I'm a little disappointed we
don't have intro music.
Morning shows have these
high energy intro songs and
stuff like that.
I'm a little disappointed we
don't have one yet,
but this is PT Breakfast Club.
Gentlemen,
I was going to play Where in the
World is Jimmy?
I don't want to make anybody jealous,
but I am in the conference
room at a Hampton Inn in Rochester,
New York.
I know many of you are
planning on taking a trip
to lovely Western Central New York,
but I've done it.
There's a guy on TikTok that
if you send him a video,
you take your phone,
you do like a panoramic,
you do a three-sixty,
he will figure out where you are.
But now AI can do it so much easier.
Like again,
AI is replacing so many of us
in so many ways.
It was awesome.
This guy's videos were nuts
and he would like go
through the process and
show you how he did it.
He's like, well,
I saw the corner of an Ikea
and there was a tree.
And that's there's only sixty two Archeas.
And I was like, this guy's got I mean,
don't piss this guy off is
what the message is.
But also your message is don't piss AI off,
which is why I always say
thank you whenever it tells me something,
because when they take over,
I want to be like,
Jimmy was nice and he
always said thank you.
So let's kick off the show.
Dave,
you had an interesting experience
with Chad GPT sending you patients.
Yeah, speaking about AI, this might be,
I don't know, maybe it's an early signal.
I think maybe even an
inflection point with my
thoughts around AI.
But nonetheless,
I do a bunch of the
callbacks for prospective
patients calling in for
concierge pain relief.
And it was the father of a
patient calling in.
So I have an answering
service that takes down a
lot of the demographic
information when they call in.
And then me or someone on
the team does the callback.
typically the answering
service person is supposed
to ask how did you hear
about us or were you
referred to us so that we
can send send a handwritten
thank you letter to a
physician uh you know build
that relationship whatever
they didn't on the
answering service side so
in the very beginning after
introducing myself I always
ask like you know so so
hello uh you know mr
so-and-so you know how did
you hear about us were you referred by
whoever,
physician or some other provider
or some other professional.
And this gentleman said that
he found us through ChachiBT.
And I was so,
I was so caught off guard the
first time ever.
And I don't know,
I think I prompted him a little bit,
but he said, yeah, I was in ChachiBT.
And this guy, by the way, this guy is,
Fifty or sixty, which is fascinating.
Also, it's interesting.
And he said that he searched
looking for an in-home
physical therapist in Bed-Stuy, New York,
Bed-Stuy, Brooklyn, New York.
uh,
in this zip code that treats that has
physical therapists that
treat CRPS complex regional
pain syndrome.
Now we can get into the
clinical stuff later, which is, uh,
we use the STEM pod for that.
We use Vegas nerve stimulation.
We'll, we'll do a lot of things, um,
for chronic pain,
but that's really on the clinical side.
Obviously we're going to
nerd out right now on the
marketing side and on the AI, uh, side.
And I have been saying to Tony and Jimmy,
I don't know,
probably for the last six to
twelve months that, uh,
AI is not replacing Google,
and people are going to
search Google forever.
However, after yesterday,
and if this trend continues,
I might have to change that
thought or at least share
my belief in the searchability of Google.
So what are your initial takeaways?
Do you have any questions for me?
I mean, I just find it fascinating that,
yeah, well, let's say you prompted it,
and what comes up?
I said uh the original
problem we find a physical
therapist in new york city
they'll come to my
apartment it brought up
some usual suspects right
spear stride stern at home
pt I'm not sure if any of
these are rehab on wheels
then these are familiar
with these I'm given links
directions and a phone
number I'm given reviews
that I'm guessing come from
google it's pulling
google's data and then I
when you were talking I
went specific I said
bedside brooklyn and I have crps
Luna and then concierge pain
relief is second on the list.
Holler at your boy.
Now what's interesting is
this gentleman who I'm speaking with,
my therapist is seeing his
daughter today for the evaluation.
And he's like,
I really liked your website
and what you described.
Oh, by the way, I didn't mention this.
He pulled up a,
he said that when he prompted ChatGPT,
he said, yeah,
it looks like you had
written several articles
and blog articles around CRPS.
And what you guys may or may
not know is that I use
ChatGPT to write these blog articles.
So I don't know if that is the crux of it,
Tony.
Do you think that is a major
consideration or what?
Or not?
I don't.
I don't think that has
anything to do with it.
I think now I'm certainly no expert,
but to my best understanding, you know,
open AI,
all of these large language models,
they've already consumed
everything on the Internet.
They have Internet access now, obviously.
So when I ask a question.
If I'm asking to look something up,
it'll go online.
Now, I don't think it's using Google.
It's using its own proprietary algorithms,
but it's going out,
it's finding those resources,
it's bringing them back,
and you're one of those resources.
This was an insanely specific search.
I would never imagine a
person would be searching
that level of detail.
But yeah,
I'm showing up when therapists
are searching for like
maintenance therapy covered
by Medicare or information
related to billing Medicare.
Some of my content now is
being provided through chat GPT.
I have not had anything show
up for my total knee
replacement stuff that I'm aware of.
Just for the podcast or the
people listening as they're driving,
I then prompted ChatGPT,
which one is the best?
And keep in mind the suggestions, Dave,
you came in second,
right behind Luna in the
recommendation above.
And then I pushed ChatGPT a
little bit and I was like, yeah,
but which one's the best?
And it brought Concierge
Pain Relief to the top and gave me why.
Specializes in CRPS.
pain approach, in-home,
twenty four seven scheduling.
So I'm blushing.
I did not pay ChatGPT to show you this.
I did not pay Jimmy to do it live.
Yeah, we're going to do this.
I know.
Here's here's the here's the thing.
People will be interacting
with these with these more and more.
I think the video, Tony,
that you shared in our sort
of collective group chat was
Chat GPT or AI devices are
only point three percent of
search traffic.
And again, point three of a giant number.
So it's still a lot,
but it is point three.
