You're listening to the PT Pinecast,
where smart people in healthcare come to
make noise.
Here's your host, Jimmy McKay.
All right.
Do you want to say thanks to some
people supporting the show?
Episode supported by Empower EMR,
the EMR built by PTs for PTs.
The tools, the workflows, all the things,
all the things.
But in one thing, empoweremr.com,
if the thing that you touch,
unfortunately, most,
if you're a clinician, is the EMR,
even more than patients, most likely,
that thing should not be a friction point.
Kick the tires,
they'll walk you right through it and show
you how it could empower your practice.
See what they did there with the name?
Empoweremr.com, it's empoweremr.com.
Our guest today, excited,
doesn't like the status quo, never has.
If you're listening, you probably agree.
This guy's questioned everything from how
PTs diagnose foot and ankle issues to how
clinics get paid to whether physical
therapists should even accept hourly
wages.
Ooh, I like that.
Sounds spicy.
He's built one of Virginia's most
respected multi-site clinics,
founded a nonprofit to protect private
practices,
and even launched a payment model that
bypasses insurance entirely.
He's got strong opinions, stronger coffee,
and he's not afraid to challenge the
system.
Please welcome Dr. Josh Bailey.
Welcome to the show, sir.
How was that intro?
That was awesome.
I hope I can live up to that.
Holy smoke.
Well, hey, appreciate the time.
You live in Virginia.
That's where I went to PT school.
So that was like a second home to
me.
So I sort of miss... I missed it,
right?
Like, it's just a good... I don't know.
I liked it.
It was... To me, it was...
It's perfectly positioned in the country
because I'm from New York and I get
it.
We're hustling and bustling.
We don't pay attention to stuff sometimes.
Agreed.
Then I moved to South Carolina and I
was like, oh, it's way too slow here.
But I came to like that.
I got accustomed to it.
And then I went to PT school in
Virginia and I was like, ooh,
I kind of like this.
This was the Goldilocks for me.
What do you love about Virginia?
Well, I'm from Virginia.
You know, I mean,
even when I left to go to college,
I just went to a different part of
Virginia.
So, you know, I mean,
it's four great seasons.
You know, they're very distinct,
but I can play golf in all of
them, you know.
You can play golf whenever you want.
It's just how cold or how wet do
you want to be?
Right.
And it never gets too cold or we
usually don't get too much snow.
Yeah.
All right.
Well,
we got some spicy things to get into.
I'm going to ask you a question and
kick it off.
What's wrong with how most PTs get paid?
And if you had that magic wand,
what would you just go ahead and change
about it?
Well, way to kick it off.
I just have a real beef with PTs
being doctorally trained,
but not always acting like doctors.
And every doctor of substance that you
know has a base pay
and then a productivity standard that
they're trying,
not that they're shamed of,
that they're aiming for.
Because it's aligned right, I'm guessing.
Correct.
And you do good care and probably a
lot of good care,
then you make more money.
And I just feel like physical therapy,
I've been around a long time,
But I feel like we're kind of moving
to the fast food version of health care,
you know, and trading.
I'm going to trade, you know,
sixty dollars an hour for an hour of
my time.
And and, you know,
and I'm going to do six hours or
seven hours or eight hours or whatever it
is.
And then I walk away and I'm not
a doctor at the end of that.
And every other doctor I'm friends with a
lot of different types of doctors and they
all live and breathe what they do.
And, um,
and I think there are some PTs that
do that,
but I think there's a lot of PTs
that don't.
Um, and I,
and it makes me worried for the longevity
of our profession.
So if you could change it,
what would it, what would the,
what would the perfect look like or the
better look like?
And then how do we go from,
this is a very PT question,
or how do we go from where you
are to that?
It doesn't need to be perfect,
but how do we skate towards what you're
the picture you're drawing?
I think the first step is there needs
to be at least some reasonable
standardization in your market,
whatever your market is, of starting pay.
But that's not what you're expected to
make.
That's just the guaranteed money.
That's your baseline.
Hopefully,
really motivated PTs don't care about a
baseline.
The baseline is you're just telling me
you know,
that I need to target above that number,
whatever it is.
And then you go do great things and
you take care of people and you build
for what you do.
Right.
Nothing that you didn't do,
but build for everything that you do.
And because anything less than that
devalues what,
what we do for a living and,
and create a profit sharing program,
right?
Like every business has to make a margin
or else you can't keep the business going,
make a,
make a small margin in the business and
everything beyond that margins profit
share.
And if I were to start my staff,
all my staff has that available to them.
