Healthy Wealthy & Smart

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Adam Culvenor on the show to discuss ACL injury. Dr. Adam Culvenor is a physiotherapist, leader of the Knee Injury and Osteoarthritis Research Group and Senior Research Fellow within the La Trobe Sport and Exercise Medicine Research Centre in Melbourne, Australia. Adam's research focusses on the outcomes of anterior cruciate ligament (ACL) injuries, in particular the prevention and management of early knee osteoarthritis in young adults following ACL injury and reconstruction. In this episode, we discuss: -The short-term and long-term burdens following ACL injury -Why patient rapport is integral to effective treatment post-ACL injury -Optimal loading strategies for non-surgical and post-surgical cases -The latest research on prevention for early-onset osteoarthritis -And so much more! Resources: Adam Culvenor Twitter La Trobe SEMRC Twitter Email: A.Culvenor@latrobe.edu.au La Trobe Adam Culvenor La Trobe University Blog For knee injuries, surgery may not be the best option A big thank you to Net Health for sponsoring this episode! Learn more about Four Ways That Outpatient Therapy Providers Can Increase Patient Engagement in 2020! For more information on Adam: Dr. Adam Culvenor is a physiotherapist, leader of the Knee Injury and Osteoarthritis Research Group and Senior Research Fellow within the La Trobe Sport and Exercise Medicine Research Centre in Melbourne, Australia. Adam's research focusses on the outcomes of anterior cruciate ligament (ACL) injuries, in particular the prevention and management of early knee osteoarthritis in young adults following ACL injury and reconstruction. His work has identified important clinical and biomechanical risk factors for post-traumatic osteoarthritis, and he is currently testing novel osteoarthritis prevention strategies in young adults following injury in a world-first clinical trial. He has published over 60 peer-reviewed articles in international journals. Adam has worked in teaching and research at universities in Australia, Norway and Austria and is a graduate of Harvard Medical School's Global Clinical Research Program. His research has been awarded American Journal of Sports Medicine most outstanding paper 2016, Australian Physiotherapy Association Best New Investigator 2013 & 2017 in musculoskeletal and sports research, and Sports Medicine Australia best Clinical Sports Medicine paper 2019. Read the full transcript below: Karen Litzy (00:01): Hey, Adam, welcome to the podcast. I'm so happy you're here. And I'm excited to talk about ACL injuries with you. So welcome. Adam Culvenor (00:08): Thanks very much for having me, Karen. It's great to be here and chat. Karen Litzy (00:11): So now the bulk of your research is in ACL injuries and not the mechanism of injuries for ACLs, but what happens after that injury? So before we get into, and we'll talk about the burden of ACL and optimal treatment and osteoarthritis and why that happens. But what I would love to know is why are you interested in this subject matter? Sort of, why did you make this kind of the centerpiece of your research? Adam Culvenor (00:43): It's a good, good question. So about 10 years ago, also, now I had done a couple of years of clinical practice as a physiotherapist in Melbourne where I'm based and was interested in pursuing a bit more of the research line into ACLs because we had a patient come to myself and one of my colleagues who was a young guy, about 35 years old, who had a very active, healthy life up to that point, he'd suffered an ACL injury about when he was 20 years old, he was about 35. Now it had a number of issues. He'd got back to sport without any problems, but then now about, you know, 10 to 15 years later, started having some pain, unable to do the things he normally would love to do. Couldn't go back and play anymore. Adam Culvenor (01:33): Sport couldn't start, couldn't really play with his kids. He'd seen an orthopedic surgeon, he'd had an Arthroscope, had a bit of a cleanup now going back to the surgeon and he was really in want of a knee replacement because he could no longer do the things that he wanted. And the surgeon basically said to him, you're too young to have a knee replacement go and see, Adam and Tom, our colleague. And so what we can do, and that really opened our eyes from a clinical perspective about these types of patients and this particular young guy had on x-ray most of his changes were actually in his patellofemoral joint. So in the patella and the trochlea, and that really set my mind up to go and look into the literature in this space and see what's out there in terms of not only osteoarthritis in these young people. And clearly it was very burdensome to this young guy, but also why are we seeing this in the patella femoral joint in particular and why is it causing so many problems? And so that really set us off for my PhD, about 10 years ago, looking into these medium to longterm outcomes, ultimately trying to help these people get back to do the things they wanted to do without the pain and the symptoms that come with osteoarthritis a lot of the time. Karen Litzy (02:48): Yeah. Oh, great story, that's a shame 35 years old. Gosh, that's so young. I can understand why that would really peak your interest because you don't want to see these patients coming into you or when you do see them, you want to be able to help them with the best evidence and best things that you can. So you had mentioned in your explanation there as to why this subject interests you, is that there is this sort of burden after having this ACL injury. So could you talk a little bit more about the burden of an ACL injury and subsequent surgery? Adam Culvenor (03:27): Sure. So I'm sure it goes through a lot of people's minds, as soon as they hear that pop or click, that if they know they've had an ACL injury, that's the initial burden is, you know, that worry of, I can no longer play sport. And often if you do go and have a reconstruction surgery, it's often the nine, 10, 12 months of extensive rehabilitation, as we know, and not going back to sport that often people find a lot of personal satisfaction and get a lot of mental health benefit from playing sport and from their peer involvement and social interaction. So it's that initial burden of the extended period out of sport. Some people do really well with great rehab. They can get back to their sport. They want to play at back to the same level of performance, but there's a certain percentage at about 50% of people we know in the evidence will develop longer term, not only persistent symptoms from a patient reported outcome perspective, but also ongoing functional limitations. Adam Culvenor (04:26): And ultimately the development of osteoarthritis be that on radiographs, on x-rays. And some of our work is which we can go into a little bit more detail in a moment is looking at the earlier changes on some more sensitive imaging like MRI to try and detect these types of people who might be more at risk of developing longer term changes. So as I said, some people do really well following an ACL injury, but rehab only, or surgery. And we can chat about the differences in the treatment options later as well, but about 50% of people at the moment. And the evidence suggests that they will have osteoarthritis within about 10 years of their ACL injury. So if we think of the typical patient is, you know, the adolescent or the young 20 year old patient playing sport, they rupture their knee only 10 years, 15 years down the track. Adam Culvenor (05:16): They're still only 30, 35. That young gentleman I spoke to earlier. And they've got a knee of essentially that looks like on imaging of a knee of a typical 70 or 80 year old. And we know that imaging findings on x-ray don't necessarily match up particularly well with what we see clinically. So that's not necessarily, you know, a sign that they're definitely going to have functional limitations on symptoms, but it certainly increases the risk of that happening. And that burden at a time when people often have really important family commitments and young family commitments work commitments, and they often still want to be active in participating in sport. And so when you bring all of those in to a knee that might not be has have recovered as well, following an ACL injury, you might still have some muscle weakness if that wasn't addressed initially and create the picture of more of a persistent pain problem, then you start getting into being quite a burdensome condition that we say these types of patients clinically come back in often five, 10 years following their injury. Karen Litzy (06:20): Yeah. And I can imagine along with that, persistent pain comes decreased activity, decreased movement, and we all know all of the sort of cascade of events that can happen when you're not getting an exercise. You're not getting in movement. You know, then you have risk of obesity, risk of diabetes mental health issues. So all of that stuff can kind of stem from, you know, this burden of an ACL, which, you know, for a lot of people, I don't think that even would flash in their mind when you're looking at a 20 something year old who just tore their ACL, because we know that population who does tear are usually pretty athletic. Adam Culvenor (07:03): Exactly. And that's the thing prior to their injury. They're often very healthy and, you know, never seen a doctor or never been to hospital before and having the ACL injury can often be that initial. Unfortunately, you know, the cascade where you become less physically active in, might not be able to get back to the sport. You really want to start putting on weight. And that increases the risk of all of these other conditions, as you've just said. And I think there was a recent article a research paper actually showing that having an ACL injury increased your risk of a cardiovascular disease by about 50% longer term. So for me, that was a real wake up. This knee is not just a knee, it's actually affecting the whole person. Exact reasons you just mentioned that it can spiral into, you know, less physically activity, the pain putting on and then being the increased risk of all of the comorbid conditions as well. Karen Litzy (07:55): Exactly. And now, so you mentioned a couple of minutes ago about treatment. So you could have surgery, you can not have surgery. So can you talk a little bit as to what the optimal treatment is after an ACL and how one comes to that decision, whether you're the clinician or you're the patient, how does that work? Adam Culvenor (08:18): And that's the $64 question. And so I can have extreme of the spectrum. You can have one end, you can have everyone has surgery. The other end is no one has surgery and the truth probably lies somewhere in the middle. So if we look to what the evidence suggests in the literature, there's very little high quality evidence comparing the two treatment options. There's really only one, what we call randomized control trial. That's compared about 120 people. Who've had an acute ACL injury and they were either allocated to having early surgery. So a couple of months of having the injury and then an extensive rehabilitation period I've nine months or so, and then the other group. So exactly the same rehabilitation. The only thing is they didn't have the surgery. And so the only difference between these two groups of patients was the surgery or not. Adam Culvenor (09:15): Now the group who didn't have the surgery initially could have the option of having surgery later on if they had ongoing problems or symptoms, or desired to have the surgery later on, and they could cross over to the surgery arm. And what this study showed is initially this was published back in 2010 now. So we've not done this for over a decade, is that there's very little differences both at two years after surgery five years. And I think that the authors are about to publish their 10 year outcomes, but certainly the two and five year Mark, there's very little differences, whether you have surgery or not, in terms of pain symptoms, strength returned to sport the need to have more surgery, quality of life, and indeed radiographic knee osteoarthritis. So I was fortunate enough during my time in Europe, conducting a research fellowship recently to work with this group of researchers based in Sweden. Adam Culvenor (10:07): And we looked at the MRI outcomes in this population, as I said earlier, trying to identify people maybe earlier in the process initially after that ACL injury, to see if we can identify those more at risk of longer term problems, which might present opportunities to intervene a little bit earlier to stop that cascade of negativity and what we found really, interestingly, when we looked at the cartilage on MRI between the time of injury to two years and to five years, is it the group that had early surgery actually had more cartilage loss compared to the group that didn't have surgery and you sort of asked, well, why might that be? Because, and I think I haven't had an ACL reconstruction, I'm injuring myself, but I know from colleagues and working clinically that the ACL surgeries is almost a secondary trauma. Like you're going in there, you're drilling tunnels, you arthroscopically opening the joint. Adam Culvenor (11:04): You come out of surgery, having a very angry, hot red, swollen knee. And so I think that whole cascade of inflammation can soften the cartilage, can create a knee that's not particularly happy. And then when you go and potentially, you know, put that knee through load, maybe going back to sport and whatnot, then that might actually be related to the development of osteoarthritis more so than if you don't have the reconstruction. And so we've actually done a little bit more work on the return to sport type of thing. And, thankfully in a group with ACL reconstruction, it doesn't seem to increase the risk of osteoarthritis if you do go back to sport. So that doesn't seem to be the main things. That's a good thing for patients knowing that if you've had an injury or reconstruction, you can go back to sport knowing that you're not going to put your knee at more risk, but it's probably more the inflammatory markers, the secondary trauma of that that's reconstruction surgery that increases the risk even longer term as well. Adam Culvenor (12:03): So I think what I always tell my patients is that you should always trial a non-operative period. First, you can always go and have surgery later. And I think, I always say, you need to prove to me that your knee is unstable. So some people can do really well without having surgery because their neuromuscular and muscle systems can compensate for that ruptured ACL and the mechanical instability, the neuromuscular system, the humans are very clever. They can really compensate quite well, and they feel you don't need the ACL. If you're only going to perhaps not go back to that high level pivoting sport, where you put your knee at high stress, a lot of the time, then if you just want to run straight lines and play with the kids, then you're likely not needing to have the reconstruction. If for instance, you try a really intensive, progressive rehab strengthening program and you're starting to run, or you're starting to get back into a bit of sport and your knee starts to become unstable at that point at the level that you want to get back to, then that sort of probably instigates the conversation. Adam Culvenor (13:12): Well, maybe your knees actually not able to overcome the structural instability to the level of activity that you want to achieve. Maybe let's have the discussion of a reconstruction as a potential option, but always get them. You need to prove that your knee's unstable by going through this rehab and putting yourself through these activities. But it's not going to do well without surgery because we know that the outcomes that are quite similar for the majority of people if you have early surgery or even delayed surgery and doing a period of rehab, irrespective of whether you go and have surgery or not, will be beneficial, if you do go and have surgery. So that prehab, if you like. So that's, I think it's my take home is it's probably actually just educating the patient to empower them with the evidence because they're the ones ultimately that need to make the decision. And so presenting them with all the best available evidence and guiding them for the initial rehab stage often can change their mind that they need surgery once they realized they were actually doing quite well without it. Karen Litzy (14:17): And when you're saying to the patient, let's do a trial for a non-operative phase, so that you can prove to me that this knee is unstable. What kind of length of time are you talking about for that rehab process and knowing that it's going to vary person to person obviously. Adam Culvenor (14:37): Oh, of course, of course. So I think a period of two to three months is sufficient to provide an intensive strengthening program. Let the knees settle down initially and then actually start you know, within the first month and even two months getting them to start really loading their knee. That's the thing, if you actually don't have surgery and actually responds a lot quicker because you don't have any of the graft morbidity, you're not taking out some of the hamstring or the patellar tendon. There's no real reason why we need to be conservative about you know tearing a hamstring or whatever that might be cause of the graft or rupturing the graft because you haven't had the graft reconstructed. So it's different for everyone because different people will respond differently, but actually there's no real hard and fast rule with this because you need to rehab them to get them to a point where they're starting to do the activities that they want to get back to. Adam Culvenor (15:37): And at any point in that step ladder of increased physical activity demands that they might fail or start having, you know, severe giving way episodes. Then that's the point that you might have that conversation with someone, but if you're running and you start giving Y and these people want to go back and play elite football, then clearly maybe you're not getting, being able to run without a stable knee. You're probably not going to be able to play football with that with a stable knee. Then that might be the point where you revisit, you're running no problems and you tried playing football and it starts giving way, but really you actually just want to run, right? Playing football is just something you tried, but didn't really want to do. Then you probably don't need the structural stability. If you just want to run off another thing, I like to set a patient's, is it like a seatbelt? Adam Culvenor (16:28): Is it, we all wear a seat belt when we drive, but very rarely do we have a crack and we rely on that seatbelt to keep us safe. So if you're someone who walks around and might run, then the ACL is a bit like a seatbelt, is that you actually don't need that seatbelt on because you're not having a crack. You're not putting the need through that real pivoting type movement to rely on it. So unless you're going to go back to a high level sport and, you know, put your knee through those pivoting jarring mechanisms of movement, then you probably don't need that seat belt. You don't need that ACL to protect the knee. Does that make sense? Yeah, Karen Litzy (17:06): That's perfect. That's really great. And it sounds to me like when, if you're the clinician working with this patient during, let's say this non-operative trial period where they have to prove, again, the instability, every single person is different. So what you're going to be looking at is different meaning, right? So if I just want to be able to play with my kids, I wasn't a runner before I don't really need to run. I just want to ride a bike or, you know, you want to put people through the things that they want to be able to do. And that would kind of be the way you would test for that instability. But are you also using sort of standardized tests when it comes to seeing if people have the stability in the knee? Adam Culvenor (17:54): Exactly. so it's really a goal based discussion with the patient come. The desires of the return to activity comes is driven by the patient. And as clinicians, you know, it's good to have that discussion to then work out, you know, what level do we need to get at, but certainly there's a number of standardized clinical tests and really great patient reported outcomes that we can use with these patients. So the very common ones are the strength tests. So if you have the resources, you know, a dynamometer, an isokinetic dynamometer in the clinic to look at the three range of quads and hamstrings strengths and making, you know, the criteria we typically use in the literature is meeting 90% of the strength compared to your uninjured side. Now, there's obviously some pros and cons about doing that. Adam Culvenor (18:44): And the other tests are typically hop tests. So single leg hop, as far as you can, with a balanced landing site, decide hop tests. There's a number of different tests we can use to try and assess the stability, the functional stability and confidence of the knee. Having said that though, we've actually just done some work I've led by Brooke Patterson here as part of our team, looking at the limb symmetry index, which is the ACL rate constructively comparing to the, I mean, delayed and what we found sort of between one and five years after their reconstruction is that often the non-injured leg isn't that healthy gold standard cause that often deteriorates because it's a period of an activity, you be back playing the sport you're back to. So that's sort of the crisis in capacity. So it's not that reference standard that we should necessarily be comparing our rate constructed. Adam Culvenor (19:44): And so there's been a couple of other bits and pieces that people have looked at alternatives to this type of measurement. And whether it's, if you have say someone initially after injury, it's a great opportunity to start doing these tests is actually the estimated pre-injury capacity. So to estimate that it's best to try and do it as soon after injury as possible, given that patients might have some fear and confidence, you know, respect that obviously, but actually trying to do a hop test quite early before that other leg has the chance to start decreasing in capacity because often the limb symmetry index overestimates, what the reconstructive legs capacity actually is. And so they're the functional type of measures that I think we should be using in this patient population, not only to assess outcomes, but also patients get in my experience really like seeing their improvements and getting feedback about having, going along their journey totally. And then an objective test of strength or a hop test they can see right in front of their eyes, how far they're hopping and if they are improving and if they're not, then why not have that conversation. And so that can be great for adherence motivation because this journey of a rehab, irrespective of whether you have a reconstruction or not, can be quite long and tedious, it can be boring. You're sitting there doing strength exercises, you know, any type of motivation to get people to continue is going to be beneficial. Karen Litzy (21:14): It's always, one of the biggest complaints is, gosh, these exercises, when do we get to the X, Y, Z, you know, that you see on, on Instagram or on YouTube. And I was like, you know, you're a month in buddy. This is it. Adam Culvenor (21:28): Exactly. And I think as physios and the evidence suggests that, we're very good at doing the early stage of the rehab because patients are probably more compliant at that point as well. But there's evidence actually coming out of Australia that less than 5% of people who have had an ACL reconstruction, so less than 5% actually go through a period of rehab beyond six months and include and return to sport type training. So I think whether it be a lack of understanding from a clinician standpoint, or also that, you know, financial and motivational points of view from the patient after six months of like, I've had enough, I'm out, I've good enough. I don't need that extra, you know, icing on the cake to get back to sport. They tend to drop off. And that's when not having that really high level agility capacity returned to school at top training, you increase the risk of re rupture. And that obviously is a devastating impact for these patients and increases the risk of longer term negative outcomes as well. Karen Litzy (22:27): Yeah. And I know here in the United States, not so much in other parts of the world, but insurance will oftentimes cut people off at three or four months. Adam Culvenor (22:36): Okay. So it's different everywhere. Yeah. Karen Litzy (22:38): So it's like, okay, so the person can walk and run and then, then what do they do? You know what I mean? So it kind of depends on your clinic model and things like that. But I mean, I've been lucky enough that I've been able to stay with my patients for 12, 13 months and upward. So it's been really great to be there the week they are out of the OR to getting them on the field and actually doing things that are going to, you know, mimic their soccer, their football place. So, but it's, yeah, there's so many obstacles. It seems. Adam Culvenor (23:25): Totally. And I think there's some really great evidence coming from Scandinavia that for every month that you delay the return to sport up to nine months, it actually reduces your injury risk by 50% that's mind blowing for me. So not only, you know, it was it from a rehab point of view, but actually from a range, point of view, having that nine months will actually you know, reduce your risk substantially of re rupturing when you do go back to sport. And I think that is why it's so heavily on people's minds when they're first going back to sport. That fear that's a huge impact psychologically for these types of patients. And I think often an ACL injury can happen. So innocuously, like you've done this movement a thousand times at training before, so why this time and that fear of, Oh, it wasn't a major blow when I first did it, like it wasn't someone running across and really hitting my knee. It was, I was on my own. And so what's stopping that from happening again. And that's that, I think that feeds into the fear of what could happen anytime again. Yeah. So I think I often try and say to patients while you injured your ACL, initially let's get your knee back to better than it was before you injured it, to prevent it from happening again. Because once we know once you have one injury, the biggest risk factor. So the biggest risk factor for a second injury is having a first. Karen Litzy (24:51): Exactly, exactly. And I've quoted that that study of that nine months reducing 50%, especially when you're working with kids who think I'm fine. Now I can walk. And I was like, listen, this, and you have to have that conversation with the child and with the parents. And once the parents hear that, they're like, okay, like we get it. Even though her physician was onboard, like you're not playing until you're one year out from surgery. I mean, wherever it is on the same page, but it's hard to keep. It's hard to keep everyone on the same page, but being able to use the literature and say, listen, I'll send you the study here it is. Adam Culvenor (25:34): When actually pulling it's actually for some people it's not in needing to encourage them, it's actually needing them to pull them back. That's where your education and clinical reasoning and discussions with patients will differ quite a bit is that some people are so gung ho in their rehab and they just want to get back to sport. You actually have to, as I said, pull them back, whereas the opposite might be true for some alpha people. So it's really interesting how different people respond differently to this type of quite devastating injury. Karen Litzy (26:03): Right. And how they respond, how you can use, like you mentioned the study of Scandinavia, how we can use that study with both of those extremes of people, right? So the people who are afraid and the people who are gung ho, so again, it's having this good rapport with your patient and their other stakeholders to kind of get them through safely through their rehab. But now we talked about it earlier on and that's osteoarthritis. So 50% of people will develop some sort of osteoarthritic changes in their knee. So what do we do about that? Are there prevention strategies? What can we do? Adam Culvenor (26:54): So this is something that we've been looking at for a few years now and obviously you know, we'd love to be able to have a treatment to stop this from happening, but we're not actually there yet. There's a lot of really nice longitudinal studies investigating risk factors for the increase prevalence of osteoarthritis in this population. And there's a number of risk factors that we can start informing how we might treat these people initially as well. So the number one risk factor is having a combined injury with a meniscus tear or a cartilage lesion. So if you have not only an ACL injury and very rarely, is it just an ACL injury, it can often be combined with a meniscus tear, cartilage lesion, bone marrow lesion, et cetera. So that more severe sort of type of injury will automatically put you at risk longer term of having osteoarthritis. Adam Culvenor (27:46): That's not that exciting because as clinicians, we can't do much about that. It's not really modifiable. So we're really trying to identify some factors that might be modifiable that we can address. So things like BMI being overweight, we know increases the risk of osteoarthritis longer term not only after injury, but in people of older age who have the traumatic type of osteoarthritis what's coming emerging from the literature more and more is the quadriceps weakness. So quadriceps in particular the muscle weakness in that muscle and also the functional impairments. So we talked about hop tests and in a balance in your muscle control a little bit earlier. So they're actually starting to become more and more prominent as risk factors for the medium and longterm outcomes for osteoarthritis. So we've just published a paper in the British journal of sports medicine, which looked at this exact question. Adam Culvenor (28:44): So do functional outcomes. So typical tests, we might use to clear someone to return to sports, a hop tests and strength tests. Do these actually have a relationship with future osteoarthritis? And what we found is, so this is a one year we tested them. And then at five years we measured their osteoarthritis on MRI. So quite sensitive measure of osteoarthritis, but also an X ray. And what we found is we combine a lot of these tests together into a test battery. So side to side hop test, single leg forward hop test. If you have a poor outcome at one year in these tests, then you're more likely to develop osteoarthritis at five years down the track. And so there's other studies that show quite similar findings in this space as well, which is really, I mean, it's upsetting because they're more at risk of osteoarthritis, but it's quite encouraging as clinicians. Adam Culvenor (29:34): This is our forte. We can actually do something about it in the initial stages of rehab. And again, this can be a great education motivational tool to say on this test, you're not achieving at a level that you need to achieve. This is not only going to put you at risk of reinjury. The research shows that this is actually going to increase your risk of developing arthritis. And we need to be a little bit careful about how we inform our patients about this. Cause as I said, some people can be really fearful and terrified about reinjuring and worried about what it is going to look like. And so presenting them with, Oh, you're going to be, you're going to have arthritis in 10 years as well. Might not be quite the right moves to allay that fear at that point in that patient. Adam Culvenor (30:16): Whereas other people having a knowing that information can be really motivating to try and get them feedback to the best possible condition that it can be. So again, it's very personalized how we educate our patients, but I think it's really important to educate them along the journey about that increased risk of OA and encouragingly. There's some, some really positive signs that we might start to be able to modify that risk with some really great rehab, getting back to the strengths, getting back to improving function in our clinical work as well. So I think that's really, really exciting moving forward. Karen Litzy (30:50): And that's great news for physical therapists because this is where we live, so wow. We can really make a difference in someone's life by good comprehensive rehab within that first year after ACL injury. And again, that's, regardless of whether they have surgery or not, is that correct? Adam Culvenor (31:08): Exactly. Yep, exactly. And as I said earlier about the return to sports, so we've also done some research which should be published shortly, hopefully looking at the fact that again, encouragingly, if you have an ACL injury or reconstruction and then decide to go back to these pivoting type sports, some people say, well, you shouldn't go back to that. You know, the high impact sport, because that's going to put your knee at undue stress and you're going to have more arthritis longer term, is that what we've found is actually that's not the case. So we can be confident that we can give these people you know, the advice to go back to sport. If that's what they really want to, for their quality of life and mental health, they do drive a lot of social pleasure from playing sport. The good thing is, is if you have a great functional and strong knee, then that's not going to put your knee at further risk by going back to sport. Sure. It's going to perhaps increase your risk of re injury compared to sitting on the couch at home. I heard that from a lot of mental health and also physical health being physically active and involved in sport has so many more benefits to our general health as well. Karen Litzy (32:11): Absolutely. And now can we, if you don't mind talk about the patient that I think a lot of physiotherapists are going to see, and it's like the patient that you saw 15, 20 years after their ACL. So we're not, we're not seeing them one to five years, but now we're seeing them 10 to 15 to 20 years later. That's when a lot of people are going to come to us with knee pain. So what can we do for these patients? Do we want to look at these hop tests in these patients? Does that make a difference? What happens then? Cause that's a big bulk of our population. Adam Culvenor (32:54): You're exactly right. And it varies about again what their goals are, but often if they're 10 to 20 years down the track and they've got osteoarthritis, we can look to the literature in the osteopath writers field. And in that space, it's very, very compelling evidence that exercise therapy and education provides the strongest effect for pain and symptoms and function in this population. And so that's almost reassuring that it's quite similar to what we're seeing in the early post-operative or post-injury stage is that whatever level on the spectrum you are post-injury and the development of osteoarthritis, essentially your treatment's going to be quite similar where you're developing the strength that underlies everything that we do in day to day activities. And indeed, if we want to get back to sport and also the functional capacity, so ask for the, what they want to do, what they can't do because of their pain and symptoms and make it a really goal oriented treatment. Adam Culvenor (33:54): And I think it's really important to also ask them what physical therapy have they actually done. A lot of those people come to us and they've seen five different surgeons and they've got different opinions. And when you actually question them and interrogate them, they've actually never had a gym program or they've never done any strength training. And it's like, well, of course you're having a few problems. So let's start you from the very basics. And not, you know, not flare them up by going too hard, too fast, but actually educate them around the importance of strength and functional control that the knee will benefit a lot from that. As well as from a function symptomatic point of view and start building on their strength, capacity and functional capacity to be able to meet whatever goal that they want to get back to. So I don't see it as being a totally separate patient from the post-injury one to the osteoarthritic, it's on a spectrum. And a lot of the treatments going to be very similar in principle depending on what their goals and their goals might change over time. So the treatment can as well. Karen Litzy (34:58): Yeah. Yeah. Well, thank you for that. That's great. Now, can we talk about the study that you are currently undertaking at La Trobe University. So can you tell us a little bit more about that? What is it and what are your goals for it? Adam Culvenor (35:18): We're super excited. Pardon the pun. So this is a project that's really stemmed from over the last 10 years of our work. Looking at identifying those risk factors, as I've talked about earlier to then be able to get some funding. So we've got some funding