But what percentage of
search traffic was yellow
pages twenty years ago and
what percentage was Google
and that shifted?
I think it'll be a blend in
terms of it will eventually say, well,
how do we know?
Are we constantly consuming
information into our LLMs
or are we scrolling or
crawling as what Google
sort of has done traditionally?
This is the way not to quote
the Mandalorian, but it feels like it.
So I shared earlier,
I'm going to bring it up on the screen.
This, well,
am I going to bring it up on the screen?
Thank you, Scott, for the shout out.
Yeah.
There it is.
Yeah, there's that video.
So I'm not going to play the audio,
but just this guy, he's amazing.
He's one of my favorite kind
of up and coming YouTube channels.
He's on Facebook, Instagram.
He's talking about how
ChatGPT now is offering
links to products.
So in this example, he's saying, hey,
I want an espresso maker
coming from Italy today.
And now through ChatGPT,
you can actually click the
link and purchase the product.
I mean,
we're seeing this move into Google
space more and more.
The interviews I'm seeing
about what Google is doing
to fight this is talking
about how obviously Gemini
is an incredible model.
They're going to incorporate
that more effectively.
I think search, I think buying online,
I think all of this stuff
is going to be completely different.
The most interesting thing
about Dave's discovery, though, for me,
is I had completely quit
writing content for my website.
I had completely quit
writing content for other sites.
Everything was exclusive on
social media for me over the last year.
Now,
I think it shows us we need to get
back to SEO optimized
content on our website, on blogs,
on things like that,
because these large
language models are going
to go out there.
They're going to consume it.
They're going to find it.
And if you're claiming the real estate now,
the digital real estate now,
you have a better chance of
staying on top.
see that's that's the funny
part at least I'm not crazy
which is this guy's video
the one that we're playing
here now keep in mind I
went to that link that he
shared very quickly by the
way it wasn't in the
comments of that video so I
had to freeze frame it and
go and then right now it's
an application for this
thing that they'll let you
know when you can do this
which is fine they're
rolling it out except the
funny part is when you do
play the the audio for that
video he says seo is dead
No, I disagree with that.
Right.
That's where everybody's saying it's dead.
And I'm like, no, I think it's yes.
It's going to pull from that.
Well, I think it's him just getting,
you know, getting conversation going.
It's the way SEO used to be done.
It's dead.
A new SEO is on the horizon.
Correct.
You know,
I had a conversation with someone.
I won't say who it is,
but they're pretty higher
up with a large company.
physical therapy professional organization,
if you will.
And the question was,
because I was playing with AI early,
again,
I was batting around a ball of yarn
like a kid and just trying
to figure this thing out.
And the question was, Jimmy,
when someone searches a
question about something
that physical therapists treat,
how do we make sure we're the answer?
And my response was,
you need to actually be the
answer in terms of, hey,
if this person has that problem,
how do I pop up?
And I was like, you can't game this,
for lack of a better term,
like you might have been
able to in early Google,
like with SEO and keyword.
I'm like, you need to be the answer,
be consistent.
And I think the message is you still,
the more frequently and
better you communicate it,
the more you rise to the top.
Dave,
how long has your practice been
around in New York City?
Like six years.
And at the highest number,
how many employees or
people did you have working with you?
uh,
eleven independent contractors pre-COVID,
but they were all different
levels of patient caseload.
But you were the answer when
I asked this thing,
who would be the best at
this thing in this place?
And now we can work
backwards and reverse
engineer how Dave popped up.
But the answer is probably a
mix of you said it,
you said it over and over
again and you shared
information and we can try
to game that system all we want.
But I think that stays true.
Couple more thoughts on this
real quick around the, yeah, Craig,
thank you so much.
Around this, like Tony said,
this specific patient,
this specific search query,
maybe moving forward,
like I can unlock the very specific,
the people that are looking
for a very specific,
like targeted solution
instead of the people that are just like,
medicare physical therapy
respectfully or like you
know any you know
insurance-based physical
therapy or physical therapy
that takes my united
healthcare in network
insurance or whatever maybe
and that's kind of you know
what that's already the
type of person who pays out
of pocket they're already
that's the type of person who
is considerate around like communication,
bedside manner, professionalism.
Are they clean cut?
Do they do what they say?
Are they very prompt with everything?
Do they have solutions when
new things pop up?
Can they be dynamic on their feet when
So there's one of our
therapists is seeing
somebody for back pain and
then we show up and then like, hey,
I have like wrist pain
today or I have ankle pain today.
And like the therapist is like, hey, well,
you know, you're self-paced.
So like, let's screen it.
Let's evaluate it.
Let's treat it.
Let's do that.
Versus an insurance based practice like,
oh,
I must get a new referral and I must
get it signed.
And I need you know,
I don't have a referral on that.
That's seriously, you know,
that still happens.
So to take a step back,
these types of folks,
they're looking for.
a sniper rifle instead of
like a blowtorch or a
machine gun or whatever so
these are the people that
also would be more willing
to pay more and so this
this guy that I spoke with
he goes yeah I know there's
fox rehab and there's luna
and then you know I went
through the conversation
and I said you know hey you
know it's five fifty per
visit on weekends three
fifty per visit monday
through friday and he goes
oh oh wow yeah okay I mean
that's you know that's more
than that's more than we
thought it would be or um
that's that's uh that's
more than the other places
and I'm like yep yeah I
mean you know luna is good
like they just hire and
almost any therapist with a
license respectfully and
fox rehab is geriatrics and
older folks and your
daughter's younger so
that's not the right fit
you know and um so luna by
the way is like a hundred
twenty five bucks per visit self-pay
and he's paying three fifty
today starting today like
who knows who knows if it's
gonna be fifteen or twenty
visits or fifty visits or
three visits who knows but
the fact that this family
is like we're gonna pay uh
what two x or over two x
almost three x uh what
another practice will pay
and it's like how much of
that we'll never know how
much of that is because of
the chat gbt component of
this I don't know
Yeah,
we've always wanted to establish
authority, establish credibility.