But if I were starting over today,
one of the things that I would do
if I opened a second practice,
it would be a, you know,
a junior partner model,
like a partnership where if I'm going to
open a new clinic,
you buy in ten percent of it,
twenty percent of it from the word go.
And each new clinic would have a junior
partner in it.
I wish I had done that.
PTs don't really work like the Dr.
Blue Sky model, right?
Where, you know,
I come into a practice and I spend
two years proving my worth and then I
get the trigger partnership.
And we've tried to make a semblance of
that.
We kind of have a succession program that
allows PTs to grow through it.
And what would that add to it?
Does that add...
I mean, it's skin in the game, right?
But when that model is in place,
what do you see?
What's different about that?
It's less trading time for money.
Now we start to get into the specifics,
right?
Sure.
And I think it's less time for money,
but it's also you're growing in the
community, right?
And you're trying to attract other
providers to come to work with you that
are like-minded.
Right.
Generally,
when you see a PT leave a practice,
it's because they wanted to something,
you know, that they were disgruntled.
They're looking for something better,
different.
I want to do practice a different way.
Or you hear private practice practitioners
opening a clinic because I want to run
it like I wanted to run it.
Why can't we have a model where all
those can go inside and and instead of
people risking their house and their car
and their marriage?
because they're working eighty hours a
week or a hundred hours a week or
whatever.
I think there's a way that there's a
happy medium that we could all do that
together and grow great physical therapy
companies without so much risk.
So the answers to big,
complicated questions are usually rooted
in simplicity.
Is this an us, meaning the PT profession?
Is this an us thing,
a mindset thing that we have to change?
Or is this external,
we have to force change on a business
model insurance, something else?
Is this an us thing or a we
got to work with them thing?
I think it's an us thing.
I think if we all just agreed that,
you don't get to be a doctor from
eight to five and you, you know,
you have to kind of live it,
breathe it, think it, um, you know,
you hear in every PT school,
I've taught in tons of PT schools all
over the country.
I never hear any group that doesn't, that,
that leaves out, um,
we're lifelong learners.
Right.
But then, right.
But then I, and you know,
one-on-one and compassion,
all the things that bring the bile in
the back of your throat, um,
Because you know that probably the seventy
percent can't do all those things.
Yeah.
And and usually it's culture.
The culture around them is what drives
them to continue to want to grow and
develop.
But a lot of people just get stuck.
And and I think if we get stuck
to what's my hourly rate versus what do
I have the capacity to generate?
Yeah.
Um,
it could be different and maybe I'm wrong
and maybe it's just my motivations are
different,
but I've spent every day of my life
treating life like a sporting event.
Right.
Somebody's got to win.
Somebody's got to lose.
I don't intend to lose.
And I mean,
I was like that in high school.
You know, I did.
I never did homework.
I just sat across the room and like,
I think I can beat that guy.
You know, they seem like the smart one.
You know, and frankly,
I did it in school.
It wasn't always the best strategy.
And I've done it in business, you know,
and I wasn't trying to beat someone to
hurt them.
That's just how I set the bar.
What's the goal?
Can I get there better, faster, cheaper?
Yeah.
I mean,
I talked to my team about if we
all just treated our profession like we
treat the speed limit, we'd be great.
Right.
And, you know, you see the sign five,
five speed limit,
but technically you're supposed to be
running fifty four.
But if you if you got behind that
person going fifty four,
we would all lose our mind.
You know, like, what are you doing?
Right.
Because that was just one of the bottom
suggestion.
Right.
But then you get into an employment arena
and it's like,
what are your KPIs or what are your
baselines or whatever you want to call it?
And then everybody targets the bar.
They don't think about what's above the
bar.
They just target the bar.
And subsequently, if life gets in the way,
they fall below the bar.
And I see that all the time.
And when I first became CEO of our
practice,
I thought it was something wrong with
their practice.
I'm like, we're really good.
Like, why are we great?
And is it an aptitude problem?
Is it an emotional quotient?
Like, what is it?
And I couldn't find anything wrong.
And so I started looking at other
businesses and I'm like, well,
they kind of have the same problems that
we have.
And then I started looking at some of
my friends and I'm like, geez,
can we all move it underachieve here?
And then I realized the issue was had
nothing to do with the capacity.
It had everything to do with what we
were paying attention to.
And if we pay attention to the bar,
then we tend to try to jump over
that bar.
And if the bar is put with trouble,
Yeah, it's funny.
It's like they teach you...
