you're listening to the pt pinecat where
smart people in healthcare come to make
noise here's your host jimmy mckay voice
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That is EmpowerEMR.com.
Guests today have stood on both sides of
a stethoscope.
First as PTs,
then architects of the digital health
revolution.
Intrigued, are you?
One race cross country on skis.
The other crushes anime marathons.
Same thing, right?
Together,
they're making sense of CMS innovation
pilots, RTM codes,
and the hybrid care wave.
reshaping rehab whether you like it or not
their newsletter is where clinicians go to
learn how tech policy and business are
reshaping healthcare delivery you don't
want to be surprised by these things be
ahead of the curve at least a little
uh get ready to meet the co-creators of
full stack healthcare ryan and jonathan
jumping in the studio there they are
gentlemen welcome to the show
Love it.
Yeah.
Let's start with the why.
Write a newsletter, creating a podcast,
doing anything.
It's effort, man.
It's work.
So let's start with the why behind this.
Why did you guys feel the need to
create this?
You saw something that wasn't there and
you were like, I want it to become.
So I don't care which one goes first,
but there needs to be a why.
And they could be two different whys for
both of you.
I mean, I'll start where, honestly,
Sharky and I have worked together for,
God, it was like five years.
And we had all these conversations on the
side about all this stuff.
We were kind of like, hey,
what's going on?
How is this working?
I had no idea how all these business
models worked forever.
And I was just like, hey,
I have to talk this out.
We had all these side conversations.
We're like, okay, this is awesome.
I have a better understanding.
And at some point I was like, okay,
when I started to talk to other people,
they had the exact same questions.
And I'm like,
why am I not taking this stuff and
just sharing it?
Why are we not putting all these thoughts
on paper?
So there was like two false starts.
To be honest,
I tried my own personal thing.
Didn't work.
Tried a different one.
Didn't work.
I just kind of kept falling off.
And Sharky and I,
I think what was really helpful,
we had coffee up here in Seattle,
and it just came down to like, hey,
dude, let's do this together.
And what's been really helpful is just
having a partner to hold each other
accountable.
He's like, hey, Shaki, like, okay,
I'm going to do this because I want
to get this out and I'm not going
to overthink it.
And that's been the thing that's actually
like made it stick this time around.
So you're like a verbal processor like me,
which is like,
you could give me the exact instruction
manual.
And I'm like, great.
I need to talk.
Like,
can you read that and then explain it
to me?
It's just how my brain brains.
Ryan, same for you.
Different.
Similar.
Yeah, definitely similar.
I think this is probably the most exciting
thing that's happening to health care
right now, in my opinion.
And so a lot of the digital transformation
that's happened really the last,
I'm going to say, ten years,
pretty much since the Affordable Care Act
kind of kicked a lot of this off,
has been increasingly more exciting.
And so, yeah,
I think John and I both kind of
share this, you know,
both curiosity towards like what what is
it that's really going on underneath the
hood here?
But but also, you know,
we see this as sort of a future
that we're, you know,
we're kind of hoping that health care runs
runs toward that.
It's going to have sort of this this
inner interwoven, you know,
human and digital aspect to it that just,
you know,
allows things to be so much more seamless
for everybody.
You're going to be naive if you say
this isn't a thing, right?
So first,
we'll get it out of the way.
Where can someone go?
I'll put it in the show notes,
but where can someone go if they're like,
all right, got it.
How can I get this delivered to me?
Where do they find Fullstack Healthcare?
Yeah, well,
they can find us on Substack at Fullstack
Healthcare is our primary newsletter.
Also,
feel free to follow John and I on
LinkedIn.
We're going to be out there continuing to
spread the word.
All right.
So let's dig into this.
You talk about new care models.
That's what John just sort of led off
with.
Not just RTM or telehealth alone,
but a full stack of delivery formats.
I see what you did there.
What does that actually look like in real
clinics?
Because I'll go through the whole,
I think it's the Schopenhauer quote.
said all truth passes through three stages
first it's ridiculed second it's violently
opposed yeah third it's then accepted and
then people just go oh of course this
is going to be a way so i
don't know where we are i think we're
still in ridicule like we're sniffing it
around maybe we're violent i mean i think
we all go through these phases but those
are the three phases of grief or whatever
whenever something new showed up
I've got this thing in my pocket.
I don't know if you guys have one
of these.
This is a smartphone.
When I saw this in two thousand and
eight,
I was running multiple radio stations.
I immediately started looking for the door
because I was like,
people were ridiculing it.
Then they were violently opposing it.
And I was like,
that's when I know this is a thing.
So, so I guess my question is like,
what is,
what does that actually look like in real
clinics in terms of a full stack delivery
format?
Paint us the future or, you know,
current picture.
Sharky, you want to go?
Yeah, I'll take that one.
