. I think one of my goals I need to try. So I really don't want to hire anybody. I do all my own billing, all my own scheduling. I see my patients. I need to try to figure out time management a little more. Because like I'll be in like I take Fridays off and I'm with my daughter and sometimes my son has off kindergarten on Fridays and I'll be like in the target parking lot. And now they know when I stopped the car and I like sit in the parking lot space, I'm like checking my email. They're like, mommy, don't check your email. We need to go into the store. And I'm like, like accepting patient appointments or just like, you know, I need to try to figure out how to do that because I want to do everything. Shannon Sepulveda: 01:18:26 But for myself. And so it may just be like saying no, it may just be having a wait list and trying to figure out like the feast or famine of owning your own business, like these ebbs and flows where like this month is like just absolutely nuts. Like I had five people call me in the last week trying to get in before their deductible resets. And so like I have like, I'm taking next week off and I'm not seeing anybody but like the 30th and the 31st, I think I'm like seven patients a day or something like that. 31st I have patients to like five 30 on new year's Eve because like, they're like, Oh please. And I'm like, okay, okay. You know, and because I know January is going to be really slow. And it's really hard. I'm staying up till 11 o'clock at night to finish my notes. And so I think either I just have to accept that that's the way it's going to be or do a little bit more time management. Karen Litzy: 01:19:26 Or even sounds like maybe just setting your boundaries or boundaries for yourself and something that you're comfortable with. I think that that is something I will say that really helped me is saying, you know, listen, the last patient I'm going to see at night is seven o'clock at night. Like I'm not going to go later than that or I'm going to take at least one day off. Yeah. It may not be, may not be a Saturday or Sunday, but I'm going to take one day off during the week and this past what I've done is that I'm going to take five hours or four hour chunk of time and have that just dealing with business kind of stuff. You not teaching care. So I think if you look at your schedule and kind of set your boundaries, then I think you'll find that your time management just flows within that. Or you can get a virtual assistant. Shannon Sepulveda: 01:20:19 I know I could do that. Yeah. It's funny cause like for some reason my boundaries… Karen Litzy: 01:20:24 Cause you're like me Shannon. I'm the same way. Like, I love to like keep everything close to me, but the moment you can like let just one little bit go. Karen Litzy: 01:20:46 You'll be like, what the hell was I thinking? What would be the sooner? But you have to do it on your own timeline and when you feel like you can, you can let go of that. A little bit of control. Like I let go of like a smidge at a time. Yeah. And then for me it was easier then. Shannon Sepulveda: 01:21:03 It's really interesting because I think about, I'm like, okay, as a business owner it is not worth my time to spend. Like I tried to keep my Mondays as admin days like that is not worth my time to do. It's worth my time to pay someone to do the admin stuff, but I keep holding it in. Karen Litzy: 01:21:20 Yeah. Yeah. That's a good way to look at it. If you have whatever your fee is, let's say your fee is, I don't know, I'm going to make this up $200 an hour. Karen Litzy: 01:21:31 Right. The task you're doing as an admin at $200 an hour task, $25 an hour task, or maybe it's a $20 an hour task. So, and when you look at it that way, it's like what am I doing? Like I could pay someone to do four hours of work and what I get paid in one hour. Do you know what I mean? So when you look at it that way, the financial offset makes a lot of sense because your time is money. And like you said that that four hours could be an hour that you get to spend with your kids having lunch. So it doesn't necessarily mean it has to be with your business, but or it could mean that's your time for, you can go to the gym or you can do X, Y and you can meet with a doctor or doula or whatever. So you know like that is $200 an hour time spent when you're having lunch with like a possible referral source doing like weird admin stuff that you don't need to do is not $200 an hour work. Karen Litzy: 01:22:35 That's what I did and just really like looked at everything, wrote down everything I do and you can attach sort of a monetary value to it. And then once it's down on paper you're like, Oh my God, okay. Shannon Sepulveda: 01:22:52 I know, I know and I haven't like it's interesting cause I hadn't gotten to that point until this December because like I'm still growing and so that's one of the things that I think I'm going to need to think about like, and I'm just going to see how like the ebbs and flows, like if it is still as nuts as it is right now, then like I got the, because the worst is, and honestly like the billing's not that hard. It's verifying the insurance benefits. And sometimes I can do it online and it's really easy. And then sometimes the online just tells me what their deductible is, not how much they've met. And so then I'm on hold with blue cross blue shield for like an hour while I'm trying to do other notes. Karen Litzy: 01:23:40 And what you'll find is like you will grow, maybe not exponentially, but you will grow bringing help on, you know, I did an interview with this woman Stephanie Nicholitch, she's like a high performance coach and she said, you're trying to do it all. Keeps you small. Yeah. And, it's true, but you have to feel ready for it. So it's in your time and you'll know. Shannon Sepulveda: Yeah, I think I'll know. And the other thing is like one day, the other Monday I just like sat in front of my computer and I did my QuickBooks and my billing and I came home and I was like, I don't even feel like I've worked today. Yeah. He's like, I hadn't seen patient, I hadn't had that compassion fatigue. So some of it's like, can I actually handle that many patients? You know, can I give good care when I see my caseload. Karen Litzy: 01:24:26 Yeah. And these are the growing pains that you have to deal with and it's a good growing pains, growing pains. So hopefully you'll continue with those growing pains. We hear it out in 2020. I think you will. Thank you. I want to thank you guys because like I said, if you do it all, it'll keep you small. There's no way I could do everything that is required of this podcast to keep it of good quality and to have good guests and good interviews and good graphics and good everything and make the guests feel like we're on their side, you know, and that there putting their best foot forward on the podcast. And I think that's what both of you and Julie and Jenna do is creates a good experience, really positive experience for the people who are on it. Karen Litzy: 01:25:28 Like Shannon, we were saying like, people bought those hats and Carol and which I think is amazing. But you just never know how far the podcast is going to go. And you know, yesterday I was with some friends and we were talking about the podcasts and what's it on and you know, it's on Spotify and it's on, well iTunes is no longer a thing. So now it's just Apple podcasts and I looked up under medicine and it's like 52 out of all podcasts. For this fully female run podcasts. That is pretty good I think. Awesome. Yeah, it was really cool to see. Shannon Sepulveda: One of my PT friends in Bozeman. He like just moved to Bozeman a couple of years ago and he referred a patient to me and this was about a year ago and I called him and he was like, yeah, I was like listening to healthy, wealthy, smart. And you were on it. And I was like, Oh my gosh, she's in Bozeman. You were like randomly listening to the podcast and then you were like happy that it wasn't because I was in Bozeman, you were listening to it. He's like, no. And I was like, wow, that was awesome. It was a great moment. Karen Litzy: 01:26:38 Yeah. And never know who's out there listening and you never know where, again, the podcast becomes a referral generator. We can call a referral generating. This we could say generates referrals, but it does and you never know who's listening and where it's going to kind of take you. So I think that's so good to hear. And like I was talking with a coach that I had on a couple of years ago and she's like, Oh yeah, I got two clients from you. And she referred one of her clients to be on my podcast, the one who was talking about poop. She ended up getting like three clients from being a guest. Whoa. All right. So I was like, Oh, that makes me feel so good that that's the case. So, you know, keep up the hard work and you know how much that I am thankful and appreciate it and wish both of you have very happy 2020 new decade so thanks again so much. And everyone out there listening. Thank you so much for listening all year and we all wish you a very happy new year and hopefully stay healthy, wealthy, and smart. Karen Litzy: 01:27:58 And again, a big thanks to Jenna, Julie, Shannon and Lex for all of their work all year. And of course a big thanks to net health. This episode is brought to you by Optima net health company Optima therapy for outpatient is a software solution enabling therapists and staff to do their jobs efficiently and accurately. Their software provides anytime, anywhere access to documentation, even while disconnected and workflows that streamline patient care and save valuable time. Check out their new on demand video to learn what's in store for outpatient therapy in 2020 you can go to go.Optimahcs.com/healthywealthy2020. 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! 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On this episode of the Healthy Wealthy and Smart Podcast, I welcome Dr. Sarah Haag on the show to discuss pelvic health for the non-pelvic health PT. Sarah has pursued an interest in treating the spine, pelvis with a specialization in women's and men's health. Sarah looks at education, and a better understanding of the latest evidence in the field of physical therapy, as the best way to help people learn about their conditions, and to help people learn to take care of themselves throughout the life span. In this episode, we discuss: -Intake questionnaires to screen the pelvic floor for patients with low back pain -Pelvic health red flags -How to address pelvic floor health with a conservative population -Assessing the pelvic floor muscles without doing an internal exam -And so much more! Resources: Oswestry Low Back Pain Disability Questionnaire: http://www.rehab.msu.edu/_files/_docs/oswestry_low_back_disability.pdf Sarah Haag Twitter Entropy Physio Website Home Health Section Urinary Incontinence Toolkit Rehab Therapy Operational Best Practices Forum For more information on Sarah: Sarah graduated from Marquette University in 2002 with a Master's of Physical Therapy. Sarah has pursued an interest in treating the spine, pelvis with a specialization in women's and men's health. Over the years, Sarah has seized every opportunity available to her in order to further her understanding of the human body, and the various ways it can seem to fall apart in order to sympathetically and efficiently facilitate a return to optimal function. Sarah was awarded the Certificate of Achievement in Pelvic Physical Therapy (CAPP) from the Section on Women's Health. She went on to get her Doctorate of Physical Therapy and Masters of Science in Women's Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women's health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010. Sarah has completed a 200 hour Yoga Instructor Training Program, and is now a Registered Yoga Teacher. Sarah looks at education, and a better understanding of the latest evidence in the field of physical therapy, as the best way to help people learn about their conditions, and to help people learn to take care of themselves throughout the life span. Read the full transcript below: Karen Litzy: 00:01 Sarah, I was going to say doctor Sarah, hey, it just feels weird because we've known each other forever. But Sarah, thank you so much for coming on the podcast to talk about pelvic health for the non-pelvic health PT. So there are a lot of physical therapists who I think are interested in pelvic health, but maybe they don't want to like dive in literally and figuratively. So what we're going to do today is talk about how we as physical therapists can treat people with pelvic conditions, with pelvic issues without necessarily doing internal work. What are the functions of the pelvis, really important for bowel and bladder health, right? Sarah Haag: 00:49 I mean, it is very important for survival, sex, very important for quality of life and propagation of the species. So these are all things that matter. But also when people come in with low back pain, when people come in with hip pain, I always find it very interesting that people say, but I don't do the pelvis. You know, the pelvic floor is only a musculoskeletal structure. We're not trained in most programs to palpate or to touch. It's just skeletal muscle. That's all we're assessing for really as pelvic floor PT's. So I just think it's interesting. It's like a blurry void when you're looking at a body diagram. Oh, there's your knee. So it's really important I think to understand what's there and you don't have to go there, but you have to know what's there and know that some people need help there and help them find the help. Karen Litzy: 01:34 So if someone, let's take this person that has low back pain because that's a diagnosis that we can all agree that we see on a regular basis. So what are a couple of questions you can ask during your initial evaluation? Sarah Haag: So the subjective part of the initial evaluation that perhaps a lot of people are missing or that can take in that pelvic area. There's a couple of ways that you can kind of like cheat your way in where you don't even have to think about what to ask to begin with. If you have a red flag questionnaire, there is a bowel and bladder question on there. So, it's really interesting because people will sometimes circle yes on those and then never discuss it. Like, wait a second, we asked the question, they said yes, it's a thing. Sarah Haag: 02:22 So there's your in, it was like, I noticed you, you marked yes on the bowel and bladder changes. Can you tell me a little bit more about that? Most of the time it is not truly a red flag. Most of the time it is not a sign they need to be referred to a physician. Most of the time it's like no one's ever asked me that. Yeah. Stuff is different. There's your in. And then also if you use the classic Oswestry. So it was modified I think in 2001 or 2002 to take off a sex questionnaire. The second question of the questionnaire and it was revalidated and all of those things, but if you use the original, it's pretty awesome because now they're like, Huh, nobody's asked me about sex. And then you'd be like, ah, I see that this is an issue. Sarah Haag: 03:06 One of my favorite Twitter stories is I get a direct message from someone asking me about a patient who was having pain with intercourse and I was like, thanks for reaching out. Absolutely. Can you tell me more about when they're having trouble and where it hurts? Would you like to know where it hurt their knees in one particular position? And I said, fantastic. You can help with that. So, so it's not always, it might be a sex problem, but it's not necessarily that problem. So we have to not be shy about asking those. Low back pain is the most expensive health care problem we have in terms of multibillion dollar, probably millions and millions worldwide. And so of course addressing back pain, we're still working on the best way to do that. Sarah Haag: 03:52 But there's a high prevalence of urinary incontinence and people who have low back pain. So if you're seeing people who have low back pain and after, if anyone else went to the pregnancy talk this morning, after vaginal deliveries, the prevalence of incontinence goes ways up, goes way up. So if you're seeing someone with back pain, if someone has had babies, all you can eat what you can do. So we were like, well I see this in your history cause that's pertinent history for back pain. Correct. And then it's like, Hey, I noticed this, any issues with this? And here's the reason I'm asking because you can't just go, do you pee your pants? Because people like, do I smell like what happened? Like, so if you're just like, you know, there is a really high prevalence and the nerves in your back go to your pelvis and all of these things. Sarah Haag: 04:32 So I'd be really curious to know are you having any issues in this area? Cause there's help if you are. And then kind of go from there. Karen Litzy: And I want to backtrack for just a second. When you were talking about red flags and said some are truly red flags and some aren't. So just so that we're all on the same page, what would be those truly red flags? Sarah Haag: Truly in the pelvic world or in the entire rest of your body world is any unintentional weight loss or weight gain, 10 or 15 pounds over a short period of time. Also like fever, like temperature issues, loss of appetite when you have those other constitutional symptoms that go along with it. So just having some quirkiness with your bowel and bladder, it's really no reason to panic. But if you have also a fever and also a recent traumatic event, no, no, we want to just make sure everything's okay. Sarah Haag: 05:26 And the cool thing is that if you go to the doctor, it's like you don't have a UTI. Everything else is looking fine. Awesome. Then I can help with that. But the red flags, there's been a couple of great papers that have come out where it's like, it's not like if you have pain at night, freak out. No, no. If you have pain at night but also a sudden bowel and bladder change and also, okay, now we need to check in for it. But don't panic if it's the only one. Karen Litzy: And now let's say you're using these questionnaires