You're listening to the P.T.
Pinecast,
where smart people in health care come to
make noise.
Here's your host, Jimmy McKay.
All right,
our guest right now returning to the show,
obsessed with systems,
not just how things work.
I feel like why they work and why
they might break or how to make it
better.
Someone who's seen the complex web of
clinical operations,
but see it like a circuit board and
maybe where the,
I learned this term from an engineer,
points of failure.
Not the whole thing isn't bad,
there's a point of failure.
A person that we're gonna talk to today,
constantly analyzing how decisions are
made in one corner of the organization,
how it affects the others.
It's called a ripple.
One thing affects others.
We know this cause, effect.
Today we talk systems thinking,
clinical innovation,
what happens when PTs are empowered to
actually fix
the things breaking under the surface
before they fall.
Welcome, Alex Banderski, back to the show.
Alex, man, good to see you.
Pleasure to be here, Jimmy.
This has been years in the making,
and finally I get a presence here.
It is truly a joy.
Well,
we had you on the show in DC.
True, true.
Yeah.
We did that at the Future of Rehab
Therapy Summit.
As someone who went to that,
that's Drew Contreras of APTA going,
all right,
let's throw a bunch of people in the
room and see what happens.
What would you,
this is not on the script,
but what'd you think about that event?
And then what would you hope that event
feels like, smells like,
tastes like ten years from now if they
keep doing it?
I think it's a perfect reflection of our
profession.
I think doing a panel,
you had five panelists that are these
brilliant entrepreneurs that are designing
technology that can help MSK care.
And when it came time to question the
panelists, there was a line of two people.
Nobody had any questions.
And then when there was a commercial panel
of how to monetize this,
the line was out the door.
So as an industry,
we care so much about commercialization.
We have so little.
Is our profanities allowed in this
episode?
Yeah, sure.
OK,
so we give so few fucks about the
actual content and substance, right?
Like we just want to make money on
it, which to me like that.
I think the entire conference was a an
excellent idea,
but it was not the future we have.
It was the present of rehab.
If you want to do the future rehab,
you really have to look into what's ahead,
not what's here.
And certainly getting a keynote speaker
that sells soap is always a plus,
but soap is not the future.
Right, right.
I mean,
I think the guys from Source Soap are
there to show you like, hey,
you can have an idea and you can
just do something with it.
Like, I think that was a great story.
It's a great human story.
But I think you're right, which is like,
what's around?
The first time I ever heard this term
was from a guy, you know, Guy Kawasaki.
Yeah, I'd never heard of him.
And then I read his book like ten
years ago or something,
and he was like employee seven at Apple
or one of the first people there.
The term I'm talking about is like
paradigm jumping,
and he explained it in his book,
which was like,
I don't need you to make the widget
red, even though no one's made it red.
That doesn't jump a paradigm.
I need you to make it wireless or
I need you to make it think for
me.
or predict and not react.
And I remember thinking, oh yeah,
that's how things are.
That's how things progress is when you,
Example, maybe an example,
when Apple changes their charger every
three years and they don't really give you
the option, that's sort of the only way.
You have to sort of burn the boat.
You can't go back.
There's no undo the update.
You have to go forward.
And the funny thing is, six months later,
you're like, oh, this is actually better.
I actually like it better.
It's like, yeah,
but you had to go through the
uncomfortable part of doing it.
So maybe that is a good point.
It's like that was a good snapshot of
the present of where we are.
But what is peering around the paradigm to
see what comes next?
It's the nudge versus sludge, right?
Like nudging,
like the Apple charging chargers.
That's a nudge moment.
They're nudging you into changing
something that may be more efficient.
And sludge is these purposeful friction
points.
You create friction because you want to
slow down progress.
Because you want people to absorb it.
Both hold value.
The sticky shit on the floor,
that's sludge.
There's one that I saw,
and I can't prove that it happened,
but I play video games and I play
Call of Duty,
and they stopped sort of moderating one of
the games,
and they made cheating sort of run
rampant.
because they had a new game coming out.
So they were pissing people like me off
who were like, hey,
I just want to be on an even
playing field.
I know you're better than me, but like,
I want to get better.
But then they just allowed like auto aim,
aim bot, cheating,
guys were under the map and could just
kill you and you couldn't do anything
about it.
So I would rage quit.
And I think that you're doing that because
they're like, we have a new game coming.
Like this game is just, hey,
you can't do anything about it.
And I'm going,
I don't know anything about programming,
but I'm like, you could...
you could easily ban these people who are
cheating pretty damn quick.
Yeah.
I mean,
have you ever heard of a concept of
planned obsolescence?
Yes.
That's what they're doing.
That is planned obsolescence.
The first light bulb, I think,
was designed to last a hundred years.
It's not a great business model.
No.
I can't sell a light bulb to last
a hundred years.
So they spent thousands of dollars
reengineering so that it actually is going
to start.
I think the same goes for all of
this.
Let me ask you this,
because what is the planned obsolescence
for our industry?
I think right now we're in that, like,
you see all the chatter, right?
And I agree with you.
Actually,
I really like your point of view.
You're an optimist.
I think you're a realist,
but you're an optimist.
So you see that there's no reason to
be down in the profession when it's going
through a hard time,
but you have to have action steps.
And I think that we are, like,
the obsolescence is that old antiquated
model.
Like,
how do we get out of this excellence
and model into something that actually is
resilient?
So what's what's I've talked I think I
had a year, you know, and again,
it's really it's I understand it's really
easy for me to make predictions and then
never have to back it up.
It's like being a weatherman.
It's like it's probably going to be great
tomorrow when it's not.
It's like, well, whether, you know,
I think I said, you know,
I like throwing out crazy ideas,
which was like,
is the future of rehab a person?
who's a PTOT speech, like,
is there this physiatrist absorbing some
of the, all these things?
Maybe not all of them,
because I feel like speech is sort of
on an edge.
Like, I don't, but is there like,
we started as,
What therapy aids, right?
Which was the construction.
Right.
Reconstruction is right.
Is there this like like I didn't even
know what a physiatrist was until I was
like halfway through PT school.