I was taught when you ski a little
bit out of bounds and there's a tree,
if you say, avoid the tree,
avoid the tree, avoid the tree,
guess what you're going to hit.
But if they say,
aim at the tree and your goal is
to aim and then move...
That's what happens.
So it's funny.
It's like when you try to avoid something,
you wind up hitting it.
When you try to hit it,
you wind up avoiding it.
So the goal is like,
how do you align those things correctly?
Who do you listen to?
You sound like you've read some of the
similar books.
Who are the authors or people?
It doesn't even matter in PT, right?
Because business is business or leadership
is leadership.
Those things translate.
Who do you look to?
Who are some of the things on your
shelf?
Well, my,
my favorite book is good to great.
I was going to say you were dripping
Collins right there.
I mean, I, I,
I can probably quote chapter after chapter
and I teach some leadership, you know,
classes that,
that I use good to great as a
tool.
Right.
And, um, and just that first chapter of,
you know, level five leadership, like,
I don't know that I've ever personally met
a level five leader.
But, you know,
it's just like that same lifelong
learning, you know,
like that's the target.
Like I got to go there.
I got to figure out how I get
above this level and above the next level
and above, you know,
so I can be that enduring leader.
And I know clearly I haven't achieved it,
but but I'm still trying.
And, you know, and I hope I'm trying,
you know, two days after I'm retired,
you know, you know,
because I don't I don't want to quit
on it.
Yeah.
um direct to employer contracting i on
purpose saw that was going to be a
topic we were going to talk about i
on purpose didn't look it up because i
like to go into certain topics or
situations where i'm like be the person
who's confused so what what is it and
why do you say it's the purest form
of pt sure so functionally direct to
employer contracting is
making a contract directly with the
primary payer of healthcare services,
which is historically in America,
the employer, right?
The employers buying an insurance plan are
paying the majority of an expense product
for an insurance plan.
And then the employee kicks in some and
they have an insurance package.
The problem with that is we have to
play by all of those rules.
which have become a huge issue in physical
therapy, you know, as far as, you know,
authorization and verification and,
you know, and then by the way,
I submitted a clean claim and, you know,
you hadn't paid it.
And then I'm tracking it down and all
those things that have administrative
burden, they chip away at,
profit and devalue what we do as providers
so you know my feeling is the best
contract is the one that's directly with
the employer i can make more money my
providers can make more money my providers
don't have the administrative burden the
employer has a discount
And we actually have PT as the front
end of musculoskeletal care,
which is what we've been trying to do
for the last ten or fifteen years.
We've been talking about it and talking
about it,
but nobody's really getting around to
doing it.
And I feel like that's the pathway to
it.
And that's why it's the purest form,
right?
It's easy.
Most of our contracts,
the patients have no payment or very,
very low copayment.
And when I say low,
I'm talking ten dollars.
is what a patient might pay.
In some contracts,
the patient pays nothing.
And the employer has recognized,
I can reduce all the downstream expenses
of unnecessary tests, medications,
surgeries.
And you don't even have to be great.
If you're just a reasonably good physical
therapist, you're probably going to say,
if you save one spinal fusion,
You can probably pay for a thousand PT
visits or more.
Right.
Wild.
Yeah.
I mean,
we can do a lot with a thousand
visits.
Yeah.
Well, yeah,
we're arguing over five and we're
skipping, we're stepping over a thousand.
I,
one of the first episodes I did ten
years ago, talking to a sports PT,
Eric Mara, and I remember I asked him,
hey man, like,
Because when I started PT school,
it was the second career for me.
I knew like post-surgical and sports and
regular, regular PT, right?
I didn't understand there was all this
different stuff or each sports team had
one embedded on the sideline.
And I just said, hey,
what's it take to be like a great
sports PT?
Because he had done some NBA stuff and
NCAA stuff.
And I was ready for this big fancy
answer from this guy.
And he gave me the three A's,
which were you got to be available because
sports are like twenty four seven.
You got to be affable because these
athletes like this is their job and they
can work with anybody.
So you better have a little bit of
a personality and be affable.
And then the third A blew me away.
He goes adequate.
He's I need to do the basics real
well.
He's like,
I know you want to do the fan.
I thought the answer was going to be
lasers and this and this.
And he just slapped me with adequate aim
for adequate.
And likely,
if you do adequate enough over time,
you're going to be above adequate.
Right, for sure.
I think that the same would be true
with direct to employer contracting.
Obviously,
our goal is to be the best at
what we do.
And really,
you have to be for a while to
have enough data for the employer to
actually pay attention to you.