and someone puts on bowel, bladder or someone circles sex as something that they're having difficulty with. And I love this question because this was something that was brought up last year at CSM. So there was a physical therapist there who said, well, I live in the south and these are not easy questions to ask because people are more conservative or they don't want to talk openly about their bowel and bladder issues or about sex with their partners. Karen Litzy: 06:28 And so what do you say to those people? Those therapists that, are dealing with a population that's maybe much more conservative and they're not sure how to approach those subject matters. Sarah Haag: I always say just always with kindness and with a good intention and with a good explanation. So you can't not do it because it's awkward for you. You should be asking for a medical reason, right? So quality of life is in our wheelhouse, right? Like we're doing all sorts of quality of life questionnaires. Pee in your pants is a huge detriment for your quality of life in many cases, not being able to have sex can impact your relationship with your partner, your feelings of ability to even have a partner, having babies. All of these things that end up being huge stresses, which is gonna make a lot of other things not as good either. Sarah Haag: 07:28 Just start simple if you're asking questions. So if someone comes in with like straight forward knee pain, I'm like, how sex, no, that's not how, that's not where we go with that. But if someone's coming in with low back or pelvic issues, the way I usually approach it is to bring it up anatomically. So this is the anatomy. This is what we're doing. These are where the muscles go. Most people don't think about them. And when they're, if they're having issues like incontinence or have had babies, those pelvic floor muscles are muscles. Like everything else. We're going to work in PT. So I'm going to ask you some questions and I try to do it in a spot where you have some privacy. I know some PT places you're like in the middle of a gym. Sarah Haag: 08:06 If you can find a quiet corner, do everything you can to put them at ease. But just to be like this is why I'm asking. And if you can see that resistance be like all right, like it's not necessarily the number one priority for this treatment anyway, but if those things happen to be issues there is help, it can get better and you just let me know if you have any questions. Cause not everybody wants to talk about it and it's not my job to convince you to deal with it. It's my job to help you if you want help. Karen Litzy: And if you're a physical therapist that isn't specializing in pelvic health, it's a little bit different. Cause if you're specializing in pelvic health and people are going to you because you specialize in pelvic health it's way easier, you know, these questions are going to come up. But for those of us who don't specialize in pelvic health, then those questions can be a little bit more sensitive. So I just want you to make that distinction there for people. Sarah Haag: 08:48 Yeah. And also if you're going to ask if you're going to take that step and be like, all right, I'm going to ask about the incontinence. I mean cause sometimes you're in situations where it is an obvious issue. Other times it's like, well, based on their history they're actually at risk for it. Then you can talk prevention, which has always been kind of fun. But just if they give you some information, especially if you got up the guts to ask them, then please, please do something with it. Don't just be like, oh yeah, so great incontinence noted in the chart. I'll put it on the diagnosis list, like how the plan and there are some things you can do without doing a pelvic floor exam that can make amazing changes. Karen Litzy: 09:49 How can you evaluate pelvic floor muscles without having to go internally? I think that's a question everybody wants to know. Sarah Haag: Great question. I'll be honest, some people don't want you to touch him there like full stop. And so I will actually give people, I would say it's kind of like a choose your own adventure. So we can actually, we can all check our own pelvic floor muscles right here. And I would basically talk you through it. You would tell me what you felt. I keep an eye on everything else to see what else you were doing. But it would be very honest that my assessment is going to be, I believe you, it seems you're doing it correctly. Right? But I have to believe you, but you can actually palpate externally. As a clinician you can actually do it and you can do it in sidelying. Sarah Haag: 10:33 You can do it in hooklying and some people will do it in prone. I'm not a super big fan cause I can't see their faces. And also it can be kind of a vulnerable position. Basically if you just palpate, if you find the ischial tuberosity, you know about where the anal sphincters are. Okay. There's normal human variation. So I always say move slow and make sure you're asking for feedback. But you know, mid line is where the sphincters are going to be. We're not going midline. So you just kind of find that ischial tuberosity and palpate your way around to the medial part of it. And that's where the pelvic floor attaches. So then you can kind of talk them through, like I'd like you to squeeze and there's a bunch of different cues. Sarah Haag: 11:22 One of the most common cues, especially for the back end, is to like squeeze. Like you don't want to pass gas and that's awesome. But if you're a main problem with urinary incontinence, that's the back side, back side, not the front side. So how do we get it up there? So another cue that has been found to be very helpful, it's only been studied in men, but it is, shorten your penis. But what's interesting is ladies, I know we don't have them, right? Imagine that feeling, right? So like just imagine like pulling in, right? It totally changed where hopefully if this is a class, it would have asked where did you feel it? But like it, it changes it from the back and biases it towards the front of it. So find a cue that gets them to go, oh my God, I felt something. Sarah Haag: 12:07 You're like, awesome. So if you're doing a Kegel and like this happens, you're probably not doing it right. If that's happening, you're probably not doing right. But if like I'm Kegeling now and then I let go, you shouldn't have seen me get taller or tensor or breathe funny. It should be very sneaky. So as you're palpating on the medial side of the ischial tuberosities your feeling for those muscles to contract. So it's kind of like a gentle bulge and you can totally feel this on yourself here if you're comfy or somewhere else. But when you feel it, it's almost like when you're feeling like if you have your biceps slightly bent and you kind of like contract and you feel at tensioning and like a little bit of a bulge, that's what you're feeling for. Sarah Haag: 12:51 Okay but it can always be tricky cause I use the word bulge. Some people will have people push down. So we should also be able to like relax your pelvic floor and push down, like having a bowel movement. That shouldn't happen when you're trying to contract. So like when I say bulge, you should feel like a gathering of the muscle. That's what you're feeling. If you feel your fingers get pushed down in a way they're doing the opposite of a contraction. So there they're relaxing. It would kind of depend on what they were doing and the cues you were giving. So it could just be like, I'm pushing down like doing a Valsalva. But it is basically a lengthening into the pelvic floor. I don't know if it's always a relaxation, so to speak. Karen Litzy: 13:33 It's kind of lengthening. And what is the difference between that Valsalva or lengthening and that small bulge? Like why is that significant? Sarah Haag: When you feel it, you'll know it's significant because if they're pushing down in a way that's not a contraction. So if you're going for strengthening or more closure to hold things in, yeah, you want that kind of like tensioning and bulge. But if you're actually the problems, constipation, I can't get things out, you want them to be able to relax and link them. Karen Litzy: Got It. Okay. All right. So now we know how we can kind of feel our pelvic floor muscles without having to do an internal exam. So once you figure out, and kind of what you said sort of leads right into the next question is if you have someone that's coming in with incontinence and you are looking for that sort of tightening or gathering up of the muscle, which I think that's a nice cue for people to understand because bulge can sometimes be a little confusing for people, but I liked the cue you're feeling the gathering of that musculature. Karen Litzy: 14:45 Is that something that you are then going to add into a home exercise program or like once you find that the pelvic floor muscles working or it's not working, what next? What do you do? Sarah Haag: Well, so I'll be honest. It's always I like him and people are brave enough and the patients were brave enough to be like, sure you can have a feel like let's figure this muscle thing out. I usually try it in a normal active kid in a normal setting. So not a public one. No pelvic settings are normal too. But in like just a normal like say outpatient therapy, be it or orthopedics or neuro, I would actually have them ask more questions about incontinence before even checking the pelvic floor muscles. Because the different types of incontinence are going to kind of tell you a little bit more about what you should do. Sarah Haag: 15:35 So some people have incontinence when they tried to go from sit to stand or when they cough or when they go running. So I want to know a little bit more about when is it happening because if it's only ever when you're putting your key in the front door or when you're running into the bathroom, that's more urgent continence. Would pelvic floor muscle exercises help? Maybe, but also probably looking at their overall bladder health, which is where a voiding log would come in very handy. And actually a shout out to the home health section and they have an incontinence urinary incontinence toolkit. It's free for members for sure, but I think it might be free for everyone. Sarah Haag: 16:15 So it's a pdf that actually talks you through the different types of incontinence because the most common form of incontinence urge incontinence, which is you're an urge incontinence is proceeded by a strong urge to go. So this is one of those things where, so there's a bathroom at the end of the hall. So if you're like, I'm totally fine, but then your eyes wander, you're like, oh, I could go and I didn't have to go. And then I would get up to go and I got to the bathroom and all of a sudden it's like, oh, where did that come from? Like all of a sudden it felt like your kidneys did a big dump, but they don't, that's not how kidneys work. Sarah Haag: 16:59 It's just how it feels to you. So what that really is, is your detrusor muscle kind of going, I'm so excited. I imagine a puppy, like have you ever like gone to let a puppy out the door? Like, so they're like, hey, I want to go out and you get up and you make a move for that door. And they're like so excited. Your bladder is like that sometimes. So that's more of a behavioral thing because what would you do with the puppy who's now like, wait, every time I do this, she lets me out. Pretty soon you're letting that puppy out every 10 minutes because yeah, because that's what the puppy trains you to do. So that's kind of more of a behavioral thing. And so that's proceeded by a strong urge. So it's not just when you're going to the bathroom, but if you get a strong, unexpected urge and leak, and that's usually a lot of people also experience some urgency and frequency. Karen Litzy: So if you feel like you're not getting to the bathroom in time, what would be a really logical plan to that? Sarah Haag: 17:52 You'd go more often, you're like, Ooh, maybe I need to not wait so long. But the thing is that then you're training yourself to go more often, your bladder is perfectly capable of holding more that kind of sensitivity and those signals you're interpreting or like, ah, no, I should go now. And then pretty soon you're that person who can't make it through a movie. You're that person who can't make it past a bathroom without needing to go. And you're the person that no one wants to go on a road trip with because you're stopping every like hour on the hour and every rest stop. But now is that because your brain is interpreting this as such? I know that there's a physical manifestation obviously, but is that like have you trained your brain and to feel that way to interpret that as such? I would say yes because most of the time, even if it wasn't intentional, like it's kind of like a slippery slope. It's like I almost didn't make it that one time. I'm going to plan ahead. And then what starts to happen, especially if you're like, all right, Sarah Haag: 18:54 your bladder is filling up. You kind of feel like you need to go and you go to the bathroom and it came out and it's like, all right, so that was nice and normal. But then imagine that time where you're like, hold on, I almost didn't make it, but you were stretched this much. You're going to start going when the bladder stretches this much. And then pretty soon if you let it so you're like, Ooh, now I'm going down here. Now I need to go sooner. And this is one way you can tell this is happening. And it can happen sometimes without ending up with a diagnosis of urgency, frequency or incontinence. But where you get to the bathroom and you feel like you've got a goal, but then nothing happened. Goals, like it's the smallest tinkle and you're like, I thought it wasn't gonna make it, but that's ah, that's all that's in there. And so that was like big urge little output. That's kind of a mismatch. And that'll happen sometimes. Sarah Haag: 19:48 But like if you're paying less than that, that's not much more than your poster board then a nice healthy post void residual. So you don't have to empty at that point if you're bladder's saying, empty me now. And that's all that's in there. Yeah. So it's kind of like you're the sensitivity of your bladder has turned way up. Just like how we would compare that to the pain. So the sensitivity is turned way up so that it takes less of a stimulus in the bladder itself to trigger that feeling of you have to go, even though the bladder is barely full. Sarah Haag: And there's actually some interesting conversations with urgency and frequency in that feeling of extreme urge, can that be considered a pain? And so it's kind of interesting conversation because there is normal, there is a normal sensitivity of normal urge, but when that urge becomes pathological, yeah. Sarah Haag: 20:47 Too bothersome. Does that crossover into it? Distressing emotional experience? I would think so. Like can you imagine if you're like on a train or something like that and you have to really, really, you have, you're having that urge. I mean, that's very distressing dressing. That's very distressing. That's like you're suffering. So if you have someone like that what do we have them do? So they keep a diary, which you can get on the home health section and we'll have a link to that in the show notes. You basically ask them to keep track of things for a couple of days. I tend to keep it simple with what are you drinking and when and when, when are you going to the bathroom? If people are willing to measure, that's the best, but not many people are willing to measure. Sarah Haag: 21:37 So what I try to have them do is to kind of come up with their own plan. And I tell them this is not an exact science because you're not measuring, but that's okay because if you have a strong urge, which is kind of a lot, but you have like a little tinkle, that's kind of a mismatch. If that only happens after your third Mimosa, okay, that might actually be like a normal bladder thing. Do you know what I mean? So we kind of look at things that they're bringing in that may or may not be irritating to them. We look at are they getting enough fluid and bladder loves, loves water. But the first thing most people cut out if they're having urgency, frequency or incontinence is water is they cut out their water. It'll almost always backfires. Sarah Haag: 22:19 So don't do that anyone watching. It also makes you constipated, which you can increase your urgency and frequency. So, so yeah, so surprise. Everything needs to work well to work well. Okay. But yeah, so you kind of look at that and I just look for patterns and then I have people try to change one thing at a time. If all you're drinking his coffee all day, but actually you have good data, good parts of your day and bad parts of the day. Is it the coffee? Because if you're drinking coffee all day, you're probably not going to be very nice to me if I say, how about you stopped drinking coffee? Um, emotional response up. So you just kind of look at it. It's like, Oh, when does this happen? What do we need to change? And it can really help you narrow down. Is it really urge incontinence? Is it actually just frequency and they're not leaking like they thought they were or you know, is this primarily a stress incontinence issue? Karen Litzy: Well, so it sounds to me like there's not a lot of hands on work there. Sarah Haag: No, no, it's more behavioral. Susan: 23:27 Do you ever use pelvic tilting to get the posterior versus anterior pelvic floor? Sarah Haag: So that's a neat work with from Paul Hodges Group. So however you're sitting, most of us are Slouchy, just do a pelvic floor contraction, however your brain tells you to do that, do it and just feel where you feel it. But then if you get yourself in a situation where you like get more of that Lumbar Lordosis, and so like you stick your tail out, you get more lumber lordosis and then you do the exact same thing. So you're not changing your cue. For most people it's cuts to the front. And it's kind of neat because one of the things, one of my pet peeves is when we were talking about earlier is my pelvic floor therapist get tunnel vision and are