You know, you're,
You're looking right now at a system that
asks for,
continue to bring patients into the door.
And that's how every clinic is paid.
They're paid simply by the number of
bodies that come in the door.
And that's where you get some of the
terms of some of the mills and some
of these clinics that are just going on
volume.
And what you're going to see moving
forward is,
That's fine.
You're solving an access issue,
but solve an outcomes issue.
You're really going to start to see a
shift towards what are the outcomes that
you're producing.
It doesn't matter how it's produced.
It can be produced by having someone come
into your clinic ten times.
It can be produced by having them come
in once and you're just sending them
whatever it is,
the exercise plan plus just checking in
with them plus
You know,
whatever else you need to do to make
sure that that outcome is achieved.
You know, that's really what, you know,
what the future of health care is looking
for.
Yeah.
What would you add to that, John?
Yes.
I mean,
like we looked at this in the very
first, I think,
two or three articles that we wrote were
all about this idea of, OK,
what we see right now are these like
pockets.
So we see a large health system.
They'll have a virtual telehealth team.
They'll have some people doing RTM on the
side.
They may have a partnership with some
digital health vendor that provides
messaging only services.
It's all kind of like broken out.
Piecemealed.
Super piecemeal.
It's super fragmented.
And then even health plans are doing this,
right?
It's like I've had Primera and I have
Regions.
You look at their thing and they have
these things,
but they're all like different solutions,
right?
So you can see they're trying to stitch
it together, but it's just,
it's super fragmented.
So as a patient, you're going through,
you're like, okay, cool.
Like I interacted with Jimmy on the
telephone.
I acted with this messaging service.
They're not talking to each other.
So we're seeing this, like,
they're all trying to figure it out as
an organization,
but nobody has really brought it together.
So the entire thing is together.
So that's kind of what we're,
that's kind of how shark,
you know what I'm saying?
It's like, it's the parts are there.
They just have to figure out how to
stitch it all together.
So we still like in the, you know,
the baby deer Bambi side of, you know,
situation where, you know,
it's amazing deer come out being able to
walk, but they're just not great at it,
but they keep working and you got a
lot of knees and elbows slapping around,
but there's a reason for it.
So if we look at a North star,
I've only been in healthcare for ten
years.
Usually the government is the one to lead
the way.
If the government says it,
they move slowly, but when they move,
they are telegraphing
what's coming.
So you don't have to even read tea
leaves.
You just sort of read the slow comet
trail.
CMS is throwing up major signals.
What do physical therapists specifically
need to understand about the access model
and RTM codes that I,
I think forward thinking PTs jumped on
this again,
a lot of baby deer we're figuring out,
but if you're not leaning into this,
I think you're already behind still catch
up, but let's start moving.
So what do PTs need to understand about
these things?
Yeah, I mean,
this all started in July of last year,
really,
where CMS got a big congregation of
different tech leaders,
and they started to hint at the idea
that things were going to change,
and they were going to throw out some
some new innovation pilots,
and really looking to create, and John,
I think you've used the words of portfolio
of different bets that they're taking to
move things forward over the next ten
years.
One of those is the access pilot,
and what the access pilot does quite
simply is it just says,
you know, we're paying you for outcomes.
And so, you know, we're,
we're going to pay about, you know,
half upfront and then half, you know,
once we actually see the data.
And so they're,
they're starting to put their monies
where, you know, a lot of,
a lot of,
a lot of times their mouth has been,
you know,
about trying to really actually change the
way that, you know,
healthcare models work.
So I think that's, that's sort of the,
The T's are into the access model,
but John, I'll let you jump into.
So Jimmy,
I'm literally pulling this up because
there was two quotes that literally,
so if you go to CMS's website,
you Google access, you can see it's all,
it's literally right there on the website.
They spell it out.
As much as we're like conspiracy theory,
they're pretty open when they start moving
in a direction.
They move slow,
but they keep going typically.
Like there's two quotes that sit out to
me.
One, and there's a little trailer video,
highly recommend watching it.
It's pretty funny.
It's pretty gnarly, but it's like,
it's right on the page.
So here's a quote,
new ways for primary care doctors to
partner with technology supported care
providers so they can continue supporting
patients with chronic conditions,
even when they step outside the doctor's
office.
That's pretty, it's like so obvious.
Here's the second part.
We value this because we understand that
doing this will save us money.
And we are in the,
love them or not,
the government is in the separating money
from its constituents game.
And second is spending as little money as
we can.
And they recognize this.
So this is good.
Yes.
Here's the second quote.
Care may be provided in person, virtually,
asynchronously,
or through other technology enabled
methods as clinically appropriate.
That is not a hint.
That is not subtle, right?
That's like,
and that's kind of when we saw that
and we're like, we,
thank God I can actually say we have,
we have the receipts.