from the Australian government health and medical research council to perform this really world first randomized control trial, to see if we can actually prevent early osteoarthritis and improve symptoms and function through an exercise therapy intervention. So in essence, we're going to get a whole lot of people, about 200 people who are one or two years following there ACL reconstruction. So they've had that initial period of rehab to get better. Cause some people do really well. We need to remember that, that some people do great following the injury and surgery and don't need more intervention longer term. Adam Culvenor (36:14): So we want to try and capture the ones that have some ongoing symptoms and functional impairments. Haven't got back to doing what they want to do at one year post op to two postop at a point where they should be able to do those things and because they are going in out by some of the research, that's just, those people are more at risk of developing longer term problems. So we want to capture those at high risk and we're going to separate them into two different groups. In our clinical trial. One group will get a really intensive physio therapist, led exercise therapy program. So a lot of strengthening, agility, neuromuscular control, education, around physical activity you know, loading of the knee return to sport. And then that's over a period of four months initially. And then the other group gets what we're trying to say is usual care. Adam Culvenor (37:06): So very little intervention, they get a little bit of education and some booklets with the types of exercises I could do if they want to essentially, which is what they'd probably get it from their GP or their surgeon. Similarly, am I going to then assess their needs and their general health and symptoms and function from baseline and that changes over four months. And then also look at the changes up to 18 months as well because the MRI is one of our main outcomes looking at early collagen changes, which is our osteoarthritis marker. And some of these can take a little while to show up. So if you have an MRI on one day and then go and have an MRI the next week, chances are, you're probably not going to see much difference. So we need that period of, you know, 12 to 18 months to be able to see an effect of our exercise therapy intervention. Adam Culvenor (37:56): Whereas the symptoms of function we're expecting to be able to improve quite a bit within the first four months, which is going to be the most intensive period. And so yeah, our hypothesis is yeah, is that there's really strong, intensive, progressive rehab program strengthening, getting nice knees back to better than what they were before is going to be beneficial for their symptoms, function, general health quality of life, but also hopefully be able to show that that's actually preventing the early changes that we see on MRI or indeed maybe slowing the changes. So we know that cartilage thickness decreases. So we have a loss of cartilage, bone marrow lesions can start developing also for small osteophytes and bony spurs can start developing over a course of one or two years. And so we want to see if there's a difference in the development of those features in the two different groups. So we are ready to hit, hit, go on this study and a little bit delighted with COVID effecting us at the moment as well. So we're really excited to get going on this study and hopefully be a really impactful research project, moving the field forward and empowering clinicians to say, we actually can make a difference in this space for these patients. Karen Litzy (39:07): Yeah. I love it. Well, I look forward to when you guys can actually get started and maybe 12 to 18 months from then. So it sounds like a great study. And like you said, it's something that can be so empowering for physical therapists or physiotherapists to then pass on to their patients and kind of transfer that power from the physio to the patient to give them a greater sense of wellbeing, which is exactly that's what we do, right. That's why we became PTs or physios. So before we sign off, I have a couple other things. Number one. What are your biggest sort of takeaway messages for the listeners? Adam Culvenor (39:55): So I think the biggest thing is probably when you first see the patient, whose had an acute ACL injury in front of you and they're devastated. They often might come into your rooms and have heard particularly here in Australia. Our media is very centric on if you've had an injury, you need reconstruction because the elite athletes tend to have the reconstruction and I want the best treatment. And therefore I need a reconstruction is actually having a conversation with them and saying, presenting them with the evidence as I spoke about earlier. And there's no problem trialing a period of non-operative management for a couple of months, because that's going to be a great help if you do go down and have surgery afterwards. And it's, I think the reality is that a lot of people given the opportunity to do is to not pretty, very happy, actually can change their mind over the course. Adam Culvenor (40:45): And I realized actually, my knees gone really well. I actually don't need to have surgery where I was. I thought I would. So that's instead of just going gung ho into surgery, I think the evidence is very clear that a period of non-operative management is beneficial. Most patients almost all. And then the second key take home for me is, is during a postoperative or post-injury rehabilitation is actually working these patients intensively and progressively, I think we tend to shy on the side of being a little bit cautious, particularly after they've had a reconstruction, we worry about the graft rupturing. And of course we have to respect the surgeons requests of what we need to do with the patient from a restriction standpoint. But I think there's evidence growing now that we can be a lot more intensive early on and progressive with our exercises and looking to the strengths and conditioning research like these guys are trained specifically to develop strength and conditioning programs. Adam Culvenor (41:46): And I think as physios where we're pretty good at it, some better than others. And I think meeting the American college of sports medicine, you know, criteria for strength gains is actually, you need to work really hard. You need to get sweaty, you need to actually be working at an intense level. And so unless we put our patients through that, those sort of levels of intensity, we're not going to see the best outcomes that these patients can then can achieve. So there my two take homes is I think try non-operative period of rehab initially and revisit that along the course of the program. And then don't be afraid to actually build a lot of strength in those people because that's going to be beneficial. So they short term prevent re injury and the longterm of preventing arthritis, likely down the track as well. Karen Litzy (42:31): Awesome. And then number two, next question is, and it's something I ask everyone knowing where you are now in your life and in your career, what advice would you give to yourself right out of a physiotherapy school? Adam Culvenor (42:51): Ooh, good question. I'd say don't worry so much about things. Things will work out. I think in the research I'll probably have my research hat on a little bit, is often clinicians who want to start in research or even researchers who want to continue in research is that the funding can be really you know, tricky and really competitive and can often make and break careers. But I think some general, you know, I'd tell myself is don't worry too much about that. Just link up with good people and strong mentors. So, and I think finding, I'm sure you've had other guests say this as well, but finding good people who can mentor you really well and put your interests or your goals in your career sort of forward to their collaborators. So you can meet new people and open doors. Adam Culvenor (43:46): I think I was always worried that it wasn't gonna be enough doors opening, but I've been really lucky in my career that I've been surrounded by a great team throughout and doors have inevitably even though I don't expect them to keep opening. And so having the being in the right place at the right time is important, but you can, you can help to create more instances of being in the right place and more instances of being in the right time by putting yourself out there and meeting new people and surrounding yourself with really good mentors. Karen Litzy (44:20): Great advice. And number three, last question. Where can people find you? Adam Culvenor (44:25): Peak pool can find me in my lantern at the moment I'm up? No. So I'm have a Twitter account @agculvenor. My profile's on the Latrobe sport and exercise medicine research center page at Latrobe university. So we have a blog at our research center with a lot of really nice impactful easy to digest, short blogs, short videos, infographics designed for clinicians designed for patients. So you can take them off the blog and give them to your patients so I can not recommend that resource highly enough. And then my email, feel free to email me. You can find that email address on the La Trobe website page as well. Karen Litzy (45:13): And, we'll have all the links to that at the show notes for this podcast over at podcast.healthywealthysmart.com. So we'll have a link to your Twitter and to your page at Latrobe and also to the blog. So people want to get those resources, they can, and we'll also put in links to the papers that we spoke about today so that people can go and kind of read those papers as well. So we can link up to all of that. So, Adam, thank you so much was a great conversation. I appreciate your time. Adam Culvenor (45:44): That's been fantastic. Thanks Karen. Karen Litzy (45:46): You're welcome. And everyone, thanks so much for listening. Have a great couple of days and stay healthy, wealthy and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Michael Greiwe on the show to discuss telemedicine. Dr. Michael Greiwe is a practicing orthopaedic surgeon with OrthoCincy, near Cincinnati, Ohio, and the founder of the OrthoLive and SpringHealthLive telemedicine platforms. The platforms allow medical practices to deliver telemedicine visits through real-time HIPAA compliant video conferencing between provider and patient increasing practice revenue, efficiency and patient satisfaction. In this episode, we discuss: -The benefits of telemedicine for both the patient and provider -Choosing the right telemedicine platform for your practice -How to meet patient privacy and compliance requirements -Practical tips for a seamless telehealth visit -And so much more! Resources: Ortho Live Website Michael Greiwe LinkedIn Michael Greiwe Twitter Email: mikegreiwe@ortholive.com A big thank you to Net Health for sponsoring this episode! Learn more about the Redoc Patient Portal here. For more information on Dr. Greiwe: Dr. Michael Greiwe, M.D., is a surgeon by day and tech guru by night. He is a practicing orthopaedic surgeon with OrthoCincy, near Cincinnati, Ohio, and the founder of the OrthoLive and SpringHealthLive telemedicine platforms. The platforms allow medical practices to deliver telemedicine visits through real-time HIPAA compliant video conferencing between provider and patient increasing practice revenue, efficiency and patient satisfaction. Dr. Greiwe is a nationally recognized expert on how telemedicine technology is changing the practice of medicine. TV news stations and podcasts across America have interviewed him about the future of telemedicine and how to use it to improve the patient experience. He attended the University of Notre Dame, where he won the prestigious Knute Rockne Award for excellence in academics and athletics. He completed his Founder and CEO of OrthoLive orthopaedic surgery training at the University of Cincinnati Department of and SpringHealthLive Orthopaedic Surgery and Sports Medicine. In 2010, Dr. Greiwe completed his fellowship in shoulder, elbow and sports medicine at Columbia University, training with the head team physician for the New York Yankees, Dr. Christopher Ahmad. Read the full transcript below: Karen Litzy (00:01): Hey Dr. Greiwe, welcome to the podcast. I am so happy to have you on today to talk all about telemedicine. Michael Greiwe (00:08): Oh, thanks so much, Karen. I'm glad to be here. I really appreciate you having me on the show. Karen Litzy (00:11): Yeah. So for any of the long time listeners of this podcast, you know that back in March and April, when the covid pandemic hit, we talked a lot about tele-health. But I think it's great to sort of revisit that now that we're a couple of months in and perhaps more people are using telehealth at this time, then were back then. But what I want to know is Dr. Greiwe, did you just start using telehealth when the pandemic hit or were you more of an early adopter? Michael Greiwe (00:42): Yeah, thanks for the question. I kind of carrying out with sort of like an early adopter. You know, I started using telemedicine back when it really wasn't cool, I guess. It was like back in the 2016 time period. And I knew it was great for my patients cause they live pretty far away. I had patients that live like two or three hours away and they would drive and try to meet me. And then you know, I'd only see them for 15 minutes. I felt really bad about that. So I started using telemedicine and it's been a great thing for my practice. And then of course, you know, recent things changed everything and it's now exploded. Karen Litzy (01:16): Right. And like I said, in your bio is that you're an orthopedic surgeon. So one question that I think is probably good that you probably get asked all the time is how in the heck do you see someone for an orthopedic condition when you can't put your hands on them and kind of feel what's going on? Michael Greiwe (01:37): Yeah, that's a great question. I get it all the time. And it's one of those things where, you know, for me, and I'm sure for you as a physical therapist, you know, so much when you hear about the history of that patient. So like the history gives you probably 80 to 90% of what you need. And then the rest is sort of verifying things through, you know, a physical exam and there's certain things on video that you can kind of catch. So like if I have somebody with the rotator cuff problem, I can watch their arm move. And I just know that the rotator cuff is bothering them. And then I'll maybe order like an MRI or something along those lines sort of confirm. But ultimately for me, it's more about like, you know, I may have to see this patient in the office at a certain point in time, but I don't always have to do that. It's kind of like depends on what the history gives me. Karen Litzy (02:22): Yeah. And I agreed from a physical therapy standpoint. I get that question all the time is, well, how can you do physical therapy on someone if you can't, if you're not in the same room. And again, it comes down to listening to the patient. Like they will tell you everything you need to help treat them to help diagnose them. If you just listen in the beginning and then you can tailor your program accordingly. Now of course, like you said, there are times where you have to see the person in person, right. And sometimes that's the same with PT. So I think oftentimes when people think about tele-health, they just paint with a very broad stroke and they think, well, how can you do that? So what do you say to people who sort of have that mentality of all or nothing? Michael Greiwe (03:13): Yeah. I think if they experience it for their, you know, themselves, they can sort of see that, okay. You know, this really works and it works because, you know, if you have somebody on the other side that's engaging you and asking the right questions, you're going to eventually come to the right answer. You know, I've had patients with a frozen shoulder and I'm sure you've treated patients with frozen shoulder. It sort of have classic signs and symptoms. Sometimes the history isn't like exactly, they're just sort of out, well, you know, my shoulder has been hurting and it kind of came on over the last several months and now I can't really move my arm as well as I used to. Or maybe you might not hear that. You just hear like, well, it hurts all over all the time, but if you kind of ask some leading questions, you have the right examiner, you can find out the answer. And so I think that's really, the key is having the right person on the other side of the screen, you know, asking the right questions. I'm sure you do the same in your practice with physical therapy. Karen Litzy (04:06): Yeah, absolutely. And you know, when we're talking about our different practices and our businesses because of the COVID pandemic, a lot of places had to shut down there in person I'm in New York city. So talk about being shut down. So we were shut down quite early. Now other parts of the country are flaring up and there's a lot of uncertainty here. So when it comes to tele-health and our business, how can tele-health help our practices grow and help our businesses grow? Michael Greiwe (04:41): That's a great question. I think it's something that people are sort of finding out more and more about right now. I mean, there's so many ways to be able to utilize telemedicine in our practices to help it grow. I mean, first of all right now as an orthopedic surgeon, I see patients from around my area because of COVID in the situation we're in right now, they don't want to come into the office, you know, so they're looking online and they find, Oh, Dr. Greiwe has got an open slot to be able to be seen via telemedicine. So we're kind of advertising that at ortho Cinc, where I practice to say, Hey, anybody that might want to come in for telemedicine appointment, you can. And it just gives me access a lot better than it normally would to be able to see patients. And then I think there's other ways too. Michael Greiwe (05:25): So for instance you know, for physical therapists, you might work with employers for instance, or workplaces that need a physical therapist and you put like an iPad there to say, if you need a physical therapist, here's how I can help you, you know, call me or whatever through this device. And so there's just so many ways for us to do that inside ortho, specifically postoperative recheck appointments, they open up slots of time that, you know, you typically wouldn't have because it's a lot more efficient to see someone via telemedicine than it is in person. And you know, also there's a lot of downtime kind of between surgeries for us too, so that downtime can be utilized for telemedicine too. So there's a lot of ways we can sort of generate you know, revenue through that and kind of open up our practice a little bit more. Karen Litzy (06:13): And, what I found is I can actually help more people. Michael Greiwe (06:17): Oh yeah, absolutely. Because you could probably have group visits too. Right. You could have you know, on those group visits or are you talking about just sort of more you know, area? Yeah. Karen Litzy (06:29): Like you were saying before we went on is sometimes you have people have to drive two to three hours to see you. Right. You know, that's really, that can be really difficult. So imagine if you have, you know, this really aching shoulder pain and you have to drive two hours. Michael Greiwe (06:45): Right. Absolutely. You're absolutely right. I think what helps, what helps you is, you know, with telemedicine, you've got the reach to be able to see somebody that's five hours away or even across the country that's heard about you or, you know, maybe they know that you have certain techniques that they like. I sort of developed like a posterior shoulder replacement where it's kind of a muscle sparing approach to the shoulder. And so I have people come from like California, Texas, Montana, you know, and now I can kind of see them postoperatively and preoperatively with telemedicine. So it's a really nice, it's a nice tool from that standpoint too. Karen Litzy (07:19): Yeah. That's great. Yeah. So you could see them preoperatively, if they're across the country, they come in, you do the surgery and then you can then see them postoperative. So they don't have to stick around by you for six weeks. Michael Greiwe (07:33): Right. So I'll have him stay for the first week and then we'll have the incision to make sure everything's looking good. Take x-rays and then they'll go back home and then I'll check in with them every four or five weeks, they'll be doing physical therapy kind of in their local area. Or of course I could refer them to you to remote therapy, but yeah. So that's how they do it currently is they go back home, they work and they get their motion back. And then we'll check in again, virtual. Karen Litzy (07:57): Now how about prescribing medications? Is that something that you can do via tele? How does that work? Michael Greiwe (08:03): Yeah, it still works pretty well via telemedicine, but I don't really do any like schedule three narcotics, you know, things like that. We don't do, but you know, anti-inflammatories, you know you know, if somebody has had some nausea like Zofran or, you know, things of that nature are pretty easy to prescribe and we still prescribe and have the same prescribing practice that we do in person, it's just, I get a little bit more wary and I think it's prudent to be more wary about, you know, narcotic prescriptions and things like that, especially in the world that we live in right now. We've gotta be very careful about that. So, we're super careful with that, but I think most of the other prescriptions are totally they're okay to do. Karen Litzy (08:46): And how about this is a question that I get sometimes is what about privacy and compliance and making sure that meeting all those standards. So how can we ensure that we're doing that as a healthcare practitioner on tele-health? Michael Greiwe (09:04): That's a great question. I think, you know, it is very important, obviously. So HIPAA compliance is what it's sort of called as you know, and it's what everybody's sort of, doesn't like to have to worry about, but it's very important for our patients, right? I mean, it's, people are very much in tune with their privacy. Data privacy is becoming like a really big thing right now, but really people's healthcare privacy and their you know, their medical privacy is very, very important. So the telehealth platform that you choose, you have to make sure that that is HIPAA compliant. And that means end to end encryption. That means like the data that starts out, you know, it's carried through the internet and it's encrypted and then wherever it's housed, it's also encrypted there too, so that no one can sort of get to that information. I think that's really critical, very important for our patients and most of the platforms they will advertise whether or not they're HIPAA compliant. And you want to know kind of how many you know, what type of bit encryption they are and things like that when you look at platforms. Karen Litzy (10:06): What was that last thing you said? Michael Greiwe (10:09): Yeah, it's sort of like, as the information is traveling across the internet there's sort of, you know, bytes of information, right? And so the amount of encryption can be sort of leveled up so that, you know, basically you can have like 64 bit encryption, or you could have 264 bit encryption there's certain levels. And so it takes, it's like a string of numbers. And so that string of numbers is how much it would take to crack the code essentially. So 256 bit encryption is like, you know, a massive amount of code breaking has to happen to catch that while it's traveling through, you know, the inner web. Karen Litzy (10:50): Well, no, that's really good because I think that's something that if people are choosing a platform, it's definitely something that as a provider you want to be looking at. Michael Greiwe (11:00): Absolutely. It's very important, you know, and most providers are pretty in tune with that, but right now, like, you know, they're allowing telemedicine to occur on FaceTime and some other platforms. Karen Litzy (11:12): Now FaceTime is not HIPAA compliant. Michael Greiwe (11:17): Yeah. So we don't want to really be using that right now. And there are some providers out there that are doing it, maybe just for ease of use and because the pandemic it's happened. But ultimately what we really need to make sure is that we don't use those platforms. Those platforms are not safe, not secure. Karen Litzy (11:35): Are there any other sort of things that you want to watch out for when you're let's say, well, first we'll start with looking at different tele-health platforms. So what are the things that you want to be looking for? And if you have any advice on a do's and don'ts, while you're actually in your tele-health session, I know some of them seem like, should be common sense, but you never know. So let's go with, what should you look at first? What should you be looking at in your telehealth platform? Michael Greiwe (12:11): It's a great question. I think the first thing that's really important for patients is making sure that, you know, the HIPAA compliance there, we covered that, right? So HIPAA compliance, probably number one, number two is, does this platform allow you to, you know, keep a schedule? So one of the most frustrating things as a provider of telemedicine is, and this is what I found out many, many years ago is that there is no schedule. You know, you have to send the invitation to the patient. The patient sort of says, yes, I'd like to do this. And then, you know, they link up eventually, but what you really want us to be able to schedule the appointments, that way you can move from one person to the next, and you're not really leaving a screen and trying to come back and forth just from an efficiency standpoint. Michael Greiwe (12:53): It's not very efficient to do that. Another thing that's important, I think is being able to chat with your patient. Sometimes it's important to be able to have a conversation. And it's also important to answer questions. And so being able to have kind of a text based chat that's secure as well, that might be, you know, maybe they can send you a picture. Maybe you can send them a video. Maybe you can send them sort of a document that gives them some exercises or what have you. And that's really important too. But I think one of the other things I was gonna mention is consenting. A lot of platforms don't have consent and of course that's part of the law. You have to consent that patient for telemedicine before you have a visit in most of the States, I think 45 of the States, you have to have a consent. So very important for the consent process to happen also. And that allows you to have a legal telemedicine appointment. Karen Litzy (13:44): And that consent process. Can that be in your initial paperwork? So if you're onboarding someone and, you have, I mean, we've all been to the doctor's office, you have to fill out a million different forms, right? So same thing with PT. So can that consent to tele-health be in that onboarding or does it have to be every time you connect for a telehealth visit, do they have to consent every single time? Michael Greiwe (14:11): That's a great question. And it's really just a onetime consent, so it doesn't have to be, you know, every time. So if they just come to your office first time, you're going to maybe have him sign some paperwork that says consent to telemedicine, and that's fine. You're good to go. But in the case where you have a new patient, it's very important to make sure that you have that consent process. And so for us and what we do at ortho live and spring health live, we just have them sign off one time that they agree to telemedicine. And then we assume every time they visit the platform, they know what they're doing and they've already agreed to it. Karen Litzy (14:44): Yeah. Yeah. Cause I have woo. You just gave me a little sigh of relief cause I have it again as part of my onboarding paperwork that people are consenting to their telehealth visits, but I don't do it every single time for each visit. Michael Greiwe (15:00): Right. Then I think it's just sorta like the billing practices in your practice too. And that people sign off that they're okay with billing and that they just do it once they're not signing it every time that they come back, it applies similarly to telemedicine. Karen Litzy (15:12): Got it. Got it. Okay. So those are the things you want to look at when you're kind of shopping around for a platform. Now let's talk about some things that you want to have in mind as the healthcare practitioner during your telehealth visit with your patient on the other end. Michael Greiwe (15:30): Yeah. It's a really good question. So the first thing is if you're going to use a phone, you know, and sometimes you're using a phone because you might be on the go or maybe your platform only allows you to have a phone it's really important to make sure that you don't like hold the phone, like right underneath your nose. Because it sort of gives you like kind of the up the nose shot a little bit. So I always tell people, you know, prop your phone up in front of you, like on your keyboard, maybe that's a really good place for it. Or if you're using a laptop, obviously like your face is kind of directly in front of that camera. And it just gives you more of a conversational type of appearance to your patient rather than you're not like talking straight down to them. Michael Greiwe (16:06): I think that's important. The other thing to sort of test out is just make sure that like, you know, when you move your right arm, like your right arm is like going up in the correct location in the camera. So you're not off to the side, you know of the camera when you're trying to show them kind of what you expect, I imagine for physical therapy and you can answer this, you know, too, I imagine for physical therapy that you may have to be seen, like your full body may need to be seen at some point in time. Karen Litzy (16:33): Yeah. Yeah. You definitely need like a decent amount of space so that you can lay down on the ground. You can come up to kneeling, you're standing you're so yeah, for physical therapy, you do need a good amount of space. So it comes down to finding those spaces, whether it's in your home or your office, where you can kind of get the right angle and good lighting. Michael Greiwe (16:54): Right. That's great. I think that's really important. You know, for your listeners on the physical therapy and for us, it's also being able to screen share too. If you can screen share, then you can show x-rays MRIs, things like that. And just getting tests sent out. Like I know for my practice, you know, we had a lot of physicians go live as soon as COVID hit and nobody had practiced. And so it was disaster on the first day, it was like, you know, it was like Groundhog day. And like no one knew what they were doing. And I was running around different pods trying to help everybody. But it's important to practice just like we would never go to surgery, not practicing what we're doing, you know, you practice to on your side to make sure that everything's working properly, your camera, your audio and all of that. Karen Litzy (17:36): Yeah. Do a couple dry runs with friends and family, make sure it's working well. Yeah, that's excellent advice. And now what do let's say, physicians or therapists what do they need to do now to kind of quickly adapt to this telehealth? Because from like, I look at, it's such old hat now, but I've been doing it since March. So now you have other parts of the country who are sort of trailed behind New York city. So they're in lockdown maybe for the first time and they really need to start adapting quickly. So what advice do you give to those practitioners? Michael Greiwe (18:12): Well, you know, providers of medical services always have a hard time with change, right? I think that's like one of the tenants of being a type a personality, the personality that ends up getting into medical practices or, you know, we're very particular. So we don't like to change. That's the first thing to recognize. And, and so there's going to be bumps in the road and they're just going to be hurdles. And I think it's really important to just understand like, Hey, you got to sort of roll with the punches a little bit, understand is not usually too difficult. We just need to kind of figure out what your plan of attack is going to be. Are you going to see tele-health patients in the morning and then see your regular, you know business in the afternoon, if you're completely shut down, how are you going to adapt to that? How are you going to get the word out? Are you going to be able to market this really, really important for you to make sure you kind of figure all that out on paper before just sorta like saying, yeah, I'm going to buy this telehealth cloud from when we get rolling, you know, it's like let's plan an attack and how we're going to be seen and how we're going to be able to see patients. I think that's really, really important. Karen Litzy (19:12): Yeah. Makes sense. And now let's talk about the platforms. Let's talk about the platforms that you're involved with and how you got involved. So there's ortho live and spring health live, right? So how are you an orthopedic surgeon with all of the work that surrounds that and then sort of this tech person entrepreneur on the side. So you must have some spectacular time management skills. Michael Greiwe (19:44): Well, I've got a very forgiving wife. I know that that's number one. But you know, it is like a it's a wonderful thing for me because I really enjoy doing kind of creative things. Things that might help my patients and telemedicine was one of those things I think really was, was a great thing for my patients ultimately. But for me, telemedicine was a way for my patients to be helped in a way that we couldn't really help them through anything else. And so there wasn't a great solution. So I decided to found ortho live about three years ago, that was 2016. And it was only because I was looking around to try to find a solution for patients and for providers that was really efficient and that worked really smoothly. But what I found was that really didn't exist and it was really hard to find the right solution. Michael Greiwe (20:32): And so I decided to create it after speaking with a CEO of a telemedicine company out in the California area, he kind of runs a lot of the video for MD live and some of the other larger companies. And he said, Mike, you know, this is a great idea. You ought to kind of through on your vision to do this for orthopedics. And so I did that with ortho live and it's been really successful and I kind of knew what we needed. We just, you know, we didn't have the efficiency in a way to be able to see patients in a streamlined fashion. So we created that within orthopedics, which I knew very well. And then we kind of branched out and now we're offering services to other specialties and subspecialties as well with spring health live. Karen Litzy (21:11): And within these platforms, do you have ways to do objective measurements within these platforms? Cause I know some do some don't so how does this, how does this work let's say from an orthopedic standpoint. Michael Greiwe (21:27): Yeah. So I mean, if you want true objective measurements we have to kind of integrate with braces and things like that. So, you know, we're like a smartphone application. And so we do have API APIs that can integrate and take in information like that. It's not something that, you know, orthopedic surgeons really use on a daily basis. I would see that more for physical therapists. So we kind of have the ability to integrate with you know, applications that give you range of motion and actual discrete data. I think that's really important because it does give you some actual feedback on a day to day basis, how a patient's doing. But from an ortho standpoint, we don't really need those, like the discrete data points we just sorta need to see, okay, well, how was that patient performing? Michael Greiwe (22:09): Are they having difficulties still, you know, moving their knee, let's see you bend your knee. And if it's not really going as well as we want, we know we need to up the physical therapy, we need some more intensity there. And it's more of a good stall for us. Less on the discrete hard numbers, but with therapy, I feel like it is really important to have that feedback to say on a day to day basis that patient's not doing well, how can we help them? Do we need to intervene sooner? So maybe that's what you're getting at, but, but yeah, we have the ability to kind of feed that information back into our platform. Karen Litzy (22:39): Yeah. Yeah. That's cool. Because a lot of times it's, you know, you could say, well, if 180 degrees of shoulder elevation is considered full, it looks like maybe they're at 75% or they're at 50%. So, but it's hard to get those, like you said, very discrete numbers because we can't measure it. Right. So having the ability to kind of integrate applications to be able to do that, I think is it can be really helpful. Although I, yeah, I guess sort of postsurgical when the patient is perhaps limited to X amount of degrees of movement, I think is where that comes in really