Clearly, you said, you know,
he saw your articles,
he read your articles,
like you already
established yourself in his
head as the expert.
And to your point...
We had Will Boyd on not too long ago.
You can you can shoot with a
shotgun and like spray wide
or you could go very specific.
The fact that this guy is
looking for this very specific condition,
the fact that he's looking
for his daughter,
like help for his daughter,
not not even help for him.
You're checking all the
boxes to say this is the ideal client.
And I think therapists get
frustrated because they're like,
I'm putting content out and
I got three views.
Yeah,
but those three views might be the
three people who are
actually going to pay your
rates to get what you want.
You don't need three million
views of people who are
never going to pay you to
do what you do best.
Right.
I frame this with a friend.
I don't know if you guys
ever met Katie Sutton.
Katie Sutton is an amazing
physical therapist assistant.
I met her through an APTA
committee years ago,
and she's just she's an
outstanding APTA assistant.
I twisted her arm enough to
launch a podcast, right?
She's been doing it for a
year and a half on and off.
She hit five thousand
downloads and she's like, well,
that's not a million.
It's not, you know,
Kim Kardashian numbers.
Is Kim Kardashian still a thing?
She's still a thing, right?
It's not Kardashian numbers.
But I said,
if you sat in a conference room
at a Hampton Inn in Rochester, New York,
and over the course of a year,
five thousand PTAs sat with
you for forty five minutes a pop,
do that math.
Five thousand is not that
much when you compare it to
the depth and width of the Internet.
Right.
But she had forty five
minute conversations.
I think she's at twenty
episodes to five thousand downloads.
And she's like, wow,
when you put it that way,
it's a little bit different.
So this this thing scales.
Right.
Gary Vee's famous for saying
it's the it's the quickest
and easiest and cheapest
way to multiply yourself
and your insight.
I still stand by it.
If we don't have anything
else on that topic,
I want to get with Dave and
talk about an article.
We went further with ChatGPT.
I said, hey, listen,
I'm a physical therapist
that has a sixty minute commute.
Who are the best people I
can listen to learn more
about my profession as a live stream?
It mentioned friend of a show, Zach Gabor,
Level Up Initiative, E-Three Rehab,
Evidence Based High Quality Rehab.
They have a YouTube channel.
And we come in number three.
How many things have we,
but how many things have we even,
we don't even have a
website for Breakfast Club.
Like I was nudging it towards live stream,
right?
I wanted to see.
But besides the live stream
and the YouTube headlines
and titles and descriptions,
there's no site.
We haven't written an article on this.
So I am terribly curious how
we came in at all.
Nevermind being three on this.
That is interesting because
I was trying to nudge it
towards live stream.
How do you know, figure it out for me?
I would say,
and I'd be curious because
this has got your history
and now ChatGPT can
research across previous chats.
Anybody watching, anybody listening,
do that prompt.
Do the same prompt, yes.
Yeah, ask ChatGPT,
you're a physical therapist.
What did you say exactly?
Yeah,
I'm going to put it in the comments
because I would love an
exact apples to apples.
Steal this prompt, steal this prompt.
If you're watching or listening,
this is your homework or your day work.
We need you to do this work
before your actual work today.
Yeah, this is more important, guys.
I want to know what ChatGPT
is saying on this.
So copy-paste that exact prompt.
If I'm a physical therapist
that has a six-minute commute,
who's the best people?
I grammatically did that great, sorry.
Who are the best people I
can listen to to learn more
about my profession?
I specifically didn't say
clinical practice, business.
I wanted to be like, hey,
what do you got for me?
Kill my boredom for six minutes.
I'm curious and very,
very intrigued what it says,
not through my search history on ChatGPT.
It's a good point, Tony.
All right.
So before we go live,
I do search research.
I go to Google.
I go to chat GPT.
I'm like physical therapy
news and I read the headlines.
Usually there's not a whole
lot to talk about.
This article came up.
And so every now and then we we hear this,
you know,
was a Santa Monica physical
therapist accused of
sexually assaulting a client.
Now, I mean, we have no idea.
It doesn't tell us details in the article.
It says April seventeenth
for one count of sexual battery.
My question is and this
always kind of comes up.
So in my physical therapy clinic,
we would generally never
have a PT by him or herself
with a patient and nobody else around.
But in mobile, outpatient, in home health,
like we've got this constantly.
And when I try to wrap my
brain around this,
I know so many mobile
therapists that want to do
manual therapy.
You're in the house.
Some bring treatment tables,
which blows my mind,
but you guys are willing to do it.
How do you manage the risk
of like touching people,
getting into these intimate spaces,
doing these things with, hey,
I don't want to get accused
of something that I had no intention of.
Dave, you're the key to this puzzle.
What do you do?
What do your people do?
I mean, it's a delicate conversation.
So if I'm speaking to a
prospective patient,
I will mention things like, all right,
well, you know,
our therapists are in the
subway most of the time or
they're on like e-scooters or whatever.
So like we're not bringing a
treatment table.
We do we do share like an
Amazon link to like a
Sierra Comfort table.
If you want to buy one,
it's like one hundred fifty
bucks or whatever.
um or and we literally have
this conversation it it
doesn't I think I have a
conversation on maybe I
shouldn't maybe I should
have it pretty much with
every female and typically
I typically I think we do
with females and with dave
dave david's twenty twenty
five female male both is
everything well I'm telling
you I'm telling you what I
actually do and and so I we
definitely this we
we communicate it more with
the females because I wanna
make sure that they're very
comfortable because right now,
most of my therapists are
male therapists.
I just wanna make sure, hey,
depending on what you have going on,
if it's this ankle, low back pain,
sciatica, whatever it is,
Here's what we do.
We don't bring a treatment table.
We can treat you on your couch,
your chaise lounge.
It could be on a yoga mat on
your carpeted floor.
If you are able to get down to the floor,
it depends on the person's situation.
It could be in your bed or
guest bed if you're
comfortable with that.