But there are people that do direct to
employer contracting that don't measure
clinical outcomes.
And I want to do it with a
third party so they can't say I
manipulated it.
Anyway, been there, done that.
You know, I've heard that song and dance.
So, you know, I'm like, look,
you don't need to believe me.
Ask them.
You know,
they'll tell you where I rank and,
you know,
but this is why I'm going to do
what I'm going to do.
And, you know,
we have volumes of research that speaks to
PT for low back pain seen within the
first fourteen days,
reducing fifty percent of downstream
costs.
If that's really true,
why wouldn't every third party payer be
all over it?
Because because they're the incentives
don't align.
Right.
What do you mean by that?
So for PT, like nine, seven, one, one,
oh, nine, seven, one, one, two,
no one really knows what that buys.
Right.
Like, cause it's so very,
it's a code for time.
Right.
Exactly.
And versus for a third party payer,
you know, they pay for a lumbar fusion.
They know what that fusion is.
we save money downstream that employer has
or that insurance company rather has no
idea if the employer is going to be
with the same insurance company next year
so they're not incented to save money
today they're incented to have a finite
expense today because their job is to make
sure their shareholders are happy as the
insurance company and so for the patient's
perspective
I think there's no argument that we do
great for patients downstream.
But for the payer,
they want to keep that employee.
Institutional knowledge gains year over
year as that employee stays.
And I think that employers started getting
frustrated with every year my health
expense goes up.
And I kind of know that.
Right.
I'm watching the news that, you know,
and whether you're on maybe you're on the
state exchange,
it's going up seventeen percent this year
or whatever.
And they're going, you know,
like I kind of know that this expense
is going to go up.
But the problem part is it's going up.
And my employees tell me they hate it.
Like this is a real problem.
If I'm spending a ton of money and
they're mad at me for it.
Right.
I got to have a different plan.
So that's kind of where I tried to
insert myself.
Yeah.
Let's change to a different topic that I
don't understand,
which is a lot of things.
You started PT Management Group of
Virginia, but it's not a business.
What is it and why did it matter
to you to start?
What is this thing and why did you
do it?
So in twenty fifteen,
I originally thought, you know,
I'm going to get a group of practices
together and we're all going to band
together and we're going to negotiate
better contracts with insurance companies.
which sounds fantastic until you realize
that there's one tax ID number in that.
And so that means everybody else would
have to give up their tax ID number
or I would have to give up my
tax ID number so we can negotiate under
one.
That was too much risk for private
practices.
They didn't trust each other that much.
So I said, okay,
we got to do something that keeps private
practices private.
And because selling to institutions,
let's just call it institutions.
So we don't stomp on any toes.
I never saw people go like that, man.
That was awesome.
You know, like it was always kind of,
yeah, I sold my soul to the devil,
you know,
like they just were generally unhappy.
So I'm like,
maybe we could find a way that we
could keep private practices private.
And so that became like a managed services
organization.
So functionally,
I became big brother to practices in the
state of Virginia where I vetted EMR
systems and I negotiated discounts.
And so there is an expense to join
PTMG.
It's fifty dollars.
which functionally covers my legal fees,
I hope, you know,
so when I'm vetting contracts,
but that's what it's delved into.
And, you know,
we've kind of branched into North Carolina
as well,
just because people were asking for some
help.
But we found ways to bring less expensive
EMR systems,
less expensive scribe documentation,
you know, AI documentation,
billing companies, medical supplies,
office supplies,
and we can get better pricing because
we're negotiating as a large group.
Strength in numbers.
Right.
So it really, if I cashed out today,
I wouldn't get to a comma.
There wouldn't be a comma in the numbers.
You know,
and it never was designed to be a
financially viable source.
It was designed to keep PTs doing what
they had a passion to do and doing
it the way that they thought they could
do it best.
And I think I've achieved that goal.
And, you know,
I'll keep doing that as long as I
can.
you know,
put one foot in front of the other.
Yeah.
All right.
We're going to take a break.
I got to pay some bills here.
Brooks IHL shows power by Brooks IHL over
the last couple of years,
world-class residencies and fellowships
built around real world patient care,
pediatrics, geriatrics, orthopedics,
neuro, women's health,
brooksihl.org down in Jacksonville,
brooksihl.org.
See what the future of your career could
look like with a residency or fellowship
at Brooks.
That's brooksihl.org.
All right, that's the break there.
You teach a foot and ankle course based
on what you say school got wrong.
I love that.
What's the biggest misconception PTs have
about plantar fasciitis or maybe just
diagnosis in general?