I had no idea.
And then I was like, oh,
they're sort of like us,
but they do all this other stuff.
And so I was like, yeah.
And I go, doesn't that make us nervous?
And they're like, well, no.
And I'm like, I don't know, man.
When you start like sanding things down
and getting rid of the bumps,
maybe we morph into something like that.
I don't know.
I think that's a perfect segue into the
complex systems theory, right?
So the interconnectedness and
non-linearity is part of the connected
complexity,
is that the interconnectedness,
everything is connected to it.
All of the things,
all of the nodes are connected somehow,
right?
We're all atoms from some star that blew
up a millennia ago.
right but at the same time it's not
like the progress is not linear it's never
linear it's it's at best it's curvilinear
but it's not it's it's this just complete
zigzag roller coaster yeah and and so we
we like that the future like it's the
prediction of the future um
I think physical therapists need to
understand that health care as a system
also has all of these entities and there's
a power effect to these entities.
And so the power effect is that the
star can produce a lot more energy because
it's big and it's bright and it's
hard to touch.
And then a little planet like us doesn't
have as much energy, but we substantiate.
Same with healthcare.
You have some entities with more power.
At this point, it's payers and providers.
Some things have less power,
like therapists and allied health
professionals.
And some things have even less power.
But the nonlinearity of it is if you're
cruising along and if you're trying to get
a little bit more
having a higher stake at the game,
then you have to understand the
interconnectedness of the entire system.
You have to understand what these
stakeholders do,
and you have to essentially,
like in layman's terms, play the game,
right?
That would give you a much better position
of the complexity.
yeah step one understand what game you're
playing like i've said this it's this
isn't the conversation we'll get into but
i i am as like you said i
think i think i agree i am a
hopeful optimist but also like a realist
like uh on the there's a dungeons and
dragons
like that nine like are you neutral evil
chaotic good whatever i'm sort of in the
middle but i'm like listen this sucks but
we got to do something about it bitching
is is you're allowed to bitch for hours
when something bad happens then you gotta
put your shoes on and you gotta go
do something about it there was actually
that was that was one thing they found
when they when they looked at um
uh women and men going through navy seal
training it wasn't strength endurance
cardiovascular fitness it was like who
rallies around this they called it the
suck it's like hey we have to carry
a log on the beach and we're cold
and sandy and wet and you know what
we're gonna do we're gonna sing a song
called you and it's gonna be about the
log and we're just gonna sing the song
it's like because this sucks right now but
we're gonna have beers in a week
yeah and it's like all right between now
and then there's going to be a lot
of suck and how do we get there
yeah lift the log though like let's lift
the log like we have to lift a
lot or cut the log up into pieces
or make the log out of aluminum now
so it's lighter or like what can you
control you can't change the log okay
What can we change?
So basically the suck is the game, right?
That's the game.
You chose this.
When you signed up for the poster next
to the Navy SEALs,
you wanted the uniform and the emblem on
your chest.
That's good.
It's not bad news or good news.
News is to get it,
you have to go through this.
Otherwise,
they just hand them out on the corner
and that's not what you want.
I know you signed up for the brochure,
which is I show up, I help people,
I get paid, I go home.
Yes.
It's just not as smooth as that.
There's some suck to it.
And that's where the episode we did this
morning was choose your heart.
If you don't like this,
don't quit or change the things you can
change because there's something you
can't.
Medicare doesn't care.
It doesn't.
It's not going to listen to you.
In forty years, here's my prediction,
It's never going to get better.
It's going to be just as crappy,
maybe crappier.
That's my only prediction.
As bad as it is,
it will get worse.
The difference, Jimmy,
between someone who complains and someone
who actually does shit.
Before we went live,
you were showing me your evolution for the
new year.
I think that's actionable,
whether you execute on it,
whether you get misogyny or not.
It's still an evolution.
You are refining yourself as an
individual.
And that is the only power you have.
You have the power of one.
Make yourself better.
Make yourself a better fit for your
environment, right?
The system, again, like the system adapts.
And when you can adapt and when you
can't habituate.
So the habituation,
like the peer models suck.
They've definitely packed you as a lowest,
like as a pawn on the chessboard.
And we'll continue to be pawns because
we're not doing much to change that right
now.
Doesn't mean that in ten years we're going
to be pawns.
But in order to grow from a pawn
to an actual...
You need to do shit to refine yourself
as a professional.
If you're in the field,
learn something today that you didn't know
before.
Plan how you're going to climb.
I'm not even sure if it's a Russian
thing,
but I never want to be among soldiers
who don't see themselves as generals in a
few years.
You don't want to surround yourself with
people that are just complaining but not
doing shit about it.
We as an industry,
I've never been a part of any other
industries,
but we suck at forecasting the future
because we just want to complain about the
past.
But no,
it's better days ahead because systems
organize themselves.
Self-organization is part of the
complexity.
It's from order to chaos,
but it's through an organization.
Truthfully,
there's no such thing as chaos.
Chaos is just a loosely organized system
too.
So as clinicians, what can you do?
What impact do you have?
I was talking to Dana yesterday.
So Dana and I are doing this side
project with MedBridge.
uh and we're exploring the obviously
value-based systems but but in terms of
what can you as a practice owner do
to participate in these alternative
payment models well let's step one explore
step two plan step three strategize and
step four execute like just go boom boom
boom and wait a second at no point
in those four was it complain about it
though where does the complaining go
At all four steps you can complain.
In the background.
Negativity bias is part of our thing.
Negativity saves you from that cobra in
the woods that's making the noise.
You want to have that aversion behavior
because it saves your ass.
But complain and do shit.
Don't complain and just sit and groan.
That's not actionable.
My dad was a firefighter.
And when I feel like my dad was
like drilling me and testing me as a
kid, nothing dangerous,
but like he put like it would be
driving.
He put me in a scenario and there
was one message that he had,
which is he watched
kids in a fire,
he was a New York City fireman,
they would hide because fire is scary and
your first reaction is hide.
But in a fire,
you want to get out.
You don't want to hide.
You can't hide from fire.