We, we put up our blog,
our sub stack before this came out,
but I looked at like, that's false.
That is exactly what we're trying to
describe.
We're saying as a patient,
you should have access to in-person
virtual asynchronous and technology
enabled methods.
That's,
that's the way it should go and clinically
appropriate.
That's,
That's essentially what we are trying to
say.
Like, okay, this is where it's going.
CMS is putting a big,
this is not a small bet.
There's a big bet.
Yeah.
Government typically makes big bets,
right?
Cause it's got to do it for everybody.
It's also not novel because the employer
health space has been doing this for years
now where they've allowed these digital
health companies to come in through their
benefit system and say, okay,
you're going to help to reduce some of
the spend in our company.
Great.
All right.
We'll let you kind of figure out how
to do that.
One of the big levers has been just
the fact that it's free.
If you have an employer and your employer
has one of these digital health vendors,
most of the time you are going to
get that vendor for free as a part
of your employee benefits.
Access is taking that page right out of
the book.
They're saying, okay, great,
we're going to waive co-pays for Medicare
members if they're a part of this model.
I think that's something that's going to
be really enticing for a senior that's on
a budget or a clinic that sees a
senior on a budget and says, hey,
how do I get them in the door?
How do I actually allow them to come
in?
One, I can help them,
but also we can have them in for
for generating revenue.
So yeah,
I think that's another really interesting
piece that CMS is taking right out of
the employer book.
You've said before,
total caseload is the new metric.
Explain that idea to PTs who've only
really ever been judged on billable units.
How do you reframe that?
That's such a hard one.
Yeah, I think it's, it goes back to,
I think what Sharky said about outcomes
and, you know, it's, it's hinting at,
you know,
we can stop beating around the bush.
Ultimately,
this is always goes back towards the
concept of value-based care.
That's kind of where this is trying to
get to.
Right.
And it's saying essentially, it's like,
As you said, as Sharkey said,
you can see a patient for one visit,
you can see him for ten visits,
you can see him for half a visit
and then remotely monitor them without
worrying about billing.
Let's take the billing part out of RTM,
like remote monitoring and messaging by
itself as a concept.
You could do that.
And so you have, let's say,
let's say a traditional PT could see maybe
one eval day, two evals a day.
And then if you had a higher volume,
you're going to be certainly higher than
that.
But in the end,
if you have a population of thousands of
people that you have to manage their
health,
how do you actually do that effectively?
And if you were to say you're going
to get X number of dollars to do
that,
Eventually then you say, okay,
do whatever you have to do to manage
that population's health.
How would you actually do this?
What I've seen in time,
and I've seen this time and time again,
ultimately what ends up spinning up is
something like there's some virtual care,
there's some asynchronous care,
there's high touch care for people that
need it,
there's low touch care for people who
don't.
That's what happens.
And so ultimately,
it's that idea of rather than how many
units, Jimmy,
did you bill for that patient for that
forty five minutes?
It's with that hour of time.
How many people did you touch and did
you actually impact their health?
Right.
Those two completely different metric.
Right.
And that's that was the thing.
Again, second career PT here.
I think I figured this out or started
to get like clued in on my first
clinical rotation.
I was like, oh,
I'm incentivized if I'm bad at this.
That sucks.
Like if I could have done it in
three, but I did it in ten,
I'm financially better.
But the patient did, you know,
we wasted the patient's time and effort
and we wasted money.
And that just seems like a crappy system.
I remember like, you know, because I came,
I've seen doctors, I saw PTs.
And then once I was on the other
side, I was like, oh, this game sucks.
Yeah.
I think it, this, you know,
it changes a little bit as a PT
of also what you're going to do with
your downtime.
You know, if,
if you have a new show,
what does that mean?
It completely changes, you know,
how you're going to view that time because
now you're, you're, you know,
most likely going to be looking at your
panel and saying, you know, Hey, who's,
who's dropping off.
You know, most likely you're going to see,
you know,
tools come out that are going to let
you just assess everybody, you know,
and start to reach out to them
individually.
Hey, you know, I got whatever it is,
you know,
ten percent of my caseload hasn't done any
exercises this week because I can see it,
you know, on this dashboard.
So I'm going to reach out to them
and I say, hey, you know,
what's going on?
Is there anything that I can do?
You know, I think that changes things.
This sort of just came to me.
Burnout is sort of caused by doing a
lot of work that doesn't have results.
I never have had or have problem doing
a lot of work that I felt was
impactful, right?
Might be overwhelmed.
I'm not saying you're not tired.
I'm not saying it's not difficult.
I'm saying it doesn't feel burnout-y.
I mean,
for my example was staying in a radio
station until one o'clock in the morning
because we had something really big coming
out.
I felt like I was being pulled.
It feels like when...
When RTM or AI Scribes first came out,
everybody's first panic was,
what do we say?