What are we close but not exactly on
the button?
So I'm going to back up before I
answer that question and just get to how
I got there.
Yeah, I like that.
So I grew up thinking I wanted to
be a physical therapist.
My father was in a very bad motorcycle
accident when I was seven.
Spinal injuries,
he had burst fractures from T-ten to
L-five.
Thought he was going to be paralyzed,
said he wouldn't walk again.
Well, he walked, he lived,
he did all the things.
And through that,
he wasn't saying the trauma surgeon saved
my life.
He was saying the PT saved my life.
So I grew up thinking PT was like
super special.
That I wanted to do foot and ankle.
I wasn't the prototypical PT student.
I went to PT school saying I'm gonna
be a foot and ankle PT.
And my professor said, well,
you have to do an acute care rotation
and then skilled care.
And I'm like, nope.
And I didn't really understand why they
cared.
You know, I thought it was my problem.
And, you know, so anyhow,
I focused all on foot and ankle for
forever.
And I treated other things when I wasn't
well known enough to treat them.
foot and ankle only um but through that
process i started following podiatrists
and orthopedic surgeons and um you know
and i you know got to hang out
with some real gurus and uh and see
what everybody was doing and there's some
really great foot and ankle physical
therapists particularly in the eighties
and nineties and i spent time with them
And what I realized was we're all trying
to do the same thing,
but they're they're trying to do it four
different ways.
Right.
Like pedorthics has, you know,
the foot and ankle appliance approach.
And orthopedics is really very good at
differential diagnosis, you know,
with with they have a lot of special
tests at their disposal.
But orthopedics usually get the diagnosis
right more often than not.
Podiatrists really can also do the same
thing.
That's very regional.
East Coast versus West Coast podiatry
seems to be quite different to me.
But many understand biomechanics very
well,
but their biomechanics kind of stop at the
knee.
And PTs are supposed to be the function
group.
And we learn a lot about evaluation and
not that much about treatment and really
very little about function.
yet then we're supposed to go treat
patients and do function so as i was
trying to roll all those things together i
realized that the only real right answer
was to pull research from all of them
and um and understand what the other
groups were talking about so to answer
your question about plantar fasciitis um
about ten percent uh in my estimation of
what comes into a pt clinic diagnosis
plantar fasciitis actually has pathology
to the plantar fascia
It's some other structure.
And, you know,
as simple as if you put if the
plantar fascia is the problem and you put
the plantar fascia on load and then you
palpate it,
you would anticipate that that plantar
fascia would be more painful.
But more often than not,
those patients diagnosed with plantar
fasciitis in a PT clinic,
if you do a windlass mechanism and you
extend their great toe or all of their
toes, the plantar fascia is taught,
their pain goes away.
And, you know, PT school, you know,
we're taught to, you know,
it's an inflammatory reaction.
It's an itis.
You know,
you're going to do your calm it down
type treatments.
And then the patient goes,
it felt better while you were doing it.
Yeah.
But we don't have a great history.
And that's why the research looks like
what it looks like for PT.
It's like PT might help.
PT might not help.
Orthotics might help.
Maybe over-the-counter products.
Maybe it's walking barefooted.
Maybe you need a different shoe.
And it's all of these maybes when probably
the issue is,
The most common diagnosis is a muscle
problem,
like it's a tendinopathy and that causes
heel pain.
There's others.
There's seventy two things that cause heel
pain,
like pathologies that cause heel pain.
But the most common is flexor digitorum
brevis tendinopathy.
And you can find that in research outside
of PT.
You can't really find that in PT research
that well.
So then you decided to teach a course
because you, what,
I'm guessing you had all this special
knowledge and you're like, hey,
the way to do it or the way
to touch the most people is to teach
the teacher?
I wish that were true.
Honestly,
I had been practicing for about a year
and a half, two years,
and I studied only foot and ankle.
And I said,
how am I going to make sure?
I had this crazy goal of being the
best foot and ankle physical therapist in
the world.
I don't even know how you measure that.
Right.
I had this ideology that that was what
I was going to do.
So I decided I would create a course.
with no one to buy it, right?
No one to even market it to.
No one who would even care.
But I would use that as my discipline
tool to comb through the research,
understand differential diagnosis,
understand actual functional change.
Because our books were so challenging.
If you ask a PT,
what's the purpose of the gastroc?
What's the action of the gastroc?
It's plantar flexion.
which is a hundred percent true unless the
patient stands up and then his job is
to decelerate the tibia.
And,
but we don't train deceleration of the
tibia that often in the clinic.