just doing pelvic floor exercises, but not reintegrating it into how they're, they're using their body. Sarah Haag: 24:18 So if you have a runner who's a chronic but Tucker and she's leaking out of the front, obviously, how would it feel if you like got those glutes back a little bit? Because you can't run and Kegel at the same time. You can't, you can try. It's not going to go well. And certainly not for like a 5K and let alone not a marathon. So changing how that is biased because most of us don't think about the pelvic floor until you have a problem, right? But they've been working, right? They've been doing their thing. You're using them when you walk up those stairs you're using them when you're getting up off the floor. So they do something, the key goal is like your bicep curl. You want a stronger bicep, you're going to do some curls, you want a stronger pelvic floor, you're going to have to do some pelvic floor exercises. Sarah Haag: 25:07 But that's not your management plan. You kind of want to, someone said it yesterday, kind of like the core muscles are there like automatic, like when you get ready to do something you don't think, okay transversus were good. Like it just all happens and you want to kind of get the pelvic floor back into that system and make sure it's strong enough and coordinated enough to do its part. So you don't think about it. Dave: 25:37 So along those lines then, would you say that if somebody is more lordotic, they're more likely to engage the anterior floor and then flat back more of the posterior floor? Sarah Haag: 25:47 That tends to be what they're finding on like EMG studies and what I will see clinically with people if they do a ginormous buttock. It's really interesting if you're like, how's your breathing when you do that and, and how good is your squat, let's say when you do that. And it's like, Eh, it is what it is. I'm like, okay, so what if we do kind of take it into where some people, especially if they've been told by other practitioners to like watch your Lordosis, it's kind of huge. Which isn't really a thing. But you know, they kind of, they're kind of like going in there, they're like, I'm so scared but it kind of feels good and then you have them do that movement or try that exercise. Usually they're like, that was way easier than I thought it was going to be. Sarah Haag: 26:30 But again, if it's not working, then we try something else cause everyone's anatomy is different. Sometimes if they have a lumbar issue, getting into the ideal position for their pelvic floor, may or may not be easy for them, at least at first. But I think you need to play around with how it feels and how it's functioning as opposed to, I mean, I've been guilty of it in my career of like, ah, you need more or less of what you're doing with your spine and were just different. So it's where it works best is where it should be. Jamie: 27:03 So for a lot of the outpatient conditions and orthopedic setting, there's still an emphasis on giving some kind of qualitative documentation to the muscle contraction, whether it's a manual muscle test or something like that for payment purposes. So what are some strategies or tips for clinicians to be able to take that palpation externally and then relate that into their strengthening documentation? Sarah Haag: 27:29 So if you're just checking externally, like just palpating outside, it's like a plus minus like, Yup, I felt it. Uh, they couldn't find it. So kind of plus minus, cause you can't give it more than that. We also have to remember, so when I write about pelvic floor strength in my documentation, I have a number I can put and you can grade it. You have to do that internally, which is why if you're like, ah, we need to know more, refer him to a friend or go to the training. But I usually give a lot more information. So like, all right, so they, you know, they had like a three out of four, three out of five squeeze. The relaxation was not very coordinated and kind of slow, but then their subsequent contractions were five out of five. Sarah Haag: 28:09 All right. Do you know what I mean? We have to, because of payment and insurance and all of those things, we have to write something down. So what I do is I write down what I find and I'm happy to talk about it. So if you want to deny it, I can talk vagina all day with you. And I have, and their questions usually get shorter and shorter. Um, because really they're asking for information that isn't necessarily the most helpful. So if you're checking an externally plus minus, but also I've had people who five out of five but still incontinent, Sarah Haag: 28:41 So then they're like, well they're not weak but you put down, you're going to do strengthening. I'm like, well yeah, because it's more of a strengthening, not just a strengthening with a functional goal attached to that, if that makes sense. So sometimes it's more words, but don't be shy about one. Well, first of all, please be honest, be as accurate as you can be, but also don't be shy about doing the best care and be willing to stand up for it. If it gets denied. It's not cause you gave crappy care likely. I mean, do you know what I mean? I'm like, I dunno how long you practice, hopefully. Good. But if you get denied, it's not necessarily key because you gave bad care or even did a bad note. It's because they decided they weren't going to pay based on something. Hopefully logical that you can talk about. You can always appeal. So don't let payments scare you away from giving the best care. Sarah Haag: 29:36 Sorry. Another soapbox of mine. So that was urge incontinence. Stress Incontinence. Karen Litzy: So let's talk about that because I think that gets the more airtime, so to speak. So that's when you see the crossfitters are the weightlifters or there's a great gymnast pitcher yesterday going backwards where you there backwards over the pommel horse, not the pommel horse. It's the worse just a horse. A spurt. Like it was, yeah. And you're just like, that could be photo shopped, but also it probably isn't. Yeah. Or like we've all seen like the crossfit videos where women are peeing and then everyone high fives them because they worked so hard that they peed, which, you know, not normal. We know that that's been addressed by a lot of a pelvic health physical therapists. Karen Litzy: 30:32 So I would like to know first I think we just gave the definition of stress incontinence, but I'll have you give the definition quickly. But then I'd like to go back to something that the question that Dave had asked about the positioning and how that works within weightlifting or within, you know, waited or loaded movements. But go ahead and give the definition of stress incontinence first. Sarah Haag: So stress incontinence is basically when there's an increase in intrabdominal pressure that is greater than the closure of pressure of the urethra. And you have some sphincters as well as the pelvic floor helping keep all of that closed. But if you increase the pressure enough on the insides, and that's why you hear, and again, it's primarily women, but also a lot of men after prostate surgery, they cough and you get a spurt or you know, you jump and you feel it come out. Sarah Haag: 31:21 Those are usually because the closer pressure has gone down or the intra abdominal pressure has gone up. Karen Litzy: Okay, great. So now what does that look like? For the average physical therapist who's not a pelvic health therapist. And let's say they are seeing someone for hip pain and you ask them, are you ever incontinent? Or if they are, you know, heavy lifters are, they are adding load and they say, oh yeah, but that's normal. Or they have low back pain and they say, yeah, but that's normal. Everybody does it at my crossfit box or whatever at my gym. So how do you then, if you're not you, you are someone who's not a pelvic health therapist, how do you address that? Sarah Haag: Well, first of all, what all of us should know while incontinence is super common, it is not normal. Sarah Haag: 32:16 Not ever being dry is normal. So we need to get away from this idea that like, well, everyone's doing it. It's like does that make you want to do it? Like I feel like, no, I feel like no is the answer. So first of all, just, and sometimes they don't know that. Like, I know that in some like young girl gymnastic teams, like the color of their leotards are chosen to like, not show the pee because they're incontinent that young. Yeah. And I see a lot of women as adults sometimes before they've had babies sometimes after, right? So like what's the, what came first? But they've had lifelong issues with what's essentially public flourish. She's with incontinence, sometimes pain with intercourse, all of those things. Competitive gymnasts, competitive cheerleaders. Dancers tend to be probably the biggest, runners or another group. Sarah Haag: 33:12 There's been some studies, there's one study and I cannot recall it. I mean, it's probably like 15 years old now. We're 100% of this division one female track team reported urinary symptoms. 100%. Like every girl. So common. Heck yeah. Normal. So many girls. Yeah. So the biggest thing if you're not a pelvic floor therapist is to check out their function. So if they can identify when they're having issues, it's when I get to this particular weight or it's when I get to mile 17. Okay. And I usually throw in, like if I ran 17 miles, I'm not really sure what my body would do. Like I dunno, but it still shouldn't leak. But if you can find out where that breakdown in the coordination in the endurance and the strength and whatever it is happens and look at what's happening there. Sarah Haag: 34:04 Because if you can run 17 miles or you can lift 200 pounds without leaking, but then you do, you're not, you're not weak. Right? Like if you can do all of that, something's happening there to make this happen. Cause if you can lift 200 pounds in that league, something's working, it's just not still working when you try to live 210. Okay. So let, let's look at what's changing or number of repetitions. Right? That's what you're looking at. Sarah Haag: 34:52 So if you collapse your chest and which I would probably do after running 17 miles and I'm like this. And now what happens when I collapse what happens to my bottom half when I collapsed my shoulders? Well my butt just tucked. Cause I'm just trying to get through now. The funny thing is the breathing is also harder. So while I'm doing this as kind of a mechanism to keep going, it's harder to breathe because nothing's working diaphragm to have a full excursion, right? Yeah. So, so I like to look at if you're running fine for 17 miles, I want to see you at mile 16. I want to see what's changing over that mile. I want to see what you looked through my team. And can you, when you start to get to that point, can you make an effort to change something? Sarah Haag: 35:32 Do you notice a change in your breathing when you're lifting 210 instead of 200 and kind of look at it from that way cause you're not going to kegel why you do that. What do you mean? Oh well say to like precontract and prime and all these things and, and that's fine, but it's like if we go back to the running, you're not kegeling and all that time your pelvic floor after like 30 seconds is like, dude, you don't want me to get that tired. Like it's going to be like, we're going to stop that now. So yeah. So the way I would approach that, if you're not me, yes and not going to do a vaginal exam, is you look at their performance. So if they said, I have knee pain when I do this, when I go from 200 to 210, they're my squat. Sarah Haag: 36:13 How they do, they're looking at the mechanics. You would look at what's happening, what is different? Cause you know, the joint can do it, you know, the muscles can do it. What's changing. And you would address that. So it's really no different if they can tell when they're leaking, you're just looking what can, what are the things that can change it? Usually the tail lift and looking at their breathing or two really easy ways to go about it. Karen Litzy: Okay. All right. That's great. And, and, and that goes with that. Does that also work with, let's say instead of you're not a runner weightlifter, but you're like a new mom or something like that and you're okay, but then by the end of the day after you've been maybe lifting the baby or you know, doing whatever you're doing it, it doesn't necessarily have to be sport related is what I'm saying. Sarah Haag: 37:06 I think about like function, but definitely, I mean, you asked about, but no, just everyday if getting out of a chair makes you leak, that's, but then it's basically a squat. So you are, you're looking at the activity that they're having difficulty with and making small changes got in most cases. Karen Litzy: So I think the biggest takeaway here for me is that not everything is solved by doing a kegel. Sarah Haag: I think a lot of non pelvic health PT's may have that, that misconception that if someone has incontinence, well Kegel time. Right? And that's all you gotta do. That's what most people do. If they go to the doctor and they mentioned it's like, ah, you know, that's pretty normal. It's not, it's common. And then they'll be like, do some kegels and, and a lot of women and men don't know how to do them. Sarah Haag: 37:53 So then they're just, I'm squeezing stuff and it didn't work. And it's like, Oh, before we get too far, can we check and see how you're doing them? And I think that's kind of a beautiful segway. So let's say you have your new mom or you have your athlete or whatever and you are, you've tried some stuff, right? Cause none of this is life or death, right? I mean it's fine to try some things. So already not doing anything about it. So trying to change up a couple of things is perfectly within your purview, especially again, you're seeing them for hip or low back. It all, it's all together. You're good. But if it's not changing, if it's not getting better, if when you ask them, you know, can you contract your pelvic floor, what do you feel? They're like, I got no idea. Sarah Haag: 38:33 And they're like, but please also don't touch me there. Or are you touching there and you're like, yeah, I don't feel anything either. And I've used all my cards but I don't know what to do. That's when you refer. Because just like any other things, somebody coming to see you as a physical therapist, you're going to do some things. And if those things are not working or they're getting worse, you're going to try something different. Or call the doctor or refer to a friend. Right? So if you change some things and you're like, I'm amazing, they're all better. Awesome. Do they need to go to pelvic floor therapy? I'd say no if their incontinence resolves or their pain resolves. But sometimes with especially we see it a lot more in I would say the more active athletic population is a pelvic floor that's more like this. Sarah Haag: 39:19 So it's like tight and there's a hundred people call it hypertonic or high tone or short pelvic floor and all these things and basically in my brain, the way I categorize it is like you should be able to contract your pelvic floor and you should be able to let it go. And we can all get better at that. But if you're like, I'm here, how good is my contraction going to be? Because I'm not showing you my pelvic floor. Like it's not going to, it's going to taste like it's going to not move very much. But if you get them to relax more or they're like, oh, I didn't know that was there, that's better. Then you all of a sudden you have a good contraction. Karen Litzy: How do they relax? Do you just say relax? Sarah Haag: 40:01 Before somebody tells him to relax, the worst thing to do is be like, can you just relax? So I try to have them feel the difference between contracting and not contracting. Because what will happen and people use what the traps all the time is like. So like, ah, so much tension. All right. Again, telling you to relax your shoulders. Things I didn't think of that. But if you squeeze and let go like as a little bit of like, Oh, I feel that, oh, oh there's some more space there. So I start with that. Okay. The pelvic floor. But again, if they're like, I just don't know, that's something that is so easy to feel with a vaginal or rectal exam. So that's where it's like, ah, you're having some trouble. I would recommend, would you see my friend for one visit have this exam, they're checking out your muscles and just see if he can feel that relaxation and then come up with like cueing or a plan that works for them. Sarah Haag: 40:54 Cause it's not just about like slacking everything out. It's really feeling that that relaxation, that lengthening of the muscles there and being intentional about it. You don't want to lie there would hope like maybe it'll let go at some point. Audience member: So you talked about kegeling and what about dosage or prescription and quality versus quantity and how you prescribe that to your patient. Sarah Haag: There is no hard and fast rule as to like how many, how much. So that's where, again, I would have them do some and see how the coordination goes. Cause if they're otherwise neurologically intact and they're kind of getting it, how many do they need to do? Sarah Haag: 41:57 I would say it's not unreasonable to go kind of basic strength and conditioning principles of, you know, like I know eight to 12 reps three times a day. That's an okay starting point. And actually, I don't know if you know this, so I'm writing a book on incontinence and the PT people have it, but it's the editor just asked me, she's like, well, since we don't have like a hard and fast number, do we, should we put that in there? And I said, I think we do. So that's a good starting point. Not everyone would be able to do that right off the bat, but also some people be able to do that and they're not getting better. So it's kind of like let's start here and see what happens. And then you can kind of titrate it up and down. If I do an exam on somebody and they can't contract for 10 seconds, they can only contract for five, I'm not going to have them contract for 10 seconds at home. I would probably