So they were taught to look for kids
under beds, in showers, in toy boxes,
in closets.
So he would drill why that's not a
good idea.
And I remember at like, eleven years old,
he was like,
what's the worst thing to do in a
panic situation?
And I was like, I don't know,
hide or he goes, no panic.
And I remember like,
oh, that's a trick question,
but it stuck with me.
And I was like, OK.
He goes, it's a panic situation.
The situation is panic.
Your response should not be the panic.
And then he goes,
a minute later after I digested that,
he was like,
what's the second worst thing to do?
And I was like, uh, and he goes,
nothing.
So what's the worst thing to do in
a complaining situation?
Complain.
What's the second worst thing to do?
Nothing.
So do something, right?
What did Churchill say, right?
When you find yourself going through hell,
keep going.
Keep going, right.
And it's tough, man.
It's tough.
It's a tough environment, right?
I can see.
So at CSM last year, we spoke.
We had a panel about non-clinical jobs.
And so the panelists are like all of
these pegs, right?
So you have a couple of academics,
you had a couple of entrepreneurs,
and then you had a schmuck like me
sitting there who was still trying to
figure this shit out.
And the point is,
when you are a new grad pto when
you've been out in the field for five
years that extra five ten thousand dollars
you can make from a sales job it
may have a positive effect short term but
at the same time is it teaching your
skills is it teaching you to do something
different is it bettering right is it
helping you actualize as a professional as
a person and if not it's just revenue
dude like that ten thousand dollars you
make up at the tail end of your
career but you just spent seven years of
your life
getting to this place and now two years
later you're pissing and groaning right do
you even like it yeah well but there's
like ten grand is a lot but like
ten grand over twelve months
Yeah.
That's not a big payment to do something
that you don't like.
I'm not saying the sales job is bad.
I'm saying if you don't like it,
the juice ain't worth the squeeze.
Yeah, for sure, dude.
So there's two.
It's an economy, right?
It's a happiness in your job and happiness
with your job.
And most of us,
and I've been through a couple of
iterations already.
I've been in the PT field for over
twenty three years and I've been playing
around the systems for a decade.
So now.
happiness with your job is that like
there's a selection bias like the job
finds you just like you find your job
what gets most pts to become pts well
i had this experience i broke my leg
i had an acl tear i really thought
it was cool so i became a pt
like that's self-selection dude and then
once you get into the field you you
discover that you don't get to take care
of the happy motivated sixteen-year-olds
you get to take care of
Sixty-five-year-olds with multiple
comorbidities with the entire psychosocial
baggage who never leave.
Who don't want to change.
Yeah.
They want to have changed.
Yeah, exactly.
But that's not happiness.
You're not unhappy with your job.
You're unhappy in your job.
Change.
Find a different position.
Do home health.
Do whatever the fuck it is that you
want to do where you're actually
actualizing on your profession because –
Like it's you can always find a sales
job ultimately.
And again,
I'm not going down on sales job.
I'm like I'm a salesperson.
I would like the company right now.
That's sales is good.
Everybody sells right.
Daniel Pink likes to sell this.
Right.
But sales is still part of your clinical
experience.
As a clinician,
you are salesman because you're selling
plan of care, you're selling services.
But there's always so much more.
Sales is just one of the skills you
have as a clinician.
You also have a skill of communication.
You have a skill of problem solving.
You have a skill of weaving out
complexity.
Those are all skills.
And together, it makes you an expert.
And expertise is this entire bucket of
different vegetables sprinkled around that
makes you a clinician.
So when you choose to leave because you
were just like, ah, fuck it.
Like, it's not for me.
I've spent two years at this...
grind like a chop shop of a physical
therapy clinic.
I'm just going to leave.
No, dude, like it's not enough.
Like certainly if it's been long enough
and if you try different iterations and
you're like, I tried A, B, C, D,
E, F, and I'm still not happy.
Goodbye, sir.
But to get to that point,
you just can't react.
And reactance, I think, is what we do.
We're losing ten percent of our workforce
because we are like, I'm done with this.
Like, that's it.
I'm reacting.
I'm going to do this.
I see that there's a really nice
opportunity available.
I'm going to leave.
Is that really the right choice?
Beyond the fact,
the economic stupidity of losing two
hundred and fifty thousand dollars plus
the earnings you did not earn because you
entered the graduate training.
So for every year you are paying tuition,
you're not earning.
So if you look at the externalities of
becoming a PT,
you are down half a million dollars by
the time you graduate.
Yeah,
but actualize like there's so many
different settings,
there's so many different ways to
actualize as a professional.
And if nothing else, like
If you can't find a setting you are
happy in, open your own clinic,
put a shingle on a wall.
Like if you are really personable and
don't have a lot of expertise,
maybe you can just provide care to these
like low complexity cases that that's your
niche.
Like, why not?
But don't just like react and say,
not for me, I'm going to do it.
So you talk a lot about in systems
thinking, right?
And a lot of times we think,
like I mentioned, circuit boards,
machines,
but like where two people interact,
that's a system, too.
And in between them is that space.
So you mentioned, hey,
if someone's in a clinical role or in
an owner role, what are the signs?
How does a PT,
a clinician or a clinic leader or an
owner know
when their system is breaking down?
What are the early indicators?
What are the canaries in the coal mine?
What are the things,
the signals that people should be looking
for to know what to actually put their
good attention towards instead of just
complain?
I think that for me,
the number one sign is psychological and
intellectual safety.
What do you mean by that?
You have to feel safe in your workplace.
And that means you have to feel safe
to express yourself and you have to feel
safe to receive feedback.
That psychological safety in a workplace
is essential and a lot of times not
found.
And the psychological safety gets
destroyed through failure of initial
conditions.