handy. Michael Greiwe (23:21): Right. Right. And we have them sort of stand kind of at the side and like watch for inflection and things like that. So I think we get, you know, to within probably five to 10 degrees, but if you're looking for exact degrees, that's where those programs, which, you know, you can strap like an iPhone to your leg now and like move your knee. And it measures range of motion through like some little track pads and things like that. And there's ways to, to really effectively get that, that motion and understand what's happening with the patient and recovery, which is nice. And so we've allowed the ability to integrate those types of applications to our platform, which is cool. Karen Litzy (23:56): Yeah. That's really cool. I was working with some developers based in Israel who have an app for gait. And so you put it in your pocket and what it does is it can tell you the excursion of your hip range of motion from flexion through extension pairing side to side, your stance time steps per minute all sorts of stuff. I think there's up to like seven or eight discrete measurements, which is super cool. So again, in times like this, this is where the technology 10 years ago didn't exist. Michael Greiwe (24:33): Yes. A hundred percent. Karen Litzy (24:36): Having that now is allowing healthcare professionals to continue to help their patients during this pandemic. Michael Greiwe (24:46): No question. I was speaking with a group that has some special socks that like will measure stride length and things like that. So they know when a person may be like, you know, unsteady with their gait when they might be a fall risk which I think is a great, it's a great thing. And so, you know, understanding when patients may need some therapy to try to help with balance is critical. I mean, falls are a multibillion dollar issue in the United States today. And if we kind of cut down on falls, it's a great, great opportunity. And so we're, I think we're leveraging little things like, you know, from a data standpoint to be able to improve population health. I think it's great. Yeah. Karen Litzy (25:26): And where do you see telemedicine moving in the future? The pandemics over is everybody just gonna wrap it up and call it quits? Or what, where do you see that moving towards in the future? Michael Greiwe (25:39): No, I think telemedicine is here to stay Karen, I think you know, so-called genies out of the bottle, you know, there's a lot of great things that have happened with telemedicine recently. I think it's here to stay. We're gonna end up seeing telemedicine continue to spike. It was on the rise. Even before the pandemic, we were seeing multi millions of patients that were being seen every year. It was doubling every year. And now it's like, I mean, I think it's gone up by 10 X. So there's going to be a lot more telemedicine, I think, in people's future. Karen Litzy (26:10): Yeah. And as we were discussing before we came on the air hopefully the providers of insurance will also agree with that and say, we are going to continue paying for these because look at the advantages it's giving look at the money we're saving because of this. Cause like you said, if you can have a telemedicine visit with someone and it prevents a fall, which is a multibillion dollar industry, would you rather pay the $2-300? Whatever it, I don't know how much it is or have that person hospitalized for hundreds of thousands. Michael Greiwe (26:48): You're absolutely right. And so if there's any, you know, any of the insurance industry listening is very, very critical that we continue with telemedicine for their patients. And it's so beneficial, not only in protecting them during this time period, you know, we definitely don't want to let them go out of the house or 70 year old patients that are potentially sick and I'll really you know, it's for their safety and it's also for the benefit of the patient. I mean, it's way more convenient for them. And so I think without a doubt, it is so important to make sure that our legislature continues to support telemedicine and telemedicine billing. Karen Litzy (27:25): Absolutely fingers crossed fingers crossed that that happened. So I'm with you on that. Alright. Now, before we start to wrap things up, is there anything that we didn't cover or anything that you want the listeners to sort of walk away with from our discussion on telemedicine? Michael Greiwe (27:43): Oh, I think the main thing is, is that, you know, there's a lot of great people out there trying to provide health care. And many of them are trying this, you know, as a new you know, thing for them in their practices. And I think supporting them in that is important. I think everybody inside their local community is really trying to do things via telemedicine now and they weren't doing that before. And so being flexible, I think with those providers, I think is important, but I also think that telemedicine is here to stay. It's one of these things where there's so much benefit on both the provider and the patient's end that it'll just continue to be here and be a part of society and medical care going forward. Karen Litzy (28:20): Yeah, absolutely. And now I have one question left and it's a question I ask everyone, and that's given where you are now in your life and in your career. What advice would you give to yourself as a fresh medical school graduate? Michael Greiwe (28:36): That's a good question. I love this question. I think for me, I was such a you know, a worrier, like I was, I was always worried about, you know, what was I going to be good enough? Was I going to be smart enough? And you know, I always knew that I believed in myself, but I didn't trust myself back in those days enough to know that I was going to be okay. And I think the thing to remember is like, you know, you went into this medical profession for a reason you want to take good care of patients. You got to believe that, you know, you're a hard worker and you're going to continue to do as best you can to take good care of people. And you're not, you know, even a few fail it's okay. I think failure is it's okay to fail. I think that's another thing that I would tell myself to, because I was so worried about failing that I wasn't willing to like branch out and take risks. But I've learned that now. And I think if I could go back, I'd tell myself, don't worry about failure. Just you're gonna be fine. Just keep working hard. Karen Litzy (29:36): Great, excellent advice. And now where can people find out more about you more about ortho and spring health live? Michael Greiwe (29:43): Great. Yeah. Well, they can actually look at our website. So our website is www.ortholive.com and then www.springhealthlive.com. So for me, I can be reached at mikegreiwe@ortholive.com. That's my email address and I'll be happy to respond. Karen Litzy (30:08): Perfect. And just so everyone knows, we'll have all of those links in the show notes under this episode at podcast.healthywealthysmart.com. So Dr. Greiwe, we thank you so much for coming on. And, and like I said, I've spoken about tele-health before, but it was way back when this started. So it's great to get more information out there for people to know that it's not just something that we're doing during the COVID pandemic, but that this is something that can be incorporated into your practice. It can help your business, help your patients. So thank you so much. Michael Greiwe (30:43): Oh, thank you, Karen. I was glad to be here. Appreciate it Karen Litzy (30:45): Anytime. And everyone. Thanks so much for tuning in, have a great couple of days and stay healthy, wealthy and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! 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On this episode of the Healthy, Wealthy and Smart Podcast, Dr. Michael Weinper speaks with guest host Dr. Stephanie Weyrauch about the American Physical Therapy Association's Vision 2020. Passed by the House of Delegates in 2000, Vision 2020 was APTA's plan for the future of physical therapy. In his 2000 Dicus Award speech, Dr. Weinper discussed his predictions of where the profession would be in 2020. Dr. Weinper and Dr. Weyrauch revisit the elements of Vision 2020 and analyze whether our profession has accomplished a vision of the future set twenty years earlier. In this episode, we discuss: -How has the physical therapy profession evolved since the drafting of Vision 2020? -The student loan debt to income ratio -Advocacy efforts to achieve full direct access in all of the States -The importance of lifelong learning and evidence-based practice -And so much more! Resources: Stephanie Weyrauch Instagram Stephanie Weyrauch Twitter Stephanie Weyrauch Facebook Email: sweyrauchpt@gmail.com APTA Website A big thank you to Net Health for sponsoring this episode! Learn more about Four Ways That Outpatient Therapy Providers Can Increase Patient Engagement in 2020! For more information on Dr. Weinper: Michael Weinper, PT, DPT, MPH, cofounded the company in 1985 with his partner, Fred Rothenberg, a former executive at Blue Cross of California. A physical therapist with more than 40 years of experience in clinical practice, management consulting, administration, and program development, Weinper is also a principal in Progressive Physical Therapy, a private practice, with four locations in Southern California. Weinper received a Bachelor of Arts degree in Industrial Psychology and a Bachelor of Science degree in Health Science (physical therapy) from California State University, Northridge. He received a certificate in physical therapy from that institution in conjunction with UCLA Hospitals and Clinics. Weinper later received his Master of Public Health degree (M.P.H.) from UCLA in Health Services Administration and his Doctorate in Physical Therapy from the EIM Institute for Health Professions in Louisville, KY. Weinper has been active in the American Physical Therapy Association (APTA). He has served as a member of the APTA's Task Force on Physician Ownership of Physical Therapy Services, as a member of its Committee on Physical Therapy Practice, as the association's chairperson on its Task Force on Reimbursement, on the Board of Directors for APTA's California Chapter and national Private Practice Section, and as trustee of the APTA Congressional Action Committee (now known as PT-PAC). Weinper received the prestigious Robert G. Dicus Award from the Private Practice Section of the APTA in 2000, and he received the Charles Harker Policy Maker Award from the APTA Health Policy and Administration Section in 2011. On behalf of the state of California, Weinper has served as a member of the Physical Therapy Subcommittee of the Division of Industrial Accidents, now known as the Division of Workers' Compensation. He also has served as an expert to the Medical Board of California, where among his activities he has appeared on behalf of the People in insurance fraud trials. He has provided expert witness testimony on behalf of more than 20 insurance companies. A former associate professor of health science at California State University, Northridge, Weinper is a frequent presenter for various professional associations including the National Managed Healthcare Conference, the American Medical Care and Review Association, and the APTA. He has authored many articles for both physical therapy and insurance industry publications. For more information on Stephanie: Dr. Stephanie Weyrauch is employed as a physical therapist at Physical Therapy and Sports Medicine Centers in Orange, Connecticut. She received her Doctorate in Physical Therapy and Master of Science in Clinical Investigation from Washington University in St. Louis. Dr. Weyrauch has served as a consultant for a multi-billion dollar company to develop a workplace injury prevention program, which resulted in improved health outcomes, OSHA recordables, and decreased healthcare costs for the company's workforce. She has served on multiple national task forces for the American Physical Therapy Association (APTA) and actively lobbies for healthcare policy issues at the local, state, and national levels of government. Currently, she serves as Vice President of the American Physical Therapy Association Connecticut Chapter and is a member of the American Congress for Rehabilitation Medicine. Dr. Weyrauch is also the co-host for The Healthcare Education Transformation Podcast, which focuses on innovations in healthcare education and delivery. Dr. Weyrauch has performed scientific research through grants from the National Institutes of Health and National Science Foundation at world-renowned institutions including Stanford University and Washington University in St. Louis. Her research examining movement patterns and outcomes in people with and without low back pain has led to numerous local, regional, and national presentations and a peer-reviewed publication in Archives of Physical Medicine and Rehabilitation, a top journal in rehabilitation. Read the full transcript below: Stephanie Weyrauch (00:00:01): Hello everyone. And welcome to the healthy, wealthy and smart podcast. I'm your guest host Stephanie Weyrauch and I am interviewing Mike Weinper who's the president and CEO of physical therapy provider network or PTPN as it's better known and also a private practice owner for progressive physical therapy in California. The reason that I wanted to talk to Mike today, as he won the Robert G Dicus award for the private practice section back in 2000, and he has been an instrumental person in practice, leadership, innovation, legislative, and political issues, healthcare reform, and a number of other areas where he's really had the opportunity to champion innovation and leadership. And one of the things that, you know, we know it's 2020, and obviously vision 2020 has something that has happened in the APTA was written back in 2000 and in Mike's Dicus award speech, he talked a little bit about where he thought the profession would be in 2020, in 2000. And so I'm really interested in kind of his take on where we are today. So Mike, welcome to the healthy, wealthy and smart podcast. And tell us a little bit about yourself. Michael Weinper (00:01:21): Well, thanks Stephanie, for the very nice introduction and it's a pleasure and an honor to be with you today. At some level, I'm considered by some, to be a dinosaur, having gotten my Dicus ward 20 years ago, and now long in my career, I'm just celebrating my 50th anniversary as a PT. So I hope that some people won't tune out just because of that. Maybe if nothing else, they can see me as a history lesson, any event, I can tell you that back in 1992 the California chapter of APTA now called California PT association created a long range planning task force that I was honored to serve on. And in that task force where a lot of leaders in the profession in California names that were household names, then probably names and most people would not know now, but our plan was to draft a long range vision. Michael Weinper (00:02:21): If you will, a crystal ball of what things would look like some 18 years later in 2010, kind of looking back, it's interesting to look at and we created, I believe 18 different points that would be goals if you will, of the association and the primary aspects of that working document, which was called PT 2010 by the California association. I'm sure if you were interested, you could look it up or get a copy of it. Then later became the working document for APTA called PT 2020. And since we are now in 2020, I wish we would have known then what we know now, because things have dramatically changed in many ways, but in other ways they have not. And so I guess I could give you some of the ideas we envisioned back in 1992, if you'd like, and then we can take it from there. Michael Weinper (00:03:23): So in that document, we said that PTs would be able to evaluate and diagnose conditions that's true today, perform specialized treatment procedures and work in teams with physical therapists and PT assistants. So all that did come true. Next, the PTs would be able to initiate services subsequent to their own evaluation diagnosis without referral from or diagnosis by another practitioner. And that in 2000 that had not yet been accomplished, but we, now we know we have independence and practice almost every state with regard to our licensure. In most therapists are, would be in independent press configurations with other therapists, maybe who would work in a hospital. In other words, there would be an opportunity to be clinically specialized in it with a board certification, which we now know has really grown quite a bit. Michael Weinper (00:04:25): And they would be sought out. These specialists would be sought out by consuming public and third party payers. Not as much. I don't think our profession has reached to the public well enough to get the public, to understand what a board certification really means and what it takes to become a board certified specialist in our profession, but I'm progressing for a moment. Anyway. So then we said that PTs would be able to be involved in the continuum of care from the hospital to the home, to the private practice. In other words, PTs would have hospital-based privileges and they would be able to go there. And then if the patient were home, many of them would be able to then go to the patient's home and treat them there and then follow them up in the office. And so that was another kind of idea we had way back then. Michael Weinper (00:05:21): So it would be basically following the patient through the episode of care from beginning to discharge and obviously getting them ambulatory and functional. We also said that this is a good one that PTs would become diagnosticians. And more importantly that we would be at the entry point in healthcare which wasn't the case in 2000, but in now in some places, it is that therapists are in fact these musculoskeletal specialists would be a cause we can do it musculoskeletal evaluation or diagnosis many states now recognize that. And some insurance companies have recognized that we can be an entry point into the system, which I believe going forward, it's going to become much more prominent because of the higher cost of care. And actually Stephanie, the difficulty we all experienced when we try to refer a patient to a specialist, state, an orthopedist or a neurologist to do an evaluation so we can follow the patient. Michael Weinper (00:06:18): We find that it can take several weeks for that patient to get in, to see the physician, whereas they can usually get in to see us in a few days. So I think that's something that we will see more of in the future, but back then we had it as a dream, but not a reality. We also said that at that time, that instead of 24 weeks of internship that were experienced by PT graduates back in those years, we thought internships would last one year. Now that I don't think there's a, but we have in fact seen fellowships and other levels of work where therapists are really going into specialization so that they in fact can do things over a year's period of time and then becoming sort of like specialists. So those were sort of the, kind of, I think the basic things that would be of importance today. Michael Weinper (00:07:15): We did also, this was a very important one. We identified that in the year 2010 PT would be a doctorate profession. That was what our key points of doctorate and profession. And lo and behold now our entry level is what a DPT, a doctorate. I'm very proud to say that I went back and got my DPT a little over 10 years ago. I talked back in 1982, and I certainly wanted to walk the walk before 2010. So cause that was our benchmark was 2010. So with that in mind I think it's important to realize that we have become doctoral people. In other words, we are now at a level of sophistication with our education and hopefully some research that gives the PT of today a much broader view of a patient, their wellness or their disability, and gives them better tools, which the function do the evaluation or assessment of the patient, and then follow up with treatment compared to how things were back when I graduated in 1969. Michael Weinper (00:08:31): So and I found that when I got my DPT that I learned quite a bit. I learned some of the things I learned actually were more on how to think differently than I had thought previously. And I will tell you that some of the things that I learned that were most valuable to me was how other people think so studying with other transitional DPT candidates gave me an opportunity for me because I was the oldest person in my class. Gave me an opportunity to hear people think and how they process, how they analyze and how they come to the decisions they do. And then how do they communicate it? I like to think I'm a good communicator, but oftentimes I get really wrapped up or wound up and, you know, I go off on a tangent and I probably go down the rabbit hole and maybe other people in today's world are much more succinct. Michael Weinper (00:09:31): And to the point also I can tell you that I was privileged back in 1975 to get my MPH at UCLA and the school of public health there. And I learned a lot about things that are important today, including epidemiology, which we now know is at the forefront of everybody's thinking and infection control and making for safe environments, which was only very basically touched in my DPT program. But one of the things that I really enjoyed was the differential diagnosis courses I took and the radiological courses I took that gave me a much broader sense for things that I'd studied back previously, or maybe taken some content courses, but went into much more depth and listening to other people discuss those kinds of things. So that's how things were back then. I can tell you also that insurance companies were perceived to be able to give PTs a lot more latitude. And it's only been in recent years that many insurance coverage industry to pay for PT. That's independent of physician referral. We're still working with Medicare on that. You and I know all the snow and I think the day will come that the feds will start to get a little wiser and realize the cost benefit of the PT being an entry point into the system. Stephanie Weyrauch (00:10:58): I think that that's a really great overview of kind of what you guys envisioned back in the early nineties and kind of correlating that with vision 2020. So the APTA vision 2020 and a couple elements that made that basically encompassed a lot of what you said. So autonomous physical therapist practice was one of them, direct access, evidence based practice, doctor physical therapy and lifelong education PPS as practitioners of choice and professionalism. So those were when the house of delegates discussed this, those were the main themes that they were looking for. So keeping those themes in mind, let's maybe start by talking about the doctorate of physical therapy. I mean, that was something that you were obviously very proud of. You will talk the talk, you walk the walk. So what do you think? Well, studies have been shown the DPT student debt now varies between 85,000 and 150,000. Okay. Do you think based off of what we're seeing today, as far as student debt, do you think that today's DPT is a good return on investment? And do you think that the salary for the physical therapist has kept up with the increases in training and inflation? Michael Weinper (00:12:14): Well, I'm very happy to hear you raised this question because it's a question that I not only think about a lot. I talked about a lot with my colleagues and I also talked with students who are becoming PTs and people have gone into residencies for a year post-doctoral now for purposes of gaining a better outlook on things. And I must tell you that when we gave thought to the idea of PT being a doctoral profession, never in our wildest dreams, did we think about the cost benefit aspects of it as it relates to educational costs back then costs were not inexpensive. You should teach part time at USC and Cal state university Northridge. And I remember students used to complain about the cost of education back then, but it was nothing as compared to today. So to get to your point, I am sad to say that we have not grown our income levels for PT to the level that they should be given the doctoral training that we received. Michael Weinper (00:13:29): And the depth that usually goes with that, unless you've got some kind of a rich uncle or a greatness scholarship, having said that most PTs coming out with a lot of debt, and then they find themselves in jobs that they don't want to do. Let me just elaborate a little bit on that. PTs in private practice is considered by many to be the desired venue in which to work because patients are coming to you. You have all kinds of equipment and resources and hopefully a nice facility to work in. And the patients for all intents and purposes are ambulatory or said differently. You're not going to be ambulating a patient in a hospital hallway and have something happen to your shoe. If you can get my drift in any event, it seems that most PTs that come out of school today are struggling with where they want to work versus where they have to work and where they have to often work or those places that pay more because they're less desirable. Michael Weinper (00:14:35): So as the desirability quotient increases, the unfortunately the salary decreases because of in part supply and demand. And also to a greater extent because insurance companies are not reimbursing PTs in private setting, like they are in the hospital, for example. So if I go to work in the hospital, I can make a lot more right out of school than if I go to work for an independent therapist in the same community. On the same side, I can go to work for a home health agency, not have this desirable of a work environment. Have you seen changes from patient to patient, but make better money, but then again, have other costs of doing business. And I think at the end of the day, those who do home health, and I don't mean to criticize those of you who do, but if you look at your cost of doing business and take that away from your income, you find that your true income is much less than you thought it was going to be. Michael Weinper (00:15:30): Whether it's wear and tear on your car, gasoline insurance, you have to carry on your own, whatever it may be, equipment you might have to buy and so on. So it seems to me that the desirability of where you'd like to work and the pay ratio is a universally, but proportionate with that in mind, it's a function of insurance companies, and this is where I really go down a rabbit hole. And that is why are PTs and private practice paid less? And the answer is because PTs in private practice accept less, they have an, I am very secure, experienced on this. Having started PTPN 35 years ago, a managed care company for PTs in private practice. And we have always advocated for higher reimbursement. And in fact, we Protestant have been successful in getting a higher reimbursement for PT and practices that are in our organization. Michael Weinper (00:16:30): Then PTs were in the community who are not in our organization. However, because PTs are willing to accept whatever insurance company pays. In other words, they don't want to lose business. They accept fees. They're much lower than they should. And that has driven down the value of PT in the mind of the insurer and that's led to lower salaries. And so to get to the end of this thought, PTs coming out of school, don't get proportion of the kind of income they should with a doctorate. And let's contrast that for just a moment to a PA, a PA has less training than we do. They will usually get a master's degree. They work in a physician's office, but the way that they can bill under the physician's license gives them much better reimbursement. It makes them more valuable to the physician and therefore their income is oftentimes much greater even out of school, you know, apples to apples. Then we get as a PT out of school. Stephanie Weyrauch (00:17:31): Yeah. I think you make a lot of really great points there. I mean, the doctor, the DPT was obviously great as far as, you know, gaining direct access, being more autonomous, but you know, the cost of education has obviously sky rocketing it. So based on, you know, your ideas, what do you think that the private practice section can do to help guide new graduates through the uncertainties of student debt? Michael Weinper (00:17:57): Wow. there's a lot of things that come to mind. First of all, we, as a profession have to be better educated to know when to say, no, that's a K N O W and N O in the same sentence. Know when to say no. In other words, if insurance companies are offering rates that are below what it costs us to business or below what we think we should be reimbursed, we need to learn to say no to them and walk away from that business. Maybe it's better to see fewer patients and make more money and be able to compensate our staff better than to take every insurance contract that comes down the road that pays less than it costs you to run your business. Those in private practice who might be listening to this podcast are shaking their heads affirmatively I'm sure because they get it. Michael Weinper (00:18:47): Those who are not in private practice probably don't understand what I just said. I don't need that it was criticism, but I think that at the educational level, during your basic education it's therapists need to learn more about socioeconomics as it relates to our profession. Supply demand economics certainly, and cost of doing business are key points. In years past for APTA taught courses on economics made easy for PTs because many of us come out of school even today without very much in the way of business knowledge or knowing much about economics. And once you learn more about that, things become much clearer and it makes it easier to make decisions that are in the best interest of our profession. So I think the PPS can, it does from time to time try its best to educate us on how to be better managers, if you will. Michael Weinper (00:19:51): And that includes things like the economics. But I think we, as a profession need to be top of mind with economics and learn how to advocate more as a group, as a profession, not just individuals because insurance companies will not look, listen to individuals. They will disappear to larger groups. To that point, larger groups get better reimbursement. So that point hospitals being really affiliated with one another or powerful entity as an association get better reimbursement. So I think that getting PTs together to understand I know APTA has advocated for many years better reimbursement. I worked with APTA in different retreats for payers. So there was a way to bring together a summit, a payer summit, they call it where they bring together many insurance companies. Actually I did one in Connecticut where you are cause that's a sort of a hodgepodge or location of many insurance companies. Michael Weinper (00:20:55): So we had several speakers who knew a lot about reimbursement, including Helene furan, a dear friend of mine and others who would speak to insurers about what is PT? What does a PT do? How do we evaluate patients? What does it cost to run a business to give these payers a better understanding, but remind you be reminded. These were not big association meetings. We brought peers together. So we might have 25 or 30 people in a room, some of whom which were larger decision makers than others, but when it came right down to it, we didn't have the ability to follow up with them and push them down the road to where they would be accepting of what we do. So we today, the cost benefit of coming to PT, I'm sad to say is very disappointing. It takes you a long time to work off your debt. Hopefully in the future, our government will see fit that people in professions like ours need to have better forgiveness of their debt in return for doing public service for the public we serve. Stephanie Weyrauch (00:22:06): Yeah. I think that you make a great point about the fact that we as private practitioners need to walk away from some of these more measly reimbursement contracts. And you know, one of the things that we hear a lot with incoming graduates is that there are a lot of private practices that have very high volume. And one of the reasons that they have low job satisfaction is because they're seeing so many patients. So I think that you make a really great point in saying that, you know, maybe it's better that we take fewer insurance companies, see fewer patients, but get paid more because now you're eliminating that burnout and that poor job satisfaction and allowing that new professional, or, you know, even if it's a veteran physical therapist, make the money that they actually deserve with the training that they have. Michael Weinper (00:22:58): Exactly right. And that's why we need to really advocate politically. And that's why the PT PAC is a very important thing to be involved with because we, as a profession can be heard through advocacy many, many years ago, I was one of the early trustees of what we used to call APTCAC American physical therapy, congressional action committee, which now PTPAC. And I always used to say, and I consider you to say today, if every PT would just give $25 to political action, how much more strength we could have because we live in a world where legislators listen to those who support them, support them with votes and support them financially so they can get folks important that we do get to legislators. Michael Weinper (00:23:54): We have a lot of people in Congress who are friends and have been our friends for many years, but we need more. And when things come up like budgetary cuts of Medicare, where they talk about an 8% reduction in Medicare reimbursement coming in next January, which I hope goes away. I think it will go away. I pray it would go away. But if it doesn't, I mean, think about that. You're getting a reduction in your reimbursement, which is not that great today. And they're going to reduce it even more. What's that gonna do to salaries? It's not going to help the PTs in private practice. And this is something that I think many people who are not in private practice, the students podcast may or may not, may not believe, but it has to be true. Michael Weinper (00:24:40): I've spoken to hundreds of PTs in private practice over the years. And I think many people would be appalled or shocked at least to realize that many people who own private practices do not make a lot of money. I spoke to a PT just last week here in Southern California, who was impacted by the rallies that were going on with black lives matter. And unfortunately, during that time, there was some looting and pillage went on by some bad actors, if you will, not people who were affiliated with the rallies themselves, but people who took advantage of that and broke into places and solving fuel and burn places. We all heard about that here in Southern California was one of those places in other parts of the country, the same thing that held true, that PT, when I talked to them and was trying to do what I could do to help them rebuild their practice. Cause your practice had been broken into and everything taken. Michael Weinper (00:25:42): I asked this individual if they would be willing to share with me how much they make per year. This person said to me, under $80,000 Michael Weinper (00:25:58): And I pause for a second. And since not only for the problems they were experiencing because of the looting and stuffed up to their office, but for the fact that even under good times, they weren't making a lot of money and they were working hard. They're working 10, 12 hours a day, sometimes on weekends. That is because they were in a situation where their cost of doing business is almost as high as what they would receive in payment. Michael Weinper (00:26:24): And we know that owners of businesses get what's ever left over after paying all the other bills, including salaries and benefits and rent and all the other things that come to mind. And it's not uncommon to find people who own their own practices, who do not make a lot of money and you have to take a lot of risks. So it's one of these things that we need Congress to better understand that it's important to support physical therapy as a profession, because we are a very valid and important aspect of the health care continuum that if we aren't there the cost of care will go up because rehabilitation, I believe, and I'm sure you believe decreases overall cost of care. So getting Congress to vote that in and to budget more money for us and Medicare, and then hopefully getting insurance companies to understand that not every therapist is going to do things on the low ball side of it, but really are going to hold out for a higher compensation that they're entitled to. Michael Weinper (00:27:36): They're going to be more inclined more and as a parent more it's my idea that therapists should be able to own practices to be able to pay their staff more. I've always said, Stephanie, that I wish I could pay every therapist that works in our practice, $150,000. I think they're easily worth it, but it's a function of what we get paid. And I can tell you that, you know, my own practice, progressive PT my income hasn't gone up in over 10 years and I don't make, you know, I don't make a lot of money in it, but it's because I get what's left over after