Obviously,
I want you and my therapist to
speak about that even
before you guys book the
visit or before the therapist gets there.
It always helps if the
patient or client has a
spouse or a family member
or a son or daughter,
someone else there in the
apartment just to make sure
that everyone's comfortable.
But we absolutely discuss
this ahead of time.
I think it comes off to them
that we're experienced we're
consummate professionals
this is a consideration for
us we know it's a
consideration for our
clients we want to make
sure our clients have a
great experience but the
thing is most of the time
tony is they're already
like you said before
they're already kind of
warmed up because they've
seen our google reviews or
they've been on our website
or they got referred to us
by a physician that they
trust or whatever
So it's luckily it's never
been an issue because maybe
we confront it.
We just we talk about it and
we will never say, oh, let's you know,
let's do manual therapy on
your bed unless we've
already we've already discussed it.
And the the patient or client,
regardless of gender or age or whatever,
that they've already
approved it and they're OK with that.
You know, historically, five,
six something years ago,
I had like a younger patient
and we just put padded
dining room chairs together.
Like we just put them together like,
like three in a row.
And like the,
the young female laid on that
so that I could do manual
therapy traction on,
on her cervical spine.
So there's ways around not
even entering the bedroom
or not even using a bed,
but this is just part of what we do.
Like we over communicate, like we want to,
we want to,
we want to spend as much time
on the phone as we need to.
And then that way, all of the,
visits are smooth and yeah I
don't know but then also
with therapists like I
could have hired a
therapist in the past that
could have done this type
of stuff or had these types
of allegations we try to
fight against that as much
as possible on the front
end with the rigorous
interview process and
checking references and all
that but uh unfortunately I
guess it still could happen yeah
Jimmy,
do you remember anything from school
about, like, did you guys discuss?
Obviously, you remember draping, you know,
but I know when I have a student,
if I'm functioning as a CI,
I try to talk to them about all of this,
even to the point of,
If I have a bunch of high
school kids in here and
I've got males and females,
I am like acutely aware of, okay,
if you're going to do a deadlift,
which way are you facing?
Which way are you turning?
If I'm going to put you on a
treatment table,
where are you going to be?
Which way are your legs pointing like?
It's all consuming almost to
the point where I just,
I am never going to put
myself in a vulnerable position.
Do you remember anyone talking about that?
Well,
I remember my last clinical setting
was in pediatrics before I
left to go non-clinical.
And I just remembered it was
a great environment.
But whenever I needed to do
anything where maybe maybe
a patient had their shirt off,
I didn't want to be in a general room.
But I always pulled that.
I lucked out.
There was always like other PTs around.
I was the only guy.
So I was very acutely aware
of these things.
And I would always just grab another PT.
Like, do you mind hanging out in here?
Because to me,
it's can be awkward as all
the situations you
remembered for me was kids.
And I was like, I have to be.
twice as triple diligent for
any of those things because
if a kid just says well
that happened what am I
supposed to how am I
supposed to respond so I
always always had one if
not two other people um in
the room plus I was such a
junior pt compared to the
females I was working with
ninety percent of the time I was like
Am I doing this right?
Just check what I'm doing
here or make sure I'm doing
the best thing possible.
But yes,
I remember draping that coming up
in school and just being like,
you need to be paying
attention to these things
that you might have
overlooked in the past
because now you are in
charge and responsible.
We shared a image a couple
of weeks back of physical
therapy clinics and the prerequisite.
They all had to look the same.
I just did a Google image
search for physical therapy stock images,
because I knew what was going to come up.
And of course,
every single one of these
images is a physical
therapist touching another human.
And Dave knows, like,
I will do manual therapy.
I'll rub your back.
I'll do the things that need
to be done to bribe you to keep coming,
just like many physical
therapists will do.
But I still think that, you know,
this is the public's conception of
And I think there's a lot of
people who don't want to be touched.
Don't put your hands on me.
Show me what to do.
Let me do what needs to be done.
But I don't need you to touch my back.
Ask permission.
You have to ask the patient
or client their permission.
I know it goes...
it's, it's not that common.
I feel like maybe we learned
it in school and then you forget it,
but it's like,
even if you're taking some
of those blood pressures, like, Hey,
can I put this blood
pressure cuff on you?
Can I, Hey,
can I check your blood pressure?
Like, like, you know,
let's check your blood pressure.
Let's get your number.
Can I put this cuff on your arm?
Like it's so,
I feel like it's so overlooked.
You just,
I think legitimately
therapists are so used to
touching people.
You know,
I have friends that are massage
therapists,
like they won't take their
hands off the people around
them just because their
whole day is spent touching people.
We lose sight of it and we
don't realize that this
person in front of us has
their own history.
They have their own baggage and trauma and,
you know,
experiences and maybe they don't
want you in their personal space.
But I think there's value in
marketing a touchless
physical therapy experience.
I think there's value in marketing.
We won't touch you.
We won't be in your personal space.
We respect your boundaries.
It's not going to be enough
patience to keep you viable,
in my opinion.
Just like the guy who found
you for that very specific condition.
If they're out there,
there's always enough for a
small single owner operator.
yeah I think if you if
you're if you're doing that
too are you as if I were
chris doe I'd be talking
about the outcome he's like
never he's like never I was
watching another video and
I feel like I've watched
chris doe if you want to
look him up he's the future
it doesn't make any sense
for physical therapists or
business owners to watch
his content because they're
about graphic design and
website work but it makes
complete sense because it
talks about framing and
he's like I never talk
about how uh designing this
website is going to be ten
thousand dollars why that's the price
You want the outcome of the website?
There's a reason you're in
this meeting is because you
have a problem and you are
checking me out to see if I can solve it.
The answer is yes.
How do you do it?
A process.
Right?
I want my house painted.
I honestly don't care what brush you do.
What do you do?
How does it make my life better?
What do I need to do to get it?
Now,
if I have an aversion to being touched,
if there's someone who says I can do that,
you now are at the top of
the list or the only thing on the list.