First, they ridicule it.
Then they V it, let me impose it.
Like, well,
then they're just going to give you more
patience.
Yes.
And I sort of feel like, well,
if it's better work,
the stuff that I showed up for,
I feel like it doesn't completely remove,
but it starts to improve that feeling of
burnout.
Like, this is what I'm here for.
Give me more of the thing that I
thought I was going to be doing that
was on the brochure when I signed up
for school, right?
Yeah.
Totally.
Yeah.
I was talking to this one clinician owner
and he, he had this strong,
really strong perspective,
like about RCM particularly.
He's like, I was like, why are you,
why are you guys doing RCM?
Get to the bottom of it.
Yeah.
And he's like full stop patient
experience.
He's like,
we want to deliver the best patient
experience.
Why would I not give them access to
me between visits?
Why would I not say I want to
be the provider of choice?
And I was like,
that's a completely different view.
on why you would do RTM and it
said she's like I want my therapist to
have a caseload of a bunch of people
where their patients love them and trust
them that's why we're doing RTM and I
was like
You're probably in the one percent right
now.
That is the concept.
That is kind of the idea is like,
how do you build stronger relationships
with patients?
But also,
how do you do it in a scalable
way?
Because in the end,
if you do hour long appointments,
you know, five or six a day,
you just you can't scale that.
It's not possible.
So is there a way to do it
in a way that's not so intensive in
the in-person side?
Yeah, absolutely.
That's somebody who understands what game
they're playing, which is step one.
Understand what game you're playing.
Then you can understand which things to
lean on.
It also shows that people should
understand.
I heard this in the nonprofit world and
it landed, which was no margin,
no mission.
I know that you're like, icky,
I want to touch money.
But if you're the American Cancer Society,
the Leukemia Lymphoma Society,
no margin, no money, no mission.
You don't have money to pay the people
or keep the lights on or do the
things that you're set off to do.
You don't have a better relationship with
money.
I put a post on LinkedIn the other
day.
We will argue with insurance companies and
then poo-poo the idea of a patient giving
us money for a thing that we just
said was valuable.
I don't know.
The call's coming from the inside of the
house.
It's us.
We are the people who have a bad
relationship
with money.
Let me get a good relationship with money.
Want to thank U.S.
Physical Therapy for sponsoring the show.
You've built something special,
but scaling your clinic and planning for
what's next can feel overwhelming.
At U.S.
Physical Therapy,
they partner with clinic owners who want
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That's USPHPartnership.com.
Why do you think there's still resistance
to RTM or hybrid care,
even with reimbursement outcomes and
access benefits?
You just talked about that example right
there.
I have a thought.
You want me to throw my thought out
first?
It's always fear.
We're big, dumb animals.
It's fear.
It's I don't like this.
This is new.
This is scary.
If I do this and fail, what happens?
So to me, it's fear.
It's not technology.
It's not policy.
it's fear that's my assumption i think
that's i mean i think that's that's
probably spot on for a lot of people
right it's fear fear of change fear of
doing something different right um yo i'll
say i i do always wonder about this
because i you know i talk to a
lot of different therapists and like
owners all over and so one thing i
hear a lot of is it's almost like
this mis perception of what rtm is about
right and so i think you know what
i've heard is
There's this,
this perception is not skilled and I'm
just like, okay, okay.
Let's have that conversation.
Yeah.
Right.
Let's have that combo.
And it's like, they don't view.
Like looking at someone's messages and
responding to someone's messages,
like in concerns between business is
skilled care.
And I'm like,
I'm not really sure I have a strong
opinion against I'm like,
this is skilled care.
Yeah.
If you,
if you fundamentally disagree with that,
it's going to be hard to get you
on board with RTM.
The right message at the right time for
the right person, the right situation.
I mean, I'm not a policy guy,
but that feels like skill.
Yes.
Like if you could handle it in a
minute sending, hey, Jimmy,
I'm going to change your exercises because
you told me X. That's skilled care.
And that's better care, in my opinion,
than waiting for the patient to come back
in six days from now.
And lower costs.
Yeah, exactly.
So that's like a fundamental kind of thing
that I want to dig more into and
understand, like, okay,
how do we just kind of continue that
conversation and be like, okay,
how can we help you understand this is
skill?
because the research is pretty darn good
on whether it's like RPM or RTM.
It's there.
It could be better.
Like there could be more of it,
but it's pretty consistent.
That's why being a researcher is a great
job because at the end of every,
you could just boilerplate this,
at the end of every paper,
like more research is needed.
And that's just one researcher elbowing
the next going, I got you, bro.
I got you, right?
You're never going to get there.
You're never going to get perfection.
So I think it's fear, fear,
all those things.
Ryan, what do you think?