honestly in that case, have them go, I need you to make sure you can feel the good contraction. So you actually also asked about quantity and quality. I want quality, because all of us can do 100 crappy ones. I'm not sure how much it would help. So really looking to be like, okay, so I feel that contraction and I'm breathing Sarah Haag: 43:10 and I usually actually have stopped counting seconds. I've had people go by breath, so if you, let's do it. We're going to squeeze our pelvic floors and you're just going to keep squeezing as you breathe in and breathe out normally. Nothing, nothing fancy. And then keep squeezing while you breathe in and breathe out and let go. And what I hope you felt was a squeeze to start with maintaining the squeeze. Some people will feel kind of like a little, a little wave as they breathe, which is not unusual. But then when you stop the breathing and you let go, you should feel that let go. So if you didn't feel that, let go. I usually say that's one of two things without feeling right. I can't tell without feeling is that you got tired and you lost it or you forgot to let go. Sarah Haag: 43:51 So that's okay. Have a wiggle reset and try again. Because if you're not feeling the contraction, what are you doing? Like you might as well take a walk because then you'll actually be using your pelvic floor. I like going with the breath because a lot of people like to hold their breath when they're like, they'll do like they'll just suck at it and it, you'll feel a lift, but it's just a vacuum. It's not really your muscles doing their thing. So by doing the breathing, if you breathe in and out twice nice and slow, it's 10 seconds. You don't have to count. So if I have you do four of those, you just have to like count on fingers, two breaths come and arrest for two breaths. So much easier to keep track of. And then people actually do them. Cause if I could tell them to do ten second holds, one, two, three, four, five, six, nine, done. And that's not really helpful either. So like the too slow breaths. Now you're breathing and don't have to count and you're going to stay honest. Audience member: 44:57 So trying to bring this into the neuro world for someone who's post stroke and has stress incontinence or they've had neural damage of some sort and have stress incontinence, Are there any PNF techniques where you can incorporate the pelvic floor to help with that? Sarah Haag: I haven't had PNF stuff since college. And I'm old. So what I would say is, is if I'm recalling that they go through movement patterns and as you're doing those things, there are things will be happening on the pelvic floor. It seems to make sense. What specifically, I don't know, but if you're kind of working more with that tone in general, I've only had a couple of patients come see me like post CVA and feeling their pelvic floors is amazing because while it makes perfect sense that one side might be like hypertonic are nonfunctioning until you feel it. Sarah Haag: 45:49 It's like, wow, that's so cool. Like once I totally normal springy, they can contract and relax the other side just like they're, they're hemiparetic arm. It's cool. With stuff like CVA or neurological involvement, you really want to make sure you're on board with the physicians and you know that bladder function is still intact because depending on where the stroke is and what exactly happened or where the spinal cord injury is, you don't want to mess around with screwing up the bladder or the kidneys. So if they're not going to the bathroom or they're only leaking during transfers, that could be stress incontinence or it could be overflow incontinence because their bladder is so distended with the effort. So that's something you would really want to make sure you talk with their nurse or their attending physician and make sure, so how are things working? Sarah Haag: 46:38 Because the other thing we need to remember is a lot of things we're still working on people who have had neurological insults, right? So once you're like, okay, bladder is relaxing as it fills, contracting, as it empties, it's emptied fine. We're not worried about this being overflow incontinence. I would actually start to incorporate stuff like blow before you go. Where you're managing it the same way you would for someone not having a stroke, but half of that, the beam continent and actually going to the bathroom it seems, I can make it sound very simple, but I have a slide and of course that I teach where it has all the like the tracks up to the brain and all the tracks who, the spinal cord to the bladder. But we got the sphincters, we got the detrusor, all of this stuff just happens. Sarah Haag: 47:25 And when I click the slide from this beautiful simple picture, it's just font about this big, explaining all of the complex things that are happening so far as we know. So again, as long as they're, bladder is functioning on that basic level where it knows when to empty and it can empty, I would treat him like a anyone else and not assume that it's just because of a high tone pelvic floor on that one side. That's the issue. But if you get that person and you do your PNF, please tell me what happens. And if it changes their incontinence, I would really like to know. Karen Litzy: And when you're looking at the bladder function, that is something the physician is doing through an ultrasound, is that how that works? How did they do that? Sarah Haag: They can do it through an ultrasound so that that they are, they can look mostly at like post void residual. Sarah Haag: 48:12 But then also there's a test called neuro dynamics. And this is a test that involves, a catheter and there you're a threat. And then a probe and another orifice down there to help measure for intra abdominal pressure. And it's kind of a neat test. If someone wanted to do it on me for free, I would probably do it. But they're also looking at an EMG the whole time. So they start to fill up your bladder was sailing so you know how much is in there and you're awake for this test because they go tell us when you, when you feel the first urge to go and they mark where that is. And so you can see how much fluid is in there. And I'm like, tell us when you get like the, I should go to the bathroom now urge. And they mark that and then they're like, okay, tell us when you can't take it anymore. Sarah Haag: 49:00 And they mark that. So then they know how much your bladder can truly hold. But also looking at what's your detrusor doing, which is the smooth muscle around your bladder, what's happening to your pelvic floor, where is the weakness? And usually when they're full, sometimes they'll have people cough to see if anything leaks or if any sphincters happen or sphincters what they're up to. But it's, it's involved. But there's a lot of good information. And interesting side note is that if you do so, that's really I think really helpful for like a neurologic population just to make sure. I did have one patient I was lucky enough to work with a PT who became a physiatrist who specialized in neurogenic bowel and bladder and she let me come down to watch urodynamics of one of my patients who was really against cathing. Sarah Haag: 49:46 He didn't want to cath. So she came down, she brought him down to the urodynamics and as it and cause he's like, I am voiding 400 to 600 milliliters every time I have a bowel movement. And like that's pretty good. I mean like most are four to 600 CCS and turns out it was only under very high pressure. He was already getting reflects into his kidneys and after he voided four to 600 CC's, he still had four to 600 left, which is too much. So even though he was having some output, that was the test that really made it clear to him like, oh, it's coming out, but it's not healthy. Like I need to cath. Jamie: 50:41 What are some of the considerations that you might go through in your thought process when you're dealing with a male versus a female pelvic pain or incontinence issue? Sarah Haag: 50:53 That's a lot. I could talk for days on that. Well I'm not sure. When you're talking about considerations. We need to take into consideration our patient preference and what they're comfortable with. We can tell when our patients are uncomfortable or we should be able to but then kind of try to work out, they might not want to talk to me about this, but who can I get that they would, cause a lot of people would assume that men aren't really comfortable talking to females. But a lot of the men who come to see me, just want help, and we've had several male students come through and you know, they run into like women not wanting a male therapist to do it. Sarah Haag: 51:36 It's just finding that, right? Just like any other body part, finding the right person to help. But then if we go to, you know, bringing up those subjects, I don't know that in my brain it's so, so different. Male to female, you're going to take into consideration their history for sure. I feel happy saying that because now with we have kind of like a gender spectrum, right? We have people who, who have transitioned in varying degrees and we have people who haven't transitioned but totally identify with the gender. They weren't assigned at birth and all of these things. So basically I take it functional. So can you just walk me through the issues you're having, your questions, concerns when it's a problem, if anything makes it better, does anything in particular make it worse? And then we problem solve from there? Sarah Haag: 52:26 So I guess I didn't really have a good, a good answer, man. Male to female. Their situations are usually different, but it's kind of different across one gender or the other. Anyway. Is that kind of answer it? Yeah. Great question. Karen Litzy: Well, thank you so much. Thank you. I think we covered a lot and I thank you guys for being here and I hope that you guys got a lot out of this and can kind of take this back to your patients now. So last question that I ask everyone and it's so knowing where you are now in your life and your career, what advice would you give to yourself as a new Grad? Sarah Haag: Ask more questions. To be honest on, I came out of school pretty much like, like the teachers know best and what I learned is right. Sarah Haag: 53:16 And then when you get into the real world, I ended up thinking I was not very good at my job for awhile because like you would do what you were taught to do but it wouldn't work. And then, you know, some things happen and I got older and more comfortable and when you start asking questions you realize there isn't one answer. So if you start asking those questions, you're part of, you're part of the solution. By kind of pushing those boundaries and not like, I wish I would've just asked more questions sooner. I'd be so much smarter than I am now. Karen Litzy: Where can people find you on social media if they want to get in touch with you? Sarah Haag: Sarah Haig, PT on Twitter, you can find me on my website, www.entropy.physio and um, I mean Facebook, Sarah Hague. Sarah Haag: 54:07 I don't know what my picture looks like right now, but I'm friends with Karen, so if it says I'm friends with Karen, that's probably me. Karen Litzy: Awesome. And just so that everyone knows a lot of this stuff that Sarah spoke about, we will have links to it. We'll have links to the home health section. We'll have links to the testing, the urogenic testing. Is that neurodynamic testing? You could just send me a link or something about it. So we'll have it all in the show notes. Thanks everyone for watching the live. We appreciate it and everybody, thanks for listening. Have a great couple of days. 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 iTunes!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Steve Anderson on the show to discuss leadership coaching. Steve is an Executive Coach with Orange Dot Coaching and the host of the Podcast, Profiles in Leadership. He is a former Board of Trustee for The Foundation for Physical Therapy and was the President of The Private Practice Section of APTA for 6 years between 2002-2008. In this episode, we discuss: -Why you should invest in a coach -The importance of outside perspective when you're pursuing excellence -How to be open-minded and gracefully accept constructive criticism -Redefining your daily operations with purpose and vision -And so much more! Resources: Steve Anderson Twitter Steve Anderson Facebook Steve Anderson LinkedIn Orange Dot Coaching Website Episode 197: The Graham Sessions with Steve Anderson Profiles in Leadership Podcast Optima: A New Health Company A big thank you to Net Health for sponsoring this episode! For more information on Steve: Steve Anderson is the ex-CEO of Therapeutic Associates which is a physical therapy company that consists of 90 outpatient clinics in Washington, Oregon and Idaho and a major hospital contract in Southern California. He currently is an Executive Coach with Orange Dot Coaching and the host of the Podcast, Profiles in Leadership. He is a former Board of Trustee for The Foundation for Physical Therapy and was the President of The Private Practice Section of APTA for 6 years between 2002-2008. He was awarded the most prestigious award the Section gives out annually to a physical therapist, the Robert G. Dicus Service Award in 2010. Steve received the APTA Leadership Advocacy Award in 2006 for his efforts in Washington D.C. and Washington State in the legislative arena. In 2012 Steve received the Distinguished Alumnus Award from Northwestern University Physical Therapy School. In 2016 Steve was awarded Physical Therapist of the Year by PTWA, APTA's Washington State Chapter. Currently Dr. Anderson works with business executives and their teams to improve their leadership skills and coaches them to improve communication skills and working together better as a team. He lives on Hood Canal in Washington state near Seattle with his wife Sharon. Read the full transcript below: Karen Litzy: 00:00 Hey Steve, welcome back to the podcast. I am happy to have you on. So thanks for joining me today. Steve Anderson: 00:07 Well, thank you Karen. I'm very happy to be on and I'm looking forward to our discussion. Karen Litzy: 00:13 Yeah. So last time you were on, we talked about Graham sessions and we'll have a link to that in the show notes to this podcast so people can kind of go back and learn more about that. But today we're going to be talking about the importance of having a coach. And first I'll swing it over to you if you want to kind of describe what you do as a coach and maybe what is your definition of a coach because there's a lot of coaches out there. Steve Anderson: 00:45 Okay. So what I am is I'm an executive coach and so that means that I deal mostly with leadership training and communication skills and things like that. So what I do specifically is I work with people that are running companies, CEO types, and executives that are in leadership roles. And so helping them develop their leadership and communication skills. But then I also like to work with teams. And so I have clients that I work with, the CEO and their executive staff on how they can communicate together and how they can work better as a team when they're trying to run their business and grow their business and so on. So that's pretty much what I do. You know, but the definition of a coach is just somebody to help you, you know, figure out. Steve Anderson: 01:40 I think what happens is we are in a very complex world and in our businesses and so on that they get very complex. I think a coach can help you simplify, look at things and simplified a little bit, help you kind of get out of your overwhelming rut, so to speak, and how you can start to look at things that are the smaller pieces and put that together and then just learn how to communicate with others and grow your business. And in a sense that doesn't seem so overwhelming or overpowering. I see a lot of my clients in that mode of, they're just, they're just overwhelmed and they've just got so much to do and so many things to look at that they don't really know what the next step is. Karen Litzy: 02:27 Yeah, I hear you there. I definitely feel like that on almost a daily basis. Now before we kind of go into a little bit more about coaching, just so the audience gets to kind of understand where you're coming from. So you are a physical therapist and you owned a multisite practice, but let me ask you this. You could have retired and just kind of spent the rest of your retirement hanging out and you know, relaxing. So why make that shift to being a coach? Steve Anderson: 03:04 Sure. So I was a physical therapist and came up through a company called therapeutic associates where I started out as a staff therapist and then I became a clinic director and eventually became the CEO of that company. And it had a very unique ownership structure in the sense that every director of every clinic in that company is an owner in the company. So I was certainly not the only owner in the company. I was one of many owners in the company. And so when I retired, you know, I retired fairly young, I guess when you look at what age people retire these days. And so I thought, well, you know, what do I want to do from here? I don't feel like I'm ready to just do nothing. And so I kinda did the soul search and say, what are things that I really like to do? Steve Anderson: 03:54 And when it comes right down to it, what I really liked to do is I just really liked to grow leaders and work with people as they're going through their journey. And so, I went and got certified in a program called insights discovery, which is a communication system or style and started reaching out to people and I've got some clients and worked with them and learned, you know, how to improve and get better at what I was doing. And so now I do it on, you know, certainly a part time basis. I'm not doing this full time by any means, but it brings me joy. It feels like I have a purpose and it's something that I just really look forward to doing. Karen Litzy: 04:39 I think that's such a great transition from the work you were doing as a physical therapist to the work that you're now doing as a coach. And for me, it