we pay everybody. I feel that we've got to give our employees reasonable compensation for what they do. And we don't use a lot of extenders. We don't do a lot of things that are in the realm of I'm doing it on the cheap side as many people do. Stephanie Weyrauch (00:28:31): Yeah. I think that your points about advocacy are really important because I know APTA has been working on that 8% cut. You haven't written to your Congressman. I definitely encourage those of you listening to this podcast today to log onto APTA's website, whether you're a member or not and write a letter to your Congressman, it really only takes three seconds. Additionally, there has also been a legislation that has gone forward with trying to increase the loan forgiveness for DPT students. APTA is always trying to get us to have pay, be paid more so that advocacy piece is really important. So that kind of brings me into the next pillar or the next element of vision 2020 and that's full direct access. So we do have at the some form of direct access in all 50 States right now, however, there are three States where the direct access is extremely limited, where you basically can only do a wellness evaluation without a doctor's referral. And then there are about 27 States where you have direct access with basically limitations or rules attached to it. And a lot of those have to do with say diagnosis or with different interventions like dry needling or electrical stimulation. Those types of things. So kind of along that route, how can PPS ensure that we get full direct access in each state? What are some things that the association can do and that physical therapists can do? Michael Weinper (00:30:04): That's a wonderful question. And I think the answer is create stronger advocates in each state because what you're talking now is not about federal legislation, but state legislation. In other words, each licensing act is governed by the state legislature. So having a good group of PTs who can rally and lobby, if you will, or have a lobbyist, if there is a big enough state to meet with members of the state legislature to express how important it is in an effort to control costs in healthcare, to give therapists more clinical rights and abilities, that's where it starts. Once you get that, then you can get insurance companies to start to buy in because they realize that is legal in that given state. I have seen this happen throughout my career that has been slow to come. We've been shooting for direct access. And at the same time also trying to eliminate the need for there to be physician intervention in certain musculoskeletal situations where we now are trained as diagnosticians to be able to evaluate and treat these things. Michael Weinper (00:31:17): It's my hope in the future that we get the opportunity from a licensure standpoint to order x-rays, to order lab work and things like that, to where we can have more information at our fingertips, but then to have to refer out. But only where it's appropriate, where we're adequately trained to do that. You have to teach legislators what is PT and what is the benefits of PT and what are the cost savings that insurance companies, the public. And we all save by giving the opportunity for patients to be strong entry points into the healthcare field. It's certainly fond for us to evaluate patient. And in some States you can do, like you said, dry needling. I live in a state, California doesn't even allow dry needling. I have people in my practice who teach dry needling to therapists around the company because he used to do that where they worked in other States, very frustrating for them, extremely frustrating for me, but it takes legislation. Michael Weinper (00:32:25): It takes talks. It takes contributions to your local state PAC, and most of them have it now. And to be involved in APTA, I think is key that so many PTs I call nine to fivers. They come in and they do their nine to five and go home and they forget about their profession. People like you and others who are dedicated to making this a better profession for PTs of the future, not to mention the public that receives our care are the ones that make things happen. And so being more involved in our field through volunteerism obviously is key, I think, to change and too many of us look to the other guy to do it, whether it's writing a letter to your congressmen, or there's going to meeting with a state legislator, whether it's inviting your local state representatives into your practices, see who you are and what you do. Michael Weinper (00:33:27): All of the things bode well for growing our practice. And too few of us, unfortunately do that. We don't realize that it starts fortunately with regulations and what we can do and how we can do it. So the quest, if you will, or request, I should say would be that we as a profession, get more involved in our association because the association is the focal point for getting the information to legislators. It's our association that has the greatest credibility. And I can tell you that one of the reasons I went back and got my DPT was that I saw that when I would testify on a bill in Sacramento here, there would be people with a doctorate, not necessarily in our field, but just doctorates, so would speak against what we were doing it. And I would get up there and I would have 40 years of experience, and we have a master of public health degree then on my doctorate. Michael Weinper (00:34:26): And I were always, and I would like to think I had good presentation and good preparation and knew the facts. And yet it was those who had doctorates that were, or had the title doctor who were paid more attention to now, we as PTs have that title. And now we're sort of in a level playing field with other professions, from the term being entitled a doctor. And with that credibility, we need now to take more action, we need to spend more time trying to create change in my Dicus talk back in 2000, I said that people were afraid of change and it's true. And even today they're afraid of change and we all like the status quo, but the reality is we need as a profession to embrace change because with change comes progress and we need to progress as a field of profession. If you think about things it takes a village if say and certainly in our professional, it's no different, we have to be part of that village. We can't just be part of the tribe. We need to be active leaders of our village. Stephanie Weyrauch (00:35:43): Yeah. And I think, you know, if you look back at where we were with direct access 20 years ago, I mean, obviously we're in a much better state than where we were, but some of the resources that I know PPS has for people with their fighting, the direct access is they do offer grants to state associations if they're doing any type of lobbying. So if you haven't applied to one of those, it's a pretty hefty amount of money. It's like five or $10,000, which that goes a long way when you're paying the lobbyists to do the work for you. You know, they also have a key contacts program and they offer resources for practitioners that if you do invite a legislature in a legislator into your practice, or you are trying to advocate for a bill, like they provide all that information for you on their website and on the APTA action app. Stephanie Weyrauch (00:36:29): So, I mean, PPS does have resources out there that we can utilize to try to continue in our fight with direct access. And I mean, yes, we're in a much better place than where we were 20 years ago, but like you said, change takes time. And as a, you know, as a young professional, I definitely would love to see change happen even faster. So you know, the more people we can get together and build that village, the faster it's going to happen in your Dicus speech, you also talked about how you envisioned that physical therapist will be evaluating and diagnosing conditions, performing specialized treatment procedures and working with the PTA team. And then you also envision that there would be no referral needed by another practitioner. And I know you've kind of covered this a little bit, but give us an idea of where we are, where we're at with this prediction and what you think the future holds. Because as you know, a lot of these direct access bills that we have still restrict our ability to quote unquote diagnose conditions or even perform specific procedures. So kind of give us an idea of where we are compared to 2000 and where you see us going in the future. Michael Weinper (00:37:41): Well we are obviously light years ahead of where we were in 2000, just by hearing what you described to helping things in what I predicted. And I think from the standpoint of going forward, we need to be cognizant of the fact that we can change things if we put some effort to, and in other words, so many therapists don't do things because I think I hear people say, Oh, it doesn't make a difference, or they'll say somebody else will do it. And the truth is that we all need to be more involved. And I'm one of those key contacts and have been for many, many years. I can only tell you that how rewarding it is to invite a legislator or even somebody who works in their office, into your office, into your practice, to visit with you, see what you do, talk to you, the things that are your barriers to growth and barriers to doing for patients, what we should be doing and should have been doing for many years. Michael Weinper (00:38:46): And I think it's more important to understand what you can't do versus what you can do. And you only learn that by going to stage or talking to people in other States who have full privileges to do those things and have that true autonomy. So I think that by attending association meetings, for example, PPS is a great example or CSM when it comes back. And, and I say this, not just going to the meetings, but talking to people, not just your friends, but talking to people you don't know, but from other States where you might know there's a lot more progress, ask them what they did and how they did it, or talk to the leadership in those States, in those state associations and ask them, how did they accomplish what they accomplished? Because it takes a lot of work and there's a lot of resistance by other professions, physicians be it chiropractors, osteopaths, even dentists from time to time resist, having us grow to where we should grow. Michael Weinper (00:39:53): And the key again is educating the public, what we do. So when you're treating them, let them know what you can do, what you can't do all because of the laws, even though you might be trained to do these things. And sometimes the best advocacy doesn't come from ourselves. It comes from the people we serve our patients. So getting people to write letters to their members of the legislature is very important. But I think getting more people to stand up, write letters, attend hearings in your state Capitol become more involved, become more aware of the benefits you can create, not only for the professional, but certainly for yourselves as well. And that's one of the reasons that I've been very involved in APTA throughout my career was I felt that I had the ability to change things if I would only work at it. Michael Weinper (00:40:47): And I was very blessed. You haven't brought it up, but Bob Dicus for who the Dicus award is named obviously was one of my mentors. When I was a student, I got to meet Bob. He was already very deep in his ALS disease in Georgia. He was fully wheelchair bound and tied to a respirator, but that man had so much knowledge. He was one of the first private practitioners. And one should only go to the PPS website and learn more about Bob and what a great man he was and what a visionary he was for our profession. As a matter of fact, just to digress for a moment, he is the one who created the ALS society nationally. He was the inventor of that. He had a second professional. He was in, he was a motion picture producer in his later years when he couldn't be a PT, he went into motion pictures. Michael Weinper (00:41:48): A lot of them had to do with rehabilitation and things that we do. They weren't necessarily featured like Sims, but he got involved in that kind of communication. So it always goes to the fact that I think some of the best PTs are the ones who are best able to communicate with their patients, with the public, with our legislator. Sure. Those are the PTs who really do the best, because if you're good with your patients in communicating, you're able to motivate them to do the right thing. Right. And communication is something that we need to study more perhaps in school. I teach a lecture on communicating with different generations because as I become part of the older generation and looking at the younger people, I see how you and others in your generation and younger generations communicate with one another as much different than what my experience is. Michael Weinper (00:42:43): I grew up with our computers. I remember the very first calculators. We were not what I was going through school in high school. We used an Abacus and a slide rule. And then going forward, we used a Texas instruments brand calculator, which was very expensive and very elementary looking back at it. That's an idea of technology when technology and communication are, I think are very interwoven. In other words, as technology increases, communication becomes dependent on that technology. And we tend to communicate less with one another or said differently. I can see my son-in-law and daughter at our house, sit on the couch, waiting for dinner, remake, and what are they doing? They're texting. And I said, who are you texting to talk to them? Wait, what answer? Just speaking with one another. And that's just the world we live in. And then all the little acronyms, all these simple things that you know are, are part of the lexicon today. Michael Weinper (00:43:56): Today's younger people, older people don't necessarily know. And when treating an older patient, it's key that you speak to them in a communication form that they're going to understand. And don't assume they understand. I mean, you're saying just because you're saying it, and the same is true for older therapists like myself, talking to younger people, you have to motivate them in a different way. Young people want it. Now they want things quickly. They're used to getting information quickly. You go with something up on Google and get an instant answer on something. Whereas back in my day an encyclopedia sales person used to knock on our door, trying to sell my family a big set of 30 books of encyclopedia. We were tell much to us what we needed for today's knowledge. And I don't think those people around anymore. If at all. If you wanted an encyclopedia, you've got it. Michael Weinper (00:44:50): Just look up something in Google or another search engine, and you've got instant. You got too many answers. Sometimes you get different answers for the same question, but with all that in mind, communication is key to success. And we as service need to communicate better, not only with our patients with one another, with our legislators and with the public in general, and to that point, having better PR public wise. And I think APTA is trying to do that. Now that we're into our hundredth year, starting there as your celebration or Centennial celebration. I think you're going to see a lot more information going out to the public, through electronic media and social media, to where we gain a higher visibility with the public. Michael Weinper (00:45:38): I had the TV on the other night, I was watching a game show and one of the contestants was a PT. And he was a young PTA until that. And he didn't want a whole bunch of them. I think it was, I believe the show was a wheel of fortune actually, which I don't watch too often, but it was on. And I've heard the word physical therapist. It's just like you, whatever you heard that word somewhere. Even as sitting in a restaurant, you hear somebody talking about their PT, your ears perk up and you sort of start to eavesdrop a bit. And we as a profession don't hear that word in the public as much as we hear about doctors or other things. So I think the public needs a better awareness of who we are and feel comfortable talking to us. And we need to feel comfortable talking to them and educating more about who we are for. They haven't needed to see us. Stephanie Weyrauch (00:46:26): I think you make some really good points about the communication aspect and that kind of leads into the next element of vision 2020, which is us being practitioners of choice. So in kind of going off of that with communication, it's too bad Bob Dicus, isn't around anymore to make the next hit healthcare drama on physical therapists. I mean, how many physical therapists and healthcare dramas do you see walking patients or stretching patients? You know, it's never really, they're never main characters in, you know, like Chicago med or Grey's, you know. Michael Weinper (00:47:05): Anytime I see a PT portrayed in these situations. I cringe because first of all, they're wearing, and I hate to say this cause I'm going to probably, I'm going to take an issue with some of you they're wearing scrubs. I don't think I don't scrubs when I grew up were for people working in surgery. Now everybody wears scrubs. So you go to the grocery store. People were in scrubs. They, I think people not even in healthcare wear scrubs sometimes, but I think we should look more professional. We should be more professional and the public will respect us better if we act more professional. And so there are some times PTs who are brought in on dramas to be a technical advisor. I have been in that position before twice, and I have talked to directors and producers about what they need to show. Michael Weinper (00:48:05): And I can only tell you that what you tell them to do and what they end up doing sometimes is different because maybe they don't have the right equipment or the character. They thought they already lined up costumes for their characters. It becomes very frustrating, but getting in on the front end and getting the public to understand who we are, hopefully through drama and maybe through, you know, like I say, public service announcements or ads on TV where we're portrayed better or having the opportunity. Many of you are in smaller cities and towns, your local newspapers and television are hungry for local news. And you may be doing something you don't need to think second thought about, but it's newsworthy. Maybe you just purchased a very important piece of equipment to help with ambulation or suspension or something technical electronically to create new opportunities to treat patients your local TV stations would love to demonstrate, come to your clinic, film you doing that and have it as a segment on their TV show. Michael Weinper (00:49:21): And many of us don't even think about that. So and I, again, even in Los Angeles market, I've had the opportunity to do that a couple of times. And it can be a little bit overwhelming, a little bit scary, but you know, something at the end of the day, you feel really good about it and how you come across is much better than you perceived. You are going to come across when you're getting ready to do it. So don't be shy, but reach out to your local media and try to get them interested in what you do, because what you do, what I do is very newsworthy and very important for the public. Stephanie Weyrauch (00:49:52): Yeah. And you know, obviously people are following what the media says and listening to the media. So, I mean, the media is, has been a very powerful force that you can utilize to spread the gospel of physical therapy so that we can become the providers, the practitioners of choice, for the musculoskeletal system. And so the people actually know that PT means physical therapist and not like personal trainer or part time, people actually know what it means in your speech. You also stated that PTs would be recognized by payers as diagnosticians an entry point into the healthcare system. And I know you've talked, you you've touched on this a little bit, but how do payers recognize physical therapists and how do today's payers recognize us compared to back in 2000? Where are we at with that? Michael Weinper (00:50:43): Well, back in 2000, and even in day sense, payers felt we needed to be treating only under a physician's referral. If you looked at insurance policies that you might have, or if you spoke with payers, they would say that PT was a covered service when provided or the auspices of a physician referral or diagnosis today. Many of those policies from the same payers do not have that language. So because of the direct access laws and because of therapists and given States talking to their insurance companies, the payers they've educated them to where certain payers are starting to realize the benefits of PT first. And let's just take substance abuse and chronic pain. We know as musculoskeletal experts, there are lots of things that we can do for the patient to avoid surgery, to avoid downstream costs like expensive imaging that may be unnecessary. We can certainly get the patients treated properly and get them in a mindset to where pain is not top of their mind. I have a book sitting right behind me on my bookshelf. It's called explain pain. Are you familiar with this book? Stephanie Weyrauch (00:52:13): Oh yeah, that's a very familiar book. Michael Weinper (00:52:16): Okay. And this was a very good book for people to read. It's the authors are David Butler and Lorimer Moseley, and they're down in Australia, but they talk about dealing with the mental side of pain, the cognitive side of pain, if you will, and how to best creature patients in deemphasize of pain and emphasize wellness or health. And we need to do more of that as practitioners. And as we can educate our insurance companies, that by sending the patient to PT for four or five, six visits, we can avoid surgery, many cases, what is a cost benefit to the insurance company? Their insurance companies listen to money. And I know this from my experience for many years of working with many of them speak with probably too many insurance companies to not only remember, but to count. And they are driven by dollars and they do not put enough emphasis on times in their underwriting to allow PTs to do the things we do. Stephanie Weyrauch (00:53:26): Yeah. Michael Weinper (00:53:28): Shortsighted because they ended up then forcing patients to go to a physician first, wait, several days or weeks to see the physician where the patients only getting more deconditioned. And rather than just seeing us first, and we have the opportunity and the knowledge on doing things that get the patient out of the problem or fixing the problem, if you will, from a nonsurgical standpoint. So insurance companies in some cases have become much more enlightened and other cases are still in the dark ages. And those who allow us to treat without referral and pay us for what we're worth are the more enlightened ones, some insurance companies that I've dealt with now in recent years are paying for outcomes. There's concept of paper for pay for performance or P for P. I like to call P fro. It's really not what you do, the process of what you do, but really the outcome that you get. Michael Weinper (00:54:27): So if you can get a great outcome with fewer visits, then insurance company should be willing to pay you more because you reduce their costs. And, not only of what you did in terms of your crew cough, but in terms of what would otherwise cost them to treat the patient going forward. So I like to pay to pay for outcomes Peterborough, and that's why we, as a profession, need to do more in the way of outcome measurement, whatever tool we use and be able to communicate to the payment payer community, the benefits of what I do. So I'm going to go back now to the mid seventies again, when I got my master's degree we learned even back then that the definition of quality in healthcare was composed of three things. And the author of that was a fellow who's no longer with us. Michael Weinper (00:55:22): His name was Avitas Donabedin. He was a physician. He was very involved with the new England journal of medicine, D O N A B E D I N, if you want to look it up and Donabedinn even back then said that quality health healthcare was three things structure, which is where you do it and what you use in terms of equipment process, what you do okay. And outcome, or the results. So we all have been able to measure it structure, and we were able to mission measure the process where you, but not enough of us over my career have been able to truly prove that what they did was a benefit. And I think that that's one of those things that we have to focus more on proving the benefit of PT two outcomes or said differently because of what we do, patients get better quicker. Stephanie Weyrauch (00:56:16): And that leads us really nicely into the next element of vision 2020, and that's evidence based practice. So obviously APTA has done a lot over the years to try to improve how we're measuring outcomes. So you have the outcomes registry CoStar was created. If you look at how much the literature has been put out for, if you search, if you search up physical therapy, even in Google, it's, you know, an exponential growth since even 2000 and even the larger growth. If you think about it from even the 1970s, when outcomes were first described. So, I mean, this is something that, you know, we've been working on for a long time. I think that obviously it's come a long ways, but we still have confirmation bias in our literature. We still have group practice that people are practicing. We have treatment fads that really don't have a lot of evidence behind them. And we have practice variation that continues to affect our outcomes and affect our profession. How can PPS help offset this? How can we continue to go forward to mitigate some of these things that are occurring? Michael Weinper (00:57:24): Well, that's a $64 question, as we used to say my hero. I think it's important that we need to, you talked earlier about one of the goals of PT, 2020 is lifelong learning. And I see too many people in our profession who don't come to meetings of the profession, whether it's a local meeting in your area, whether it's a state conference whether it's CSM or PPS meetings, too many of our colleagues never go, or maybe they went as a student cause their school paid for them or somehow or another they're were to go. And they never ever go. If you think about people, you went to school with Stephanie, you never see them again. And you wonder, how are they getting their education? One of the things that has occurred a dream the last 15 years I would say is the requirement by States that each PT in order to continue, their licensure must have continuing education, a certain amount. Michael Weinper (00:58:35): And it varies state by state, as we know, and what things have to be parts of that, continuing education, again, vary by state by state, but at least we're being forced now as a profession to continue our learning. Having said that, and having taught in different venues in different ways. I can tell you, there are people who are serious learners, and there are people who we call lazy learners. The lazy learners are those who will buy the cheap level CEU kind of stuff, and do a quick read on something and take a test and not really spend the time to investigate what was being offered. And maybe some of the quality of that they're learning is really not up to date either. Versus those of us who will go to con ed meetings, we'll do things online. Now there's a lot of opportunity. PBS shows a lot of things out ABQ has a lot of things. Michael Weinper (00:59:35): I'm a member of the orthopedic session section and the oncology section. They have lots of stuff going on that, yeah, there's too much of it. There's just like there's like education overload. So you have to be selective, but do choose things that I think will be beneficial to you. And that are evidence-based. So it brings back to the evidence based part because too often I've heard people get up at meetings and start to talk about things. And then when challenged on what's the word, what's the basis of your comments? They sort of stammered. And they said they gave answers that weren't really appropriate. So we do need more focus on, on lifelong, which we're mandated to do, but some people take the easy way out. You know, people, we all have people we know who will take the high road and others who take the low road and the low road may be the easier road that may not be the get to the right end. Michael Weinper (01:00:29): So we want to challenge ourselves to learn more each day. And I can tell you that when I went back and got my DPT, I thought it would be fairly easy. And some of the things that I was exposed to, I'd already learned in my master's level, but I can tell you a lot of things that I learned were new concepts that I had never even thought about. And that goes to the idea of this lifelong learning and evidence based practice you learn, most of you learned in school all about evidence-based theory and practice, and some of you embraced it very well and other views sort of gone a different path. So I would say, take a step back and look at the research that's coming out. There's all kinds of journals. And that's another thing that I have to digress on a moment. Michael Weinper (01:01:17): And that is, here's a question for each of you, how many journals or publications that are healthcare oriented, do you read or subscribed to, if you say only PT, then I think you're making a big mistake because there's so much literature and so many things that are appropriate for what we do in our field. And to validate what we do in other journals and research is being done that we miss the boat by not looking at it at other professional journals or other modes of information, or even attending meetings for physicians and so on. I used to specialize in the treatment of hand injuries. And so I would go to the society for hand search and they actually had a PT sub, a PTO to see subset of that that my friend, dr. Susan Mike Clovis, was very involved in and she got me involved and I would listen to physicians. Michael Weinper (01:02:18): We collegial meetings where PTs and physicians would interact to try and come up with the best ideas. And many of us don't really have any contact with physicians, except when we're talking to them in the halls of the hospital or when we're going out to market them, or we're trying to take lunch to them. We don't talk really about concepts and about theory. And what do you base this upon? And what can we do to learn more about the benefits of what we do? And that gets us to the idea of each of us having the challenge to do some research, research is fascinating. It doesn't pay a lot, but you can still do research in your clinic. You can be parts of research projects. If you just look for them, is they're out there to take advantage of. And if you do that, it opens your eyes so much more. Stephanie Weyrauch (01:03:09): And I think a lot of the things that you've touched on kind of goes with the last element of vision 2020 and that's professionalism. So when the house of delegates originally defined what professionalism means in vision 2020, it's that we as physical therapists and physical therapist assistants are consistently demonstrating core values by aspiring to and wisely applying principles of altruism, excellence, caring, ethics, respect, communication, and accountability by working with other professionals to optimize health and wellness in individuals and in communities. So obviously one of the bigger focus is of APTA has been this optimizing society or optimizing movement to impact society. And we've been kind of taking more of a population health kind of perspective, trying to get out of the silo, physical therapy and move more into the interdisciplinary healthcare, healthcare, professional realm. Where would you say we are? As far as our professionalism goes in 2020, compared to where we were in 2000? Michael Weinper (01:04:15): Oh boy, I think many of us have because of our increased education, gotten more credibility with the medical profession. They tend to listen to us more rather than just seeing us as a technical entity or a technician versus a professional. Although I can tell you still today, physicians oftentimes don't see the benefit that we do even orthopedist. And we have come a long way in some with so many physicians, but we've missed the boat with others. I think it's critical than medical stuff, schools, especially if you're doing an orthopedic residency, that's a resident spend time with a PT. I was in a well known physician, internationally known physicians office recently with my wife who, when she had her shoulder surgery. And he has no to fellows at all times. And occasionally a PT will visit and come in and, and be there not to get paid, but just to talk and work with the physicians, educate the physicians and the younger ones, the fellows who are going to be out there real soon in their own practice. Michael Weinper (01:05:34): We need to do a better job of educating physicians. I said that a little bit earlier, but I really mean it. We can do it when they're in school, when they're doing their fellowships, we can invite them into our practices. We can go to doctor's offices and shadow them much more than we do. We can go into surgery with physicians and talk to them while they're there doing their procedure, learning why they're doing their procedure. And sometimes a light bulb will go on in your head say, Oh, I get that. And that's, I think there's something I could do a little bit differently with like, with your patients when I'm treating them by seeing what you're doing surgically and listening to what your concepts are. So I think there's a lot more collegial realism of that goes to being a professional. And to that point, if you don't see yourself as a professional others, aren't going to see you as fun and too many of us lose track of the fact that we are in it. Michael Weinper (01:06:27): When you say it's a profession, a profession requires one of the key points of any profession is that you learn, you keep current and you give back to society. And giving back to society means more than just treating people. It means educating the population, doing things from a wellness standpoint or avoidance of injury. I guess going back to my public health days where one of the key things is getting people not to have to see you clinically as a post op or whatever, but helping people to avoid surgery and do things the proper way. Ergonomics for example, is a good, good use of our skills and what we've learned as I sit up in my chair properly. And we doing things that people just don't think about. And when we break away from just being the PT, treating person and branch out to media with other professions, talking to them about what are their challenges, what can we do to help though, or thinking about things we can do to help them communicating better in collegially at different levels. Then we go a long way towards not only building those relationships, but most importantly, helping the patients we serve. So it's one thing to say your profession. That's another thing to give back to society and find different ways to give back Stephanie Weyrauch (01:07:55): What, you know, from this conversation. Obviously we've come a long way since 2000, we've achieved many things that vision 2020 set out to achieve, but we still have a lot that we yet need to achieve. So kind of on that note, Mike, you know, what is a clinical Pearl that you can kind of leave all of us with? What is some advice you could give a young graduate or somebody new in the profession that maybe you wish you would've known when you were coming out of school? Michael Weinper (01:08:29): Oh, that that's an easy question to answer because I oftentimes get asked by younger PTs, how did I become successful? I say very simply through volunteerism, volunteering your time to help your profession and help those we serve, whether it's going to a health fair and educating the public, you ever done that fascinating what they don't know and how the aha moments you see in the public. When you spend two minutes with them screening students preseason athletic screening, another great opportunity to follow tourism positions you're working with, Oh, that's how you do that. That's how you measure that. I didn't realize that. And that's another idea, again, of getting involved, getting I talked earlier about legislation, getting involved in legislation, getting involved in your association is what I think makes you successful. And to that point, I think that the best jobs of PTs get are not the ones they see through a Craigslist or three C on the association. Michael Weinper (01:09:41): Advertisements is from talking to other therapists, word of mouth learning, where are the best jobs to be had. And the only way to do that is not staying in your little house if you will, but getting out and talking to the PTs. That's like I said earlier, getting to know other PTs there's this PT pub nights that I see around the country, what a great idea I've gone to them. And they're actually fun. I stood out in the rain. They had an outdoor one here in Southern California, and you don't get a lot of rain here, but that particular night, we all were standing outside of this venue drinking our beverages of choice, getting soaked, but having a good time. And it's very memorable and getting to know other people and volunteering just goes a long, long way. I think, to learning more and learning what needs to be done, if you could learn what needs to be done and then not put it on somebody else, but say, I'm going to take responsibility again, getting back to I'm a professional. Michael Weinper (01:10:43): I need to be professionally responsible. I need to be the one who does this. I know you're one of those people. I'm preaching to the choir. Stephanie, when I say this and you know exactly what I'm talking about, but so many people who might be listening to a podcast like this, don't quite follow it. So my challenge to each of you would be get involved in your profession and spend a little time here and there, away from family away from work away from your social activities and back to your profession. That's part of being a professional. And as you give back, the more time you give the more you get. And I like to leave this thought with people. And that is for all the thousands of hours, I guess, at this stage of my career, I have given to my profession, whether it was the local district or my chapter or the national association or the private practice section or other sections I've been involved with or doing things in the public realm, getting involved in I was involved in a college board. So people got to know me as a PT and as an individual and get to know more about PT, getting involved in society, rather than just going home at night, turning on the TV, or turn on your computer or playing games, getting more involved with people and trying to do good things for the public benefits you directly. Stephanie Weyrauch (01:12:11): There were some wise words spoken by a true visionary of our profession. So thank you so much. And thank you for all of those who listened to this episode of the healthy, wealthy, and smart podcast and I'm your guest host Stephanie Weyrauch. And I hope that you stay healthy, wealthy, and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts!