You know,
I think that there's a lot of clinics
that have figured out a great operating
model,
and the operating model is everything to
do with fee-for-service.
Again,
whether you call it fear or resistance to
change,
going into something that's totally new
and saying, well, okay,
how does the model that we have today
fit into this model of tomorrow?
That's valid.
I think that's a tough one.
But yeah, fear is probably the primary.
Any sort of resistance is going to come
off of that.
Yeah.
I mean,
Shrek and I have talked about that with
Access in particular, too.
We're like, we're looking at it.
And so you can see where a company
that's tech first,
they could probably be pretty successful
in this model.
And then we're talking about, okay,
how would a brick and mortar health system
or a brick and mortar clinic get involved
here?
And I think they can.
I mean, I think CMS wants them to.
But we talked about like, hey,
you might need to break off a pilot
team.
You might need to do this a little
bit differently.
Give them some freedom to try and figure
this out on the side.
If you try and cram it into your
existing operations,
it's going to be really, really, really,
really hard.
I mean, it's the inception concept, right?
Make it their idea.
you can only do that so much,
but like when I was working with a
tech organization,
I would say we would do pilots of
six for a piece of tech.
And then I would say,
and I love doing this,
especially with an owner who was pretty
hands-on,
give me three people who are pretty
forward thinking,
like three people who were like, yeah,
they'll enjoy this.
And then I say,
give me three crusty laggards.
And they're like, what?
And I'm like, here's the thing, man,
I'm gonna, I'm selling you this.
And I was upfront about it.
I think this is great.
You know the three people who are forward
thinking are going to love this.
If the three crusty laggards love it,
I don't have to sell this at all.
Now you know that your people will do
it.
You being on the phone with me tells
me you understand that this is a problem
and that I'm in the running to be
a solution.
I'm okay with that.
It's a jump ball.
I'll take the jump ball all day.
But if I can convince the crusty ones,
my man,
I ain't got to do no pitch.
At the end,
you just said the people who would want
to resist this the most are cool with
it.
That's a risk,
but I try to get to the no
as quick as possible.
Yeah, I think that's smart.
Yeah, it's smart.
Rather than kind of dragging the feet and
then like seeing it kind of trail off,
you're saying like,
let's do this and let's actually see.
Let's get the people on board, right?
Yeah, because I think that's...
This is the format of every episode of
Bar Rescue.
First, they see the ugly...
Then they come in and they poke and
then the owner yells and John Taffer yells
back and then they do a pressure test.
They bring in,
if the bar can hold a hundred people,
they bring in two hundred and they watch
where it fails.
And that's good.
I think we're resistant to that.
Yeah.
I'm like, dude,
I need to know where the leak is.
Like a good plumber is going to go
turn the pressure up.
Well, there's going to water squirt.
I go, this is dripping already.
Like let's squirt it for ten minutes and
let's figure it out.
What are we doing here?
Are we just giving the leaky pipe vibes?
That doesn't do anything.
Let's get to the point.
I'm here to solve problems.
You're here to solve problems.
Let's solve problems.
Avoiding it.
Although I recently found out ostriches
don't actually put their head in the sand.
That's a fallacy.
I know.
Welcome, internet.
But that's, you know, using that cliche,
that's you just burying your head in the
sand and pretending that it's not going to
be a problem or it's not going to
slowly kill you.
I don't know.
I heard the line once,
there's always going to be a leading cause
of death.
There's always going to be a leading
problem in your business.
Why solve the smaller ones?
Because they feel easy.
Because I feel like I get to check
something off.
And the bigger ones are hairier and
scarier,
except they're the reason you're going to
close, not the small ones.
What's one question every PT should ask
their clinic owner?
or director,
this is what I'm talking about.
You have the forward thinking PTs at your
clinic, you got the laggards,
but what's a question they should ask if
they want to explore innovation where they
work?
We hear from owners saying, oh,
we want our clinicians to be intrapreneurs
and bring up,
you want to make more money?
Let's make more money and you get a
cut.
So what's the question a clinician could
be or should be asking an owner or
a director,
no matter what situation you're in?
Such a good question.
I'll go first.
I think every clinician should be asking
their owner, manager,
give me three pain points that you have
that is just sort of eaten away at
you throughout the day.
Because what these types of models are all
of a sudden doing is they're opening the
floodgates for forward-thinking clinicians
to be able to see that pain point
and say, oh, we got a no-show issue?
Okay, great.
I think I have somewhat of a solution.
In fact, John and I just...
put out an article that we,
we built a startup, you know,
quote unquote, where we, you know, said,
Hey, there's, there's a, you know,
nationwide issue with no shows, you know,
about, you know, clinics that, you know,
have, you know, are, are dealing with,
you know, what,
I think it's
so great let's use access to you know
create all of a sudden a a network
where you know if you have a space
of time great get on a virtual visit
with the senior because they're just right
there um you know you'll have a company
do the marketing or your company will do
the marketing and then all of a sudden
you you have a whole new you know
influx of patients starting with solutions
is a bad idea start with the problem
then test out solutions
Start with the problem and then, yes,
just don't go right to your first solution
and then stop there.