gives a lot to think about because oftentimes, especially as a physical therapist, I know I felt this way when I graduated from college was, okay, I'm going to start working for a company and then I'm going to work there until I retire. And then that's it. So oftentimes, you know, it's hard for us to think far ahead, but being able to hear stories like yours I think can inspire a lot of people to say, Hey, wait a second. Like there's more to retirement or there's more to when, maybe whenever it is, you feel like your clinical work as a physical therapist is maybe run its course that you can use your physical therapy degree and you can use information, you can seek out new information in order to start a whole new career, but you're still firmly rooted in the physical therapy world. Steve Anderson: 05:43 Right. I think you bring up a really great point in the sense that, you know, you don't, when you come out of school and you start your profession, start your career, you know, you can't see often that thing that you want to do. In other words, it's hard to visualize what exactly I want to do and what exactly I want to be. And I see new professionals coming out kind of tortured with that a little bit. Like they wanted to do something but they can't see it other than just the day to day. You know, we're working with the patient. So I can just share my journey a little bit in the sense that, you know, I was an orthopedic physical therapist and I worked hard at being good at that skill and then I became a director and I realized that I really liked working with the team and working with people and people don't always, they think I'm just messing with them when I say this, but I was kind of a reluctant leader. I didn't go in thinking that this is what I want to do, this is how it's going to look. And, I just kind of evolved into that leadership role. And then as I took steps going through my career, all of a sudden I was voted to the CEO of a very large company at 41 years old. And to be honest with you, I was scared shitless. Karen Litzy: 07:03 I mean, I would be. Steve Anderson: 07:06 Yeah, I was excited to be in this position, but I'm like, Oh my gosh, I mean, you talk about imposter syndrome and I was like, what do I do now? Everyone thinks I'm going to have the answers. So at that point I didn't really know what coaching was or what coaching services wasn't. As a matter of fact, it was fairly a new concept to have a coach. And so I didn't have an opportunity to reach out to one and I didn't really know what to do. And so when I look back on that time, gosh, I could've really used a good coach. And so what I did was I looked for other ways to try and improve my position or my skills. And so I took a few college level or I mean graduate level MBA courses and they were okay, but they weren't really, you know, just resonating with me too much. Steve Anderson: 08:01 And so then I eventually found this group called Vistage and you may have heard of that, but that's an international group where they have CEOs that work together usually 12 to 15 in a group. They meet on a monthly basis and they basically just learn from each other and help solve each other's problems. And so it's like a group coaching, so set up and I was in that for seven and a half years and really, really learned a lot from that because I had, you know, peers to bounce things off or like could get vulnerable with you. Got to know him really well. And, I think when you can trust somebody and work with someone to get to that level of vulnerability, I think that's where the learning really takes place. Karen Litzy: 08:50 And that group that was multidisciplinary group, that wasn't just specifically for therapists or even just for health care, is that correct? Steve Anderson: 08:58 Exactly. In fact, I was the only CEO in that group from healthcare. And then they make sure that there's no competitors or you're not competing with anybody in that group. And so you start out kind of with people you don't know. And over a period of time you start to know and trust each other. And, and over a longer period of time you can really, you know, really get down to things that you have a tough time talking to most people about because you've really gotten to know these people. So I look at that as kind of a coaching relationship and the fact that my clients that I work with now, once they get to know me and once they trust me, you know, they can tell me the thing that they're afraid of or they can tell me the things that they don't know, without looking weak to the people they lead or without, you know, being their fear of, you know, people thinking maybe they don't really know what they're doing, but they can share that with the coach. And then we can get down to the real nitty gritty of that and what that means and how to work through that. Karen Litzy: 10:08 And it sounds like you were able to take what you learned there and combine it with what you learned through your career and then the extra courses taken after retirement to kind of hone your individual coaching skills in order to better grow your clients. Steve Anderson: 10:30 Right. And I think the emphasis on that scenario you just discussed was the experience. I think the experience you can't buy experience, you can't, you know, like when I look back on mistakes I made when I had less experience, you know, I wish I could go back and do those again cause I think I would do them a lot better. But yet that's how you learn. So hopefully a coach has the experience to help you, say this happened to me and this is how I went through it. And, and this is how I can see you maybe, you know, getting there. I do question or scratch my head sometimes when I see, cause I do see business coaches that have never run a business. Steve Anderson: 11:18 So that always kind of makes me feel like, well, you know, I want somebody who's been in the trenches. I want somebody who has worked through this before and can help me see some ways through it as opposed to someone who's just read a lot of books and knows all the catch phrases and the authors and so on. But I think the experience is the key there. And if we look at it from the clinical side, you know, if on the clinical side as a physical therapist, we probably refer to it more as a mentor, maybe then a coach. But same thing there. You want somebody who has experience and who has seen, you know, tens of thousands of patients and has that experience that you don't have that can help you maybe see through some things from their experience. And to me that's what makes it a really good mentor and a really good coach. Karen Litzy: 12:12 Yeah, I would agree with that. 100%. And you're right, there's nothing worse than seeing coaches advertise their services and they've had a business for less than a year. So, let's talk about pros and cons of having a coach. Let's get practical here. So what are the pros? So if someone's out there looking for a coach and they're on the fence, what are some pros to having a coach? Steve Anderson: 12:43 Well, again, I think I said a little bit earlier, but I think a good coach can help you simplify what you're trying to accomplish. You know, I think a good coach can look at a complex situation and help you make it simpler. You know, coaches can be your external eyes and ears and provide a more accurate picture of your reality and recognize fundamentals that you have and that you can improve on. And then just breaking down some actions that you do to make them more practical. To me, one of the things that I work a lot with my clients with is it seems so simple, but communicating with others is so powerful. And if you really know how you communicate yourself or what motivates you and how you come across, and then you really get to know the people that you're communicating with and what resonates with them, then you construct your language and you construct your behavior in a way that connects with them. Steve Anderson: 13:51 Because I can think that maybe my approach is I totally get it and I totally understand what I'm saying and I can look at the person across from me and they're looking at me like, you know, so I'm not connecting with them. So I have to know how to communicate that. And, you know, as we talk about it here, it seems simple, but I think there's a real skill to that. And I think there's a real ability to kind of craft your message in a way that connects with people. Karen Litzy: 14:26 Yeah. And I think whenever you talk about relationships, whether it be a personal relationship, a business relationship, the thing that tends to break it down more than anything else is lack of clear communication. Right? Steve Anderson: 14:47 I was just going to say, and it's like if you look at your family or you look at your people in your business, I've always believed that you don't treat everybody the same. I mean, you have to be fair, but when we're talking about communication, in other words, the way that I would approach one employee could be very different than another depending on who they are, and you know, how they communicate. And so I think a really good leader is able to go in and out of these different styles, I guess, of communication that resonate with that person. And it's not the same for everybody. Karen Litzy: 15:29 Yeah. And it's funny, I was just about to bring that up because I was going to ask you a question of, let's say we'll take a scenario here. You're the CEO of your physical therapy business and you've got two people working in your front desk and you've got four physical therapists, and let's say you, I don't know, you notice that you have an unusually high cancellation rate with your patients unusually high. And so you kind of want to get to the bottom of it. So how you would speak perhaps to the people working at your front desk may be a little different than how you would speak to the therapist because they have different roles in your business, right? Steve Anderson: 16:18 Absolutely. You have a different message for them. And, even when you look at your four physical therapists, let's say, out of those four physical therapists, you have an analytical person who thinks in very analytical terms. Well then the way to approach that would be to talk about the cancellations and no shows from a data perspective. You know, here's the numbers. Here's what it used to be. Here's what we want it to be here. You know, so you talk in very analytical ways. You may have someone else that has a real, you know, that they have more, they have a real caring about people in their feelings approach. And so you might talk to them about that situation and don't talk about analytics, but you might talk about, look at what our patients are missing. Look what we're not, we're not reaching their potential. We're not, you know, touching their hearts, you know, or whatever. So you talk more in those terms and then, other people, you will have different approaches. So I think that you have to know your people well enough to know that sitting in a meeting with six people, I'm giving the exact same message and expecting all of them to embrace it and have it resonate with them all at the same time is probably unlikely. Karen Litzy: 17:35 Gosh, it's so much more complicated than it seems at the surface, isn't it? Steve Anderson: 17:40 Well, it is, but I think that that's what most of us feel. And that's where I think a coach can come in and say, okay, it's complicated, but we can make it simple. It's a step by step, day by day thing that we can break down. And then it's just like anything else, once you understand kind of the process, then it's practice and you just practice and you practice and you get better and you make some mistakes and yet you do some gaps. And yet, you know, you put your foot in your mouth. Sometimes you learn from that. And over time that's where experience starts to build and improve. Karen Litzy: 18:17 Yeah, I guess it is. Once you have that framework, can it become sort of a plug and play kind of practice thing? Steve Anderson: 18:28 It's good to break it down as simple as possible, but you're also dealing with humans. So just when you think that you just wouldn't, you'd think you've got it figured out. Someone will throw you a curve ball that you didn't see coming and so then you're going to have to, you know, readjust. But, it can be done much better than I think most people do it as just a general statement. You know, there's a great if I can put a plug in for this, a great Ted talk by Gawande, who most of us know who to go on deals and the title of the Ted talk is want to get good at something, get a coach. And he goes through the scenario of how, you know, he is a surgeon was thinking that he was doing pretty well and he improved and he improved. Steve Anderson: 19:20 And then he got to a point where he just couldn't, he felt like he'd hit his limit. He just wasn't improving much after that. So his question was, well, is this as good as it gets? Is this how I'm going to be? And I'm pretty happy with that, but you know, does that mean this is where I'm at? And then he decided to go back to Harvard medical school and hire a retired professor who was a surgeon and had him come in and watch one of his surgeries. And as he's doing the surgery, he says, Oh man, I'm killing this. This is going so well and I probably just wasted the guy's time and the guys and my money. Cause what's he going to tell me? This was going great. And then the guy came back with a whole two full pages of things that he could work on. Steve Anderson: 20:09 And he was kind of taken aback from it at first. But then he started doing that and he said, and I broke through that limit. I mean, he said, I'm a way better surgeon now. My infection rates are down, my outcomes are better. You know, and that just proved to him that anyone has a coach. And then he looks at the sports world and says, why is it that the number one tennis player in the world and the number one golfer in the world, they still have coaches. If they're the best, why would they have a coach? Well, because they need that extra eyes and that extra set of ears and so on to kind of help them break through the next level and the patients. And so I do think that that all of us could benefit from a coach or on the clinical side, a mentor. And I just think it's a really good way to spend your time and money to get to the next level. Karen Litzy: 21:01 Yeah. And, I love that you brought up that Ted talk. I'm familiar with that Ted talk. And you're right, it just shows that even when you think you're at the top of your game, to have that external eyes and ears on you because you don't know what you don't know. And so to have someone there to point that out in a constructive way and in a way that is going to make you improve, I think is the key. I think opposite, but as the person. So if I'm looking for a coach, I need to be mentally prepared for that person to maybe tell me things that are going to make me feel uncomfortable or that might hurt my feelings. I say that in quotes. But I think you have to be mentally prepared for change. Would you agree with that? As far as the people that you have coached in the past. Steve Anderson: 21:55 So, yes, you're exactly right. You know, as people that educate and all different ways, we know that the person who's going to learn something has to be in a position that they're ready to learn. In other words, they have to be open to the fact that they have to look at themselves and be willing to realize that there's things to learn and they need to be open to suggestion. And so, yes, I have had some clients where, you know, they kind of thought they were just doing really great and, you know, our discussions were more like them reaffirming, you know, that they did it right and that this is how it should be and whatever. And you're kinda on the other end of the lines, like, I'm okay, so then why am I on this call? Steve Anderson: 22:49 You know, so it's almost like they're using you to reaffirm to themselves how great they are. That has happened. But, it's rare. It doesn't usually happen. Usually the people that I work with are people that want to work with me because they want to get to the next level. They know that they and I don't really have any clients that are horrible at this. You know, it's kinda like Gawande said is it's people that are really functioning at very high levels but just want to get to the next level. And so, I think the people that are really bad at it are so bad that they don't even recognize that they need a coach or they can improve. I think the people that are the best clients are the ones that are functioning at a very high level. But no, they could maybe just get a little bit further, a little bit higher, if they had a boost or if they had somebody that could help them get there. Karen Litzy: 23:48 Yeah. That makes a lot of sense. And now we spoke about the pros. Let's talk about the cons. So I think maybe we might've just said one con that if you're not ready for a coach, then it might not work out so well for you. And that's coming from the person who's seeking. Right. So, yeah, I think you have to be really ready for it. And if you're not, then maybe it's not the right time, but are there any other potential cons that you can see? Steve Anderson: 24:19 Well, I think that, you know, the, the obvious one is it costs money, you know, and it takes time. You know, so, the way that I would answer that is yes. But then also, you know, look at how much money PT's spend on con ed and going to conferences and things like that. That takes a lot of money and a lot of time too. So it is just a priority. And, you know, I believe that the return on investment, so to speak, is very high in coaching. Because you really are getting that one-on-one approach. So, and then the other mistake that I see people make sometimes is, you know, I work with a client for awhile and then they kind of say, Oh, okay, this is great. Let's stop now and I'm going to go work on this stuff and then I'll get back to you when I've had time to work on it, practice it. Steve Anderson: 25:15 And, I think that that's okay. But I do think that sometimes, just