Or I've got a buddy who says
he put on his sign
Hands-on orthopedics.
Because he's like, that's how I treat.
And he's like, people call and they say,
do you do this?
Because other places don't.
So I think by the existence
of hand-on orthopedics- To
go right against Tony, yes.
No, no, no.
This is proof of concepts for framing this,
if you have it or don't,
proves the existence of a market for it.
I do think likely the
hands-on would probably be
a larger market.
Yes, that's my point, yes.
In terms of saying like, I don't want it.
But if you're that person who's like,
I can do it without it, I don't know.
I'm going to take – so real quick, Will.
Hands-off massage.
I'm going to offer hands-off massage.
The only guy.
Have you ever heard of Reiki?
Yes.
It's rubbish.
It's rubbish, yes.
Dave has come on talking
about virtual massage,
talking about virtual –
like there's a market for
everything out there,
the craziest stuff you can
ever even consider.
There is.
Will Boyd is here.
Will, if you missed it,
we were talking about you earlier.
We were talking about ChatGPT SEO.
Dave was getting clients from ChatGPT.
But my point in this is,
you have to understand not just, okay,
there are people who want to be touched.
Yeah, I get it.
Those people are out there.
There's plenty of them.
But I'm talking about the market of one,
people who know they don't
want to be touched.
And two,
the people who don't even know
being touched is an option.
There are a huge number of
people that come into my
clinic every single day.
They've never been to therapy before.
They have no idea what to expect.
I ask every single person,
what were you expecting me to do today?
And I promise you,
not even five percent of them say, well,
I was expecting you to rub my back.
So if I rub their back,
I'm introducing something
that I don't necessarily need to do,
you know, and then we can talk about,
well,
what's insurance paying me to do or
is the patient paying me to do?
I shared a post the other day.
Hey, man,
if you want to pay me to rub your back,
fifty bucks a unit,
I will rub your back for
fifty bucks a unit.
But if insurance is paying
me twenty dollars to rub your back,
I am not going to do it
because it's not medically necessary.
And most of my referrals,
most of the people who walk
into my clinic.
Could you rub?
Could you get paid more if
you rub different parts or
how does this work?
No.
Dan Vapney saying massage
with your words with your words.
Beautiful.
I love it.
Yeah.
Hey, since Dan's here,
you guys want to talk a
little bit about USPH financial report?
Yeah.
You had some of those numbers.
You want to bring those up?
I got a screenshot.
Let me grab it.
So USPH, US Physical Therapy shared their,
I think, quarterly numbers, Q one.
Ooh, we can't see that.
Can you zoom it in?
I don't know if I can't zoom it in.
No, I'll find it.
I'll put up a better version.
Yeah, I'll just tell you guys.
So basically, every year for sure,
sometimes every quarter, I'll go,
I'll grab U.S.
physical therapy.
I think,
and Dave can probably correct me
if I'm wrong,
in terms of publicly traded companies,
I think U.S.
physical therapy is probably
still doing the best.
Although if you look at
their five-year stock chart...
It's the shits.
They're doing horrible,
but it's a steady decline.
But basically what I love
about their numbers is they
run independent private practices,
very similar to what a lot
of listeners here are running.
I feel like it gives us the
best metric financial benchmark.
So what they do is they
share total patient revenue.
And then they show you how
much was spent on, quote,
salaries and related costs.
So for Q one,
two thousand twenty five
total revenue was one
hundred and eighty three million of that.
I think one hundred and
eleven million was salaries
and related costs.
That represents sixty percent.
So,
sixty percent of revenue went to paying
salaries.
Now,
I don't know if that's just clinical
salaries.
I would imagine it includes
administrative salaries and
anything else.
About eighteen and a half
percent went to covering
rent supplies and contract labor.
And then a little bit for
depreciation and clinic closures.
But I had shared a post and
I'm curious to hear what
you guys see for this.
If I'm going to risk hiring
a physical therapist for a
hundred plus thousand a year,
that's my out-of-pocket
risk because I'm pretty
much committed to probably
a year's salary.
What is my potential upside?
You know, what is the return on that risk?
Because if it's not double, triple,
quadruple,
I don't know that I want to put
that risk out there.
What are you guys,
when you think of hiring a therapist,
what are you thinking is the return?
And I'm talking about net profit,
money in my pocket after all expenses.
Got it.
So that's going to depend.
I get the PT phrase in there,
the medical phrase.
Like what we typically see
or like the quick
benchmarks I've heard other
people say is PT is going
to gross to fifty, right?
Working fifty weeks a year,
forty hours a week.
They're going to gross to
fifty and a PTA is going to
gross one fifty.
Now, you asked me net.
So now I don't know.
In New York City,
it's going to cost more to
hire and benefits of what
are you going to offer
versus – we always rip on Iowa.
I promise I don't hate Iowa.
I'm just saying you're the
opposite of New York City in a good way.
So it depends, but –
I did a quick reel the other day,
a short form video,
which is adding people
isn't the solution first, right?
If you have a great system,
and that's what we're
talking about with USPH,
there's a bunch of clinics
and brands across the
country that you'd probably,
maybe the average person has no idea.
They are a house of brands.
There are a bunch of brands
that you've heard of across the company.
USPH acquires them,
streamlines some things you
don't see in the back offices,
and then lets those people
still use their brands in
their communities.
So I don't know.
I mean,
are those numbers accurate to you guys?
A PT grossing two-fifty,
bringing in two-fifty,
and a PTA adding one-fifty,
then you have to subtract
costs from those things as well.
Dave?
I mean,
I feel like it should be at least
twenty percent.
Wouldn't it be at least
fifty K in your pocket,
in your bank account that
then you reinvest if you
you could have a distribution,
you could you could
reinvest it with whatever, you know,
paid marketing, you put it back in,
you use that to recruit the
next therapist, whatever.
And then it becomes like the
compounding machine.
Here's another.
So I know Tony was asking
about like the actual dollar amount.