Take it, you know, five, six, seven, ten,
you know,
different ideas and then see what sticks.
Yeah.
Okay.
I got two on this.
One's a question, one's not a question.
One is, or actually neither are questions.
Tell me how the business works.
From a money perspective,
if they're willing to share with you,
tell me how the money flows.
Cause I think that's one thing, honestly,
I,
I did not ask the question of early
in my career.
And I realize now like how important that
really is because whether it's like
private practice, health system contracts,
all that stuff, it's like, you,
you really can't understand what the
actual pain point of that director of the
business owner is until you have a better
understanding of how the money flows.
You're like, oh,
I get reimbursements going down.
How do we solve that?
Oh, I get it.
No shows are a problem and that's driving
revenue down.
How do we solve that problem?
that's like if you don't have that
understanding of how this works it's going
to make it really hard to actually
understand the financial drivers that are
kind of moving it the second is almost
just ask for ask for forgiveness so just
start doing something i'm that guy yeah go
to your owner yeah and they'll be like
hey i tried something and it works uh-oh
That's almost like, in a way,
an easier way.
It's just like,
I forgot what the podcast was,
but basically it was just like,
just do things.
Just start doing stuff.
You probably can figure it out.
You may need to spend a little time
outside work doing it, but just do it.
And you'll be surprised.
And that's initiative.
That's like showing innovation.
It's just doing something.
And you don't want to break the rules
or anything,
but that's not what I'm telling you.
Just do something, try it out,
prove it out,
then bring the value back to them.
I mean,
I was in a profession as a broadcaster,
right?
Working at a radio station where I was
in a studio alone for four or five
hours.
It was my show.
I couldn't run and ask my boss every
time I was going to turn the microphone
on.
Hey, I was going to say this.
What do you think?
He was like, dude,
you have the chair and the microphone.
If you can't fit,
your job is literally figure out what's in
bounds and what's good and what's bad.
I'm paying you for taste.
I'm not paying for you to read a
liner card.
We used to call those liner card jocks.
That was somebody who was on the air,
who they just sort of read what was
in front of them in radio voice,
which is not a skill.
It's not.
And I was always taught when I got
a little higher and became program
director of the station, it was like...
And I was always nervous about screwing
up,
partly because I got like a woo
personality and I wanted my bosses to like
me.
but I wanted to be seen as clever.
And literally my boss just sat me down.
He goes, Jimmy,
just run this through your head.
Like you're going to have to explain
whatever you're doing.
If you're okay saying this happened,
I did this to me in my office,
then do it.
Like we're all make,
we're monkeys on a rock in space, dude.
We're all, this is all made up.
Everything's made up, right?
So it's like, if you're okay with saying,
I saw this, I did this,
that's the filter.
And if the answer is yes, hell yes.
Then don't do it.
I also had kids that were younger than
me who were my broadcasters.
I'm thinking about doing that, and I go,
if you're asking me, the answer is no.
We're not going to win or lose based
on this ridiculous Hail Mary.
We're not.
We're not going to win on that,
but we sure might be able to lose
on that.
So I like that.
Ask the questions.
Just do stuff, kids.
Are you guys ready to play a quick
game?
We're going to do a quick game.
You guys cool with that?
Let's do it.
The game is brought to you by Sarah
Health.
Big thanks to Sarah Health.
Good timing.
The remote care platform helping clinics
boost revenue without adding staff.
It's almost like we timed it.
Sarah automates daily patient check-ins
via text.
You just did the math.
No app, no logins.
All you have to tell me is I
don't have to log in or I can
log in with my face and I'll show
up.
Just better outcomes.
It's a simple way to meet RTM
requirements, improve follow-through,
and actually get reimbursed for care
between visits.
Sarah Health.
It's Sarah without the H.
There's always that girl in your class
who's like, no H. S-A-R-A health.com.
That's S-A-R-A health.com.
This game is called Full Stack Fire.
So I'm going to throw out a line
or a question.
And then you guys have to respond.
We'll go John, Ryan, John, Ryan.
Those will be the lines.
So first question on full stack fire
round.
RTM or telehealth, you have to keep one.
You have to ditch the other.
You can only have RTM or telehealth.
Which one is it?
Keep RTM.
Got it.
Why?
Real quick, just a second.
Yeah, yeah, for sure.
You know, in the end,
telehealth is always going to have a
point.
By the way, telehealth is part of RTM.
It's lodged in there, if y'all want to.
No, but I think in the end,
I think that's the one that scales better.
And it's actually the one I think patients
will like and adopt in the future.