having a person continually working with you, even if it's a lesser frequent time interval, I think it is good to reinforce that because it's hard to just take all this information and then drop everything and then just work on that without step-by-step approaches along the way. You know, it's kinda like I would make a reference to working with a patient that if you gave them a whole bunch of exercises and then say, okay, when you get all these exercises perfected, then come back and we'll go to the next one. Well, you can imagine what those exercises look like without some coaching along the way. If you returned in three months and said, okay, let's look at the exercises, you likely wouldn't even be able to recognize cause they changed them or they haven't done them. Right. And then they kind of, you know, one thing leads to another. Karen Litzy: 26:12 Right. Or because they don't have the accountability, they don't do them at all. Steve Anderson: 26:17 Yeah, that's true. Karen Litzy: 26:18 Right. So I think that's the other part of the coach. Steve Anderson: 26:22 Coaches will help you, you know, be responsible to help you, or be accountable is probably a better word. Karen Litzy: 26:32 Yeah, absolutely. Cause I know like I have certainly done continuing education courses and things like that and you learn so much and you're all gung ho. Then a couple of weeks later you're like, what? I haven't been doing everything that I learned at that course or I haven't been as diligent let's say. Steve Anderson: 26:58 Yeah, exactly. Right. And, I think the other thing that's kind of scary when you start any new thing is that you've probably heard of the J curve. You know, whenever we change behaviors or we try and improve on something, we kind of go in this J curve, which is, if you can imagine what a J looks like, a capital J, you start at a certain level and you dip down into the bottom of the J because you often sometimes get worse before you get better. And so it's that struggling time and that fumbling time and you just can't quite, you know, get it then, then you kind of come up on the other side of the right side of the J and then you reach a higher level. And so some people are unwilling or don't want to get into the bottom, bottom end of the J because it's frustrating. Sometimes you struggle and so, I mean some people would just rather, you know, go with the mediocrity and just keep going solid without the struggle. But sometimes you need to jump off the cliff and then get down into that lower J curve a little bit before you can really improve. Karen Litzy: 28:09 And I think it's also sometimes if you've had this level of success, let's say the, you know, high level executives or entrepreneurs who have multiple six figure businesses, you know, they have this certain level of success and I think you can get a little complacent and you can think to yourself, well, I am doing well, I'm already successful. What do I need a coach to help me get more? Like I'm there already. I've made it. So what do you say to that kind of comment? Steve Anderson: 28:41 Well, it just depends on what you want to do. You know, earlier in my career there was this Harvard business review article that was kinda, I used it as my management Bible cause it was, it just resonated with me so much. And the story was about the owner of Johnsonville sausage. This was in the day of Johnsonville sausage was only a Wisconsin company. And people who's constantly knew about it, but no one else knew about it. And he described how he was making ridiculous amount of money. He was really successful. He was just, you know, kinda on the top of everything, but he couldn't leave the factory without people calling them all the time. He was working horrendous hours, you know, all these things were happening. And so on the outside you would look at him and say, wow, he's so successful. Steve Anderson: 29:37 And then he went through this whole series of changing how he did things. Then in the title of the article is how I let my employees lead. And he grew leaders within the company and they took on the security responsibility and accountability. And so, you know, the end of the story is, is that now Johnsonville sausages, there across the country and probably international, he works less hours, makes more money and is happier and he's ever been. So, you know, I sometimes, as you said earlier, we can't always see what the other side looks like, but we just have to realize that there could be a better way. And then there could be a bigger prize at the end if you're just willing to go down that road. Karen Litzy: 30:22 And I don't know many people who would argue against that. I think it's right. I mean that seems like it makes a lot of sense why to have working a little bit smarter, maybe still working hard but at least working smarter and making a better impact on the world, making a better impact with your patients. You know, being able to grow your business or your practice and seeing more patients help more people. So I think that another misconception when it comes to I really need a coach is that the coach is just for you and that no one else is going to benefit from it. Right. But that's not true, is it? And on that note, we're going to take a quick break to hear from our sponsor and be right back. Karen Litzy: 31:13 Are you interested in a free opportunity to check in with the latest thoughts of other rehab leaders? Well, I've got one for you. There's a new online rehab therapy community designed for the intersection of the clinical and business sides of rehab. It's the rehab therapy operational best practices forum, catchy name, right? It's all about habits and initiatives that juice up your attendance, revenue, workflows, documentation, compliance, efficiency and engagement while allowing your provider teams to keep their eye on the prize. There are patients and outcomes. I personally believe that a better connected rehab therapy profession has the power to help more people jump in, subscribe and join the conversation. Today. You can find the rehab therapy operational best practices forum @ www.nethealth.com/healthy. Steve Anderson: 32:06 It's certainly not true that your influence and who you work with and who you touch on a daily basis will greatly, you know, benefit from you being better at your job. And a lot of times it comes down to just helping you see, helping you find ways to resonate with what you're doing. I'll give you another personal example. So do you know who Seth Goden is? He's kind of a marketing guru guy. And, so, you know, I was in my CEO position and I'm overwhelmed like everybody else and there's so much to do and whatever. And so people used to always ask me, well, what do you do as a CEO? And I would always hesitate because it was like a kind of, what do I do? I answer emails, I talk on the phone, I go to meetings, I go, boy, is that, how boring does that sound? Steve Anderson: 33:04 You know? And so I happened to be hearing Seth godin and going at this lecture and he said that you have to find a way to even identify within yourself, what do I do and why do I do it? And he gave out some, some ideas and it really resonated with me and I got excited about. So I went home and I worked at it. And so now people say, when I was a CEO, they'd say, well, what do you do as CEO. And I go, I'm an ambassador for my company. I'm a storyteller and I grow leaders and that sounds a lot better. Karen Litzy: 33:42 That sounds so much better than I go to meetings and answer emails. Steve Anderson: 33:48 Exactly. And so you know, so now when I'm doing, I'm sitting there trying to get through my emails. I say, okay, what am I doing? Oh, okay, this email was because I'm being an ambassador for my company. Or this email was cause I'm helping this leader grow. This phone call was for this. And so now those things seem to have more meaning and more purpose. And it just changes my mindset. And so I think that's what a good coach can help you see sometimes. Karen Litzy: 34:18 Yeah. What a wonderful example. And I often wonder that I would even say to my patients sometimes who are like executives and CEOs, I was like, well, what do you do all day? And they're like, what do you mean? I'm like, you get into work. And then what happens? And it's amazing how many people are like, I dunno, I mean I go to meetings and I answer emails and I'm on the phone quite a bit, like telling me what they're physically doing at their job versus what is the meaning behind the job. And I think that's the distinction that you just made there very well. Steve Anderson: 34:56 Yeah. And I'll give you another example. On the other end of the spectrum, I talked at a PT school once, gave a lecture and a young man came up to me and said, God, I was really impressed with what you were saying and it was a talk on leadership and I was really impressed with it and it seems like you really know what you're doing. And he goes, could I come and just shadow you for a couple of days? And I said, you mean just my CEO job? And he goes, he goes, yeah, I'd love to just follow you and see what you're doing. Whatever. I said, Oh yeah, you're going to be bored to death. I mean, what am I going to be able to show you? I mean, you know, I'm sitting at a desk, I'm doing that. He says, why? And he wouldn't drop it. Steve Anderson: 35:37 So I thought, well, what the heck? So here, this a PT student came and shadowed me for a day and a half and he went to meetings with me and he sat there when I was on the phone and he watched me get caught up. I mean, it was just, you know, he just hung out with me. And when he left he said, Oh, this was really great. I'm kind of thinking, God, I hope I didn't bore him to death. And I got an email from him about six years later and he said, Hey, you remember me, I followed you in whatever. And he says, I just wanted you to know that that day and a half set me on my course roots and my career and now I'm doing this and now I'm doing that. And so it had a huge impact on him. It was very gratifying and it made me feel really good, but I had no idea. So through his eyes, he saw things that I, you know, thought was mundane and day to day, but he saw things that he remembered and helped him, you know, find the career position that he wants. So that was a good story. Karen Litzy: 36:38 Yeah. That's great. Yeah. And again, like you said, it's that external eyes and ears, you know, we often don't see what others see and you never know who's looking. You never know who's listening and you never know who's watching. Steve Anderson: 36:50 Right. Karen Litzy: 36:51 So what great examples. Steve Anderson: 36:56 Yeah. And that's another great point is when you are in a leadership role, people are looking and watching and everything you do and everything you say, matter. And, you shouldn't take it lightly. You shouldn't be afraid of it, but you should realize that you probably have a lot more influence than you realize. And so recognizing that and being aware of that and trying to make that message better, benefits everyone in life. Karen Litzy: 37:26 Yeah, totally. And now before we kind of wrap things up here, I have a 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 yourself as a new grad right out of physical therapy school? So pretend you're coaching yourself back in the day. Steve Anderson: 37:52 You know, I told this story earlier because I remember it like it was yesterday and I came out of school. I wanted to be, this good, you know, manual physical therapist as I could possibly be. And so I was doing a lot of extra study and study group work and so on. And I can remember driving home from one of those sessions, I was probably about two or probably two years out of school. And I remember almost becoming overwhelmed with how can I possibly be as good as I want to be, an understand all this information and hone my skills and see the diagnosis and so on, how I was just overwhelmed with it. And, so I look back and I got through it somehow, but I would have loved to have had a coach then or a mentor that said, no, you're doing exactly what you should do. Steve Anderson: 38:52 You're working on your craft, you're putting in the time and effort and then you just have to go step by step, day by day. As I said earlier, because I would never imagined I would someday be the CEO of a large private practice physical therapy company. It just had never entered my mind at that stage in my career. So instead of being overwhelmed with, you know, this knowledge I have to get in whatever, I just need to start my journey, keep going and keep, keep moving and putting in the time and effort and where I end up in or I evolve into, I may not be able to predict, but I just know, I just know it's going to be something exciting and fun. And as long as I make the right decisions along that journey, I can reach a level I would have never imagined I could reach. And I do see that in new professionals today and they're struggling with that, you know, a few years out of school. And so my advice to them as it would have been to myself is just keep moving forward, step by step. Take some risks, find some things that resonate and excites you and don't be afraid to try them and see where it leads. Karen Litzy: 40:15 Great advice. And now before we go, let's first talk about your podcast and then where people can find you. So talk about the podcast. Steve Anderson: 40:27 Okay. Well, I just want to say on this podcast, how inspirational and how helpful you were to me. Because as you probably remember, I thought, well, maybe I should do a podcast and I believe I called you and asked you some questions and I had not a clue how to start it and what to do. And, I really, I commend you and thank you very much for helping me answer some of those early questions and so on. So my podcast is called profiles in leadership and I just try and focus on leaders and then how they lead and just learn something from discussions with each one of them. I've been doing it about a year and a half now, a little bit longer. It's great. I mean, I've gotten some really fun, fun interviews, some inside the professional physical therapy profession and some are outside. I'm doing more outside the profession lately, which is fun. And, again, people ask me, why do you do the podcast? And, I say, because I learned something every time I do one, you know, every time I talk to somebody, I've been around a long time and with my experience, I still learn something every time. So it's like that, that gets me in the jazz and I'm inspired by that. So that's why I keep doing. Karen Litzy: 41:58 Yeah. And I also heard you say several times that it's fun, so why wouldn't you want to do something that's fun? Steve Anderson: 42:04 Exactly. And, and you improve. I mean, I heard somebody might've been Joe Rogan who said, you know, if you think I have a good podcast, you should listen to my first few. Karen Litzy: 42:15 Oh my God. Steve Anderson: 42:16 I think we all start at a certain level and if you're not improving, then you probably need to get out. Karen Litzy: 42:23 Yeah, probably Steve Anderson: 42:26 I'm doing it. I think mine are much better than my first ones were. So, you know, that keeps me going too in the sense that I, you know, we all like to get better. We all like self-mastery. If we're not improving, we're probably not not having fun. Karen Litzy: 42:42 Yeah. I mean, like I look back at like the first couple of interviews that I did and it was like a straight up boring interview for a job that was not good. It was like, I was not showing my personality. It was very much like, so Steve, tell me about your job and what you do. And it was so, Oh my gosh. Yeah, it was not good. But you know, you got to start, like you said, you got to start somewhere. And I just took courses on public speaking and improv courses in order to help me improve because I knew where my limitations were and what needed to be done. But yeah, I can totally relate to that. The first couple are no good, not good, and it's not because the guests weren't great. It was because of me. Steve Anderson: 43:33 Well, but look at the risk you took. I mean, to me that's how you reach a higher level of excellence is you're willing to take the risk. You are vulnerable. You were willing to be on camera and on audio and stick your neck out there and, you know, struggle through it a little bit and you improved. And then now you're, you know, you should be very happy with where you're at now because you do a wonderful job. So that's to me what it takes. And if we relate it back to coaching, it's the same thing. It's yeah, I need to take a risk. You need to be vulnerable. You need to realize that, you know, with work time and effort and practice, you're going to get better. And that's what it's all about. Karen Litzy: 44:19 Absolutely. Very well said. And where can people find you, find more about you and find more about your coaching business? Steve Anderson: 44:27 Sure. So, my podcast it's on all of the podcast platforms, but, probably the easiest way to find it is through iTunes. You just search for profiles with leadership, with Steve Anderson. I did some as I did with you early on. I was doing the videos. And so, I do have the video gallery. You can search YouTube for profiles in leadership with Steve Anderson and then also all my podcasts and all the videos that I've done are on my coaching website, which is orangedotcoaching.com and that's orange, the word dot coaching.com. And you can see my services there for coaching. And then if you go to click on the media center, that's where the podcast and the videos are stored. Karen Litzy: 45:18 Perfect. And just so everyone knows, we will have all of that information on the show notes at podcasts.Healthywealthysmart.com. So one click, we'll get to all of Steve's information. So Steve, thanks so much for taking the time out today and coming on the podcast. I appreciate it. I appreciate you. So thanks so much. Steve Anderson: 45:37 Well, thank you Karen. And again, I just thank you for your early mentorship to me when I was trying to figure this all out and I haven't forgotten that and I'm very appreciative that you're willing to help me. Karen Litzy: 45:50 Anytime, anytime. You are quite welcome and everyone else, 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 iTunes!