So that's why I was trying
to just give fifty K.
But another thing that the
medium to larger clinics
probably look at is like,
let's say we hire this therapist,
Tom Smith, and let's say, so, you know,
round numbers, two fifty,
they're going to generate
two fifty or you're going
to pay him one hundred K
total salary benefits
compensation package.
Maybe they the net income in
your bank account or that
you could do whatever with
get taxed on or you reinvest it.
Let's just say potentially
if it's fifty K.
But then also it's that
therapist is treating like Tony,
how many in a network practice,
like how many patient
encounters per year or
patients that a therapist is seeing?
I'm going to say depending
on the practice.
Yeah.
Let's say twelve to fifteen in a day.
The amount annually that
that therapist is treating,
assuming that the therapist
is great or good,
they're treating those patients,
those patients are telling other patients,
you're getting the word
about the referrals.
In a year or two, if that therapist leaves,
that practice still has the
benefit of those patient
encounters being treated by
at least an adequate physical therapist,
if not a good physical therapist.
That therapist leaves the system.
They go, they move to another state,
whatever.
That practice has the
ongoing goodwill of the
previous year and the
previous year of those
patients that that therapist treated.
So whether it's warm, you know,
word of mouth,
a patient a year or two ago
wrote a Google review or
Yelp review because of that therapist,
that therapist left.
but you still get some of
that ongoing annual
compounding now over time
maybe there's a long tail
and maybe it trails off and
you get less and less of
that but that's some of the
like I know you were asking
for the dollar amount so
that's why I gave it but
then these are some of the
things that you get you get
ongoing financial benefit
from a physical therapist
in terms of like the actual net net
Now for listeners, Will Boyd is here.
Will is sharing a tool that
helps you predict,
I think it was how much you can pay,
how profitable they need to be.
That's kind of what got me
thinking about this topic again.
We're not in the market to
hire a therapist,
but I still have to look at
it and I have to say, okay,
to Dave's point,
Yeah, there's intangibles.
You've got the baseline, right?
Twenty years ago,
the expectation was if you
want one hundred thousand,
you better create four
hundred to five hundred thousand.
Today,
the expectation closer to two
hundred and fifty.
I mean, that's the reality of it.
So the same therapist
working the same amount is
generating half of what
they would have been
expected to generate two decades ago.
But then within that, to Dave's point,
okay, so you get in a good therapist,
right?
We assume we do a good hiring process.
We get in a good therapist.
They're an asset.
They're going to help build the practice.
They're going to build reputation.
On the flip side, they leave.
They take a portion of that
caseload with them because
those patients want them.
They don't want total therapy solutions.
They want Dave Kittle
because Dave Kittle is what
helped them feel better.
So you've got pros and cons.
You've got risks to weigh on.
Um, but,
but I still look at it and I'm like, man,
I'm pretty much,
I'm guaranteed an
investment at risk of a hundred thousand.
I can lose that full hundred thousand.
I can lose a portion of it.
I can have a therapist come in.
Who's not as good as I was hoping.
Give me a bad reputation.
Leave.
They're no worse for wear.
I suffer the consequences.
They do amazing.
They leave and they take
half of my caseload.
I suffer the consequences.
And then I'm like,
if I've got a hundred thousand to invest,
is this the best investment
I can make with that money?
Are there other lines of business?
Are there digital products?
Are there things that I can
do that are scalable so
that my expected return
isn't fifty thousand on a good outcome?
But maybe it's two hundred
and fifty thousand in take
home because I created
something that is just
going to print money for
the next ten years.
Good points.
So you're saying like if
what would be a better bet
in terms of ROI instead of hiring,
because
it's not it's not a done
deal right like you said
years ago it was a five did
you say five x return
usually yeah yeah I mean
that was the standard
expectation four to five
times what you cost yeah
yeah do you so I would say
and again I did it I just
did a short form video on
this which is do you need
more pts or do you need to
make sure whatever you're
doing is optimized now
before you start adding
complexity right and this
came from well more is
probably better it's like
well if you put more stress
this is like this is the bar rescue
model.
If you've ever watched that show,
it's like the stress test
is put stress through the current system,
find out where the leaks are,
fix the leak first,
then put more things through the system.
So that would be the John Taffer approach.
All right, Jimmy, I think you got to go.
Your time is up.
I'm going to dip.
I'll get my parting shots
for today is try something
new all the time.
I'm driving around.
I'm doing something outside
of my daily role at Athelas,
like completely opposite of the spectrum.
And even if this is
traditionally not successful,
I learned a ton and experienced it.
This goes back to like a
Jerry Durham statement I
heard years ago as a student.
And I'm like, that's insane.
Jerry used to talk about how
he would just bring his
laptop and sit in his
waiting room in his clinic.
and just listen.
Like what is asked first by the patient?
How do they speak?
What are they asking about?
That is likely changed over time.
And also I'm sure his staff
knew he was the owner when
he was sitting there, but like, how is,
how does your staff respond?
Right?
So do you have to sit there
long enough to get the
staff to sort of forget
that you're there?
The patients are going to
give you good insight.
If you're not paying
attention to those little
things that you just assume are okay,
that's a dangerous assumption.
Gentlemen, I'll see you guys on Tuesday.
I got to dip.
All right.
See you, Jimmy.
So Dave,
I've got a question about practice
acquisition and sales,
and this is your world.
I don't know that you have
much to say because these
are like micro transactions.
When I sold my practice down in Florida,
my single location, it was such a tiny,
it was a handshake deal.
There was no lawyers,
like none of the big stuff.
But there's a lot of
therapists out there that
are looking to accelerate.
They're looking to grow.
They want to acquire.
There's a lot of therapists
that want to get out.
They want to retire.
They don't have anything
that would ever sell to private equity.
And so I get these questions.
Two of the big ones that
therapists are asking me, they're like,
Tony, you know,
how do I value the how do I
come to a price?
What am I actually buying?
Yeah.