And just as an example,
if it's an initial condition where you are
set up for failure
in that grind the assembly line therapy
place right because you you the economics
are setting you up to not be successful
so you you either can become a very
good hustler uh or a very shitty artist
um but but you're not going to become
a successful professional when when the
economics are set up against you against
your human capacity to provide
valuable care but psychological safety on
expression is also the fact that if you
are in a clinic and you can't go
to your administrator or your manager and
say like dude i'm just not feeling this
like i i'm breaking down like it's it's
it's great it's making me like
go bananas i'm like really not in a
good place if you don't feel comfortable
doing this like that you're not in a
good setting like because you have to have
this freedom and safety to communicate how
you are and in return receive feedback
from your manager to say like you know
you're just like a wimp like suck it
up motherfucker like it's like it's okay
to do that too because ultimately a lot
of people don't have the capacity or the
resilience that you're saying about navy
seals right the navy seal can take uh
a cold water plunge and stay in a
fifty degree temperature water for hours,
not because they're better or bigger than
you are.
It's because they have the capacity to
externalize.
They have the capacity to distance
themselves from the immediate suck because
they are forecasting that beer in a week.
Yeah.
If you're in a clinic and you are
being asked to fulfill a specific quota of
X amount of patients per day,
Because ultimately, you have to.
You have to see patients.
You have to generate revenue.
You have to make the clinic profitable.
Profit is good.
Money is good.
And volume is good.
But if you don't have the capacity,
you have to have a communication with your
manager and say, like, dude,
I'm not feeling this.
And the manager should say, like, well,
maybe you need to attend a few CU
courses so you become more comfortable
managing patients.
Maybe you need to utilize ancillary stuff
because you can't do this alone.
You shouldn't do this alone.
BTs try to do everything by themselves
from point A to point Z.
We onboard patients.
We design plan of care.
We designate plan of care.
We execute plan of care.
We complete plan of care.
Why the fuck are we doing everything?
We're the only profession that does that.
But your clinic has support staff.
Maybe have a conversation that we need to
add additional support staff so they can
oversee this low value redundant care
capacity.
But that's communication, right?
And if you don't have that safety or
that capacity to talk to your peers,
to talk to your superiors,
find a different setting,
find a different position.
Right.
Yeah.
analyzing the system figuring out what's
not working and bringing a solution and
then there's also complaining that this
sucks and one of them does not on
the first iteration or one try get to
a solution but the other one definitely
doesn't i mean i know it feels good
in the moment i've been guilty of it
myself like this sucks everything sucks i
want to go home let's you know let's
throw in the towel
But I think you bring up a good
point,
is if this place isn't ever going to
listen to me.
I've worked at places like that.
Yeah, you bring up good points, Jimmy.
OK,
are we going to do anything about it?
No.
Cool.
I don't want to be here anymore.
But to be honest, I'm able to dissociate,
be like, got it.
This boat isn't going in the direction
that I want.
I'm going to get off this boat.
I've looked at it.
I've looked at the course.
It's not good.
I'm not going to yell at the person
to change course.
I've already tried, whispering.
They're not listening.
Therefore,
I have decided to look for a new
boat.
Dude,
I think Annie Duke had a book called
Quit, right?
Oh, she was the poker player,
pro poker player.
Yeah, yeah.
She was a poker player with a PhD
in psychology or something like that.
But quitting is not against the rules.
It's not a bad thing.
Well, look,
it's perfect that she would have
psychology in poker because folding means
giving up.
But we all look at poker and we're
like, if you don't got it, fold.
yeah right yeah yeah yeah because you're
you're just gonna you're just gonna go
you're you're gonna keep putting more in
and you're gonna lose more seth godin had
a a book and he was smart because
he writes really short books so then you
got to buy the next book but he
had one called the dip
And essentially it was like sort of like
talking about the suck,
which which David Goggins,
who is a Navy SEAL, talks about.
He's like, listen,
I worked at a radio station.
My job was like play music,
give away beer and concert tickets like
that's a cake job.
Still a job.
He's like, listen,
no matter what your job is,
there's going to be a dip into this
into stuff that you have to do,
but don't love to do.
But it's got to get done because that's
your job.
pick your Beck's dip, understand,
do you like this suck or not?
And if you're like, this ain't for me,
like if I taught elementary school
students, I think I'm smart enough,
but I wouldn't like that.
I wouldn't like the stuff that a good
elementary school teacher would like,
the dip would kill me.
And Seth Godin was like,
it's okay to get out.
this this stay with a job thirty years
because you're loyal um that's not a great
if it's not a good fit it's not
i don't think an employer wants you to
stay for thirty years if you're miserable
either on the on the flip side i
i don't think you you you have
anything to give to your employer anymore
after x amount of years unless you're
always growing and even in that job that's
a good point right like you don't like
and i'll use an analog clinical analogy
right like there's there's a law of
diminishing returns uh when it comes to
clinical care you know that visit two in
the pt clinic is very different than the
visit in terms of what you're getting out
of your encounter because there's
diminishing returns you you become
indoctrinated into that
structure into that setting,
but you're not getting the same level of
skill as you were initially because now
you are the expert patient.
You gain expertise of being a patient.
On the job,
unless your job has specific milestones,
growth milestones,
developmental milestones,
after a certain amount of years,
you just ingrain into this minutia of
monotony, like I'm going to do this,
and then you become that assembly line
worker.
A neurosurgeon becomes an assembly line
worker.
right yeah there was a an article a
couple of years ago actually more than a
couple years ago but it looked into that
the diagnostic expertise and efficiency of
physicians leaving residency and they
looked into that like the diagnostic
accuracy after a certain like i think
after five years the agnostic accuracy
plateaus and after ten years it wanes
like so so in a way like you
you have five years to ramp up to
like to become efficient to become good uh
and then you you can cruise along for
a few years you can kind of kind
of and then you just like you stop
giving because then like yeah i'm a
neurosurgeon i'm gonna go get out get this
glioblastoma out
I've done three thousand of them.
If you haven't learned anything,
but I think as a neurosurgeon,
you have the capacity,
you have the diversity in your profession
that allows you to expand to different
medium.
As a physical therapist,
if you're working in that assembly line
outpatient clinic,
you're not even seeing the diversity
because you're indoctrinated into this
volume and managing.