On this episode of the Healthy, Wealthy and Smart Podcast, Dr. Michael Weinper speaks with guest host Dr. Stephanie Weyrauch about the American Physical Therapy Association's Vision 2020. Passed by the House of Delegates in 2000, Vision 2020 was APTA's plan for the future of physical therapy. In his 2000 Dicus Award speech, Dr. Weinper discussed his predictions of where the profession would be in 2020. Dr. Weinper and Dr. Weyrauch revisit the elements of Vision 2020 and analyze whether our profession has accomplished a vision of the future set twenty years earlier. In this episode, we discuss: -How has the physical therapy profession evolved since the drafting of Vision 2020? -The student loan debt to income ratio -Advocacy efforts to achieve full direct access in all of the States -The importance of lifelong learning and evidence-based practice -And so much more! Resources: Stephanie Weyrauch Instagram Stephanie Weyrauch Twitter Stephanie Weyrauch Facebook Email: sweyrauchpt@gmail.com APTA Website A big thank you to Net Health for sponsoring this episode! Learn more about Four Ways That Outpatient Therapy Providers Can Increase Patient Engagement in 2020! For more information on Dr. Weinper: Michael Weinper, PT, DPT, MPH, cofounded the company in 1985 with his partner, Fred Rothenberg, a former executive at Blue Cross of California. A physical therapist with more than 40 years of experience in clinical practice, management consulting, administration, and program development, Weinper is also a principal in Progressive Physical Therapy, a private practice, with four locations in Southern California. Weinper received a Bachelor of Arts degree in Industrial Psychology and a Bachelor of Science degree in Health Science (physical therapy) from California State University, Northridge. He received a certificate in physical therapy from that institution in conjunction with UCLA Hospitals and Clinics. Weinper later received his Master of Public Health degree (M.P.H.) from UCLA in Health Services Administration and his Doctorate in Physical Therapy from the EIM Institute for Health Professions in Louisville, KY. Weinper has been active in the American Physical Therapy Association (APTA). He has served as a member of the APTA's Task Force on Physician Ownership of Physical Therapy Services, as a member of its Committee on Physical Therapy Practice, as the association's chairperson on its Task Force on Reimbursement, on the Board of Directors for APTA's California Chapter and national Private Practice Section, and as trustee of the APTA Congressional Action Committee (now known as PT-PAC). Weinper received the prestigious Robert G. Dicus Award from the Private Practice Section of the APTA in 2000, and he received the Charles Harker Policy Maker Award from the APTA Health Policy and Administration Section in 2011. On behalf of the state of California, Weinper has served as a member of the Physical Therapy Subcommittee of the Division of Industrial Accidents, now known as the Division of Workers' Compensation. He also has served as an expert to the Medical Board of California, where among his activities he has appeared on behalf of the People in insurance fraud trials. He has provided expert witness testimony on behalf of more than 20 insurance companies. A former associate professor of health science at California State University, Northridge, Weinper is a frequent presenter for various professional associations including the National Managed Healthcare Conference, the American Medical Care and Review Association, and the APTA. He has authored many articles for both physical therapy and insurance industry publications. For more information on Stephanie: Dr. Stephanie Weyrauch is employed as a physical therapist at Physical Therapy and Sports Medicine Centers in Orange, Connecticut. She received her Doctorate in Physical Therapy and Master of Science in Clinical Investigation from Washington University in St. Louis. Dr. Weyrauch has served as a consultant for a multi-billion dollar company to develop a workplace injury prevention program, which resulted in improved health outcomes, OSHA recordables, and decreased healthcare costs for the company's workforce. She has served on multiple national task forces for the American Physical Therapy Association (APTA) and actively lobbies for healthcare policy issues at the local, state, and national levels of government. Currently, she serves as Vice President of the American Physical Therapy Association Connecticut Chapter and is a member of the American Congress for Rehabilitation Medicine. Dr. Weyrauch is also the co-host for The Healthcare Education Transformation Podcast, which focuses on innovations in healthcare education and delivery. Dr. Weyrauch has performed scientific research through grants from the National Institutes of Health and National Science Foundation at world-renowned institutions including Stanford University and Washington University in St. Louis. Her research examining movement patterns and outcomes in people with and without low back pain has led to numerous local, regional, and national presentations and a peer-reviewed publication in Archives of Physical Medicine and Rehabilitation, a top journal in rehabilitation. Read the full transcript below: Stephanie Weyrauch (00:00:01): Hello everyone. And welcome to the healthy, wealthy and smart podcast. I'm your guest host Stephanie Weyrauch and I am interviewing Mike Weinper who's the president and CEO of physical therapy provider network or PTPN as it's better known and also a private practice owner for progressive physical therapy in California. The reason that I wanted to talk to Mike today, as he won the Robert G Dicus award for the private practice section back in 2000, and he has been an instrumental person in practice, leadership, innovation, legislative, and political issues, healthcare reform, and a number of other areas where he's really had the opportunity to champion innovation and leadership. And one of the things that, you know, we know it's 2020, and obviously vision 2020 has something that has happened in the APTA was written back in 2000 and in Mike's Dicus award speech, he talked a little bit about where he thought the profession would be in 2020, in 2000. And so I'm really interested in kind of his take on where we are today. So Mike, welcome to the healthy, wealthy and smart podcast. And tell us a little bit about yourself. Michael Weinper (00:01:21): Well, thanks Stephanie, for the very nice introduction and it's a pleasure and an honor to be with you today. At some level, I'm considered by some, to be a dinosaur, having gotten my Dicus ward 20 years ago, and now long in my career, I'm just celebrating my 50th anniversary as a PT. So I hope that some people won't tune out just because of that. Maybe if nothing else, they can see me as a history lesson, any event, I can tell you that back in 1992 the California chapter of APTA now called California PT association created a long range planning task force that I was honored to serve on. And in that task force where a lot of leaders in the profession in California names that were household names, then probably names and most people would not know now, but our plan was to draft a long range vision. Michael Weinper (00:02:21): If you will, a crystal ball of what things would look like some 18 years later in 2010, kind of looking back, it's interesting to look at and we created, I believe 18 different points that would be goals if you will, of the association and the primary aspects of that working document, which was called PT 2010 by the California association. I'm sure if you were interested, you could look it up or get a copy of it. Then later became the working document for APTA called PT 2020. And since we are now in 2020, I wish we would have known then what we know now, because things have dramatically changed in many ways, but in other ways they have not. And so I guess I could give you some of the ideas we envisioned back in 1992, if you'd like, and then we can take it from there. Michael Weinper (00:03:23): So in that document, we said that PTs would be able to evaluate and diagnose conditions that's true today, perform specialized treatment procedures and work in teams with physical therapists and PT assistants. So all that did come true. Next, the PTs would be able to initiate services subsequent to their own evaluation diagnosis without referral from or diagnosis by another practitioner. And that in 2000 that had not yet been accomplished, but we, now we know we have independence and practice almost every state with regard to our licensure. In most therapists are, would be in independent press configurations with other therapists, maybe who would work in a hospital. In other words, there would be an opportunity to be clinically specialized in it with a board certification, which we now know has really grown quite a bit. Michael Weinper (00:04:25): And they would be sought out. These specialists would be sought out by consuming public and third party payers. Not as much. I don't think our profession has reached to the public well enough to get the public, to understand what a board certification really means and what it takes to become a board certified specialist in our profession, but I'm progressing for a moment. Anyway. So then we said that PTs would be able to be involved in the continuum of care from the hospital to the home, to the private practice. In other words, PTs would have hospital-based privileges and they would be able to go there. And then if the patient were home, many of them would be able to then go to the patient's home and treat them there and then follow them up in the office. And so that was another kind of idea we had way back then. Michael Weinper (00:05:21): So it would be basically following the patient through the episode of care from beginning to discharge and obviously getting them ambulatory and functional. We also said that this is a good one that PTs would become diagnosticians. And more importantly that we would be at the entry point in healthcare which wasn't the case in 2000, but in now in some places, it is that therapists are in fact these musculoskeletal specialists would be a cause we can do it musculoskeletal evaluation or diagnosis many states now recognize that. And some insurance companies have recognized that we can be an entry point into the system, which I believe going forward, it's going to become much more prominent because of the higher cost of care. And actually Stephanie, the difficulty we all experienced when we try to refer a patient to a specialist, state, an orthopedist or a neurologist to do an evaluation so we can follow the patient. Michael Weinper (00:06:18): We find that it can take several weeks for that patient to get in, to see the physician, whereas they can usually get in to see us in a few days. So I think that's something that we will see more of in the future, but back then we had it as a dream, but not a reality. We also said that at that time, that instead of 24 weeks of internship that were experienced by PT graduates back in those years, we thought internships would last one year. Now that I don't think there's a, but we have in fact seen fellowships and other levels of work where therapists are really going into specialization so that they in fact can do things over a year's period of time and then becoming sort of like specialists. So those were sort of the, kind of, I think the basic things that would be of importance today. Michael Weinper (00:07:15): We did also, this was a very important one. We identified that in the year 2010 PT would be a doctorate profession. That was what our key points of doctorate and profession. And lo and behold now our entry level is what a DPT, a doctorate. I'm very proud to say that I went back and got my DPT a little over 10 years ago. I talked back in 1982, and I certainly wanted to walk the walk before 2010. So cause that was our benchmark was 2010. So with that in mind I think it's important to realize that we have become doctoral people. In other words, we are now at a level of sophistication with our education and hopefully some research that gives the PT of today a much broader view of a patient, their wellness or their disability, and gives them better tools, which the function do the evaluation or assessment of the patient, and then follow up with treatment compared to how things were back when I graduated in 1969. Michael Weinper (00:08:31): So and I found that when I got my DPT that I learned quite a bit. I learned some of the things I learned actually were more on how to think differently than I had thought previously. And I will tell you that some of the things that I learned that were most valuable to me was how other people think so studying with other transitional DPT candidates gave me an opportunity for me because I was the oldest person in my class. Gave me an opportunity to hear people think and how they process, how they analyze and how they come to the decisions they do. And then how do they communicate it? I like to think I'm a good communicator, but oftentimes I get really wrapped up or wound up and, you know, I go off on a tangent and I probably go down the rabbit hole and maybe other people in today's world are much more succinct. Michael Weinper (00:09:31): And to the point also I can tell you that I was privileged back in 1975 to get my MPH at UCLA and the school of public health there. And I learned a lot about things that are important today, including epidemiology, which we now know is at the forefront of everybody's thinking and infection control and making for safe environments, which was only very basically touched in my DPT program. But one of the things that I really enjoyed was the differential diagnosis courses I took and the radiological courses I took that gave me a much broader sense for things that I'd studied back previously, or maybe taken some content courses, but went into much more depth and listening to other people discuss those kinds of things. So that's how things were back then. I can tell you also that insurance companies were perceived to be able to give PTs a lot more latitude. And it's only been in recent years that many insurance coverage industry to pay for PT. That's independent of physician referral. We're still working with Medicare on that. You and I know all the snow and I think the day will come that the feds will start to get a little wiser and realize the cost benefit of the PT being an entry point into the system. Stephanie Weyrauch (00:10:58): I think that that's a really great overview of kind of what you guys envisioned back in the early nineties and kind of correlating that with vision 2020. So the APTA vision 2020 and a couple elements that made that basically encompassed a lot of what you said. So autonomous physical therapist practice was one of them, direct access, evidence based practice, doctor physical therapy and lifelong education PPS as practitioners of choice and professionalism. So those were when the house of delegates discussed this, those were the main themes that they were looking for. So keeping those themes in mind, let's maybe start by talking about the doctorate of physical therapy. I mean, that was something that you were obviously very proud of. You will talk the talk, you walk the walk. So what do you think? Well, studies have been shown the DPT student debt now varies between 85,000 and 150,000. Okay. Do you think based off of what we're seeing today, as far as student debt, do you think that today's DPT is a good return on investment? And do you think that the salary for the physical therapist has kept up with the increases in training and inflation? Michael Weinper (00:12:14): Well, I'm very happy to hear you raised this question because it's a question that I not only think about a lot. I talked about a lot with my colleagues and I also talked with students who are becoming PTs and people have gone into residencies for a year post-doctoral now for purposes of gaining a better outlook on things. And I must tell you that when we gave thought to the idea of PT being a doctoral profession, never in our wildest dreams, did we think about the cost benefit aspects of it as it relates to educational costs back then costs were not inexpensive. You should teach part time at USC and Cal state university Northridge. And I remember students used to complain about the cost of education back then, but it was nothing as compared to today. So to get to your point, I am sad to say that we have not grown our income levels for PT to the level that they should be given the doctoral training that we received. Michael Weinper (00:13:29): And the depth that usually goes with that, unless you've got some kind of a rich uncle or a greatness scholarship, having said that most PTs coming out with a lot of debt, and then they find themselves in jobs that they don't want to do. Let me just elaborate a little bit on that. PTs in private practice is considered by many to be the desired venue in which to work because patients are coming to you. You have all kinds of equipment and resources and hopefully a nice facility to work in. And the patients for all intents and purposes are ambulatory or said differently. You're not going to be ambulating a patient in a hospital hallway and have something happen to your shoe. If you can get my drift in any event, it seems that most PTs that come out of school today are struggling with where they want to work versus where they have to work and where they have to often work or those places that pay more because they're less desirable. Michael Weinper (00:14:35): So as the desirability quotient increases, the unfortunately the salary decreases because of in part supply and demand. And also to a greater extent because insurance companies are not reimbursing PTs in private setting, like they are in the hospital, for example. So if I go to work in the hospital, I can make a lot more right out of school than if I go to work for an independent therapist in the same community. On the same side, I can go to work for a home health agency, not have this desirable of a work environment. Have you seen changes from patient to patient, but make better money, but then again, have other costs of doing business. And I think at the end of the day, those who do home health, and I don't mean to criticize those of you who do, but if you look at your cost of doing business and take that away from your income, you find that your true income is much less than you thought it was going to be. Michael Weinper (00:15:30): Whether it's wear and tear on your car, gasoline insurance, you have to carry on your own, whatever it may be, equipment you might have to buy and so on. So it seems to me that the desirability of where you'd like to work and the pay ratio is a universally, but proportionate with that in mind, it's a function of insurance companies, and this is where I really go down a rabbit hole. And that is why are PTs and private practice paid less? And the answer is because PTs in private practice accept less, they have an, I am very secure, experienced on this. Having started PTPN 35 years ago, a managed care company for PTs in private practice. And we have always advocated for higher reimbursement. And in fact, we Protestant have been successful in getting a higher reimbursement for PT and practices that are in our organization. Michael Weinper (00:16:30): Then PTs were in the community who are not in our organization. However, because PTs are willing to accept whatever insurance company pays. In other words, they don't want to lose business. They accept fees. They're much lower than they should. And that has driven down the value of PT in the mind of the insurer and that's led to lower salaries. And so to get to the end of this thought, PTs coming out of school, don't get proportion of the kind of income they should with a doctorate. And let's contrast that for just a moment to a PA, a PA has less training than we do. They will usually get a master's degree. They work in a physician's office, but the way that they can bill under the physician's license gives them much better reimbursement. It makes them more valuable to the physician and therefore their income is oftentimes much greater even out of school, you know, apples to apples. Then we get as a PT out of school. Stephanie Weyrauch (00:17:31): Yeah. I think you make a lot of really great points there. I mean, the doctor, the DPT was obviously great as far as, you know, gaining direct access, being more autonomous, but you know, the cost of education has obviously sky rocketing it. So based on, you know, your ideas, what do you think that the private practice section can do to help guide new graduates through the uncertainties of student debt? Michael Weinper (00:17:57): Wow. there's a lot of things that come to mind. First of all, we, as a profession have to be better educated to know when to say, no, that's a K N O W and N O in the same sentence. Know when to say no. In other words, if insurance companies are offering rates that are below what it costs us to business or below what we think we should be reimbursed, we need to learn to say no to them and walk away from that business. Maybe it's better to see fewer patients and make more money and be able to compensate our staff better than to take every insurance contract that comes down the road that pays less than it costs you to run your business. Those in private practice who might be listening to this podcast are shaking their heads affirmatively I'm sure because they get it. Michael Weinper (00:18:47): Those who are not in private practice probably don't understand what I just said. I don't need that it was criticism, but I think that at the educational level, during your basic education it's therapists need to learn more about socioeconomics as it relates to our profession. Supply demand economics certainly, and cost of doing business are key points. In years past for APTA taught courses on economics made easy for PTs because many of us come out of school even today without very much in the way of business knowledge or knowing much about economics. And once you learn more about that, things become much clearer and it makes it easier to make decisions that are in the best interest of our profession. So I think the PPS can, it does from time to time try its best to educate us on how to be better managers, if you will. Michael Weinper (00:19:51): And that includes things like the economics. But I think we, as a profession need to be top of mind with economics and learn how to advocate more as a group, as a profession, not just individuals because insurance companies will not look, listen to individuals. They will disappear to larger groups. To that point, larger groups get better reimbursement. So that point hospitals being really affiliated with one another or powerful entity as an association get better reimbursement. So I think that getting PTs together to understand I know APTA has advocated for many years better reimbursement. I worked with APTA in different retreats for payers. So there was a way to bring together a summit, a payer summit, they call it where they bring together many insurance companies. Actually I did one in Connecticut where you are cause that's a sort of a hodgepodge or location of many insurance companies. Michael Weinper (00:20:55): So we had several speakers who knew a lot about reimbursement, including Helene furan, a dear friend of mine and others who would speak to insurers about what is PT? What does a PT do? How do we evaluate patients? What does it cost to run a business to give these payers a better understanding, but remind you be reminded. These were not big association meetings. We brought peers together. So we might have 25 or 30 people in a room, some of whom which were larger decision makers than others, but when it came right down to it, we didn't have the ability to follow up with them and push them down the road to where they would be accepting of what we do. So we today, the cost benefit of coming to PT, I'm sad to say is very disappointing. It takes you a long time to work off your debt. Hopefully in the future, our government will see fit that people in professions like ours need to have better forgiveness of their debt in return for doing public service for the public we serve. Stephanie Weyrauch (00:22:06): Yeah. I think that you make a great point about the fact that we as private practitioners need to walk away from some of these more measly reimbursement contracts. And you know, one of the things that we hear a lot with incoming graduates is that there are a lot of private practices that have very high volume. And one of the reasons that they have low job satisfaction is because they're seeing so many patients. So I think that you make a really great point in saying that, you know, maybe it's better that we take fewer insurance companies, see fewer patients, but get paid more because now you're eliminating that burnout and that poor job satisfaction and allowing that new professional, or, you know, even if it's a veteran physical therapist, make the money that they actually deserve with the training that they have. Michael Weinper (00:22:58): Exactly right. And that's why we need to really advocate politically. And that's why the PT PAC is a very important thing to be involved with because we, as a profession can be heard through advocacy many, many years ago, I was one of the early trustees of what we used to call APTCAC American physical therapy, congressional action committee, which now PTPAC. And I always used to say, and I consider you to say today, if every PT would just give $25 to political action, how much more strength we could have because we live in a world where legislators listen to those who support them, support them with votes and support them financially so they can get folks important that we do get to legislators. Michael Weinper (00:23:54): We have a lot of people in Congress who are friends and have been our friends for many years, but we need more. And when things come up like budgetary cuts of Medicare, where they talk about an 8% reduction in Medicare reimbursement coming in next January, which I hope goes away. I think it will go away. I pray it would go away. But if it doesn't, I mean, think about that. You're getting a reduction in your reimbursement, which is not that great today. And they're going to reduce it even more. What's that gonna do to salaries? It's not going to help the PTs in private practice. And this is something that I think many people who are not in private practice, the students podcast may or may not, may not believe, but it has to be true. Michael Weinper (00:24:40): I've spoken to hundreds of PTs in private practice over the years. And I think many people would be appalled or shocked at least to realize that many people who own private practices do not make a lot of money. I spoke to a PT just last week here in Southern California, who was impacted by the rallies that were going on with black lives matter. And unfortunately, during that time, there was some looting and pillage went on by some bad actors, if you will, not people who were affiliated with the rallies themselves, but people who took advantage of that and broke into places and solving fuel and burn places. We all heard about that here in Southern California was one of those places in other parts of the country, the same thing that held true, that PT, when I talked to them and was trying to do what I could do to help them rebuild their practice. Cause your practice had been broken into and everything taken. Michael Weinper (00:25:42): I asked this individual if they would be willing to share with me how much they make per year. This person said to me, under $80,000 Michael Weinper (00:25:58): And I pause for a second. And since not only for the problems they were experiencing because of the looting and stuffed up to their office, but for the fact that even under good times, they weren't making a lot of money and they were working hard. They're working 10, 12 hours a day, sometimes on weekends. That is because they were in a situation where their cost of doing business is almost as high as what they would receive in payment. Michael Weinper (00:26:24): And we know that owners of businesses get what's ever left over after paying all the other bills, including salaries and benefits and rent and all the other things that come to mind. And it's not uncommon to find people who own their own practices, who do not make a lot of money and you have to take a lot of risks. So it's one of these things that we need Congress to better understand that it's important to support physical therapy as a profession, because we are a very valid and important aspect of the health care continuum that if we aren't there the cost of care will go up because rehabilitation, I believe, and I'm sure you believe decreases overall cost of care. So getting Congress to vote that in and to budget more money for us and Medicare, and then hopefully getting insurance companies to understand that not every therapist is going to do things on the low ball side of it, but really are going to hold out for a higher compensation that they're entitled to. Michael Weinper (00:27:36): They're going to be more inclined more and as a parent more it's my idea that therapists should be able to own practices to be able to pay their staff more. I've always said, Stephanie, that I wish I could pay every therapist that works in our practice, $150,000. I think they're easily worth it, but it's a function of what we get paid. And I can tell you that, you know, my own practice, progressive PT my income hasn't gone up in over 10 years and I don't make, you know, I don't make a lot of money in it, but it's because I get what's left over after we pay everybody. I feel that we've got to give our employees reasonable compensation for what they do. And we don't use a lot of extenders. We don't do a lot of things that are in the realm of I'm doing it on the cheap side as many people do. Stephanie Weyrauch (00:28:31): Yeah. I think that your points about advocacy are really important because I know APTA has been working on that 8% cut. You haven't written to your Congressman. I definitely encourage those of you listening to this podcast today to log onto APTA's website, whether you're a member or not and write a letter to your Congressman, it really only takes three seconds. Additionally, there has also been a legislation that has gone forward with trying to increase the loan forgiveness for DPT students. APTA is always trying to get us to have pay, be paid more so that advocacy piece is really important. So that kind of brings me into the next pillar or the next element of vision 2020 and that's full direct access. So we do have at the some form of direct access in all 50 States right now, however, there are three States where the direct access is extremely limited, where you basically can only do a wellness evaluation without a doctor's referral. And then there are about 27 States where you have direct access with basically limitations or rules attached to it. And a lot of those have to do with say diagnosis or with different interventions like dry needling or electrical stimulation. Those types of things. So kind of along that route, how can PPS ensure that we get full direct access in each state? What are some things that the association can do and that physical therapists can do? Michael Weinper (00:30:04): That's a wonderful question. And I think the answer is create stronger advocates in each state because what you're talking now is not about federal legislation, but state legislation. In other words, each licensing act is governed by the state legislature. So having a good group of PTs who can rally and lobby, if you will, or have a lobbyist, if there is a big enough state to meet with members of the state legislature to express how important it is in an effort to control costs in healthcare, to give therapists more clinical rights and abilities, that's where it starts. Once you get that, then you can get insurance companies to start to buy in because they realize that is legal in that given state. I have seen this happen throughout my career that has been slow to come. We've been shooting for direct access. And at the same time also trying to eliminate the need for there to be physician intervention in certain musculoskeletal situations where we now are trained as diagnosticians to be able to evaluate and treat these things. Michael Weinper (00:31:17): It's my hope in the future that we get the opportunity from a licensure standpoint to order x-rays, to order lab work and things like that, to where we can have more information at our fingertips, but then to have to refer out. But only where it's appropriate, where we're adequately trained to do that. You have to teach legislators what is PT and what is the benefits of PT and what are the cost savings that insurance companies, the public. And we all save by giving the opportunity for patients to be strong entry points into the healthcare field. It's certainly fond for us to evaluate patient. And in some States you can do, like you said, dry needling. I live in a state, California doesn't even allow dry needling. I have people in my practice who teach dry needling to therapists around the company because he used to do that where they worked in other States, very frustrating for them, extremely frustrating for me, but it takes legislation. Michael Weinper (00:32:25): It takes talks. It takes contributions to your local state PAC, and most of them have it now. And to be involved in APTA, I think is key that so many PTs I call nine to fivers. They come in and they do their nine to five and go home and they forget about their profession. People like you and others who are dedicated to making this a better profession for PTs of the future, not to mention the public that receives our care are the ones that make things happen. And so being more involved in our field through volunteerism obviously is key, I think, to change and too many of us look to the other guy to do it, whether it's writing a letter to your congressmen, or there's going to meeting with a state legislator, whether it's inviting your local state representatives into your practices, see who you are and what you do. Michael Weinper (00:33:27): All of the things bode well for growing our practice. And too few of us, unfortunately do that. We don't realize that it starts fortunately with regulations and what we can do and how we can do it. So the quest, if you will, or request, I should say would be that we as a profession, get more involved in our association because the association is the focal point for getting the information to legislators. It's our association that has the greatest credibility. And I can tell you that one of the reasons I went back and got my DPT was that I saw that when I would testify on a bill in Sacramento here, there would be people with a doctorate, not necessarily in our field, but just doctorates, so would speak against what we were doing it. And I would get up there and I would have 40 years of experience, and we have a master of public health degree then on my doctorate. Michael Weinper (00:34:26): And I were always, and I would like to think I had good presentation and good preparation and knew the facts. And yet it was those