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Ryan Estis on the show to discuss excellence in business. Ryan Estis has more than 20 years of experience as a top-performing sales professional and leader. As the former chief strategy officer for the McCann Worldgroup advertising agency, he brings a fresh perspective to business events. As a keynote speaker, Ryan is known for his innovative ideas on leading change, improving sales effectiveness and preparing for the future of work. In this episode, we discuss: -Three actionable tips to constantly reinvent your business -How to stay relevant and achieve excellence with changing customer expectations -Four key practices you should adopt to thrive and avoid stagnation -Why you need to reframe problems in order to produce lifetime customers -And so much more! Resources: Ryan Estis Website Ryan Estis Facebook Ryan Estis LinkedIn Ryan Estis Twitter Ryan Estis Instagram For more information on Ryan: Ryan Estis has more than 20 years of experience as a top-performing sales professional and leader. As the former chief strategy officer for the McCann Worldgroup advertising agency, he brings a fresh perspective to business events. As a keynote speaker, Ryan is known for his innovative ideas on leading change, improving sales effectiveness and preparing for the future of work. He was recently recognized as one of "the best keynote speakers ever heard" by Meetings & Conventions magazine alongside Tony Robbins, Bill Gates, Colin Powell and Mike Ditka. Ryan delivers keynote speeches, courses and online learning with an emphasis on actionable content designed to elevate business performance. His curriculum emphasizes emerging trends influencing leadership effectiveness, sales performance and customer experience. Ryan helps participants prepare to thrive in today's ultra-competitive, hyper-connected business environment. Ryan supports the world's leading brands, including AT&T, Motorola, MasterCard, Adobe, MassMutual, the National Basketball Association, the Mayo Clinic, Honeywell, Thomson Reuters, Ernst & Young, Lowes and Prudential. Ryan and his team publish original research featuring client case studies to expand the live event experience. He is also the author of a popular blog on business performance. His writing has been featured in Inc., Forbes, Entrepreneur, FastCompany, SmartBrief, Business News Network, Crain's Business, and Yahoo Business. Read the full transcript below: Karen Litzy: 00:01 Hi Ryan, welcome to the podcast. I'm excited to have you on. So thank you so much for joining me. Ryan Estis: 00:07 Thanks Karen. It's great to be here. Karen Litzy: 00:09 Yes. And so like I mentioned in the introduction, Ryan was one of the keynote speakers this year at the private practice section annual meeting in Orlando, Florida. And I really loved the keynote, which is why I reached out to you. I took action now like you suggested and we'll get into that as part of my tan plan. We'll get into that a little later. I reached out to you via social media. And so here we are, but I have to say I really enjoyed the keynote and yeah, and it took a really like emotional interesting turn in the middle and I feel like in speaking with other participants that was unexpected and welcomed and really got people to sort of grab onto your words and take it to the end. So well done from a speech blueprint standpoint. Ryan Estis: 01:06 Well I appreciate it, you know, and I think an experience like that a little more emotional resonance is a good thing because I think that helps. Helps the tan plan, which I know we're going to talk about get a lot of attention. So that's always the goal. Karen Litzy: 01:20 Yeah, it was great. So thanks so much for that. But now let's let the listeners who weren't at PPS get a little bit more information from you. A little taste of that keynote. And one of the things that you know we were kind of talking about before we went on the air is at the private practice section. There are a lot of small business owners, a lot of entrepreneurs and a lot of my audience are yes, maybe work in healthcare but are also entrepreneurs. And we were talking about kind of customer expectations and how those expectations has changed over maybe the past couple of years. You probably have better research than I do on this, but can you talk a little bit about customer expectations and how they are kind of changing the small business or entrepreneurial landscape? Ryan Estis: 02:09 Right. Well, customer expectations are skyrocketing. They're changing fast because the world around us is changing so fast. I mean, I'm actually sitting at home right now and you know, when we get off this podcast I can turn to my lap and say, Alexa, paper towels and then an hour paper towels are at my front door. And that experience and experiences like those are elevating my expectations of everything. So as a consumer, I have a whole new set of standards with respect to customization, personalization of efficiency, expertise, sense of urgency and how I spend my time. And for those small business owners and entrepreneurs that are astute, aware of that and have evolving their customer experience to meet customers where they are, the future looks pretty bright. Karen Litzy: 03:03 And let's say, okay, we'll take me as an example. So I'm a small business owner and I really liked the way my business is running. I'm successful, I've been in business for 10 years. If it ain't broke, why fix it? So what kind of advice would you give to me? Ryan Estis: 03:23 I'd have some real thoughts about that. I would say if it ain't broke, it's the perfect time to break it because success breeds complacency. And complacency is the ultimate recipe for disruption. And the reality is for so many small businesses and small business owners, they don't change until there's a crisis, or they're experiencing some significant pain. And so, at that threshold, it's too late and you're on the verge of losing market share and getting commoditized, having your margin squeeze. And I know this from personal experience, if you remember from the keynote, my opening story was about exiting the advertising agency I worked for. And the reality of that situation is we had just deep pockets of resistance to change. You know, we wanted to kind of continue to do what we've always done, follow the playbook. And when the world around you changes and the marketplace changes, that's just such a recipe for disruption. And so having lived through that, I vowed personally, I am never going to experience that pain again. So the mindset of a small business owner today has to be continuous reinvention. Change is no longer an event. It's simply a way of existing. If you want to reign, remain relevant, thrive into the future. Karen Litzy: 04:51 And can you give some examples of maybe what you do with your own business to constantly reinvent? Because I feel like we can say you need to constantly reinvent and I feel listeners out there going, okay, great. Well what does that mean? Ryan Estis: 05:07 Yeah, yeah. So I'll get real, real specifics. Because here's the reality. If things are going pretty well and like the scenario you outlined, I had my business for 10 years, it's going well and I'm just going to continue to do what I'm doing. I don't see a real need or I have an appetite for change. And when things are going well that's true because change is uncomfortable. But, I've forced myself to get uncomfortable because that's where I'm evolving, stretched and growing. So we'll see a few things that I do. Three things, three very specific actionable tips. I am always in my business conducting what I refer to as three little experiments. I could be experimenting with my marketing on partnership, new software and the goal of the experiment isn't necessarily to have wild success. Ryan Estis: 06:03 The goal of the experiment is to learn and iterate forwards. So I'm trying new things that I think could help our business. And a part of that is it puts me in a position where I'm expanding my knowledge, acquiring new skills, getting education feedback, and then pantsing the business forward. So I would say some successes iterative, but you want to get out of your comfort zone and into the learning lane. So we have three very specific experiments that we're running in our business right now and there are tasks and we're getting feedback and evolving as a result. So that's one thing that I do. A second thing that I just really encourage or recommend is that in addition to working in your business, like you do, like probably a lot of your listeners do, and I do as a practitioner and a small business owner, you have to make time to work on yourself and on your business. Ryan Estis: 06:59 So for me, we just came out of a two and a half day meeting that I refer to as our 2020 growth summit. So this is literally shutting down emails, shutting down the phones, two and a half days with my team and some of our partners. There were eight of us attending in a room for two days with a very buttoned up agenda talking about the future of our organization. And you know, we're tearing apart the business and challenging ourselves to think about growth into the future. What are our priorities, budget assessment, looking back, looking forward recommendations, competitive intelligence, I mean all of it. So you know, that type of time kind of out of the business to working on that I think is imperative to having kind of a good solid plan and direction ahead. So that's a second recommendation is make you know, take time out to strategically work on your business. Ryan Estis: 08:03 Well, the third recommendation I have, and this is something I may have talked about it in the keynote, but I'm a big fan for small business owners of having what I refer to as a personal board of directors. And I have eight people that I've invited formerly this, that on my board of directors. And I invited people that I had a relationship with. I have a lot of trust and respect for their opinion or what they were doing say in their specific area of expertise. And the invitations were fairly informal, but what it's done is it's given me access to these eight people who have competency and skills perhaps to shore up some of my gaps. And I am able at inflection points when facing a critical decision or a juncture or I'm considering making an investment. Ryan Estis: 08:58 I had a group of people that, you know, I can reach out to and schedule a time with to use as a sounding board. And I think entrepreneurship at times can be very isolating. And you know, you feel you can get to a point where you feel like you're making decisions in a vacuum. And having an advisory board is moonshine option and valuable part of my growth, particularly over the course of the last couple of years. So those are three very kind of tactical things that I think everybody listening to can think about as it relates to their own business. Karen Litzy: 09:29 And, all of those three examples are things that are pretty doable for everyone. You know, it's not like there are things that are so outrageous. Like when you say three little experiments, you mean small, not like I'm going to restructure my entire business, but you know, you constantly throughout the year are doing this. Do you say I'm gonna do three little experiments a year or is it like every quarter or six months? Ryan Estis: 10:00 No, these are good questions. I would say I'm always running three experiments simultaneously. So let's say we're working on a marketing project that's a bit of an outlier, an experiment, something we wanted to do, try it. Sponsorship around some of our content branded content. And I'm not sure where this is going to go or if it's realistic. And so what we're testing this, I've reserved a little bit of budget, a little bit of investment, a little bit of capital. We're going to go down this path and then evaluate it. But through this process we'll learn things, we'll uncover things, we'll get customer feedback. We're working with, you know, our marketing partner. And so it's those, they're small tasks that, you know, if there's traction and the evaluation is, yeah, this is beneficial and we could build it then, you know, that we may expand an experiment. Ryan Estis: 10:57 So, that's the idea. They're small because I'm a big believer in that. Success is iiterative, you know, you want to be doing little things. There's been a thought about that. It's like the minimum viable effort. There's BJ Fogg, he wrote a book about tiny habits and small changes and his ideas that to create these, he's a professor at Stanford. And his idea is that you create a new habit, you need to simplify the behavior and then make the change so tiny, so little, so ridiculous that it's just something that's easy to do. So no, you don't want to and you want to take calculated risks, you know, not something that's going to jeopardize your core business. So that's when I think of three little experiments and then you build on those things based on your expanded knowledge, experience, exposure, you know, you can start to iterate your business forward. Karen Litzy: 11:59 Yeah, that makes a lot of sense. So like in my world, in the physical therapy world, for me, I can think of changes that I made over the last year. And we're joking before going on air, like I went into these changes with like white knuckles. Like I did not want to let go of the things that I was doing because like you said, it's very uncomfortable so that it works. So for me in the healthcare world, something that was, it was just simply switching my electronic medical records from one company to another and it was very uncomfortable. But now that I've been doing it for, I don't know, eight months or so or nine months, I think to myself, this is so much better. What was I thinking before? Things are better. My patients are getting reminders that they have appointments, the platform's easy, or I can do it on my phone. I don't need a computer. So you know, that's an example of something small and at least in the healthcare world that you can do. And like you said, I was getting feedback from my patients and they were like, I love this new system. This is great. I love getting these reminders. I love that I can pay through the system. So it worked. Ryan Estis: 13:14 It works. But I also think it illustrates a very, very relevant point to our conversation that, you know, it's the psychology of change, right? So our brains are wired for safety and survival, not innovation and change, the mechanism in our psychology is trying to keep us safe and alerting us when danger is near. And that's trying to keep us away from these unknown elements. And that was pretty useful in times where there were reptiles running around trying to meet us. But in the modern day society, when you're running a small business, you have to condition yourself to navigate those feelings. So the discomfort, the uncertainty, the trepidation, the anxiousness that you felt upon making this change, that's a sign that you're in the learning lane, that you're expanding, you're growing, you need to kind of learn to welcome a little bit of that tension because that discomfort means you're on the cusp of a breakthrough and you broke through in an area of your business that elevated the client experience that's better for you, that's better for your team. And you just had to navigate that tension inside yourself. And you know what, it's like a muscle cause the next time then you invest in new software or taking intelligent risks or conduct an experiment, you'll recognize that tension of assignment. Yep. I'm in that. I'm in the learning, I call it the learning lane of your comfort zone and into the learning layer. And that's where growth happens. Karen Litzy: 14:51 And it's not easy, but it's not easy and it's a little scary. But you know, I guess I love the third point you made kind of having a personal board of directors and I guess I do have this without even kind of categorizing it as such, but I do kind of run things by people and it's interesting even when you run things by this group of, let's say you have eight people to shore up your ideas with, what do you do when they come back to you with feedback that doesn't align with what your thoughts are? Ryan Estis: 14:52 Yeah. So ultimately I would say I'm the decision driver, but if I'm out of my comfort zone or I'm entering unchartered territory, then it's useful to gain some outside perspective. And so I'm taking their advice under advising and helping it shape my decision. Ryan Estis: 16:04 So if I get feedback or advice or counsel that's counter to what I anticipated and my own opinion, then that means I'm probably going to have to do a better, more thorough job of convincing myself that I was right in the first place. And, then taking that step forward. The other thing about the advisory board, I would just also recommend is I hand selected these people for their particular skill or competency. So I have a technology entrepreneur that's an expert at scaling a business. I have a good friend who owns a research business that's complimentary to mine and he built and scaled that business and sold it. And so he has a lot of expertise that's related to my business. We partner together, but I value the way he ran his business and the organization he'd built. Ryan Estis: 16:56 I have my business manager who's known me for 20 years and is a good friend. And I also have my life coaches and spiritual advisors. So, my point in kind of sharing some of that context is, you know, I reach out to the people that I think would have relevant context based on the decision I'm navigating. So, if it's a financial decision, I'll probably reach out to my good friend who's worked in finance on wall street for 20 years and say, I'm thinking about borrowing money to do this and what's your perspective and how does this look good? And these are the terms. And so I have kind of carefully vetted these people based on their experience, exposure and the competency and thinking they