You don't need to talk to one on
the video.
You can just text with somebody.
You can message them.
It's monitoring.
I think that's the way it's going to
go.
Ryan, RTM or telehealth?
It's a Highlander.
There can only be one.
Yeah, I'm going to go RTM as well.
Okay.
Yeah, as John mentioned,
I don't think it's just the scale,
but anything that's a little bit more
asynchronous is going to play better.
So forcing patients to get on a screen
every time is going to be really
cumbersome for them,
and it's just not a great patient
experience.
Okay.
Here's the second one.
Clinical pilot or product prototype?
What gets you more excited personally?
Do you want to see a clinical pilot
or a product prototype?
This is personal,
so there's no right answer here.
John?
I'll go clinical pilot because I want to
see how it actually works and what
happens.
Pressure test.
Yeah.
It's cute.
It looks great on the shelf,
but how's this thing swim in the deep
end?
Yeah, exactly.
And people do the craziest things and
you're like, oh,
I had no idea you could work around
like that.
That's pretty wild.
Like you learn a ton.
So, yeah.
Ryan?
I'm going to go product prototype.
Okay, awesome.
Because they're more fun.
I mean, yeah,
you get to kind of take what's in
your head and then all of a sudden
it's just there and then you can kind
of play around from there.
You got to pick a side here.
Clinician led or VC backed?
Which one do you choose?
This is like the Civil War.
Clinician led or VC backed?
Who's going first on this one, Jimmy?
You're going to go first.
I like that there's a pause.
It means you're thinking.
I like it.
Okay.
I will say clinician-like because that's
what Shark United are doing with our thing
here.
It's like, hey,
we think there's a lot of room.
There's a lot of room.
And they're completely different games.
I think that Shark United have had that
conversation.
They're not the same game.
I understand what game you're playing.
There's a ton of space for...
smaller more nimble companies people to do
things just just go do it and start
it up and see what happens like that's
good that's literally what shark and i're
trying to do is right we think we
can actually do something and have an
impact at a very small level like we
have no desire to be a vc backed
sub stack um you said it on february
it's recorded it's recorded well i feel
all right ryan you answer then i'll
actually chime in for this one so there's
no wrong answer
Well, since John said that,
I'm going to go beat BC back.
Got it.
Yeah.
And this is not in any way a
dig at anything that's clinician-led.
Having having voices that are outside of
the industry come in and question what's
going on in the industry is is something
that I think is very healthy.
And so there's there's that VC backed
portion that gets too far away from what
good care is.
And that's why you need clinicians in VC
backed companies to be able to help to
kind of make sure that the ship is
continuing to steer in the right
direction.
But yeah, I think it's healthcare.
It's, it's funky.
And people ask, you know,
like really great questions about things
that have happened in healthcare for,
you know, twenty, thirty plus years.
I was like,
why do you all do this?
And we all kind of sit around.
We don't know.
So, yeah,
I think it's good to ask those questions.
So clinician-led, VC-backed,
plus the money's not too bad when you
get VC involved.
But then, hey, man,
you're giving up some control.
But hey, listen, listen,
this is why it's not necessarily one or
the other.
It's like clinician-led,
who are the clinicians?
I need to know more information.
VC-backed, who's the VC?
What are their goals?
What's their experience?
What's their motivation?
What do they bring to the table?
It's a simple question.
It's just not an easy one.
Last one.
Substack post you wish every PT would
read.
What's one thing you've taken time and
effort to put out there that you're like,
listen, if I could have one,
this is the one I'd want you to
read.
I'll say the very first one that we
put out,
that was kind of that whole idea of
what the heck is full-stack healthcare.
And I think that was the one that
was just kind of,
that was burning in my mind for years.
And I was like, I just,
we got to start thinking about it.
And it's just like,
care is not just in-person care.
I think that's like fundamental belief
number one,
that if you can get over that,
it opens up a ton of doors.
And that's kind of literally the first one
we put out.
I was just trying to describe like you
can do care a lot of different ways.
Patients kind of don't care how they get
it as long as they get their problem
solved.
Like they don't care the delivery method.
It's just, just get it to them.
And I think that's, yeah,
that's like number one.
So you had your whole life to write
your first post.
And then the second one,
that's the struggle with artists.
You had your whole life to release your
first album.
And then the company's like, great,
here's a bag of money.
Do that again.
Ryan,
Substack posts you wish every PT would
read.
uh i'm i'm gonna i agree with john
i think that first post is probably um
the the most impactful for for any
clinician though i'm gonna go with we we
did a post on different models of care
uh and i i feel like this is
one of those that uh a lot of
clinicians when they read it they their
brain starts to kind of open up and
say oh there's there's other models other
than fee-for-service like yes there's
there's a number of those and let's learn
about them and i think that kind of
like gets the
the curiosity going for clinicians on,
you know,
learning a little bit more about,
you know, the broader scope of healthcare.