who had doctorates that were, or had the title doctor who were paid more attention to now, we as PTs have that title. And now we're sort of in a level playing field with other professions, from the term being entitled a doctor. And with that credibility, we need now to take more action, we need to spend more time trying to create change in my Dicus talk back in 2000, I said that people were afraid of change and it's true. And even today they're afraid of change and we all like the status quo, but the reality is we need as a profession to embrace change because with change comes progress and we need to progress as a field of profession. If you think about things it takes a village if say and certainly in our professional, it's no different, we have to be part of that village. We can't just be part of the tribe. We need to be active leaders of our village. Stephanie Weyrauch (00:35:43): Yeah. And I think, you know, if you look back at where we were with direct access 20 years ago, I mean, obviously we're in a much better state than where we were, but some of the resources that I know PPS has for people with their fighting, the direct access is they do offer grants to state associations if they're doing any type of lobbying. So if you haven't applied to one of those, it's a pretty hefty amount of money. It's like five or $10,000, which that goes a long way when you're paying the lobbyists to do the work for you. You know, they also have a key contacts program and they offer resources for practitioners that if you do invite a legislature in a legislator into your practice, or you are trying to advocate for a bill, like they provide all that information for you on their website and on the APTA action app. Stephanie Weyrauch (00:36:29): So, I mean, PPS does have resources out there that we can utilize to try to continue in our fight with direct access. And I mean, yes, we're in a much better place than where we were 20 years ago, but like you said, change takes time. And as a, you know, as a young professional, I definitely would love to see change happen even faster. So you know, the more people we can get together and build that village, the faster it's going to happen in your Dicus speech, you also talked about how you envisioned that physical therapist will be evaluating and diagnosing conditions, performing specialized treatment procedures and working with the PTA team. And then you also envision that there would be no referral needed by another practitioner. And I know you've kind of covered this a little bit, but give us an idea of where we are, where we're at with this prediction and what you think the future holds. Because as you know, a lot of these direct access bills that we have still restrict our ability to quote unquote diagnose conditions or even perform specific procedures. So kind of give us an idea of where we are compared to 2000 and where you see us going in the future. Michael Weinper (00:37:41): Well we are obviously light years ahead of where we were in 2000, just by hearing what you described to helping things in what I predicted. And I think from the standpoint of going forward, we need to be cognizant of the fact that we can change things if we put some effort to, and in other words, so many therapists don't do things because I think I hear people say, Oh, it doesn't make a difference, or they'll say somebody else will do it. And the truth is that we all need to be more involved. And I'm one of those key contacts and have been for many, many years. I can only tell you that how rewarding it is to invite a legislator or even somebody who works in their office, into your office, into your practice, to visit with you, see what you do, talk to you, the things that are your barriers to growth and barriers to doing for patients, what we should be doing and should have been doing for many years. Michael Weinper (00:38:46): And I think it's more important to understand what you can't do versus what you can do. And you only learn that by going to stage or talking to people in other States who have full privileges to do those things and have that true autonomy. So I think that by attending association meetings, for example, PPS is a great example or CSM when it comes back. And, and I say this, not just going to the meetings, but talking to people, not just your friends, but talking to people you don't know, but from other States where you might know there's a lot more progress, ask them what they did and how they did it, or talk to the leadership in those States, in those state associations and ask them, how did they accomplish what they accomplished? Because it takes a lot of work and there's a lot of resistance by other professions, physicians be it chiropractors, osteopaths, even dentists from time to time resist, having us grow to where we should grow. Michael Weinper (00:39:53): And the key again is educating the public, what we do. So when you're treating them, let them know what you can do, what you can't do all because of the laws, even though you might be trained to do these things. And sometimes the best advocacy doesn't come from ourselves. It comes from the people we serve our patients. So getting people to write letters to their members of the legislature is very important. But I think getting more people to stand up, write letters, attend hearings in your state Capitol become more involved, become more aware of the benefits you can create, not only for the professional, but certainly for yourselves as well. And that's one of the reasons that I've been very involved in APTA throughout my career was I felt that I had the ability to change things if I would only work at it. Michael Weinper (00:40:47): And I was very blessed. You haven't brought it up, but Bob Dicus for who the Dicus award is named obviously was one of my mentors. When I was a student, I got to meet Bob. He was already very deep in his ALS disease in Georgia. He was fully wheelchair bound and tied to a respirator, but that man had so much knowledge. He was one of the first private practitioners. And one should only go to the PPS website and learn more about Bob and what a great man he was and what a visionary he was for our profession. As a matter of fact, just to digress for a moment, he is the one who created the ALS society nationally. He was the inventor of that. He had a second professional. He was in, he was a motion picture producer in his later years when he couldn't be a PT, he went into motion pictures. Michael Weinper (00:41:48): A lot of them had to do with rehabilitation and things that we do. They weren't necessarily featured like Sims, but he got involved in that kind of communication. So it always goes to the fact that I think some of the best PTs are the ones who are best able to communicate with their patients, with the public, with our legislator. Sure. Those are the PTs who really do the best, because if you're good with your patients in communicating, you're able to motivate them to do the right thing. Right. And communication is something that we need to study more perhaps in school. I teach a lecture on communicating with different generations because as I become part of the older generation and looking at the younger people, I see how you and others in your generation and younger generations communicate with one another as much different than what my experience is. Michael Weinper (00:42:43): I grew up with our computers. I remember the very first calculators. We were not what I was going through school in high school. We used an Abacus and a slide rule. And then going forward, we used a Texas instruments brand calculator, which was very expensive and very elementary looking back at it. That's an idea of technology when technology and communication are, I think are very interwoven. In other words, as technology increases, communication becomes dependent on that technology. And we tend to communicate less with one another or said differently. I can see my son-in-law and daughter at our house, sit on the couch, waiting for dinner, remake, and what are they doing? They're texting. And I said, who are you texting to talk to them? Wait, what answer? Just speaking with one another. And that's just the world we live in. And then all the little acronyms, all these simple things that you know are, are part of the lexicon today. Michael Weinper (00:43:56): Today's younger people, older people don't necessarily know. And when treating an older patient, it's key that you speak to them in a communication form that they're going to understand. And don't assume they understand. I mean, you're saying just because you're saying it, and the same is true for older therapists like myself, talking to younger people, you have to motivate them in a different way. Young people want it. Now they want things quickly. They're used to getting information quickly. You go with something up on Google and get an instant answer on something. Whereas back in my day an encyclopedia sales person used to knock on our door, trying to sell my family a big set of 30 books of encyclopedia. We were tell much to us what we needed for today's knowledge. And I don't think those people around anymore. If at all. If you wanted an encyclopedia, you've got it. Michael Weinper (00:44:50): Just look up something in Google or another search engine, and you've got instant. You got too many answers. Sometimes you get different answers for the same question, but with all that in mind, communication is key to success. And we as service need to communicate better, not only with our patients with one another, with our legislators and with the public in general, and to that point, having better PR public wise. And I think APTA is trying to do that. Now that we're into our hundredth year, starting there as your celebration or Centennial celebration. I think you're going to see a lot more information going out to the public, through electronic media and social media, to where we gain a higher visibility with the public. Michael Weinper (00:45:38): I had the TV on the other night, I was watching a game show and one of the contestants was a PT. And he was a young PTA until that. And he didn't want a whole bunch of them. I think it was, I believe the show was a wheel of fortune actually, which I don't watch too often, but it was on. And I've heard the word physical therapist. It's just like you, whatever you heard that word somewhere. Even as sitting in a restaurant, you hear somebody talking about their PT, your ears perk up and you sort of start to eavesdrop a bit. And we as a profession don't hear that word in the public as much as we hear about doctors or other things. So I think the public needs a better awareness of who we are and feel comfortable talking to us. And we need to feel comfortable talking to them and educating more about who we are for. They haven't needed to see us. Stephanie Weyrauch (00:46:26): I think you make some really good points about the communication aspect and that kind of leads into the next element of vision 2020, which is us being practitioners of choice. So in kind of going off of that with communication, it's too bad Bob Dicus, isn't around anymore to make the next hit healthcare drama on physical therapists. I mean, how many physical therapists and healthcare dramas do you see walking patients or stretching patients? You know, it's never really, they're never main characters in, you know, like Chicago med or Grey's, you know. Michael Weinper (00:47:05): Anytime I see a PT portrayed in these situations. I cringe because first of all, they're wearing, and I hate to say this cause I'm going to probably, I'm going to take an issue with some of you they're wearing scrubs. I don't think I don't scrubs when I grew up were for people working in surgery. Now everybody wears scrubs. So you go to the grocery store. People were in scrubs. They, I think people not even in healthcare wear scrubs sometimes, but I think we should look more professional. We should be more professional and the public will respect us better if we act more professional. And so there are some times PTs who are brought in on dramas to be a technical advisor. I have been in that position before twice, and I have talked to directors and producers about what they need to show. Michael Weinper (00:48:05): And I can only tell you that what you tell them to do and what they end up doing sometimes is different because maybe they don't have the right equipment or the character. They thought they already lined up costumes for their characters. It becomes very frustrating, but getting in on the front end and getting the public to understand who we are, hopefully through drama and maybe through, you know, like I say, public service announcements or ads on TV where we're portrayed better or having the opportunity. Many of you are in smaller cities and towns, your local newspapers and television are hungry for local news. And you may be doing something you don't need to think second thought about, but it's newsworthy. Maybe you just purchased a very important piece of equipment to help with ambulation or suspension or something technical electronically to create new opportunities to treat patients your local TV stations would love to demonstrate, come to your clinic, film you doing that and have it as a segment on their TV show. Michael Weinper (00:49:21): And many of us don't even think about that. So and I, again, even in Los Angeles market, I've had the opportunity to do that a couple of times. And it can be a little bit overwhelming, a little bit scary, but you know, something at the end of the day, you feel really good about it and how you come across is much better than you perceived. You are going to come across when you're getting ready to do it. So don't be shy, but reach out to your local media and try to get them interested in what you do, because what you do, what I do is very newsworthy and very important for the public. Stephanie Weyrauch (00:49:52): Yeah. And you know, obviously people are following what the media says and listening to the media. So, I mean, the media is, has been a very powerful force that you can utilize to spread the gospel of physical therapy so that we can become the providers, the practitioners of choice, for the musculoskeletal system. And so the people actually know that PT means physical therapist and not like personal trainer or part time, people actually know what it means in your speech. You also stated that PTs would be recognized by payers as diagnosticians an entry point into the healthcare system. And I know you've talked, you you've touched on this a little bit, but how do payers recognize physical therapists and how do today's payers recognize us compared to back in 2000? Where are we at with that? Michael Weinper (00:50:43): Well, back in 2000, and even in day sense, payers felt we needed to be treating only under a physician's referral. If you looked at insurance policies that you might have, or if you spoke with payers, they would say that PT was a covered service when provided or the auspices of a physician referral or diagnosis today. Many of those policies from the same payers do not have that language. So because of the direct access laws and because of therapists and given States talking to their insurance companies, the payers they've educated them to where certain payers are starting to realize the benefits of PT first. And let's just take substance abuse and chronic pain. We know as musculoskeletal experts, there are lots of things that we can do for the patient to avoid surgery, to avoid downstream costs like expensive imaging that may be unnecessary. We can certainly get the patients treated properly and get them in a mindset to where pain is not top of their mind. I have a book sitting right behind me on my bookshelf. It's called explain pain. Are you familiar with this book? Stephanie Weyrauch (00:52:13): Oh yeah, that's a very familiar book. Michael Weinper (00:52:16): Okay. And this was a very good book for people to read. It's the authors are David Butler and Lorimer Moseley, and they're down in Australia, but they talk about dealing with the mental side of pain, the cognitive side of pain, if you will, and how to best creature patients in deemphasize of pain and emphasize wellness or health. And we need to do more of that as practitioners. And as we can educate our insurance companies, that by sending the patient to PT for four or five, six visits, we can avoid surgery, many cases, what is a cost benefit to the insurance company? Their insurance companies listen to money. And I know this from my experience for many years of working with many of them speak with probably too many insurance companies to not only remember, but to count. And they are driven by dollars and they do not put enough emphasis on times in their underwriting to allow PTs to do the things we do. Stephanie Weyrauch (00:53:26): Yeah. Michael Weinper (00:53:28): Shortsighted because they ended up then forcing patients to go to a physician first, wait, several days or weeks to see the physician where the patients only getting more deconditioned. And rather than just seeing us first, and we have the opportunity and the knowledge on doing things that get the patient out of the problem or fixing the problem, if you will, from a nonsurgical standpoint. So insurance companies in some cases have become much more enlightened and other cases are still in the dark ages. And those who allow us to treat without referral and pay us for what we're worth are the more enlightened ones, some insurance companies that I've dealt with now in recent years are paying for outcomes. There's concept of paper for pay for performance or P for P. I like to call P fro. It's really not what you do, the process of what you do, but really the outcome that you get. Michael Weinper (00:54:27): So if you can get a great outcome with fewer visits, then insurance company should be willing to pay you more because you reduce their costs. And, not only of what you did in terms of your crew cough, but in terms of what would otherwise cost them to treat the patient going forward. So I like to pay to pay for outcomes Peterborough, and that's why we, as a profession, need to do more in the way of outcome measurement, whatever tool we use and be able to communicate to the payment payer community, the benefits of what I do. So I'm going to go back now to the mid seventies again, when I got my master's degree we learned even back then that the definition of quality in healthcare was composed of three things. And the author of that was a fellow who's no longer with us. Michael Weinper (00:55:22): His name was Avitas Donabedin. He was a physician. He was very involved with the new England journal of medicine, D O N A B E D I N, if you want to look it up and Donabedinn even back then said that quality health healthcare was three things structure, which is where you do it and what you use in terms of equipment process, what you do okay. And outcome, or the results. So we all have been able to measure it structure, and we were able to mission measure the process where you, but not enough of us over my career have been able to truly prove that what they did was a benefit. And I think that that's one of those things that we have to focus more on proving the benefit of PT two outcomes or said differently because of what we do, patients get better quicker. Stephanie Weyrauch (00:56:16): And that leads us really nicely into the next element of vision 2020, and that's evidence based practice. So obviously APTA has done a lot over the years to try to improve how we're measuring outcomes. So you have the outcomes registry CoStar was created. If you look at how much the literature has been put out for, if you search, if you search up physical therapy, even in Google, it's, you know, an exponential growth since even 2000 and even the larger growth. If you think about it from even the 1970s, when outcomes were first described. So, I mean, this is something that, you know, we've been working on for a long time. I think that obviously it's come a long ways, but we still have confirmation bias in our literature. We still have group practice that people are practicing. We have treatment fads that really don't have a lot of evidence behind them. And we have practice variation that continues to affect our outcomes and affect our profession. How can PPS help offset this? How can we continue to go forward to mitigate some of these things that are occurring? Michael Weinper (00:57:24): Well, that's a $64 question, as we used to say my hero. I think it's important that we need to, you talked earlier about one of the goals of PT, 2020 is lifelong learning. And I see too many people in our profession who don't come to meetings of the profession, whether it's a local meeting in your area, whether it's a state conference whether it's CSM or PPS meetings, too many of our colleagues never go, or maybe they went as a student cause their school paid for them or somehow or another they're were to go. And they never ever go. If you think about people, you went to school with Stephanie, you never see them again. And you wonder, how are they getting their education? One of the things that has occurred a dream the last 15 years I would say is the requirement by States that each PT in order to continue, their licensure must have continuing education, a certain amount. Michael Weinper (00:58:35): And it varies state by state, as we know, and what things have to be parts of that, continuing education, again, vary by state by state, but at least we're being forced now as a profession to continue our learning. Having said that, and having taught in different venues in different ways. I can tell you, there are people who are serious learners, and there are people who we call lazy learners. The lazy learners are those who will buy the cheap level CEU kind of stuff, and do a quick read on something and take a test and not really spend the time to investigate what was being offered. And maybe some of the quality of that they're learning is really not up to date either. Versus those of us who will go to con ed meetings, we'll do things online. Now there's a lot of opportunity. PBS shows a lot of things out ABQ has a lot of things. Michael Weinper (00:59:35): I'm a member of the orthopedic session section and the oncology section. They have lots of stuff going on that, yeah, there's too much of it. There's just like there's like education overload. So you have to be selective, but do choose things that I think will be beneficial to you. And that are evidence-based. So it brings back to the evidence based part because too often I've heard people get up at meetings and start to talk about things. And then when challenged on what's the word, what's the basis of your comments? They sort of stammered. And they said they gave answers that weren't really appropriate. So we do need more focus on, on lifelong, which we're mandated to do, but some people take the easy way out. You know, people, we all have people we know who will take the high road and others who take the low road and the low road may be the easier road that may not be the get to the right end. Michael Weinper (01:00:29): So we want to challenge ourselves to learn more each day. And I can tell you that when I went back and got my DPT, I thought it would be fairly easy. And some of the things that I was exposed to, I'd already learned in my master's level, but I can tell you a lot of things that I learned were new concepts that I had never even thought about. And that goes to the idea of this lifelong learning and evidence based practice you learn, most of you learned in school all about evidence-based theory and practice, and some of you embraced it very well and other views sort of gone a different path. So I would say, take a step back and look at the research that's coming out. There's all kinds of journals. And that's another thing that I have to digress on a moment. Michael Weinper (01:01:17): And that is, here's a question for each of you, how many journals or publications that are healthcare oriented, do you read or subscribed to, if you say only PT, then I think you're making a big mistake because there's so much literature and so many things that are appropriate for what we do in our field. And to validate what we do in other journals and research is being done that we miss the boat by not looking at it at other professional journals or other modes of information, or even attending meetings for physicians and so on. I used to specialize in the treatment of hand injuries. And so I would go to the society for hand search and they actually had a PT sub, a PTO to see subset of that that my friend, dr. Susan Mike Clovis, was very involved in and she got me involved and I would listen to physicians. Michael Weinper (01:02:18): We collegial meetings where PTs and physicians would interact to try and come up with the best ideas. And many of us don't really have any contact with physicians, except when we're talking to them in the halls of the hospital or when we're going out to market them, or we're trying to take lunch to them. We don't talk really about concepts and about theory. And what do you base this upon? And what can we do to learn more about the benefits of what we do? And that gets us to the idea of each of us having the challenge to do some research, research is fascinating. It doesn't pay a lot, but you can still do research in your clinic. You can be parts of research projects. If you just look for them, is they're out there to take advantage of. And if you do that, it opens your eyes so much more. Stephanie Weyrauch (01:03:09): And I think a lot of the things that you've touched on kind of goes with the last element of vision 2020 and that's professionalism. So when the house of delegates originally defined what professionalism means in vision 2020, it's that we as physical therapists and physical therapist assistants are consistently demonstrating core values by aspiring to and wisely applying principles of altruism, excellence, caring, ethics, respect, communication, and accountability by working with other professionals to optimize health and wellness in individuals and in communities. So obviously one of the bigger focus is of APTA has been this optimizing society or optimizing movement to impact society. And we've been kind of taking more of a population health kind of perspective, trying to get out of the silo, physical therapy and move more into the interdisciplinary healthcare, healthcare, professional realm. Where would you say we are? As far as our professionalism goes in 2020, compared to where we were in 2000? Michael Weinper (01:04:15): Oh boy, I think many of us have because of our increased education, gotten more credibility with the medical profession. They tend to listen to us more rather than just seeing us as a technical entity or a technician versus a professional. Although I can tell you still today, physicians oftentimes don't see the benefit that we do even orthopedist. And we have come a long way in some with so many physicians, but we've missed the boat with others. I think it's critical than medical stuff, schools, especially if you're doing an orthopedic residency, that's a resident spend time with a PT. I was in a well known physician, internationally known physicians office recently with my wife who, when she had her shoulder surgery. And he has no to fellows at all times. And occasionally a PT will visit and come in and, and be there not to get paid, but just to talk and work with the physicians, educate the physicians and the younger ones, the fellows who are going to be out there real soon in their own practice. Michael Weinper (01:05:34): We need to do a better job of educating physicians. I said that a little bit earlier, but I really mean it. We can do it when they're in school, when they're doing their fellowships, we can invite them into our practices. We can go to doctor's offices and shadow them much more than we do. We can go into surgery with physicians and talk to them while they're there doing their procedure, learning why they're doing their procedure. And sometimes a light bulb will go on in your head say, Oh, I get that. And that's, I think there's something I could do a little bit differently with like, with your patients when I'm treating them by seeing what you're doing surgically and listening to what your concepts are. So I think there's a lot more collegial realism of that goes to being a professional. And to that point, if you don't see yourself as a professional others, aren't going to see you as fun and too many of us lose track of the fact that we are in it. Michael Weinper (01:06:27): When you say it's a profession, a profession requires one of the key points of any profession is that you learn, you keep current and you give back to society. And giving back to society means more than just treating people. It means educating the population, doing things from a wellness standpoint or avoidance of injury. I guess going back to my public health days where one of the key things is getting people not to have to see you clinically as a post op or whatever, but helping people to avoid surgery and do things the proper way. Ergonomics for example, is a good, good use of our skills and what we've learned as I sit up in my chair properly. And we doing things that people just don't think about. And when we break away from just being the PT, treating person and branch out to media with other professions, talking to them about what are their challenges, what can we do to help though, or thinking about things we can do to help them communicating better in collegially at different levels. Then we go a long way towards not only building those relationships, but most importantly, helping the patients we serve. So it's one thing to say your profession. That's another thing to give back to society and find different ways to give back Stephanie Weyrauch (01:07:55): What, you know, from this conversation. Obviously we've come a long way since 2000, we've achieved many things that vision 2020 set out to achieve, but we still have a lot that we yet need to achieve. So kind of on that note, Mike, you know, what is a clinical Pearl that you can kind of leave all of us with? What is some advice you could give a young graduate or somebody new in the profession that maybe you wish you would've known when you were coming out of school? Michael Weinper (01:08:29): Oh, that that's an easy question to answer because I oftentimes get asked by younger PTs, how did I become successful? I say very simply through volunteerism, volunteering your time to help your profession and help those we serve, whether it's going to a health fair and educating the public, you ever done that fascinating what they don't know and how the aha moments you see in the public. When you spend two minutes with them screening students preseason athletic screening, another great opportunity to follow tourism positions you're working with, Oh, that's how you do that. That's how you measure that. I didn't realize that. And that's another idea, again, of getting involved, getting I talked earlier about legislation, getting involved in legislation, getting involved in your association is what I think makes you successful. And to that point, I think that the best jobs of PTs get are not the ones they see through a Craigslist or three C on the association. Michael Weinper (01:09:41): Advertisements is from talking to other therapists, word of mouth learning, where are the best jobs to be had. And the only way to do that is not staying in your little house if you will, but getting out and talking to the PTs. That's like I said earlier, getting to know other PTs there's this PT pub nights that I see around the country, what a great idea I've gone to them. And they're actually fun. I stood out in the rain. They had an outdoor one here in Southern California, and you don't get a lot of rain here, but that particular night, we all were standing outside of this venue drinking our beverages of choice, getting soaked, but having a good time. And it's very memorable and getting to know other people and volunteering just goes a long, long way. I think, to learning more and learning what needs to be done, if you could learn what needs to be done and then not put it on somebody else, but say, I'm going to take responsibility again, getting back to I'm a professional. Michael Weinper (01:10:43): I need to be professionally responsible. I need to be the one who does this. I know you're one of those people. I'm preaching to the choir. Stephanie, when I say this and you know exactly what I'm talking about, but so many people who might be listening to a podcast like this, don't quite follow it. So my challenge to each of you would be get involved in your profession and spend a little time here and there, away from family away from work away from your social activities and back to your profession. That's part of being a professional. And as you give back, the more time you give the more you get. And I like to leave this thought with people. And that is for all the thousands of hours, I guess, at this stage of my career, I have given to my profession, whether it was the local district or my chapter or the national association or the private practice section or other sections I've been involved with or doing things in the public realm, getting involved in I was involved in a college board. So people got to know me as a PT and as an individual and get to know more about PT, getting involved in society, rather than just going home at night, turning on the TV, or turn on your computer or playing games, getting more involved with people and trying to do good things for the public benefits you directly. Stephanie Weyrauch (01:12:11): There were some wise words spoken by a true visionary of our profession. So thank you so much. And thank you for all of those who listened to this episode of the healthy, wealthy, and smart podcast and I'm your guest host Stephanie Weyrauch. And I hope that you stay healthy, wealthy, and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Jamey Schrier on the show to discuss how to develop your dream private practice. Jamey Schrier, P.T. is the Founder and Chief Executive Officer of Practice Freedom U, a business coaching and training company. He's an executive business coach and leadership trainer. In this episode, we discuss: -Jamey's entrepreneurial journey -The importance of vision and giving yourself permission to imagine your dream practice -How to generate revenue even during unprecedented times -Why building a team of experts is necessary for you to grow your practice -And so much more! Resources: Jamey Schrier Twitter Jamey Schrier Instagram The Practice Freedom Method Facebook FREE GIFT Practice Freedom Method Website A big thank you to Net Health for sponsoring this episode! Learn more about the Redoc Patient Portal here. For more information on Jamey: Jamey Schrier, P.T. is the Founder and Chief Executive Officer of Practice Freedom U, a business coaching and training company. He's an executive business coach and leadership trainer. Founder of Lighthouse Leader®, Jamey helps physical therapy owners create self-managing practices that allows them the freedom they want and the income they deserve. He is the best-selling author of The Practice Freedom Method: The Practice Owner's Guide to Work Less, Earn More, and Live Your Passion A graduate of The University of Maryland Physical Therapy School, Jamey specialized in orthopedics and manual therapy. He was the sole owner of a multi-clinic practice for more than 15 years. Jamey's passions are basketball, tennis, golfing, and reading. He and his wife, Colleen, and there 2 kids live in Rockville, Maryland. Read the full transcript below: Karen Litzy (00:00): Hey, Jamey, welcome back to the podcast. I'm happy to have you on again. Jamey Schrier (00:05): Karen. It's lovely to be here. Karen Litzy (00:07): Yes, no stranger to the podcast. That is for sure. And that's because we love having you on because you always give such good information to us PT business owners. So thanks for coming back now, you were a PT business owner yourself. People can go back and kind of listen to the past podcast that you did with us to get even a dive in a little bit deeper to your history and how you kind of went from a business owner to now coaching and mentoring in a training business. But can you give the cliff notes version for us now? Jamey Schrier (00:45): The cliff notes. That's how I got through school. Yes. Be happy to give the cliff notes. So I always wanted to have my own business ever since I was younger and went with my dad to his store. I thought it was the greatest thing. So when I got the opportunity to open up and put up my shingle, I went all for it. And I had my fiancé Colleen at the time. Now my wife who you have met, she was, yeah, she was my fabulous front desk. So it was a perfect scenario. Right? I was the quote, the doctor doing the treatments. It was the happy go lucky front desk. And it was a perfect scenario. And that lasted for a couple of years until we started to hire people until I said, honey, do you want to get married? Jamey Schrier (01:35): And she said, sure, boom. She left. She got 35 books on weddings. And she was like, not really there that much. So we had to actually grow a real business. Well, I really didn't know how to hire. I just assume everyone worked like I did everyone thought like I did. Everyone just did quote the right thing. And that's when a whole lot