could bring to support mine, if that makes sense. Karen Litzy: 17:43 That makes perfect sense. And did you do any sort of like self evaluation to see really where your gaps are, whether conscious or unconscious gaps? Ryan Estis: 17:54 Yeah, I've gone through coaching programs and have done some assessment work and then I also just recognize, you know, after having been in this business for a decade now, what some of the things that I'm really good at, some of the things that, you know, I'm not strong in. And so I just, I think in this kind of point on the journey, I have some exposure, I have some exposure to that. And some of it's based on my previous experience too. You know, I'm not a finance expert. I've never scaled the business and sold one. And you know, I'm not a technology expert. I've never launched an app. So these are things I'm like, Oh, these are things that, you know, as I move forward and navigate these waters, you know, it'd be good to have people that occasionally can jump in the boat and row with me and that elevates my confidence too. Karen Litzy: 18:47 Sure, sure. Yeah. And I'm sure it gives you more confidence in your decisions. And you know, I'm thinking of those like brand new entrepreneurs who feel like completely overwhelmed with absolutely everything. What advice would you give to them to kind of really hone in on what their zone of geniuses or greatnesses if you will, and then what may be they need to fill in the gaps? Ryan Estis: 19:12 Yeah. You know, a new honor, first of all, new entrepreneurship is overwhelming. So the best advice I have is be patient with yourself and be honest with yourself and you know, because everyone talks about entrepreneurship and freelancing and the gig economy. And you know, I guess when I quit my job, people thought I was crazy and I don't know, we weren't, entrepreneurship is so celebrated in our culture today and it's really happened in the last 10 years. You know, we've got magazines like fast company and we're putting, you know, these YouTube millionaires on the cover of ink. And I don't know, I think there's all this pressure to succeed and scale and get and just I would say just remember, focus on the next most important thing. Ryan Estis: 20:09 Build what you'd want and make and you know, achieve some semblance of success before you move onto the next thing. Focus is so critical for an early stage entrepreneur. It's so easy to get distracted and trying to do seventeens that we try and do 17 things at once. Well, and then you want to be networking. So you're meeting with people in a coffee shop that did it before you and you're just slow down, focus, get the next thing right, be patient, success of build. So that kind of perspective I think is so important. Karen Litzy: 20:47 Awesome. Thank you for that advice. That was great. I'm trying to take notes as quickly as I can here, but I'm going to have to go back and listen to this again. Now, you know, before you said you were kind of built to survive, you know, our nervous systems are built as human beings for us to survive. But something that you had mentioned in the keynote was, yeah, it's great to survive, but we also need to adapt and thrive. And you had sort of four keys to this breakthrough for poor performance are four keys to really help us adapt and thrive. So, can you kind of go through those for the listener? Ryan Estis: 21:27 I can. So the first one is very related to kind of where we started, which is about change. And the first one's initiate continuous reinvention. So you want to be an agent of change. You want to look at change in challenge through the lens of opportunity. And you want to be invested in this idea of successes that are rid of them to constantly be conducting experiments. And really I'm going to disrupt myself before the marketplace or competition does it for me. So stay in the learning lane, push yourself, get uncomfortable. That's the first one. The second one is really about customer experience, the idea of brand, the customer experience. We're in the experience and kind of, we touched based on how fast customer expectations are changing. The actionable recommendation around that as audit your own customer experience. Ryan Estis: 22:20 Look at every customer touch point your app online, offline, and look for opportunities to elevate it and add more value and make the experience better for your customers, meet customers where they are. Then the third one was it's related, but it's really about kind of, you know, the internal operation of your business, which was be a culture champion. I think culture is a catalyst for, you know, employee engagement, discretionary effort and contribution and culture is merely a reflection around how you lead. So think about purpose, vision, values, why are you doing what it is you're doing and what are the people who join you on this journey? Gonna get out of it. And employee experience and customer experience will always be directly correlated. And then the last one was take action. Now you talked about a Tan plan pan is, that's the acronym. Ryan Estis: 23:16 Take action now. And it's that, you know, great leaders, entrepreneurs, small business owners, they have a healthy action orientation so they don't get paralyzed. They're able to make decisions. The idea that you take in new information and then you immediately take action on those ideas, right? So, just like this, your listening to this podcast, you invest 30 minutes, 45 minutes or reading a new book, it's then taking a pause after you've taken that information in and say, what can I decide and commit to doing and doing differently that's going to create some momentum or advanced my clots. And that's, you know, really successful people they have, they're hungry for information, but then they back it up with action orientation. And those were the four tips. Karen Litzy: 24:04 Great tips. And I want to go back briefly to where you have branding the customer experience or patient experience in the healthcare world. Often times people use the B word, I call the B word branding to be all encompassing, right? Like you just have to, Oh, you just did your work in your branding, or B, be a better brand. But Ryan Estis: 24:32 Yeah, that's not really it. Karen Litzy: 24:34 It's sort of this term, you know? Ryan Estis: 24:37 Yeah. I have an ad agency background, so I'd probably throw that word out too much. I liked how you call it, the B word that's actually good for me. But let me clarify. So I guess a more specific way to describe what I mean by brand. It's establishing an identity, standards of excellence right away you go to market, tell your story, engage customers, deliver service, follow up and follow through that differentiates you from the competition. And that delivers value or resonates in a compelling way with customers, right? It's how you do things and if that, you know, look every touch point with the customers and opportunity to add value in advance or relationship. And it's just imperative in the experience economy that we're carefully thinking about that and looking for ways to elevate. Karen Litzy: 25:36 Yeah, and I love the example that you use. Where were you at? A Ritz Carlton or something. Is that where you were? So if you want to like briefly tell that story because I think, you know, when people hear Ritz Carlton, I mean, I know the first thing I think of is expensive, very elevated sense of customer service and is the same thing with like, a St. Regis. And you know, this is what I want to do real quick. I'm going to tell a story about my stay at st Regis and then we can contrast to your stay at a Ritz Carlton, which I would say are on par, right? So I was at a st Regis, I went out, it was like in a very warm part of the country and in the middle of the summer, came back, the air conditioner in the room, not only broke, but flooded the room and like you walked in and it was steamy and it smelled and it was like the carpet was all like squishy with water. Karen Litzy: 26:46 So we called down and said, Hey, you know, our air conditioner broke, there's water everywhere. And you know this just like one in the morning, I realize it's like the seed team on but still, so the guy knocks on the door with a mop and a bucket and I was like, Oh no buddy, you're going to need more than that. Like this is not good. So we have to call back down. Say, yeah, no, like we can't actually stay in the room. It's really bad. So someone came up, knocked on the door, handed me a key and said, you're in room three 47 and walked away. I was like, boy that wasn't very st Regis of them was it? And then the next morning I went to the front desk and I was like, well maybe cause everybody was like real tired and like I was with my boyfriend at the time. We just wanted acknowledgement and maybe like have breakfast on us, have a drink at the bar. I went back down and said, yeah, my room flooded last night and they just came up and handed us a key and now we're in this room. The girls like, yep. Got it. Karen Litzy: 27:46 And that was my experience. So I wrote a letter and what the st Regis did is probably more along the lines of your experience at the Ritz Carlton. I wrote a letter, I didn't make a big deal while I was there. Wrote a letter, said what happened to general manager, came back and he said, thank you so much for not ranting and raving and making a big deal of things. Any weekend you want. No blackouts. It's on me. So we took him back and they gave us a whole redo. And now I'm like, I would stay at a st Regis again in a heartbeat. They were fantastic Ryan Estis: 28:25 There and that's the ultimate lesson for any entrepreneur. It's the last sentence. You just say, cause here, here's the key. And it's similar to my Ritz Carlton experience and their philosophy is that problems are our best opportunities in business to deepen a relationship and that. So it's a real reframing of the problem, opportunity and customer relationship. It's so interesting. The best customer service stories always start out with a problem. My room got flooded, I lost my Ray-Bans in the Bay and was, you know, frustrated. And then some heroes steps in and resolves the problem beyond our wildest expectations. And it deepens our affinity, loyalty and evangelism for that particular brand. And so it's just, it's important to remember, it's never the problem, it's the way it gets resolved that people remember. And that ultimately shapes how they feel about doing business with you and Ritz Carlton leaving keys like PR. Ryan Estis: 29:38 It's almost celebrated. We have a guest that has a problem. Here's our moment to shine, to be magic, to create that wonderful, memorable feeling. And you know, so often I think in business and small businesses, you know, we get aggravated, Oh, customer's upset. Oh there's a complaint. And just next time that happens, pause and say, how can we turn this problem into an experience that creates a customer for life? And you'll reframe it. And you know, it's just interesting it's when problems come up for me. Now I have some of my, God, there it is. Now we've got a real opera, a magic moment as arrived. Karen Litzy: 30:16 Yeah. Ryan Estis: 30:17 How are we going to raise, how are we going to respond? Karen Litzy: 30:20 Exactly. And, you know, for the listeners who weren't at PPS, and you correct me if I'm wrong, but you were like paddle boarding and the Bay, you lost your sunglasses. And like some guy that worked at the Ritz Carlton went snorkeling down and got them for you and returned them to you. And you were like, what in the hell? Ryan Estis: 30:40 Yeah. And keep in mind, I never said, Hey, I mean I lost it. It was my fault. Karen Litzy: 30:47 Yeah. Ryan Estis: 30:48 And he just overheard me talking about it. I never, you know, I never went and said, Hey, this happened to me, you know, so it was just totally my thing. And the fact that they picked up on that and did what they did. And I was just, you know, I was dumbfounded and the more I researched and unpacked it and learned and actually spent some time with one of the executives at Ritz Carlton that runs a leadership Academy, you learn how based in their culture that is, right. So it's their values, it's their service standards. I mean, one of the great things at Ritz Carlton is that, you know, they have these very simple standards for how they greet and interact with guests. And part of what's great about that is that it creates consistency across all Ritz Carlton properties, right? So there's a way they greet and interact with the guests and they train on that, not what I mean by brand and things standard of excellence that's repeatable, that differentiates them, that resonates with the customer. So it's just a great takeaway from that is do you have standards? You know, you say customer service excellence that may mean something very different to me than it does to you. And that's my point is you don't leave customer experience up to the subjective interpretation of each individual. You standardize it, create protocol around it, process discipline around it so you can deliver a world class experience every single time. That's the idea. Karen Litzy: 32:20 Yeah. So really get specific. Ryan Estis: 32:23 Yeah, get specific. Karen Litzy: 32:25 Yeah. Yeah, that makes perfect sense. All right, so before we wrap things up here, I just have a couple more questions, but first one is, is there anything we missed? Any key takeaways that you want the audience to get? Ryan Estis: 32:41 You know, I think to just, you know, and this isn't new, but I think really spending some time as a small business owner, looking out, being forward thinking, you know, spending a little time, this is a great time of year to do it. We're coming up on the end of the year and I know it's an exercise I'm going through. I'm asking myself, you know, why am I doing this, first of all, and then what do I really want this to be a few months from now, but even five or 10 years from now? And some of that forward thinking and visioning and purpose, solidification. It helps reconnect me to why I got into this in the first place. Why it still matters to me. And the solidification and the articulation of that can really be beneficial to a culture and connecting your people to it and being able with clarity to say, this is where we're going, this is what we're building and this is why we're doing it. This is the impact that it's having. And I think for your listeners in your industry, some of that work could be, so useful and so, so meaningful. So I would think that's another, you know, Simon Sinek did the great Ted talk. He wrote the book and starts with why. And I think that's true. Karen Litzy: 33:55 Awesome. Well, thank you for that. And then the last question, I probably should have prefaced this question, but I forgot. So here we go. It's a question that I kind of ask everyone at the end of the interview. And that's knowing where you are now in your business and in your life. What advice would you give to yourself straight out of college? Ryan Estis: 34:19 Yeah, I would say, relax, have fun and enjoy the ride because it goes by pretty quick and you know, if it's not something that is going to matter five years from now, don't give it more than five minutes of your time and attention. I think for a lot of, you know, achievement oriented, entrepreneurial type a people, which I am one of, we can tend to get perfectionist and stress about the details and kind of, you know, that creates low grade anxiety and overwhelm when things go wrong. And it's just, as I've gotten a little older and wiser, I think just relaxed and letting some of that stuff go and really making sure that, you know, yeah, hard work is great and building something that you care about and are proud of matters, but just really make sure that you're enjoying the moments and the journey your on, you know, while you're moving through it. Ryan Estis: 35:14 I think that's just so critical. I think we project outward and delay our happiness until, you know, I call it the if when happiness travel, if my business gets to this point, you know that then I'll take a vacation or once I get here, then I'll finally be happy. That's a real, a real miss. And so I let some time go by. I think it's certain phases of early phases, my career and my life where I would have been a little more relaxed about things and that's important. Karen Litzy: 35:46 Yeah. I know I'm guilty of everything you just said for sure. And now totally guilty. Oh 100% guilty of everything that you just said. And I'm trying to work through that myself. So that's wonderful advice. Now, where can people find you if they want more information and they want to connect with you? They want to hear you speak, all that fun stuff. Ryan Estis: 36:11 So I would say that the website's a great place. We do a weekly newsletter called prepare for impact. It comes out every Sunday and it's just kind of a couple of actionable tips to help you get ready to be the best version of who you are and the week ahead. And then social media. LinkedIn, I'm pretty active on Instagram. We have a company Facebook page, pretty pretty active YouTube channel. So all of the social properties. But I'd love to connect with any of your listeners. This was a lot of fun. Karen Litzy: 36:45 Fabulous. Thank you so much for coming on. I really appreciate it. And do you have anything coming up? Anything in the works Ryan Estis: 36:55 And I do. So, you know, we're working on a book. Karen Litzy: 37:02 Yes. Ryan Estis: 37:04 I think we're at the point now that we're at the point now where I think it's actually gonna be a pretty good book and it's about sales, service and leadership. I think it'd be very relevant to the, you know, small business owners and practitioners listening and that'll be out sometime next year. So for anybody listening that's interested in, you know, if they subscribe to the newsletter and stuff, we'll be sure and do promotion on it. Karen Litzy: 37:32 Awesome. Well, thank you so much for taking the time out and coming on. I appreciate it. Ryan Estis: 37:36 Yeah. Thanks for having me. Karen Litzy: 37:38 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 iTunes!