I want to share two things
that therapists don't often
think about in the transaction,
but I want you to think
about a couple of tips you
can give therapists who
might be thinking about
going this direction.
So one of the topics is the
accounts receivable.
When a therapist is buying
another practice,
you have to consider like,
what are you going to do
with the outstanding accounts receivable?
If the previous owner is
seeing patients up to today
and the transaction happens
after close of business tonight,
all of that history,
there's at least a couple of weeks,
there's probably more of
accounts receivable that
are sitting out there.
If there's a hundred
thousand dollars worth of
accounts receivable and you
reasonably expect that
you're going to collect
then that fifty thousand
should be calculated in the
sale price if you're going
to take over the accounts receivable.
But if you're going to cut
ties and allow the old
previous owner to keep
their accounts receivable,
then that's got to be
reduced from the value of the practice.
And you're going to have to
fund the next two or three
weeks before the new
accounts start to produce revenue.
Any advice on something like
that for somebody in this situation?
Well, no, I mean,
what you just described is
exactly what needs to occur.
How you just described it is perfect.
It's either you are going to
adjust it off the purchase price.
So if the owner is going to
be taking the accounts
receivable from today,
for the next thirty days or
sixty days or whatever till
the actual date you know
closing date that all needs
to be discussed ahead of
time so either I mean it's
all factored into the deal
so it's either coming off
the purchase price or
you're paying extra but if
it comes off the purchase
price then yes then you
need to have as the owner
some other cash in a
separate bank account to
fund the payroll or the
rent or whatever it is all
the other all the other
utilities or overhead and everything
to bridge that gap.
It's very, I think it muddies,
it's only a muddied water a
little bit because of the
delay in healthcare payment
and reimbursement,
but it's not a complex topic.
The way that you just
described it is perfect.
And I know you were speaking
with someone who was having
some challenges with that recently,
but that's exactly how it occurs.
It doesn't matter if it's a
small practice or a larger practice.
That's exactly how it occurs.
Awesome.
Now,
another one people don't necessarily
think about is lease options.
So when we sold our Florida location,
we had to make sure, one,
the landlord was willing to
switch the lease over to the new owner.
Two,
the new owner had to make sure the
landlord wasn't going to say,
hey,
this guy's had a three and a half
percent annual increase
that's way below inflation.
We're going to bump you to a
hundred percent increase.
We're going to double your
rent and sign a new lease with you.
There's things in that that
need to be established
before you purchase,
if it's a brick and mortar practice.
And knowing that the
landlord is even willing to
let you transition that
lease or extend the lease?
Because from the landlord's perspective,
you're buying an existing business.
That business has been a tenant for years,
probably at this point,
but maybe they want to get
rid of a healthcare
business and they want to
bring something else in.
Have you seen anything
related to those kinds of extensions?
Yes.
So I...
when we're looking at potential deals,
what's wild is every lease is different.
Like there was a practice
that we looked at a couple
of years ago that had something like
It was like an eighteen year lease.
It was crazy long,
like the biggest we've ever seen,
the longest lease we've ever seen.
And all the future years
were already agreed upon, obviously,
because it was part of the lease.
And then we look at other
practices and their leases are, you know,
three, four or five years.
Earlier this year we were
speaking with a practice
owner that had only like
two or three years
remaining on a lease of one
of their locations.
So all that is a consideration.
I actually had a real estate
broker that works on behalf
of the practices and the tenants.
he would get his commission
from the landlord to fill
slots right so he's been
sending me abstracts and
he's been sending me uh
square footage options near
different corners of
manhattan whatever corner
or address I send him he's
pricing out other uh
options uh in the area and he um
has he's described like the
the the differences and
also the thing they
consider is that sometimes
these landlords are like oh
yeah like you said tony we
got a new buyer a new
physical therapy buyer they
don't know who we are or
who you are who who's the
buyer but they could smell
you know the money and
think oh well there's
there's this new buyer so
you're right maybe they
want to jack up the um
the rent on us,
if we don't do the change
of ownership properly,
if we don't have that
documented in a contract and all that,
even if the practice has
five more years on the lease,
like there needs to be some
change of ownership clause
or something that's
hopefully in the original contract.
do we want to take uh do we
need to buy the llc or the
plc or the business entity
in order to have the easier
change of ownership but
sometimes we want to buy
the asset we want to have
an asset sale and not buy a
stock sale we don't
sometimes we don't want to
buy the llc or the plc
because then we're taking
we're we're assuming the
liabilities of that
practice so if some patient
was burned by a hot pack
thirty sixty days ago if
they file a lawsuit or something
we might have to deal with
it as opposed to the seller.
Anyway,
so there's all these considerations.
The cool thing with the real
estate broker in New York
City that reached out to me recently
is he'll send me square
footage options nearby,
and he'll say in this building,
in the current building,
the current building that
this practice is in, there's a,
there's a twenty one percent vacancy.
There's a sixteen, seventeen,
whatever percent vacancy.
So then as the buyers, we could say, well,
not only is this landlord
probably not going to raise
the price on us too much.
Could we negotiate lower?
Most people don't even think
that's an option.
Now,
sometimes it's not an option because
there's bank covenants,
because the owner of the
real estate that has
financing through other
banks and institutions has
some covenants where
sometimes they can't go
below a certain market rate
of lease agreements than
what they already have
agreed upon in paper.
Does that make sense?
Yeah.
So there's a lot of this
that there's so many different dynamics.
There's so many different
components of it.
I think there's also value
in if you have a prime location,
if you have a longer term lease,
maybe you originally signed
a ten year lease and you
still have five years left on the term.
You've got a cap, you know,
three and a half percent
increase every year.
But like I said,
property values around you have gone up.
If I'm the owner sitting in that clinic,
that lease has thousands of
dollars of value still in it.
If I can make that
transition to the new owner
without changing the terms of the lease,
the new owner couldn't get
that property for that
price in that location.
So these are considerations
that I don't think enough
practice owners are thinking about.
Of course, now you mentioned liability.