Yep.
And I mentioned that Schopenhauer quote,
right?
First, it's ridiculed.
Then it's violently opposed.
Then it's accepted as being obvious.
And of course,
I believed in this thing the whole time.
I remember I got ridiculed launching a
podcast as a PT student.
Classmates were like,
are you still doing that?
That's cute.
I had a professor tell me it was
a giant waste of time.
And I was like, all right.
So there's the violent opposition.
I think she just wanted to like...
exert force and was like that's silly you
should just study more and i'm like i
gotta be honest i am studying when i'm
asking these questions and getting great
answers i'm a verbal processor as we
started the episode off uh last thing we
do on the show guys is called the
parting shot this is the parting shot one
last mic drop moment no pressure just your
legacy on the line
Whenever you want to be your last, yeah,
just your entire legacy on the line.
Not really, though.
Whatever you want to leave with the
audience as your parting shot.
What do you got, John?
All right.
So I think my,
I really challenge anyone listening.
So whether you're a PT,
you're a leader in the field,
really take a step back and think about
what will change the trajectory of the
profession.
I guarantee it's not going to be,
it's the new best exercise.
It's the new investment.
It's not in the new best manual therapy
technique.
It's not going to be that it is
going to be how technology changes care.
It's going to be payment models.
Like those are the two things that will
literally change.
They will,
they will change how you practice without
you even knowing it.
And I think that that took me for,
I did the whole fellowship route.
I did all that stuff.
I tried to go there and I was
like, that's just incremental.
And it's fine.
We need that.
I'm not saying we don't need that.
But if you're really going to take the
PT as a profession,
technology and payment,
you got to look there.
You just got to start to understand that
stuff better.
Ryan?
If you are a PT and you hang
your hat on diagnosing the perfect injury
type and creating the best exercise plan
for that,
you will readily be made obsolete in the
next five years.
What's going to what's going to separate
really great clinicians from someone who's
average is going to be the way that
you communicate, you know,
and it's going to be your communication
style.
There's a ton of research that's starting
to come out on communication,
a lot like how we were starting to
understand habits about fifteen years ago.
We're starting to understand that there's
just different ways of communicating and
there's different conversations that are
happening in the exact same way.
In the exact same conversation,
are you having a logical conversation?
Are you having an emotional conversation?
And being diagnosed that is going to
massively improve how you're able to
connect with people.
my parents are so excited that i got
a journalism and communications degree
then came to healthcare and it didn't make
any sense but now i'm like guys guys
this is my jam look at this this
intersection i live here this is my house
come on in let's solve this thing yeah
it's a communication thing you mentioned
uh emotion or logic if i'm having an
emotional conversation
if i'm sorry not a conversation i'm having
if i'm giving emotional statements and
you're having a logical you're sending me
logical statements back that's when we're
just starting we're just two dubbermans
yet barking at each other through a fence
understand what game you're playing
understand what kind of conversation
you're having or it will not progress it's
just not going to do it the book
i would suggest would be uh chris voss
never split the difference,
communicate like your life depends on it.
Former FBI hostage negotiator.
He deeply understood
how to do this with little to no
scientific like formal background but he
was like i'm in a high-stakes situation i
gotta figure this out that's why i love
the title of the book too it's like
never split the difference he couldn't
roll up to a bank robbery like all
right what do you got you got a
million dollars and ten hostages all right
why don't you keep five i'll take five
take you half a million dollars we'll take
the half a minute we'll call it a
day that's not how it works it's sort
of a zero-sum game and that's how it
is in your business
That's every and the line I love there
is every conversation is a negotiation for
information,
whether you're trying to get someone to
understand or you're trying to get
information out, treat it as such.
And I don't think it's a silver bullet,
but it's pretty dang good.
It's pretty dang close and starts to make
things better.
Say it again where people can go read
these full stack health.
Hit the website one more time.
Yeah, so fullstackhealthcare.substack.
Fullstackhealthcare.substack.
I'll put it in the show notes.
That's why I like the show notes after.
It makes me look like I took notes
in class, but it's all at the end.
Gentlemen, thanks so much for doing this.
We'll have you back on when we've got
something that pops, right?
Something that's the great thing.
The only constant is change.
Something will change and it'll shift and
then you guys will be there to explain
it to me.
Appreciate your time, guys.
Thanks, Jimmy.
That's it for this one,
but we're just getting warmed up.
Smash follow, send it to a friend,
or crank up the next episode.
Want to go deeper?
Hit us at pgpiecast.com or find us on
YouTube and socials at pgpiecast.
And legally, none of this was advice.
It's for entertainment purposes only.
See you.
Bulls**t. See, Keith?
We read the script.
Happy now?