You no longer get satisfaction for what
you think you've entered the profession
for.
then find something else like your own um
actualizer yeah i was looking at that in
radio not to bring everything back but
that's my only that's my only other
experience was things were getting very
homogenized i ran a local radio station
for a number of years i made all
the decisions and then these big companies
were coming in and they were buying
more and more stations and they were
going,
we don't need a hundred dudes in a
hundred cities making a hundred different
decisions.
We're gonna make one decision and then
multiply it by a thousand and then you
just execute.
And I looked and I was like,
that's not fun anymore though.
I'm here to do the radio station was
a giant social test in real time.
Awesome.
All the ideas that I have are like,
this is going to be cool.
And they flop.
I was like, huh, why did it flop?
Or this idea, I'm like, eh,
it's not going to go anywhere.
And it blows up.
And you're like,
why did that blow up and this didn't?
And the answer a lot of times was,
I don't know.
Let's try it again.
And they were going to take that away.
And that's when I started looking for the
door.
I'm not going to be able to contribute
to the outcome here,
except also my name's on the door.
So if this doesn't work, I get fired.
So I take all the risk and failure
and none of the reward and success.
I have no part to play in either.
And that was demeaning.
Well, yeah, demeaning.
It was just like, it was deflating.
So I can tell you,
you have layers of complexity, Jimmy.
Have you ever read Nassim Taleb's Skin in
the Game?
No, I've heard of it, though.
What's that one about?
Nassim Taleb.
I always like to read books,
and then I want to read about people
who wrote these books because that's
almost just as interesting, right?
Yeah, go one layer deep.
Yeah, so this dude,
he's a mathematician that entered the
financial market.
and understood the actual Black Swan
events.
Most of the catastrophic or most of the
fundamental changes in the economics and
in the market happened from these isolated
events like in the year of two thousand
and eight.
So he has a book called Skin in
the Game,
essentially is that it's the agency and
autonomy,
your ability to control your environment.
But then here's another one that's called
Anti-Fragile,
which
Yeah, delicious.
The book is like a cheeseburger with some
real turkey bacon on top of it.
And the antifragile is exactly what you
were discussing,
is that when you have the suck,
the fragility,
if you collapse under the first point of
adversity,
if you crumble down and you start crying
in a corner and saying, this sucks.
You need to admit that things suck.
You actually need to tell yourself that
right now we're going through a shitty
period.
Maybe the shitty period lasts a year and
maybe the shitty period lasts a fucking
decade.
But it's okay because the fragility comes
for those who succumb to this shitty
period instead of for those who are able
to persevere.
And those who persevere,
they learn every fucking element from the
shitty period because that makes them
stronger, man.
like and i hate the cliches of like
the steel is forged through heat but it
is dude like you like you have one
life i'm kind of like i'm an agnostic
non-practice agnostic right so like uh
this is like to me this is it
like you're born you go through these
eighty two years of and then you die
and then you become dust right so is
the game that's the thing yeah yeah like
the is the game so like like even
if you're going through it like the shitty
chapter of your book it's still a shitty
chapter like it's like you're writing it
like it will be the maybe the chapter
you want to flip later on but it's
it's your chapter so yeah that's where
like i don't read it or pay attention
to them as much as i should like
i'm not a practicing stoic um but whenever
i come across like a ryan holiday i'm
like like simply changing what is this why
is this happening to me to what what
am i learning from this is a wild
flip
It's weird.
I've had people say, your personality,
I'm pretty high energy.
I'm all over the place.
I jump from topic to topic.
And then I tell them what sport I've
been doing since I graduated from college.
Now, in high school,
I did immediate reaction sports, baseball,
hockey, tennis.
I want immediate return on investment.
I want instant gratification.
And then after college,
marathon running and long distance
triathlon.
And they're like,
that's weird because there's no one to
talk to.
There's no one watching you.
There's no return on investment.
for days weeks or months and i was
like yeah it slowed everything about my
thinking down to how do you feel what
should you change now so three miles later
you don't feel like crap and how are
you gonna get to the finish line and
there's no help and i was like i
loved it so i wish i i don't
know that i would have been able to
do the long distance stuff as a great
one year old but post-twenty-one-year-old
it was great for my my mental health
Oh, dude.
So I'm a marathoner, right?
And I'm probably the world's second worst
marathoner.
My wife, she comes and cheers me on.
I just ran Madison Marathon in twenty
five.
And she's like,
I can fucking see you from a mile
away, like this complete graceless,
like stumbling around like this,
like little like bag of bones,
like moving forward,
just
hoping for momentum to take you through
the finish line.
You know this.
You're a distance runner,
so you know that there's a point where,
like mile eighteen,
where everything sucks.
Your mental state is shit.
Everything aches,
and you just want to be done.
But the ability to go through that,
because in another seven miles,
you're going to be at the finish line,
and there's going to be cold beer,
and then you're going to sign up for
the next one.
The thing is, like people have said,
if you sign up for the marathon or
triathlon for the finish line,
you might not get there if you you
have to learn to like the tr the
training is the gift it's not the metal
it's not the t-shirt in fact when i
look when i put on an old race
shirt i think about where i was training
i rarely think about race day it's it
i and i just gave advice to another
pt who did their her first iron man
and i said um this is a catered
workout
This is not a race.
Your success or failure has already sort
of been determined,
unless you get hit by a car on
the race course or something.
But you're not going to pull out seven
miles in a row of running two minutes
faster per mile out of nowhere.
You're probably not.
So it's already been determined.
Put it on cruise control.
Whatever you've been able to do,
do that now.
yeah and it's a mind it's it's it's
that it's and i agree with you completely
that the training is the gift the training
is like it gets you out of the
house like and like and if you train
for like i run chicago marathon frequently
and so you do your longest miles in
the hottest days in chicago yeah and
there's nothing more delicious than
struggling like just like completely like
dying like you you have to do a
twenty miler and you're in mile six and
you're already dying
You know,
it's going to be a lot more sweating,
like the eyes are burning.
And but then you come home and you
know what,
like you feel like shit and then you
feel better and then you recover.
You know, man,
do you know what I do on race
day?
I play games, right?
And I like messing with other people in
good ways.
I don't ever actually like throw people
off.