And so anyhow,
I used that as an approach to make
me a better PT.
And then after about three years of
culminating all of that, I was like,
I think this could be a course now.
And, um, and then thankfully, you know,
one thing led to another and a few
people started calling and, um, I,
I taught with North American seminars for.
Twenty years or so.
And then private,
I use COVID as kind of my break.
And, um,
and then I've just done private courses
since then.
I kind of,
I have a level one course,
which is like an advanced evaluation and
treatment of foot and ankle course.
And then a level two course,
which I call beyond the textbooks.
It's the things that you really can't find
in one place.
And like tricks of the trade.
To me,
that was the part that kind of rejuvenated
me.
And it's like, oh, that's super cool.
And, you know,
it's kind of like the first time you
learn spinal manipulations.
You watch people do it and you're like,
man, that's awesome.
And then you try to do it and
you're like, I'm not very good at it.
And then the first time you can
repetitively create a cavitation,
you're like, yeah, I've arrived.
And so I tried to create those summaries
of if you see this,
then here are maybe the three to five
things you should be thinking about.
How are you going to rule it in,
rule it out?
How are you going to know if the
patient's getting better?
How do you know if you're on the
right plane of treatment?
You know,
what's a reasonable timeframe for
treatment?
What are the things that you shouldn't
even treat?
Like we know historically we fail at,
maybe we just need a punt.
So anyway, that's how it all came about.
It wasn't,
it wasn't this cool knowledge set.
Yeah.
But you sort of,
you started with the end in mind.
And the end,
you created an obstacle course for
yourself and you made it at such a
level that eventually the audience found
you.
They started sniffing around.
Once you started letting people know that
this thing that you created was there,
that's the way to actually do it.
The opposite would be like,
who do we sell to?
right where it should be like what do
i care about what am i willing to
do push-ups for even if i get no
return i'm still getting muscles out of it
and then you were like well other people
want this path too look at all the
put look all the work i've done you
started with the end in mind which is
even if nobody i told people this before
even if you have a pod like we
could use it as a parallel
Even if you go to write a book
or even if you launch a podcast and
no one reads it or no one listens
to it, you did the work.
You got to interview the people.
You walked away.
It's a giant cheat code for life.
But you could do this at a laundromat
or a bar or street corner,
which is if you ask enough questions and
shut your mouth long enough to let people
answer, you can learn.
You can learn.
Period.
Hard stop.
Yeah,
and that's exactly how it came about.
And I forced myself to look at things
that maybe I had been told were wrong.
It's like, well, why would they do that?
What were they trying to achieve?
And I was reading research that really I
had learned in school was not valid.
Like, oh, that's from the fifties.
Like, that makes it wrong, right?
But when I started going through and
understanding what their methodology was
and why they were trying to approach it
the way they were approaching it,
I was like,
maybe there's a lost piece in here.
And so the more I learned, you know,
over the last twenty eight years,
the only common thing I can say is
the more I learned,
the less I'm confident about, you know,
like the things that as maybe a new
therapist, I was going,
you always do this.
there's not that many always and nevers
for me anymore.
Well, that's done in Kruger, right?
Which is like, it's like when, you know,
you get a new grad, myself included,
that's why it's so easy to spot.
Like, you know, your second, third year,
maybe a year or two out of school,
it's like,
you're dangerous because you know enough,
but you don't know what your blind spots
are.
But in the moment,
it's like youth's wasted on the young,
myself included.
It's like, oh no,
I know lots of stuff.
And then you get some reps and that's
the difference between knowledge and
wisdom, right?
It feels like.
Right.
Yeah, I couldn't agree more.
And, you know,
I've actually looked at some data that,
you know, for PTs, like,
when are you really good?
Right.
And the data is like between year eight
and year fifteen.
And, you know,
it's a hard pill to swallow, though,
right?
It especially if you're on the other side
of fifteen, you know, but, you know,
from year one to year eight, you know,
you are learning,
but you probably don't have enough reps.
Right.
And I mean,
I'm just summarizing what I think the
state is trying to say.
And then after year fifteen,
I jokingly say, like, you've arrived.
And so you quit digging.
You know,
like you feel like you don't need to
prove anything anymore so you can just
rest on your laurels.
And so you just slowly go away to
nothing.
And frankly,
that scares me at twenty eight years.
And I don't want to I don't want
to be washed up.
And and and so I have to have
some reason to.
be better tomorrow than I am today.
And whether that's in leadership,
whether that's as a clinician,
whether that's as a business owner,
whatever,
those things still have to be true, um,
to be successful.