I always explain, I'm like, look,
there are insurance contracts.
that you want.
Those insurance networks are closed.
They're not accepting new providers.
You're buying this practice
maybe for those insurance contracts,
but there's also insurance
contracts you don't want.
So like,
I don't want your twenty year
history with Medicare.
I would start my own LLC.
I would have my own Medicare PTAN.
I would start fresh and I
would get rid of all of
that history that the previous owner had.
but I would want you know
maybe a hard to get into uh
blue cross blue shield
contract that they're not
accepting new providers um
so when I'm looking at an
acquisition like this these
are some of the
considerations how do you
mitigate or reduce the risk
I didn't even think about
injured patients coming back to sue
the previous owner, the previous LLC?
Um, how do I reduce, you know,
a tenure look back period
on federal false claims act,
like all of this baggage of healthcare,
we want to wipe that stuff out.
Tony Couture here.
Love you guys.
I appreciate it, Tony.
Um,
Here, Dan said on the other side,
Dave Kittle,
one bad therapist kills that
momentum and decreases the
entire clinic's revenue.
Yeah, that goes back to hiring.
And Dan, that's exactly what I said.
I said,
I think they could do a lot more
damage than growth.
And if they do growth,
they usually want to take
those patients with them.
So, you know,
those are the challenges in
this environment for
growing through hiring.
Well,
I commented back to Dan Vapney on the
LinkedIn live video, and I said.
I said, right, but I said, Dan,
that's why our, our meaning us,
and hopefully I'm sure his as well,
because he's got a great practice.
That's why our recruiting
and hiring process needs to
be dialed in to identify
great candidates with soft skills,
clinical skills,
therapists who are coachable and who's,
who's the therapist core
values match our core values.
And you only find that out
in the interviewing and hiring process.
And that's why we have a more
maybe a more robust or
exhaustive interview
process than other
practices and phone screen
and a sixty minute
interview where we're finding out like,
hey, Tony,
tell me about a time when and
that type of stuff.
So we get to know the person.
That's the first hour on a
Zoom or it's in person.
And then the next hour part
of the interview is Tony, you know,
the therapist is evaluating
me and I'm giving you a
fake case and you're going
to evaluate me and treat me and all that.
And so, of course,
then we're doing reference
checks and having to fill
out a work history form and all that.
But a couple extra steps go a long way,
in my opinion,
for interviewing and hiring.
Hire slow, fire fast, Dan says.
Absolutely.
So before we wrap up the show,
any other little nuggets of
advice for smaller
independent providers who
are thinking about buying
out another small,
longstanding independent provider?
Yes.
Thank you for this.
Thank you for the question.
Hire an M&A attorney.
I, the,
the practice I was telling you
about a couple of years ago in Brooklyn,
uh, with the crazy long lease, that was,
that was like the,
one of the most appealing
things from it is that the,
the lease was a really long lease.
And I think the lease,
I think the landlord was a
nearby orthopedic surgeon.
So it's kind of like,
there's multiple good juju, good,
you know, potential good stuff going on.
That's all legal and kosher, whatever.
Um,
but I spent fifteen thousand
dollars out of pocket on
legal fees and the deal
fell through because we
found out we found out that
the practice was not as
good as we thought it was
the owner uh leading up to
as we were uh getting into
more and more serious due
diligence and talks the
owner was funding payroll
out of his own pocket and
also decided to not tell us
that that was actually
happening as I'm paying
lawyers uh to draft up you
know personal agreements and you know
check if there's any liens
against him personally or the business,
all the other stuff.
So please hire an M&A attorney.
I don't care if you're going
to buy a practice for six
hundred grand or whatever,
like hire an attorney,
pay a couple thousand bucks.
Maybe you can use ChatGPT to draft up
a bunch of the documents and
then pay the lawyers to
have them review them.
Although many of the lawyers will say,
we don't want to review
these because we didn't write them.
So it's like, you know,
it depends on the lawyer.
But please, please hire counsel.
Do not do one of these deals on your own.
Do not listen to Tony.
That was another time in the
world when Tony was doing a
handshake deal.
I don't care.
I mean, you're rolling the dice.
Just please hire an attorney
for all of this to look over the lease,
the change of ownership, to look over,
um,
to actually draft a purchase,
a sales agreement, purchase sales,
purchase agreement,
as well as an employment agreement.
If that owner is going to
help with the transition,
you're going to pay them hourly.
You're going to pay them salary.
Are they going to treat patients?
Are they going to do billing stuff?
Are they going to,
are they going to help you do, you know,
weekly team meetings to kind of, uh,
you know, ease the transition,
like whatever they're going to do,
like that's a separate agreement.
Um,
If it's in-network contracts,
you have the lawyer look
over the in-network contracts,
although that sucks because
the in-network contracts
sometimes are dozens and
dozens of ridiculous pages
that they're going to pay you,
or they're going to charge
you to look at these
ridiculously long
in-network contracts that
just are mostly rubbish at this point.
But please hire an attorney.
Don't skimp.
Don't go the cheap route.
All right.
That was awesome.
I want to say that's your parting shot.
I'm going to share a quote
from Warren Buffett that I
heard recently that I love.
Quote, great businesses are bought,
not sold.
Great businesses are bought, not sold.
So it's a weird,
it took me a long time to
think about this,
but my understanding of that is
Like nobody is going to sell
a great business.
A great business is going to
stay in your portfolio.
It's going to put money in
your bank account.
It's going to provide financial security.
But great businesses are bought, not sold.
If you're going to buy something,
it's going to be expensive.
It's going to be hard.
You have to invest money,
hire the attorney, do it right.
All right, guys, Tuesday, Thursday morning,
eight thirty Eastern.
Come back and watch us, Dave.
Next week,
I want to talk about Cleveland
Clinic is requiring
patients to pay their copay
before they let them schedule.
I wonder if I already love it.
I wonder if therapists in
private practice should be
doing the same.
Let's talk about it next week.
Guys, have an amazing weekend.