But in triathlon,
you have to wear your race number turned
around.
So it's like on your back, right?
And your name,
your first name is below your number.
So I'll be passing someone on the bike.
And I'll go, Alex, looking great, baby.
How we doing today?
And I love watching people's face go, who?
How does he know who?
And then all of a sudden,
you see the light bulb go on.
And there's that laugh between both of us.
And that propels the crap out of me,
because we're both in pain.
I don't care that you're twenty minutes.
You started twenty minutes behind me or
twenty minutes in front of me.
We are in the suck together.
I got news for people near me.
We're not going to the Olympics.
We're just trying to get home.
That's the gift.
The training is the gift.
It's the best one with it.
I have a blessing of being ridiculously
slow, too.
You get more race.
You get to do more race.
Oh, yeah.
I'm getting my money's worth, man.
I'm getting my four and a half hours
worth of money's worth.
But usually at the last couple of miles,
I'm just schlepping along.
And it's all of the other schleppers like
me just trying to get there, right?
And you just start talking to me.
Like, oh, yeah,
I'll get you to the next mile,
and you get me to the mile after
that.
we'll do it together and you meet some
like awesomest people the dude and chicago
marathon and maybe like i think that had
a bib and it was like this was
my last marathon and i'm like dude why
is this your last marathon and he's like
you know i've run and they've all been
my last marathons so yeah like it's it's
that right like it's the people you meet
right but but don't you wouldn't you agree
and just to pivot a little bit but
it is about the people too like a
lot of times like so you were talking
about like that uh
Changing the framework from Stoics and how
Ryan Holiday tells you to reframe things.
Now,
the best reframing that I learned is that
whenever you have to tell yourself,
I have to,
you have to change it to I get
to.
Like when you,
when you have to take out the trash
and you,
your wife tells you to take out the
trash and you say, ah, fuck,
I have to take out the trash.
I get to take out the trash.
I get to walk outside.
And like,
it just immediately changes the
perspective that if you get to actually
wake up in the morning,
that's really a blessing.
If you get to get to work,
that's a blessing, right?
I think you hit a point in life
and some people fortunately or
unfortunately hit it earlier where I
really didn't lose anybody in my family
until I was like in my teens.
Like,
either my grandparents passed before I was
born or they were just around.
And I think losing people or seeing people
like my dad had a stroke two years
ago.
So seeing him lose some abilities that
puts things in perspective.
Like otherwise I ran through like super
privileged walking through life my first
twenty, thirty something years.
losing a grandmother and being like, well,
she was old, like that happens.
And then you start to see like other
people like lose parents at a young age.
And you're like,
they had that perspective shift way
earlier.
Things got, gravity is not equal.
You know what I mean?
Gravity for someone who I imagine loses a
parent as a child is vastly different than
later.
Or someone who lives in poverty then gets
out, they have this perspective.
And that can be a superpower or something
that drains you.
These are simple, not easy concepts.
I think that it's also the culture and
country we live in, Jamie.
I'm an immigrant.
So for me,
it's an easy perspective of coming from
Soviet Union.
to know like how ridiculously spoiled we
are that's why we don't know because we're
in the pot we've this is all we've
known oh you just we don't and and
like so if you think about it like
my my biggest blessing my my uh aunt
who immigrated to the united states
earlier with with
male as like bubble gum.
Right.
And it was such a commodity in Soviet
Union to have bubble gum because you
didn't have bubble gum.
So like we would chew bubble gum for
days and like in the evening because it
was a sign of state.
Right.
Like you were a hierarchy if you had
bubble gum or you didn't have bubble gum.
And if you show up to school chewing
something, you're cooler.
So like in the evening,
you would put it in the windowsill and
in the morning it would resume chewing
your gum until it would just fucking
disintegrate.
But that gum would last you days and
a few careful weeks because that was a
privilege to have it.
My first and only pair of jeans when
I was a kid came six sizes too
big.
And then my grandfather had a sewing
machine,
so he sawed it in and I would
fucking grow into these jeans for the next
four years.
It would expand and lengthen with me.
But I didn't feel neglected.
I didn't feel deprived because at least I
had genes.
Somebody else didn't, right?
Right.
But you need that perspective.
It's like I could have nothing or could
have something.
my uh my i wore number eighty nine
playing high school hockey because there
was this player alex alexander mcgillney
and he was on the famed red army
limbs him sergey federov and and pablo
buray and i believe it was mcgillney and
i didn't know this story i just saw
them as great hockey players and i assumed
i don't know they just i looked at
ivan draga that was my only experience
with russians right he had this lab where
he everything was great and then there was
there was this story where
Alexander McGilney was playing hockey and
the skate was so big,
he had to wear a shoe,
not several socks.
He had to wear a shoe in the
skate
And he still was, he just,
he didn't know any different.
By the time he had skates that fit,
it was over.
Like you couldn't catch this kid.
But if you had said,
we're gonna put this kid into skates that
are like nine sizes too big,
was that an option?
We couldn't get one that well,
it was a little tight or a little
loose.
He only knew just absolute
uncomfortability.
By the time you gave him real skates,
it was over.
Like the NHL was too easy for some
of those guys.
But it goes into that whole embracing the
suck, right?
Like sometimes the culture,
sometimes it's the society that puts the
suck on you.
And then like your medium,
your baseline is to be in a suck.
Then it's just variable degrees of the
suck.
And you just want to suck a little
bit less than everyone else, right?
Right.
But here, like, and again,
it's a different perspective,
but maybe it's immigrant optics,
but we are so fucking blessed to have
everything we have, right?
We, like Anna Maslow's hierarchy of needs,
we're continuously fighting over the last
two chapters when nobody's fighting over
the, like the safety and stability.
Right.
It's a good point.
Yeah.
We're not, we don't have these problems.
We're creating our own fucking problems
because like all the problems that you can
have that people do have, you know,
like we, like, like we, we, we are,
we're good.
Like it's like, even when the things suck,
they don't suck like they do for somebody
else.
So I remember I,
I planned for a triathlon in Lake Placid
and I think the race was in like
September,
And it's supposed to be cooler.