of stress and a whole lot of struggle started to happen, which caused me to create this sense of anxiety that I really didn't experience before. Definitely not as an employee, but I didn't experience for the first couple of years in business. So my hours started to increase. So not only that I have to do the treating and some of the other duties that I had to, but I also had to oversee them and all their stuff. So I took half of their job as well. Jamey Schrier (02:23): And about four years into it, a crazy thing happened, which I've shared before, but I will quickly share. It is my place burned down. We had a fire and it burned down and I was caught with these weird feelings of feeling relieved. Great. I don't have to go to work on Monday and feeling scared to death and feeling, Oh my God, what do I do now? Not just similar to what has happened with, COVID like, Oh my God, I wasn't prepared for this. What do I do now? Jamey Schrier (03:00): So after some soul searching, I realized, I don't know anything about how to build a business. I was a very good clinician. I thought being a good clinician was enough. It was not. So I spent the next nine years learning, trying, failing, learning again, trying and failing of how to build a business that can literally operate with a little bit of maintenance, but not me. They're doing all of it. And fortunately I figured it out and in January of 2013, I removed myself scared to death, but I did it anyways. Remove myself from the schedule no longer I was treating my team was handling it and my business shot up. So I got more time and I made more money and my team was great and my patients were happy and I was like, Oh my God. So I went on a webinar. I believe it was the private practice section webinars that they do. And I just shared my story. People reached out. And next thing you know, I was in the coaching business because they were asking me how I did it. And I've been doing that and being on a mission to help other practice owners try to build, grow their business for the last seven years. Karen Litzy (04:11): Awesome. And the name of your courses? Jamey Schrier (04:19): So the name of the company is Practice Freedom U, the letter U kind of playing off the university thing. And it is a really a business training and coaching firm. So we help the practice owners and we help their teams and grow and build the kind of business they like. So they can have the kind of life that they want. Karen Litzy (04:40): Awesome. And now you had mentioned in your story about when your practice burned down, you kind of weren't prepared for it. It's like kick in the guts. So the country, the world continues, not has been, but continues to live through the COVID-19 pandemic. A lot of clinics had to close. Some may still be closed as we tape this. I am in New York city. We are just reopening now. So as owners begin to reopen and restart, delivering their patient care, what are some of the not so obvious things that they should be aware of? Jamey Schrier (05:23): Yeah, that's a great question, Karen. What I learned in my experience when the place burned down and literally I had nothing to go back to, what was difficult about that was I was the only person going through that everyone else was just business as usual. And my initial instinct, because I am a high achiever because I am a doer was to do more like, okay, what do I got to do? What are we going to do? And it wasn't until maybe a couple days into it that I began to learn that, you know what me trying to do more me trying to be busy and filling up my day with just stuff. Even though I had no patience at all. And there was, by the way, there was no tele-health right. I mean, there wouldn't be telehealth right now if there wasn't a whole country, if it was just one person, the insurance companies wouldn't be changing all their rules. Jamey Schrier (06:26): So, but we didn't even have the technology for that. So what I did was I just started to sit and think and just sit with, well, okay, I'm going to rebuild this. If I'm going to rebuild this, what is it that I really want from this business? What wasn't working well. And I started to write out this, this idea, this outline of what I wanted the business to be. Now, mind you, I didn't know how I was going to get there. Right? I didn't know that, but the more I ask questions, the more I said, what would my business have to look like for me not to work 70 hours a week, which is what I was working, what would happen? What would my business have to be? If I didn't work the weekends, who would I need to hire ultimately to perhaps not have to treat or choose the people I want to treat. Jamey Schrier (07:26): So, as I started asking these questions and gave myself permission, love that word, I gave myself permission to imagine what it would look like. It started to create the outline. And this is exactly what I did and what I shared with other practice owners, what to do during this time. First of all, pause, acknowledge what the hell was going on right now, because it is unprecedented. I hate that word because everyone's saying it, but it is something that you are not prepared for. And it is something that everyone is going through. The people that are going to get through this and be better than they were before, or the people that are not trying to go back to where they were. It's the people that are pausing and saying what an opportunity to fix the things that were broken and to ultimately create what I want. Jamey Schrier (08:21): It doesn't mean it's going to happen today or even in a week, or even in a month, or even in six months. But it's something that can start to help you create the outcome you're looking for, which then causes you to focus on where do I work today, this week? Who should I keep? Who should possibly, I keep furloughed, right? If you're like me at the time I was treating for, you know, 12, 14 years, I was like, maybe you want to reduce your schedule. What would that have to look like to reduce your schedule? Because now's a great time to start searching for therapists. Cause they're out there. And then maybe you weren't as keen on some of the metrics you weren't as clear. Well, what a great time to start getting really organized. So I tell people the not so obvious things is for you to pause, reflect, and start to ask the question. Jamey Schrier (09:21): I love questions better than statements, but start to ask the questions. What would it look like in order to blank? What would it have to be? Who would I have to have in place? What technology we would have to be. You don't have to answer the questions. And that's the mistake that people make. They put all the pressure to have to answer them today because we are doers. We are problem solvers, give yourself a break, give yourself permission, just put them out there. And something interesting is going to happen. I know you and I have talked about this in the past. It's amazing how things start to happen. How people start to show up people that are like, wait a minute, fall into place. They start to fall in place. And it seems like this voodoo magic. It isn't, your mind will start to look for your subconscious mind will start to look for these and it could be right in front of you, but you never saw it before. It's kind of like, where's the salt honey, where's the darn salt. Then she comes in just right in front of you, your mind, wasn't seeing that. So that's kind of the things that I would initially suggest, and then that kind of guides you to. So what are the key elements that you have to do now, which I'm sure we can dive in. Karen Litzy (10:34): Yeah. So let's talk about that. So aside from the obvious safety of your staff and of your patients, that's clearly number one, right? And we want to make sure that when places reopened that that is number one priority. So putting that to the side, because that is hopefully a given for all physical therapy practice owners, right. If it's not, I think you need to go back and ask yourself some questions, but so that should be number one. I think the other thing that a lot of owners are struggling with is the lack of money, lack of revenue that you missed from your business, let's say over the past three months or so. So do you have any thoughts on how owners can build back that revenue? Jamey Schrier (11:22): Yeah. And that is from the people that I've spoken with the surveys we've done, I mean, that is the number one stressor. I mean, you would want to think it's safety it's to protection. Well, the thing that stresses us out is if we don't have any money, we don't have security and stability and we can't take care of our own family. And that stresses the living daylights out of us. Cause for many people, that's why we went into business to be able to have that control and freedom to create the lifestyle we want. So we know that the biggest stressor Jamey Schrier (11:54): Now, for many people, you have a PPP loan, you have maybe a EDIL loan. So it's important to get clear on what options you have find eventually. So some people are kind of coming out of that PPP loan, like the money's gone, they just reacted, they got the loan and they thought they were doing a good job by keeping their staff, even though their staff didn't do anything, except write some blogs and send out some YouTube videos, but it didn't generate anything. So you know, you have to look at what you have available. So that's number one, get your financials in check. So you know, for our business we brought in accountants, we brought in attorneys, I'm sure you know, Paul well so we brought in people and I know for me personally, when this happened, I reached out to experts in this area. I reached out to my accountant, to my financial advisor. Karen Litzy (12:55): Are you kidding me? I was on the phone with my accountant, like literally, almost every single day and emailing him several times a day and thank God for accountants, what gems. Jamey Schrier (13:08): Yeah. But you know, what's interesting, Karen, not everyone thinks like that. You see, we are rugged individualist at heart. What is this business? We struggled. We sacrificed, we studied, we got A's and that is not how you build your business. You need to be. Karen Litzy (13:25): Yeah. That's how I used to be. Now. I'm like could you help me with this, this, this, and this? I mean, because I don't, I'm not an account. I've never filled out. Like I got a PPP loan. I didn't know what I was doing. So I would take screenshots of everything, send it to him. And then he was like, put this number here, put this number here, put this number here. And I was like, did it digit to do? And guess what? It was approved. If I didn't have his help, I wouldn't have been able to do that. I have learned, I've seen the light. Jamey Schrier (13:54): Don't tell anyone. I did the same thing. I call my accountant very calmly. I said, Hey Greg, what should I do? He said, well, it makes no sense not to get the PPP loan. I mean, it's more or less going to be free money. Who knows what's going to end up happening with it. But go ahead and apply that. I said, great, can you have someone help me with that? Because if I don't feel like doing it and he's like, sure, yeah. So everyone's talking about PPP loan. Everyone's freaking out. I've had, I can't tell you how many dozens and dozens and dozens of conversations I've had with business owners. Because I asked him, I go, so who's on your team. Do you have an accountant, financial advisor, someone that understands this and they went, well, I have a friend or a neighbor that does my taxes. And I'm like, see there lies the problem because you don't look at your business as a team of people that are experts in different areas. Jamey Schrier (14:52): So if you're going to learn from this whole COVID thing, start building the experts in your business. So it doesn't fall on you to try to be the expert that you're not. And give yourself permission, Karen, like you did. And I did. I'm not the expert nor do I want to be. However, I do know enough to know that I need to talk to the accountant about this particular problem. Yeah. So talking to someone, even if it's your bookkeeper and start to design what you have available, because that is going to determine if you have literally no money available, then bringing back all your staff isn't feasible, right? It's just not going to happen. But if you have some money available, if you have some other loans, maybe you have equity in your house. Maybe you have some things, not that you're going to use it, but you have it there. Jamey Schrier (15:46): Then the next thing is, start to create the plan, have a plan. Now I typically teach what's called a 90 day sprint, right? 90 day sprint is what is the outcome? The number one outcome you want in the next 90 days, once you're clear on that outcome, let's say the outcome is I want to be a lot of outcomes for people. I know I want to be back up running the way we were before at the same level, it doesn't mean they're going to do it, but it's amazing how many people have believe it or not. It's amazing how many people have that. They are literally 80, 85% pre COVID and they just, you know, kind of reef officially grew up in a, you know, for six weeks ago. So it's amazing what happens when you put that scary goal out there. But the purpose of it is to just reverse engineer down to, so what has to happen this week? Jamey Schrier (16:46): What are the two or three things that have to happen this week for you to start moving towards that? So once you get clear on your financials, you got to start making decisions about your staff. The one thing I would be very weary of is diving back in. If you weren't that before, if you were not treating 40 hours a week, I would not knee jerk reaction to go back to that. The reason is this, I know it seems. Yeah, but if I do it, it's like free money because I'm not paying myself. Yes. That would seem to be the case, but it's not. It's actually going to cost you more money because your mind, your creative energy is all taken up by taking care of the patients in a very emotional setting, dealing with the notes and the insurances and all that. And you're not taking a step back and a 30,000 foot view and really seeing the different components of the business. Jamey Schrier (17:50): And if that happens, your natural response is going to be quick, impulsive decisions. Even you think you're a hundred percent sure of the decisions you can't trust yourself because of the emotional state that you're in. So if you've been a treater before, okay, if you want to go back to that fine, cause you still need to remove yourself at some point, even if it's cutting your schedule down, cause you need to look at things to run your business. So, but if you're not, take a survey of your staff, who's essential. Well, you need people that can generate money. I would choose the people that were the most productive before. COVID sounds obvious, but sometimes you kind of like so and so more, but even though they weren't a great therapist or not a producer and you make decisions like that, or you haven't really had numbers, you're not even sure what your metrics are. Jamey Schrier (18:45): We never really tracked productivity. I think this person was good. So look back at that. Or when, in doubt, who was sought after bring those people back. Now, if you're deciding on will Jamey, should it be full time or part time there's other models out there. I just got off a conversation with a guy that has a business around employment payment models. And he was talking about, you know, this model of shared risk is becoming more and more popular. So perhaps you do an hourly model. Perhaps you explore a shared risk model where the person gets maybe one third or 40% of their income and then they get targets and they make money based on that. You don't have to know what that is. You just have to know that someone is out there that knows what those options are. Your job is to go out there and find out about it and then share it with your staff. Jamey Schrier (19:48): So really getting clear on your team and who you need. I would absolutely bring a front desk back, obviously your billing and all that can be done from anywhere. And then the biggest thing is if you don't have patients in the door, none of this is going to matter. Your money will eventually run out. So I am a simple person, you know my stuff isn't rocket surgery. As one person once said it isn't rocket surgery. What was working before COVID hit? Like, what were you doing? I know most people will answer. I don't know. It was kind of word of mouth. I was kind of doing this. Like they weren't really clear on that. Well, first of all, moving forward, let's be really clear on that. What's working. What strategy was working. One of the most basic strategies you can use. Jamey Schrier (20:39): That's a human strategy is reach out to your people. If you haven't already, most people have reach out to your patients, reach out to the list of people, check in with them, see how they're doing. And they've been cooped up for months. I don't know about you, but I got problems all over the place. Cause I haven't been able to exercise the way I want I'm stress. Of course, stress goes to my back and my head shoulders, these people, it's not like COVID took their health. I mean, they still are human beings. They still have the same problems they did. If not worse, how can you help them? So approach it from, Hey, how are you feeling with all this? Well, my shoulder hurting, Hey, you know what? And then you just offered maybe a free consult. Then you do it either in person or through tele medicine. Jamey Schrier (21:30): Yeah. If you do that and you approach it genuinely like you want to help them, man, I've had people generate dozens and dozens of patients quickly. And I would put the people that are best on the phone that had the highest level of communication. Don't put someone that doesn't really like people that much, you know, like don't put that person on the phone. They're not going to like having that conversation. Same thing for your referral sources, same thing for your referral sources. And you know, can I share one strategy, marketing strategy, eight marketing strategy. And you and I were just talking about it right before this, you said, you know, I couldn't get half these people on my podcast and now what else are they doing? They're like, sure, I'll come and share all this stuff. Well, we have a simple strategy that is called an interview spotlight strategy. Jamey Schrier (22:27): And all you do, same thing. What we're doing here. You just reach out to a rep. We call them referral partners. But someone that oversees and has influence of your target audience, right? If you're going to do this, do it with someone that as you build a relationship can send you the kind of people you want and you offered to interview them and you choose the topic. That would be interesting to your audience, to your list of people. So do you specialize back pain? Are you a vestibular person? Are you pediatrics? Women's health doesn't really matter? And you say, Hey, I was you know, I was thinking we're starting in an interview. Spotlight interview love to interview you. It's all through zoom, 20 minutes, 30 minutes, whatever it is, we'll promote it to all of our people. So I'm sure you'll get some recognition and business out of it. And if you'd like, you could promote it to your people as well. And then you end up with marketing term leads, prospects as well. But what really happens is you start building a connection, a deeper connection with the referral source, who obviously is, you're going to be top of mind with them because you reached out and helped them. You weren't the person sucking on the teat did, give me, give me, you were actually providing something first. Jamey Schrier (23:46): One of my clients did this and he generated 50 cases, 50 in a very short period of time in New Hampshire, like massive town. And he said, this is like, I think it was like 52 people. Exactly. But he said, Jamey, this was easy. And it was fun. It was really a lot of fun. And because we're all used to zoom now, the technology is so easy to use. You just record it. Doesn't have to be video. You can do audio and you just save it and slap it in an email. Karen Litzy (24:18): Yeah. Yeah. That's a great marketing tip. Thank you for that. And just so people know it doesn't, you don't have to have a podcast to do that. You could just, like you said, save it, send it out to your list. Even if your list is five people or if it's 500 people just, you're just creating good content that people want to hear. Jamey Schrier (24:40): And you're meeting people, who's a great marketing, same and it can be used for anything. Always meet people where they are not where you want them to be. So if I was going to do this in New York and let's say reach out to some docs or reach out to some other people that may I'm like if you do with personal trainers or CrossFit or whatever your audience is, my approach in New York would be different than my approach in the Midwest. Of course, right now, the template's the same, but how you're going to do it, how you're going to, I mean, what you're going to talk about the content has to meet your people where they are. If you start talking about, Oh my God, we're opening up. Things are great. And all that. That's not going to land on a lot of people in New York. Jamey Schrier (25:31): So meet people where they are meet the doctor, meet the people, meet the other referral partners where they are and see how you can help start cultivating these relationships. And as your town opens up more and more and things get back to quote normal, whatever that is that bonding is what separates you. That's what keeps giving again. And again and again. So how many of these can you do? I mean, I know some people are doing like twice a month and they said, this is just fun and it's easy. And by the way, it does lead to other opportunities. Karen Litzy (26:07): Sure. Tell me about it. Jamey Schrier (26:09): I mean, your whole business is built on, you started this. You're like, I'm trying to figure this out and all of a sudden you've done. I don't know thousands of episodes. You've met all kinds of people. I know you used to travel around the world. So this is a formula. And it's a really powerful formula. I'll tell you the hardest part about the whole thing. Karen Litzy (26:31): Yes, absolutely. Jamey Schrier (26:35): Passion. Don't let the little critic on your shoulder go, but you can't do it. I think you need to be, you need to learn more about zoom. Just do it, just do it. Karen Litzy (26:37): Yeah. So yeah, it doesn't have to be perfect. Jamey Schrier (26:49): It better not be, if it's perfect. It's too late. You're not doing something that's rusty, not rusty, but like just rough around the edges and stuff. You've waited too long. You need to get what is called the minimum viable product up running and out. Then you learn from it and your fourth interview will be a hundred times better than your first. And there's nothing you can do about it. Yeah. So true. So how quickly can you get to the fourth interview? Karen Litzy (27:19): Yeah, that's great advice. And now as we kind of wrap things up here I know that as we were going through this conversation, one thing that struck out as like, you just can't do all of this stuff on your own. It's what I should say. You can, but it's really, really hard, right? Why would you, so having a mentor coach, is something that can be so helpful. So where can people get in contact with you if they feel like, okay, I've got this business, I'm ready for it to grow. I don't know what the hell I'm doing. So where can people find you and learn a little bit more about what you're doing and if you've got any free resources and things like that for people that would be helpful. Jamey Schrier (28:12): Sure. So I want to just real quick, I know we're coming up on time here, but I want to address real quick with the idea of the coach or a mentor. You know, a coach isn't the end all be all it. Isn't the person that has all the answers and all the solutions to your problem. The way I got into coaching was I resisted it because I was a rugged individualist. Who's smarter than most people who could figure it out. And eventually I started looking at my bank account, looking at the amount of stress I was dealing with and looking at how many hours I put in. And I said, these aren't the results I want. So whatever I think I am doing, it's not getting the results. So can I just swallow my pride and my ego and go ask for help. Jamey Schrier (28:55): And that is so hard for high-achieving individuals like ourselves. So if you are at the place where you're like, you know what, I want some guidance because to me, a coach is guiding you. It's a co collaborative effort. It's strategic thinking partners. If you want that person go and find the person that connects to at practice freedom U I built our company based in part of providing people that kind of business coach, that kind of guide that helped them through some of these problems. Cause it's hard to think of it. I've had a coach for over 14 years. I'll never not have a coach because I don't trust my own thinking because I don't know what, I don't know. So if you're interested in that, you can certainly reach out. You can check out our site, practicefreedomu.com. Jamey Schrier (29:50): You you can get my email from Karen, but one of the things that I thought would be a great thing for your audience is to give them a little insight on some of the things we talked about today and a lot more other things that I think are very appropriate in how to restart, rebuild, and build your business the right way. I did write a book called the practice freedom method and it's 12 chapters of various things from marketing to hiring, to financials a lot with my story and all the struggles I went through. I share all the crap that I went through. So you can learn from it and I wanted to give it to your people for free. You can download it immediately. It's the entire book, but feel free to just go through the chapters it's in digital form. Jamey Schrier (30:42): You just go to practicefreedomu.com/healthywealthysmart-podcast, and you'll just get it immediately. So that would probably be the first place that I would go. And if some of my stuff resonates and you want to have a conversation happy to do so, if not, I would just seriously, you know, consider getting a mentor, finding someone or even maybe a small mastermind group, just people you resonate that can think differently than you to help you through things that alone will take you down a better path, regardless of the specific strategy or tactic that you use. Karen Litzy (31:21): Right. Excellent advice. And thanks for the free book. And that'll also be on the podcast at podcast.healthywealthysmart.com under this episode. So one click and we'll take everybody right to that site. And now last question, knowing where you are now in your life and in your career, what advice would you give to your younger self? Say a young pup, right out of PT school? Jamey Schrier (31:49): Young Jamey Schrier that's scary. Cause I was one cocky son of a bitch. God, I knew it all. Fear is a part of this fear is a part of growth and it is never the right time. You will never feel like you're enough. And if I had to talk to myself before I would've told myself, swallow your frickin pride and start hanging around people that you want to be like, that you're in that you're impressed by something of what they're doing. Just be there, just be with them. And just soak up some of that. I didn't do that a ton. I had a little bit of an attitude towards that. I don't know why. I don't know where it came from, probably because I wanted to feel improved to myself. I wanted to do it on my own. And the reality I look back and I was like, God, that was the stupidest thing I ever did. So whatever your passion is, whether it's business and you want to do your own thing, whether it's side hustle, I know that. Or whether you just want to be the greatest therapist or clinician or researcher, just connect with other people. People are so awesome in giving and providing, but they're not going to do it without you coming to them. Karen Litzy (33:10): Yeah. They're usually not knocking on your door while you're on your couch watching TV. Jamey Schrier (33:15): They're not going to come to you and what the successful people out in the world. I don't just mean financial success. I mean success and happiness success and just who you are as a person, just your own wellbeing. All of those people have these groups, these connections, these people, they reach out to, they all do. They might not talk about it, but they all do. They all have coaches. They all have mentors. They all have people they connect with. And when you do that, it just makes this so much easier and so much more fun. Karen Litzy (33:48): Yeah, absolutely great advice. So Jamey, thank you so much for coming on and everyone again you could go to a podcast.healthywealthysmart.com to get the book or go to freedom practice U the letter freedompracticeu.com/healthywealthysmart-podcast for the book. And you can also find out more about Jamey, what Jamey's doing to help so many physical therapy business owners around the country. So Jamey, thanks so much for coming on again. I appreciate it. Jamey Schrier (34:25): Oh, thank you, Karen. Enjoyed it. Karen Litzy (34:28): Great. And everyone, thanks so much for tuning in. Have a great couple of days and stay healthy, wealthy and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Erica Ballard on the show to discuss how to optimize your health and performance through nutrition. Erica is the founder of Erica Ballard Health – a wellness company that optimizes individuals' energy through food. Erica started her company after realizing health looks way different than what she thought, bought into, and sold for decades. Now, an evangelical about helping people do better, Erica teaches working professions how to truly take care of themselves despite their busy schedules. In this episode, we discuss: -The impact of optimal nutrition on performance -How to detect and remedy vitamin and mineral imbalances in your body -Mindfulness strategies to cope with quarantine stressors -And so much more! Resources: Erica Ballard Website Erica Ballard Instagram Erica Ballard LinkedIn Pantry Essentials Playbook The Lies We've Been Fed Podcast A big thank you to Net Health for sponsoring this episode! Learn more about the Redoc Patient Portal here. For more information on Erica: Erica is the founder of Erica Ballard Health – a wellness company that optimizes individuals' energy through food. Erica started her company after realizing health looks way different than what she thought, bought into, and sold for decades. Now, an evangelical about helping people do better, Erica teaches working professions how to truly take care of themselves despite their busy schedules. Erica has her MS from Tufts University School of Medicine, got her CHC through the Institute for Integrative Nutrition, is a regular contributor to WTHR 13, and has been featured by Women's Health, Lululemon, and the Young President's Organization. Read the full transcript below: Karen Litzy (00:01): Hey, Erica, welcome to the podcast. I'm so happy to have you on. And now, before we get into the meat of our discussion, I would love for you to talk a little bit more about you so that the listeners kind of know how you got from point a to point B to where you are now. Erica Ballard: Sure. So for most of my life, I have been a public health practitioner. People pleasing go getting type of gal. And so because of that, I thought I knew what healthy was. And so I was always trying to get there through the traditional means of, you know drinking the shakes, eating the bars, following the guidelines. But the thing about it was I never actually looked or felt the way I wanted to, which was again, so confusing because rule following people, please are working in public health. Erica Ballard (01:02): You think that I would look the way that I wanted to given that I knew quote, unquote, exactly what to do because I had these huge desires to not only have the body I wanted and look like the women I saw on TV or magazines, but I also had this like deep desire to be happy. And I thought that health or fitness, because I equated the two at the time was the linchpin for me because externally I had everything that one would desire, but internally I felt unfulfilled. And so the only piece that was missing in my exterior, you know, look was my weight. And so I was like, okay, that's it. So I did what everyone does, who tries to get healthy? I like, I count calories. I followed all the rules. I tried to outrun every French fry or glass of wine that I would have, and I just couldn't get there. Erica Ballard (01:57): And that all changed though, when I moved from East coast to Indianapolis, which is where I'm originally from, I moved here and I went to the Institute for integrative nutrition, even though everyone said, don't do it because I got my master's at Tufts medical. I had still student loans, all those things. I was like, no, this is the thing. And it was like, it was the thing. It actually taught me that, you know, food sleep, stress. Those are the drivers of health. And when I figured that out, I went out and I tried to share this information with people. And when I did, they were like, no, that's not right. And so while I started to get results, I would hear them or I would hear society saying girl, no. And so then I would stop doing the thing that made me feel better. Erica Ballard (02:46): And it was this weird up thing that would happen until finally I decided now I'm the expert on me actually. And I'm going to let feeling good lead the way. And when that happened, it's like weight dropped. I was able to hold conversations and happy. My mom likes me again. Right? Like I wasn't the worst human being who was like constantly snapping and more. So I just figured out that, like I was in charge of my happiness. I was in charge of my health and I knew best. And so doing that journey is what has brought me here today to help not only continue to help myself, cause you never just arrive at health. Right. But also to help others who are really desperate to get healthy, do it because most of the people that I help are high performers are people that are willing to do the work and are just like, I am doing it, but I can't. And I'm like, I got you. I've been there. And so walk them through the things that they can do in order to really enjoy their lives while being healthy. Karen Litzy (03:49): That's incredible. And now let's talk about that. Cause I love that you work with kind of high performance people, high achievers, high performers feel like I'm the same way in New York. I don't know a lot of people in New York who aren't that way. I think that's part of living in that might be a requirement for living in New York city. But let's talk about how we can optimize our performance through food, right? I'm a physical therapist. So we're used to optimizing performance through strength, training, stretching, pro programs, plyometrics, but as a physical therapist, I also know that just what you said, sleep food are paramount to when it comes to being able to optimize your performance. So I'm just going to throw it over to you. And I would love to hear your take on what that means. Erica Ballard (04:42): Sure. So it was up to two things when I have this conversation because so many people will tell me all the time, Hey, I get so much done. Even though I don't eat the way I should or I'm drinking these Cokes or whatever it is. So like screw you Erica. And I'm like, listen, you're only in second gear. Like think about that. Like you're only in second gear, you get to fifth, you have to get your food. Right. And the first reason I think that I think it's so clear that we need to get our food right for this is Maslow's hierarchy of needs. So at the bottom of Maslow's hierarchy of needs is psychological and within psychological is food. So that means in order to get the self actualization, the top that, you know, essentially self fulfillment, you have to get the base, right? So without it, you just can't be. And if that's not enough, cause social science, isn't always enough for people. The hard data is starting to show that our brain and gut aren't connected. So we know that if what you put in your gut is not good, your brain will not function. And if your brain will not function appropriately or to the best of its ability, you can't optimize because a lot of your decisions are made with your brain. Karen Litzy (05:47): Right? Absolutely. Yeah. And, and you know, when we talk about that brain gut connection and you can correct me if I'm wrong, but we are really one of the bigger there is that Vagus, Am I correct? In that a hundred percent? Do you want to talk a little bit about that? Erica Ballard (05:58): Well, I think it's one. So for me, when I work with clients, I can, but where I always find it being interesting is that when I talk with people about how to get healthy every single time, I don't know, this is what happens to you when I get into the nuances. They're not, they're like, yeah, the Vagus nerve that matters, but I'm like, yeah. Breathing, putting things in making sure that like the fibers in your gut, they're all going up to your