I think.
Um, we didn't plan this,
but who's on your bookshelf.
You mentioned, uh, is Jim, Jim Collins.
Good to great.
That's on there.
What else?
What's, what's, what's,
what's paralleling or what's on the side
of the bookshelf if that one's on there?
Um, paralleling, um,
there's a book called on fire.
Ooh, who's that?
Well, I can, um, I'll look,
I'll look it up, but what's it about?
Um, it's about, uh, a young man who,
um, was,
was playing with fire and he caught on
fire and gas and, and fireworks mixed.
And he was burned over ninety percent of
his body.
And John O'Leary is his name.
That's what it is.
You're right, John O'Leary.
Seven Choices to Ignite a Rackley-Inspired
Life on Fire, John O'Leary.
I've never heard of this before,
so tell me about it.
So he talks all about how physical therapy
changed his life.
Because at nine years old,
he was burned over ninety percent of his
body.
you know,
he went through some horrible burn
treatments and then he, you know,
he had amputations,
he lost all of his fingers and,
and his,
and he had very significant inspirational
moments in his life.
And he,
hearing his story and reading his book
just really impacted me to the point where
I called him up and said, I want,
I want you to come and do a
leadership talk for my team, you know,
it'd be motivational.
And then he told me his price and
I'm like,
What else you have?
You got a cousin that could tell your
story.
So he agreed to do a video.
Oh, that's great.
And he tailored it to our team.
And at the end of the video,
every person in our room had tears
streaming down their face.
This man has no fingers, right?
And he walked over and is pretty much
saying, you know, listen,
it comes down to grit, right?
Like,
Like, what's the next step?
How are you going to move yourself
forward?
And as he walked over with no fingers,
he sat down at the piano and he
played Amazing Grace.
Wow.
And, you know, at this point, you're like,
look,
if I can't at least be a great
PT, how bad am I?
You know, like this guy has no,
he could have given up on life.
And now he's a public speaker and he
owned a construction company.
You know,
like he had done all these great things.
So that one was,
it made me pay a lot of attention
to grit.
And, um,
and then that led to like Angela
Duckworth's book, um,
passion and perseverance.
Um, and, um, you know,
and I've kind of tried to use those
things to, to grow my practice.
Um,
I don't really think about hiring PTs much
anymore.
Um, you know, I think about hiring,
you know, character, passion, integrity,
and grit.
Yeah.
And if we have all those,
we can do great.
Yeah.
I mean, like you hear often,
especially now, you want to bring in AI,
right?
You've got people who are like,
I'm applying for this job.
And I think I check all the boxes
on this description and I don't hear
anything.
And then you hear from recruiters who are
like,
it's because your stuff's going through
AI.
It's never hitting a human eyeball.
Right.
And you just,
you have to wonder there's going to be
some
there's going to be some real loss by
organizations or some real gain by the
organizations who say,
we're not going to do it this way.
We're going to look for the person with
grit.
Because the smart people,
the people sort of at the podium at
these big organizations who've done it,
maybe whatever your version of the right
way is, has said...
Listen,
we can find people with skills or degrees.
Look, they're out there.
They're falling off of trees.
You're looking for...
And for people who maybe haven't heard
Angela Duckworth,
she's got a mathematical formula,
which makes people like me tremble because
I go, math.
But this one has words in it,
which is why I like it.
So talent times effort equals skill.
skill times effort equals achievement.
And then she explained,
she's got a great podcast as well called
No Stupid Questions.
She says, what do you notice there?
And I'm like, I don't know.
I see.
I wouldn't have done it if it was
math.
But well, that skill word's there twice.
Or sorry, effort's there.
Which means effort is squared.
So it's like, oh.
So someone would have asked me, well,
how'd you get so far in radio?
Were you just real funny?
I was like, I just kept showing up.
Just kept showing up.
Nope, here I am.
I'm going to dress like a lion and
hand out stickers at a Jiffy Lube.
Or you're going to show up early.
Whatever that is, the effort,
hopefully it gets noticed because that's
also not the only one.
So talent's what you're born with.
Skills are what you learn.
So by all means, invest in skills.
But if you're just taking con ed courses
and you're not putting effort in,
you're missing because that's that best.
The effort is squared.
The ROI is squared.
A hundred percent.
And and, you know,
we spend an exorbitant amount of time
trying to foster that and and letting
people see, you know,
when you put in this effort,
this is what you get for it.
And and it goes back to the first
thing we talked about is like getting paid
like a doctor.