And then all of a sudden a freak
cold front came in.
So now you have a bunch of people
who are supposedly all about embracing the
suck, right?
These are Ironman triathletes doing a half
Ironman.
And we're standing on the edge of Lake
Placid like in the morning ready to go.
And it's cold.
And Lake Placid is a very small town.
I went out the day before.
I was like, I didn't bring gloves.
It's supposed to be like,
I didn't bring gloves.
No gloves in Lake Placid.
so i did what my mom would have
done which is like i cut some holes
in socks man i just made mittens like
make mittens out of socks right i had
lots of socks and i remember people
standing on the on the the shore of
lake placid it was so cold out the
lake was still warm there was like fog
on it and people were bitching and i'm
like do you think the race organizers did
the weather
Like you signed up for a hard race.
I got bad news.
You're probably not gonna set your
personal record today.
But that line from, oh God,
who said it?
Everybody wants to be a gangster until
it's time to start to do gangster shit.
It's like, I wanted to be an Ironman.
You wanna wear the t-shirt and get the
tattoo.
We're here.
This is some sideways next level stuff.
And you're mad about it.
And I remember being like, nah,
tomorrow's gonna be a long,
You're going to earn tomorrow's T-shirt.
Tomorrow's shirt is going to be worth more
than the one that had good weather.
And let me ask you this, right?
Like the things that are maybe you didn't
your PR,
but the things that were most miserable,
the things you remember the most, right?
Hell yeah.
I assumed I was going to wear those
gloves just for the bike.
And I wore them the whole it was
that cold where I was wearing the socks
on my hands while I was running.
I'm like, you know what?
Go quit.
Quit.
There's a nice little that's why they make
you ring the bell, I think,
in the seals.
It's like I need a physical representation
of you quitting.
Go sit in that thing over there.
There's hot soup and there's a heater.
Go sit over there.
Yeah.
How do you instill this in a clinician
who maybe has known nothing?
I'm not saying academics isn't rigorous or
trying,
but like in Maslow's hierarchy of needs,
failing a test doesn't take food away.
How do you always feel like resilience in
people who are like, well, now I'm being,
now I'm going through suck.
Like, how do you help someone gain that?
I will tell you,
I don't think there's a clear recipe,
but I think that there's at least a
trait,
which is absolute honesty and absolute
transparency.
Just be honest with people.
It's one of those primitive senses,
but I think all of us can sense
bullshit and all of us can sense.
And so be honest with people.
You have capacity.
Some things are controllable and some
things are not controllable.
Modifiable, non-modifiable factors.
Yes.
And so in a clinician,
the modifiable and non-modifiable factors
are such that if you are in a
place,
in an organization that doesn't have
financial fortitude to pay you more,
maybe they can give you the ability to
actualize in a different way.
Maybe you can organize a community,
maybe whatever the fuck it is, right?
But that's working together,
that's communication and that's
transparency and that's psychological
safety.
or you have safety to communicate that I
know you want a pay bump.
I can't give you a pay bump.
But what I can do is I can
put you in front of a basketball team,
and you can work with younger athletes.
Or what I can do is I can
potentially make you an administrator next
year when the job opens.
Or I don't have anything to give you,
but I can call my friend across the
street who has a different clinic,
who has more money.
And I want to see you thrive.
I think I've been in administrative roles
pretty much.
I opened my own clinic one year out
of PT school.
And then I've been managing and growing
different legacy providers for years.
And my responsibility was always to the
people that I worked with.
And financially, I probably lost from it.
And career-wise,
I probably lost from it because I never
grew into that CEO-level position because
I had a territory.
I had five clinics.
I had twenty clinicians.
But the twenty clinicians that I worked
with were the five clinicians I worked
with, or the one clinician I worked with.
My responsibility was to them because I
was given the power to affect their lives
and their careers.
And I was going to do everything in
my capacity to watch them grow.
And if I didn't have the capacity to
do that,
then I was going to be honest with
them and to guide them that like find
a different job,
find a different position,
because that was my responsibility.
And it probably sucked for people who were
paying me to just maximize the whatever I
can to squeeze all the juice out of
these people.
Right.
But I slept at night and I feel
like I did the right thing by people
that I worked with because I was a
human being and I was working with other
human beings.
Right.
So this is not what I thought we
would get into.
I had all these like systems.
So we're going to bring you back pretty
soon to get into like systems talk and
things like that.
But I feel like this was I feel
like a conversation like this needs to
happen with leaders or clinicians.
Long before we teach them,
this is how you open a new patient
in your EMR.
This is how you discharge someone.
This is how you send them their plan
of care.
This is this is the operating system of
a human.
Right.
If you could tell how to get through
the suck to someone in theory,
what what could you throw at them that
they're not going to be able to process?
Yeah.
But I think as an administrator,
I can review the complexity in the next
three minutes before we log off.
But as an operator,
you are operating like humans are not pegs
in a machine.
Humans are themselves bundles of
complexity.
And so managing this complex relationship,
you can maximize the effort and you can
maximize the output from this human by
building a human relationship through
communication.
That will actually maximize how much you
can get out of this individual,
not because you are trying to,
but because the individual will give it to
you.
Because we all are first order primates
that have the luxury of living on this
planet for eighty plus years.
And once you have sincerity and once you
have honesty with someone else,
you are all going to work together towards
something that you're building.
Or you're going to admit that there's
nothing for you to work with.
In terms of complexity,
there's all these nodes that need to be
interconnected.
And they're not connected linearly.
Some are connected more,
some are connected less.
There's valence, there's power.
And that changes.
There's always entropy, right?
There's always change.
You don't always have the vision of it,
but you need to have an awareness of
it because entropy and complexity emerges.
It goes from nothing to something.
But you need to have enough capacity to
adapt and habituate to this entropy,
to this emergence.
So that adaptiveness and adaptability is
an internal trait.
That's resilience.
You're embracing the suck.
And then embrace system dynamics.
System dynamics change.
If you're in a system that's a rigid
system,
system dynamics are much more controlled.
If you're in a system that's more of
an open system,
system dynamics are much more loosely
controlled.