Do you have to know what it is
in the beginning?
Do you care about your hourly rate or
do you care about your take home pay?
Right.
What's the goal here?
What are we working towards?
Right.
And if we can all do that and
recognize there's it's never a straight
line.
Right.
It's always going to be hills and valleys.
And, you know,
and I think oftentimes like I'm worried my
kids are probably going to be scarred
because because I say, you know,
you can be anything you want to be.
But there's not a period at the end
of that.
That's a comma.
As long as you work for it.
Yeah, yeah, yeah.
Good point.
And we have so many people that just,
you know, I've graduated.
I've arrived.
Here I am.
I'm a doctor.
I have a car.
I should have a car and a big
house.
And, you know,
like nobody who's ever done it did it
that way.
You know, like it just didn't happen.
It's because somebody went out and made it
happen.
It's really funny because...
I want to foster it.
It's really funny because I work with a
lot of creative people, obviously,
in the nature of my former career.
And then I became a PT,
but now I do weird PT stuff adjacent.
And it's funny.
There's this guy named Chris Do.
And he's a graphic designer,
but he also...
He'll teach other people value.
So he's like a value guy.
And he'll do these live Q&A sessions and
say, well,
how much does it cost for Chris to
design a logo?
And he goes, "'Ten thousand dollars.'"
He's like,
but it's going to take you an hour.
And he goes, yeah,
it took me ten thousand hours to do
a great graphic in one hour.
But if you want to pay me for
the hours,
I'll just take three weeks and still
charge you ten grand.
So do you value quality or time?
And look, it's the same as PT.
Well, I want to get more per hour.
It's like, no, you don't.
You want to get more per value.
You want to sell the value,
not the nine, seven, one, one, oh,
that got you there.
That ain't it, man.
That's not the thing.
That's the thing that helps you get to
the thing.
Right.
And and those are directly parallel with
direct to employer contract.
Yeah.
They want value.
What do you want?
They don't necessarily care what it costs.
They don't.
As long as they're getting what they pay
for.
And, you know,
when when history has taught us that
health care costs a lot,
but you don't get much for it.
Um, that's a bad value proposition.
Well,
I think it's the only lever to pull.
All right, look,
you just framed it really well.
I got two sides to a seesaw.
It's going to suck and it's going to
be expensive.
Well,
can you just make the sucky stuff cheaper?
It's harder to frame.
I'm going to make the bad stuff better
because that's,
it's not tangible to people.
So, you know, I,
I give this example a lot, which is,
uh,
I love when I talk to a room
full of clinicians and I'll go, hey,
I'm just curious.
I was just talking to my friend out
in the hall.
Who here has Amazon Prime?
And of course,
I'm asking a loaded question.
Of course, ninety percent,
ninety five percent of hands go up.
And then I go, hey, man,
you guys are all smart.
You probably pay attention to your
finances, right?
Yeah.
How much does that cost?
Everybody gets real nervous.
Like, oh, it's I think it's isn't it?
And I ask that because.
We don't necessarily, most of us,
some people do, some people are sharp,
but most of us don't.
But internally,
right down here in the gut,
we know whatever it's worth isn't even
close to what it costs.
Bezos spends all day loading on the value
side of the seesaw because he goes,
I'm going to keep your eyes over here
and you'll never look over here.
We pay a hundred and thirty dollars a
year to be allowed to buy stuff on
his website.
Not even that.
You don't have to have a subscription to
buy it.
We buy it for...
two-day shipping, free returns,
and Amazon video, and Amazon photo,
and Amazon this, and Amazon that.
And it's funny.
It's like, everybody's giggles.
They're like, well, he's just real smart.
And I go,
I thought you were a room full of
doctors.
You can't figure out how to load one
side and not the other.
But you're too busy telling me, nine,
seven, one, one, no,
reimburse seventy-eight dollars.
And I'm saying, I agree with you,
but we need to aim further downfield.
Right?
Last inch is more money.
A hundred percent.
Yeah.
A hundred percent.
And, you know, we need to do
a lot fewer things and go a lot
deeper with the things that we do yeah
inch wide mounting yeah absolutely and you
know and another like trigger for me is
that you know going to a pt clinic
i'll see this therapist doing three sets
of ten and i'm like tell me why
that's important yep they're like what
like the exercise no three sets of ten
like why did you decide on three sets
of ten
And I seldom get an answer.
They're like,
I thought you were the specialist.
Like,
shouldn't there be a reason that we're,
how much we're doing?
Like we're dosing this.
Like, what's the right dose?