It's that the book by Ravi...
Bloom shots.
The book is called Bloom.
Chantal.
The phase transition.
There's water and then there's vapor and
then there's plasma.
The plasma is what happens right before
you're transitioning phases from water to
solid, from liquid to solid.
Be that plasma.
Be that intermediary where you're neither
here nor there,
but you have the capacity to become solid
when you need to and to become liquid
when you need to.
You have to have the capacity as a
human being
And then life will be good because life
continues to turn, right?
And there's most of the other factors in
that complex systems are not under your
control.
You only control the system that's here.
That's the only one you have control over.
The only consistent is change, right?
That's the stupid cliche, but that's,
I mean,
you can't boil it down any more simple
than that.
Those are the things that are so cliche,
but you're like,
no one's been able to improve them.
That's why they're repeated so many damn
times is because you can't boil them down
to something more basic.
Those are the elements of life.
That is life.
What was that book again from the guy
who wrote Anti-Fragile?
What was the other book again?
Skin in the Game.
Nasim Taleb, Skin in the Game.
So all his books,
I think it should be a mandatory read
for any human in the works to serve.
Black Swan is about these outlier events
that actually have a fundamental effect on
us.
So Black Swan,
it's like somebody dying in your family.
That's a Black Swan event.
It's an anticipated, but
It's a betful.
Stock market crashing is a black swan
event.
PTs transitioning from fee-for-service
model into more recapitated risk-based
models.
It's a black swan event because sooner or
later,
the CMS is going to come in and
say, fuck it.
We don't see value in PT at all.
We're just going to continue to reduce
your fee schedule by fifteen percent until
you're getting paid nothing.
And then are you willing to continue to
maximize your volume or are you going to
start to explore like, look,
I'm going to take on some risk and
I'm going to take on this at-risk
population because I know my skill set.
But it will happen.
So yeah, Nassim Taleb is the man.
Dude, there's so much good reading.
I guess the biggest blessing for me in
that late forties of my life is that
capacity to go on the long run and
to actually listen to an audio book or
to read in the evening.
But yeah, Jimmy, this has been a pleasure,
dude.
And for what it's worth,
you have a voice.
I think your voice resonates with the
community.
You also have a community that listens to
you.
So you have a lot of capacity and
ability to be the agent of change.
Because once you have people's ears,
make others actualize.
N equals one.
It takes one individual trying to change
himself or herself that will have a title
effect on the entire community.
I see a lot of ceiling for the
profession, even though a lot of times,
myself included,
we focus on how the floor is going
down.
I'm like, yeah,
but I can't control the floor,
but I want to connect myself to the
ceiling.
And the funny part is that people who
bitch about CMS reducing payments or
inflation pretty much eating away,
I'm like, okay,
that's where I go back to like,
not to mention too many Navy SEALs,
but Jocko Willeneck, he's like, good,
gonna force me to get stronger.
And it's gonna eliminate the people who
won't change.
Good, the net negative,
the net result is positive for our
profession,
because it's gonna wipe out the people who
won't change.
Maybe that's what we need.
Maybe we need a flood.
Maybe in the notes for this episode,
include that five-minute video he has on
YouTube about good, right?
It's my go-to video when everything sucks
and I'm down in my lock and I'm
like, fuck it.
This is just not good.
I mean,
I lost my job for the first time.
I got fired as a – I got
fired at forty-five,
three hundred and sixty-four days.
I got fired the day before my –
and honestly,
the next morning I woke up and I
literally was just like, good.
I was not a good fit.
I wasn't.
i could be mad at the people who
were like you're not a good fit here
but i was like uh they're right i
didn't like it i was not good and
didn't like it it's different if i was
like i'm not good at it but i
want to be that's different that's like
that's how i was in the beginning of
radio i was like i'm pretty terrible but
i'm i'm gonna show up and i'm gonna
be less crappy today but like yeah i
will that that
that dialect when he was like,
I know what you're gonna say,
you're gonna say good.
He's like,
why do you think I'm saying good?
I don't know, you just,
like when things suck, it's like, no.
I can't control that.
I can control, all right, good.
Like that whole,
we don't go to war with what we
need,
we go to war with what we have.
Like my marketing budget,
the radio station I ran grossed between
five and seven million dollars a year.
My annual marketing budget was zero
dollars.
do you mean if i wanted to do
a promotion around t-shirts i needed to
create a promotion that was so valuable in
attention that i could get someone to pay
for the t-shirts and margin and i hated
that at first because there were radio
stations in my market that had six figure
budgets it made me crafty
Because the minute your budget went away,
you were done.
I knew how to make fire.
You were handed fire.
I knew how to rub two sticks together
and build fire.
You don't want to compete against that
dude.
On day one,
you want to compete against that dude
because he's got no fire.
On day three, sixty five,
when he can create fire from nothing,
that's a dangerous dude.
That's danger.
And you also have to have enough vision
that you may not be able to create
fire today.
It's nothing that in a year.
Dude, it's been a blast.
It's awesome.
So keep making that fire, dude.
Keep running and keep doing everything
else.
We'll get you back on the show and
we'll talk specific systems because I feel
like
PTs don't talk in systems,
but they live in systems whether they like
them or not.
And systems are human to human or human
to computer and computer to computer and
then computer back to human.
These are all systems.
It's wherever things are interconnected.
What's your parting shot?
Your parting shot, the last idea, concept,
we always do that.
What's the last thing you want to leave
with the audience?
Could be a quote, could be a whatever,
just an idea.
um i think wake up in the morning
and express one point of gratitude to
anything and everything like i'm grateful
for my coffee today so like today i
have a trader joe's uh winter blend which
has peppercorns and something else in it
yeah and i'm grateful for this so show
gratitude uh alex appreciate the time and
thanks for uh thanks for the discussion
this woke me up i love it that's
good thank you
That's it for this one,
but we're just getting warmed up.
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Hit us at pgpinecast.com or find us on
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And legally, none of this was advice.
It's for entertainment purposes only.
Bullshit!
See, Keith?
We read the script.
Happy now?