brain, making sure that that's, they're talking matters, but the nuances I have found people don't care as much about. Karen Litzy (06:36): I can definitely relate to that because I deal with a lot of people who have pain, more chronic pain. And so when I sort of go into kind of the neurophysiology behind pain, people like get it for a little bit, but then they just don't want to go that much deeper into the weeds with it. Like you said, like the nuances, but for the purposes of our discussion, I would like to, so let's pretend I'm like your ideal client and I'm like, Erica, tell me what does all this mean? Erica Ballard (07:10): So for me, when I look at our nervous systems and how they're connected, right, we have this nerve that literally runs through our body that connects these two entities and for it to be functioning appropriately, to make sure that the fibers around it actually work to make sure that it, all of the things that it's also then connected to work appropriately. It's really important that we put in foods and fibers and vitamins that our body need for those things to communicate and talk. And so what we typically do, right, is we're like, we'll put whatever it's in and it doesn't matter. And if I just drop weight, I'm going to be the healthiest version of myself. And it's like, no, you have, you have the Vagus nerve, you have your entire nervous system. You have your gut lining. Erica Ballard (07:58): You have these, like you have these different pieces within your body that need to appropriately absorb all of the nutrients in order to make sure that everything is communicating the way that they should. And so when I think about how to optimize and when I think about food and Vagus nerve and all of those pieces is I like where my head often goes is in order for these things to function appropriately, we need the right amount of nutrients and we need our body to be able to absorb them so that these things can talk. But we were like, we think that supplements work by themselves. And we think that vitamins and minerals work by themselves, but it's a payer to make sure the communication is appropriate. Karen Litzy (08:45): Okay. That makes sense. Yeah. And I think you do see a lot, I don't know about you, but I see a lot of people Hawking different kinds of supplements and vitamins and this and that. And then you hear research on none of it matters, right? Like, Oh, why take this? Why take that? Why take a multivitamin or take a plethora cocktail of vitamins that doesn't work. You should get it all from food anyway. So what do you say to that? Erica Ballard (09:11): So I think there is, I can understand where they're coming from. And I think that from a health perspective, if you're at the beginning and you're like, I'm trying to get healthy, I can't quite figure it out. Start with food nine times out of 10, or I would, should say eight times out of 10, start with food, making sure that you have of the highest quality items. But when I think about the importance, I used to really agree with that. But now I'm starting to understand the importance of supplementation or I have fully grasp it of supplementation because the soil in which our food grows does not have all the nutrients necessary for our body, for the plant to grow to the best of its ability and for our body then to take in all the nutrients that exist. Like as a society, we are magnesium deficient as a society. We are vitamin D deficient. And as a society, we tend to be omega-3 deficient and you can't often get enough magnesium through your food, especially if you're trying to make up and provide them in D like if you're in a Chicago or Boston or in New York, it is listen, it's cold outside. Like it is hard. Erica Ballard (10:22): To get those things in. So while I believe that food is medicine, I do believe often food is the first line of defense. If your thyroid isn't working appropriately, if you're in a lot of muscle pain, if you're not sleeping so well, those are, they're probably supplementations that you need to bring into your body to make sure that it's optimized. But, before going to experiment, I would always say consult with a practitioner or like PT health coach, like certified health coach doctor nurse practitioner, because you can't like you can't really OD per se, but you can get the wrong results from these supplements. Karen Litzy (11:04): And do you suggest people take blood work? Like if you're working with someone, do you suggest they get blood work taken so that you have a clearer picture or to see like, Oh wow, you really are deficient and XYZ. And then here's a way I can plan this. Erica Ballard (11:19): So when I work with people, what I always recommend is first start with your diet. So straight up, like most people are not eating enough vegetables. You know, if you're listening to you are like eat vegetables, try to also clean up your diet, take out where you can. And if you can organics pasture, raised grass fed really just up that quality and see what happens. But if you do that and in a month, you're not moving towards the results you want. Blood work, I think is, can be extremely helpful because like, for instance, going to like to the thyroid, the amount of hypothyroidism underdiagnosed in this country is, is pretty high. And when you also look at inflammation markers, even though you're eating a clean diet, like if we're having food, like we're eating things that we're intolerant to, maybe you can't get that exact number in, or that exact food item in the blood work. Erica Ballard (12:14): But I do think it helps really show same with magnesium, vitamin D cause there's different protocols, right? Based on different deficiencies that you have. And so to be able to task, versus just to think I provides a piece of mind that a lot of people want, especially going back to the high-performer piece, like your mind is always going, like you're going a thousand miles a minute, but if you can get paperwork that will show you what's happening and different ways to track, it can feel really nice. And it also can feel like an accomplishment. Karen Litzy: Yeah, I agree. And I think that it gives you, like you said, a goal to work for, to work towards maybe like, I know I'm like a big numbers person, so I really like to see the numbers. So for me, if I had like a blood test, let's say I was vitamin D deficient, which I am by the way. And then I was like, okay, well let me change my diet or let me take this supplement. And then I got another blood test in six months and it was better than I would be like, okay, this is a little bit more proof for me. This is what I needed. And it would encourage me to stay on that healthy path. Erica Ballard (13:09): Yeah. And I think there's nothing wrong with that. I think that that's why there's such beautiful things with all the tracking devices and blood work and the availability of multiple different types of blood work now to test all these different things, because what I always find, and this is neither good or bad, it just is. It's not a lot of folks are sicker than they know that they are. And because they're so used to feeling a certain way, they don't even know that they're in deficient levels or dysfunction. Erica Ballard (14:00): And so that blood work can also, as a practitioner help us show that there are different ways to feel better. Because going back to the vitamin D example, I mean, vitamin D was all the rage. And then it was then were told it was a crock of, you know, stuff. And then now it's coming back in and it's like, if we could just show here's where it should be, that was conventionally what we said. Right. And here's where we need to be. It just fosters an easier conversation. Karen Litzy (14:53): Yeah. I think you get better buy in, you get people like, Oh boy, I don't think it's, and I don't think it's meant to scare people, but it's just meant to be like, Hey, you know, something may be some of your symptoms. Maybe they're correlated with this. You know, it may not be causative, but maybe it can correlate and let's see if we can change some and see, Do you feel different? And then retest, it's just a test retest, right? Erica Ballard (15:03): It's yeah. And if one scientific method, if you will, I'm all for that. And I think when it comes to supplier minerals, nutrition, like nutrients, things like that, it's really helpful. I think the only place I would say, and I would be interested in what you think that it's not as wonderful as doing the test on yourself is food intolerance. Because I find that the best model or the best testing out there is 85% accurate. Whereas the gold standard I have historically found is to pull it from your diet for three to four weeks and then systematically add it back in. Which you can do anything for three weeks. Karen Litzy (15:40): Yeah. Yeah. And I've done that in the past. And it was definitely very, very helpful. Like I took things out of my diet for a month and it's felt a huge difference. I had some autoimmune issues after getting the flu shot. So I had an auto immune reaction to that and it was quite painful and it lasted nine months. Yeah, it's called erythema nodosum it looked like somebody kicked me in the shins 500 times of the steel toed boots. Like it was swollen and red and purple. And I remember I was at the time dating this guy that lived in Baltimore and it was on one leg and it was like over Christmas. So it was in between Christmas and new year's and it was on one leg. I was like, what? And I remember I showed his mom like, what, what do you think this is? Karen Litzy (16:28): And she's like, she used to be an EMT. And she was like, I feel like you should just see a doctor. I'm like, why? And she's like now. And so I just went to like a ready care place, you know, like a city MD. And they thought it was like a staph infection, which I was like, this is I've seen or cellulitis. I was like, listen, I've seen cellulitis this ain't it. And then the next day I woke up and was on the other leg and I'm in Baltimore. And I said to my boyfriend, like, we gotta go to the ER. He's like, I don't know where to go in Baltimore, Johns Hopkins, Johns Hopkins immediately. And I went in and the doctor said, I'm in the ER. And he looked and he's like, it's erythema nodosum. I was like, what he's like, did you have any, like, do you get any shots lately? Karen Litzy (17:08): I'm like, well, I got a flu shot a week ago. He's like, yeah, it's the flu shot. Don't ever get a flu shot again. I was like, okay. So that was over Christmas. And then it finally, all of the symptoms went away in September. And, what I changed in September is I did an elimination diet and took a whole bunch of stuff out. So I don't know what it was, but I mean, I mean, I stopped sugar, gluten caffeine, which I didn't drink anyway. Dairy, everything, like just took it all out. Yeah. And then within a month I was like, and even like my boyfriend, he's like, you're so much brighter and you're back yourself again. And so that auto-immune really like knocked me out quite a bit. And so I do agree there is something to that pulling stuff out of your diet and just see what happens. I mean, it's the easiest thing you can do, right. Doesn't cost any money. Erica Ballard (18:06): I mean, there's so many now alternatives and just the auto immune piece of it. I work with a lot of folks who have auto immune disorders and gluten. I mean, whether or not you have an intolerance or not gluten, for some reason always seems to aggravate these autoimmune diseases. And so we're disorders. And so when you pull that out for a few months, it doesn't mean it has to be gone forever, taking it out and then allowing yourself to see if it works or doesn't is huge. And like you, like, it's the sugar and the caffeine. I know it can be really tough for people, but the rest of the stuff there are alternatives for all. Karen Litzy (18:39): Yeah, absolutely. And I mean, I don't really have a lot of sugar and I don't drink caffeine anyway. So that was easy. The other thing was no alcohol also fine. I can handle that. You know, the gluten was a little hard in the beginning, but then like you said, like I just had gluten free bread and gluten-free POS I mean, it's so easy. It's not like I was like Jones and for tea, like a loaf of French bread or anything, you know? So for me, I felt like, Oh, this was super helpful. And I have not had the flu shot since. Erica Ballard (19:09): I wouldn't either if I had to. Karen Litzy (19:11): Horrible. Anyway, so we're talking about optimizing performance through food, right? And so I think the listeners can now get an appreciation for how food should be the first line of defense. Then move into if you need vitamins or supplementation or minerals and nutrients and when these work together, your brighter you're quicker. Like you said, you're moving from second gear to fifth gear. Erica Ballard (19:37): Yeah. And the thing that always it's interesting for people when they do this is they never knew that they could feel this good. And now it's what makes continuing it so much easier. It's both a mix of like, I feel this good. And then being quite honest is when you start to eat better, like take supplements, do those types of things. When you put in things that your body doesn't like, man, does it fight back? Like you just feel the pain, you feel the grogginess, you feel the lethargy and you don't do it anymore. Because a lot of times people will say, well, you're healthy. It's easy for you. And it's like, Oh, it's either I feel horrible. Or I take care of myself because I've done enough. I find that the body always is trying to talk with you. It's always communicating and it will slap you in the face. If it does, if you do something, it does not like, and most of us can't feel it because we've put it in such a stressed out state. So that it's always feeling so bad that like, it's just hanging on because we're in survival mode. But when you get into that parasympathetic nervous system, when you get into thriving, it will literally have as many communications and conversations as it can that you move in the best direction for you. Karen Litzy (20:53): Yeah. And it sounds to me like what you're saying is the body would prefer not to feel like shit. Erica Ballard (21:03): Yeah. That's exactly in a nutshell. Karen Litzy (21:05): Okay. All right. That's what I thought. Okay. So you brought up briefly, they're talking about stress. So let's talk about stress. I mean, we're still as we're recording this, I'm in New York city, we're still on lockdown. We're in the middle of a COVID pandemic. So stress is a real thing right now. And when we're stressed, I think that's when people are like, I'll take that piece of chocolate, I'll take this, you know, so what can we do to help overcome the stress without falling back on those cravings if you will. Erica Ballard (21:39): That's a really good question. And I heard something this morning that I think was brilliant. So I'm going to share it here is when we think about stress, the idea is just, how do you get back into the present moment and how do you get back in to finding joy? I mean, it sounds a little corny, but that is that's it. And so in quarantine, what can be really helpful is identifying things that you could do that you would do on your vacation at your house. So whether you take naps on vacations or you take long walks, or you listen to music in the morning, instead of a podcast, doing those things that transport you into a state of calm is really helpful. And we can do those things in our house. We just completely forgot that we could, because we're so used to only doing them when we're out there. Erica Ballard (22:36): So that's the first thing that just came to top of mind when you were, when you asked that question. And I think the other pieces are just looking for moments of not solitude seems like the wrong word right now. But moments of peace, because while some people are not at the office, we're there were so available now. And at least we had these cutoffs, right? You go into the office, you leave the office like, and that was that. Now everyone knows we're not going anywhere. So we're getting the emails, we're getting the texts, we're getting those things. And if we could work our way in defining moments where we can shut down, whether it's the walk without the phone, whether it's actually closing your computer and not opening it back up, putting your phone away for half an hour, those things are really gonna help bring you down. Even though we don't think that they do like you feel it in your body, like 15 and another phone, you kind of, you're able to sink down into that couch wherever you're at and just be. Karen Litzy (23:40): Yeah. And you know, I've been hearing that from a lot of my clients who I normally see patients in their homes. And so at this, right. Nobody wants somebody coming into their home and I don't blame them. But they're also working from home and what everyone's saying, they're like, you know, when I'm at work and we have a meeting, I get up from my desk, I walk to a boardroom, I sit down, I go to the bathroom, I talked to other people. I come back, I walk to work. I walk home from work. I go out for lunch. I come back in or at least I go to the kitchen and I come back to my office. And now I said, you know, I'll have a meeting from two to three. And they're like, Oh, you're available at three. We're gonna have another meeting from three to four. Karen Litzy (24:20): Oh, you're available from four to five. She's like, so all of a sudden my patient, she was like, I'm not leaving my computer. Whereas when I'm at work, I do. And I also have the opportunity to get fresh air, but now I'm 12 hours. I barely have time for lunch. And I'm just, and I heard that again and again and again, so you're right. It's that, that feeling of, we all have availability and for some people, their only option might be a five minute break, you know? Like they might not be able to take that half hour break if they've got people sort of like breathing down their throat. So do you have any advice for those people to do like a five minute break or a three minutes something to help at least ground them a little bit. Erica Ballard (25:04): Yeah. So there's two ways to do it depending on who you are as a person. So I think standing up planting your feet from on the ground and just breathing in and out in a really calm, amazing fashion and like feeling the breath go through you is just such a great way to literally move yourself into a very present state. The other way is to move your body, right. It depends on who you are and what you need. When I have five minutes between meetings, I'm not even going to hide it. Like I, right now, I'm here for the Jonas brothers. You can judge me all you want. I turn on the Jonas brothers and I like dance in my house. Cause those songs are only like three and a half minutes. So I will literally put it on and I will just dance around my house because a music makes me happy. But also it like moves. My body moves. My energy moves like that stagnation. And so whether it's squats for you going up and down the stairs dancing, whatever it is, it's just shaking off what was for what is. And I find that that is very helpful when you're chained to your desk for 12 hours on end. Karen Litzy (26:10): Great advice. Thank you so much. So now before we wrap things up, is there anything that we didn't touch upon or anything like, what is the thing that you want the listeners to leave this discussion with? Erica Ballard (26:24): I would say that if you want to get healthier and you're not where you want to be really taking a look at your food and at your stress and seeing which one is holding you back. Cause I pretty much guarantee it's probably one of the two and then make a few decisions and change as necessary. Karen Litzy (26:49): Excellent. And again, the good thing about this is that doesn't take a lot of money, may take some time, but it certainly is not something that's going to break the bank. And, and again, because we're in these uncertain times right now, you know, people might be a little less wary of like, Oh, do I have to, you know, go and leave my apartment or my home and go and do this and go and do that. But if there are easy ways, like you said, look at your food, look at your stress easy. Now, if you are the kind of person that needs someone to help walk you through it, that's where someone like you Erica would come in, you know, at being a health coach, like that's where you would come in to kind of not hold their hand, but be their coach and give them the game plan. Erica Ballard (27:41): Yeah. And, that is why if you do need help, I'm so huge on working with a practitioner because like at the beginning, it's an N of one, you are actually the unique snowflake you think you are. And so helping you figure out the right things for you in a safe space is really important because health is so personal and you get a lot of feels when he's searching to move, try to move in the direction you want to move. And so I do really believe people can do it on their own with a little bit of support from online programs and things like that. But if you can't, asking for help is the best thing you can do. Karen Litzy (28:26): Yeah. And I know you have a free resource for the listeners. It's the pantry playbook. Is that right? So do you want to talk a little bit about that? And just everyone knows, we'll have a link to that in the show notes at podcast.healthywealthysmart.com, but talk a little bit about it and where people could get. Erica Ballard (28:43): Sure. So I heard from clients all the time, I want meal prep, I want meal prep. I want meal prep. And I was like, no, you don't, they don't want it. But it's what they kept saying that they wanted. What they really wanted though, was they wanted it to be able to make really quick meals on the fly that tasted good because three days into the meal prep, if throughout all of their foods, they're sick of it. So I said enough, that's like, yeah. I mean, I don't like five day old food either. So I get it. And so what I did is, I was like, well, I don't ever meal prep. I don't. And so I was like, why don't I meal prep? Oh, cause I have everything I always need on hand all of the time. Erica Ballard (29:25): And so I went to my pantry and started to look at, and then think about all what my clients do and me, and they're there, the special needs that go on and was like, Oh, I can create a list that if you always have on hand, it's going to be faster to make healthy meals than it is to go out and get takeout, because these are our options, right? We meal prep, we get take out or we make it home. And if I can help you make a fast healthy meal at home that cuts the meal prep and cuts the time it would take to get takeout. It works. So I have that resource for them and it'll be at https://www.ericaballardhealth.com/pantry-essentials-playbook. Karen Litzy (29:59): Thank you so much. And now onto the last question that I ask everyone, knowing where you are now in your life and in your career, what advice would you give to yourself after college? Let's say grad school Erica Ballard (30:12): That I love this question and I really, really wish I knew this, that you can do it your way. Karen Litzy (30:22): Mm, powerful. Erica Ballard (30:24): It's just with health. Like you go into people's homes. Like I go into people's homes via camp, like what, like, you know, zoom, you can do this thing. You were away. So don't follow someone else's rules. If it doesn't feel good inside. Karen Litzy (30:41): Excellent advice. And where can people find you social media website? Erica Ballard (30:47): Okay. So I play a lot on Instagram. So it's at Erica Ballard health. I'm actually on LinkedIn quite a bit. Website is EricaBallardhealth.com. And I had a new podcast that's actually dropping on June 2nd called the lies we've been fed. And it's an eight part series that walks people through the lies that we have been fed about food to give them a path forward. Karen Litzy (31:12): Awesome. It sounds great. I look forward to listening and thank you so much for coming on. This was wonderful. Thank you and everyone. Thanks so much for listening. Have a great couple of days and stay healthy, wealthy and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Erica Ballard on the show to discuss how to optimize your health and performance through nutrition. Erica is the founder of Erica Ballard Health – a wellness company that optimizes individuals' energy through food. Erica started her company after realizing health looks way different than what she thought, bought into, and sold for decades. Now, an evangelical about helping people do better, Erica teaches working professions how to truly take care of themselves despite their busy schedules. In this episode, we discuss: -The impact of optimal nutrition on performance -How to detect and remedy vitamin and mineral imbalances in your body -Mindfulness strategies to cope with quarantine stressors -And so much more! Resources: Erica Ballard Website Erica Ballard Instagram Erica Ballard LinkedIn Pantry Essentials Playbook The Lies We've Been Fed Podcast A big thank you to Net Health for sponsoring this episode! Learn more about the Redoc Patient Portal here. For more information on Erica: Erica is the founder of Erica Ballard Health – a wellness company that optimizes individuals' energy through food. Erica started her company after realizing health looks way different than what she thought, bought into, and sold for decades. Now, an evangelical about helping people do better, Erica teaches working professions how to truly take care of themselves despite their busy schedules. Erica has her MS from Tufts University School of Medicine, got her CHC through the Institute for Integrative Nutrition, is a regular contributor to WTHR 13, and has been featured by Women's Health, Lululemon, and the Young President's Organization. Read the full transcript below: Karen Litzy (00:01): Hey, Erica, welcome to the podcast. I'm so happy to have you on. And now, before we get into the meat of our discussion, I would love for you to talk a little bit more about you so that the listeners kind of know how you got from point a to point B to where you are now. Erica Ballard: Sure. So for most of my life, I have been a public health practitioner. People pleasing go getting type of gal. And so because of that, I thought I knew what healthy was. And so I was always trying to get there through the traditional means of, you know drinking the shakes, eating the bars, following the guidelines. But the thing about it was I never actually looked or felt the way I wanted to, which was again, so confusing because rule following people, please are working in public health. Erica Ballard (01:02): You think that I would look the way that I wanted to given that I knew quote, unquote, exactly what to do because I had these huge desires to not only have the body I wanted and look like the women I saw on TV or magazines, but I also had this like deep desire to be happy. And I thought that health or fitness, because I equated the two at the time was the linchpin for me because externally I had everything that one would desire, but internally I felt unfulfilled. And so the only piece that was missing in my exterior, you know, look was my weight. And so I was like, okay, that's it. So I did what everyone does, who tries to get healthy? I like, I count calories. I followed all the rules. I tried to outrun every French fry or glass of wine that I would have, and I just couldn't get there. Erica Ballard (01:57): And that all changed though, when I moved from East coast to Indianapolis, which is where I'm originally from, I moved here and I went to the Institute for integrative nutrition, even though everyone said, don't do it because I got my master's at Tufts medical. I had still student loans, all those things. I was like, no, this is the thing. And it was like, it was the thing. It actually taught me that, you know, food sleep, stress. Those are the drivers of health. And when I figured that out, I went out and I tried to share this information with people. And when I did, they were like, no, that's not right. And so while I started to get results, I would hear them or I would hear society saying girl, no. And so then I would stop doing the thing that made me feel better. Erica Ballard (02:46): And it was this weird up thing that would happen until finally I decided now I'm the expert on me actually. And I'm going to let feeling good lead the way. And when that happened, it's like weight dropped. I was able to hold conversations and happy. My mom likes me again. Right? Like I wasn't the worst human being who was like constantly snapping and more. So I just figured out that, like I was in charge of my happiness. I was in charge of my health and I knew best. And so doing that journey is what has brought me here today to help not only continue to help myself, cause you never just arrive at health. Right. But also to help others who are really desperate to get healthy, do it because most of the people that I help are high performers are people that are willing to do the work and are just like, I am doing it, but I can't. And I'm like, I got you. I've been there. And so walk them through the things that they can do in order to really enjoy their lives while being healthy. Karen Litzy (03:49): That's incredible. And now let's talk about that. Cause I love that you work with kind of high performance people, high achievers, high performers feel like I'm the same way in New York. I don't know a lot of people in New York who aren't that way. I think that's part of living in that might be a requirement for living in New York city. But let's talk about how we can optimize our performance through food, right? I'm a physical therapist. So we're used to optimizing performance through strength, training, stretching, pro programs, plyometrics, but as a physical therapist, I also know that just what you said, sleep food are paramount to when it comes to being able to optimize your performance. So I'm just going to throw it over to you. And I would love to hear your take on what that means. Erica Ballard (04:42): Sure. So it was up to two things when I have this conversation because so many people will tell me all the time, Hey, I get so much done. Even though I don't eat the way I should or I'm drinking these Cokes or whatever it is. So like screw you Erica. And I'm like, listen, you're only in second gear. Like think about that. Like you're only in second gear, you get to fifth, you have to get your food. Right. And the first reason I think that I think it's so clear that we need to get our food right for this is Maslow's hierarchy of needs. So at the bottom of Maslow's hierarchy of needs is psychological and within psychological is food. So that means in order to get the self actualization, the top that, you know, essentially self fulfillment, you have to get the base, right? So without it, you just can't be. And if that's not enough, cause social science, isn't always enough for people. The hard data is starting to show that our brain and gut aren't connected. So we know that if what you put in your gut is not good, your brain will not function. And if your brain will not function appropriately or to the best of its ability, you can't optimize because a lot of your decisions are made with your brain. Karen Litzy (05:47): Right? Absolutely. Yeah. And, and you know, when we talk about that brain gut connection and you can correct me if I'm wrong, but we are really one of the bigger there is that Vagus, Am I correct? In that a hundred percent? Do you want to talk a little bit about that? Erica Ballard (05:58): Well, I think it's one. So for me, when I work with clients, I can, but where I always find it being interesting is that when I talk with people about how to get healthy every single time, I don't know, this is what happens to you when I get into the nuances. They're not, they're like, yeah, the Vagus nerve that matters, but I'm like, yeah. Breathing, putting things in making sure that like the fibers in your gut, they're all going up to your brain, making sure that that's, they're talking matters, but the nuances I have found people don't care as much about. Karen Litzy (06:36): I can definitely relate to that because I deal with a lot of people who have pain, more chronic pain. And so when I sort of go into kind of the neurophysiology behind pain, people like get it for a little bit, but then they just don't want to go that much deeper into the weeds with it. Like you said, like the nuances, but for the purposes of our discussion, I would like to, so let's pretend I'm like your ideal client and I'm like, Erica, tell me what does all this mean? Erica Ballard (07:10): So for me, when I look at our nervous systems and how they're connected, right, we have this nerve that literally runs through our body that connects these two entities and for it to be functioning appropriately, to make sure that the fibers around it actually work to make sure that it, all of the things that it's also then connected to work appropriately. It's really important that we put in foods and fibers and vitamins that our body need for those things to communicate and talk. And so what we typically do, right, is we're like, we'll put whatever it's in and it doesn't matter. And if I just drop weight, I'm going to be the healthiest version of myself. And it's like, no, you have, you have the Vagus nerve, you have your entire nervous system. You have your gut lining. Erica Ballard (07:58): You have these, like you have these different pieces within your body that need to appropriately absorb all of the nutrients in order to make sure that everything is communicating the way that they should. And so when I think about how to optimize and when I think about food and Vagus nerve and all of those pieces is I like where my head often goes is in order for these things to function appropriately, we need the right amount of nutrients and we need our body to be able to absorb them so that these things can talk. But we were like, we think that supplements work by themselves. And we think that vitamins and minerals work by themselves, but it's a payer to make sure the communication is appropriate. Karen Litzy (08:45): Okay. That makes sense. Yeah. And I think you do see a lot, I don't know about you, but I see a lot of people Hawking different kinds of supplements and vitamins and this and that. And then you hear research on none of it matters, right? Like, Oh, why take this? Why take that? Why take a multivitamin or take a plethora cocktail of vitamins that doesn't work. You should get it all from food anyway. So what do you say to that? Erica Ballard (09:11): So I think there is, I can understand where they're coming from. And I think that from a health perspective, if you're at the beginning and you're like, I'm trying to get healthy, I can't quite figure it out. Start with food nine times out of 10, or I would, should say eight times out of 10, start with food, making sure that you have of the highest quality items. But when I think about the importance, I used to really agree with that. But now I'm starting to understand the importance of supplementation or I have fully grasp it of supplementation because the soil in which our food grows does not have all the nutrients necessary for our body, for the plant to grow to the best of its ability and for our body then to take in all the nutrients that exist. Like as a society, we are magnesium deficient as a society. We are vitamin D deficient. And as a society, we tend to be omega-3 deficient and you can't often get enough magnesium through your food, especially if you're trying to make up and provide them in D like if you're in a Chicago or Boston or in New York, it is listen, it's cold outside. Like it is hard. Erica Ballard (10:22): To get those things in. So while I believe that food is medicine, I do believe often food is the first line of defense. If your thyroid isn't working appropriately, if you're in a lot of muscle pain, if you're not sleeping so well, those are, they're probably supplementations that you need to bring into your body to make sure that it's optimized. But, before going to experiment, I would always say consult with a practitioner or like PT health coach, like certified health coach doctor nurse practitioner, because you can't like you can't really OD per se, but you can get the wrong results from these supplements. Karen Litzy (11:04): And do you suggest people take blood work? Like if you're working with someone, do you suggest they get blood work taken so that you have a clearer picture or to see like, Oh wow, you really are deficient and XYZ. And then here's a way I can plan this. Erica Ballard (11:19): So when I work with people, what I always recommend is first start with your diet. So straight up, like most people are not eating enough vegetables. You know, if you're listening to you are like eat vegetables, try to also clean up your diet, take out where you can. And if you can organics pasture, raised grass fed really just up that quality and see what happens. But if you do that and in a month, you're not moving towards the results you want. Blood work, I think is, can be extremely helpful because like, for instance, going to like to the thyroid, the amount of hypothyroidism underdiagnosed in this country is, is pretty high. And when you also look at inflammation markers, even though you're eating a clean diet, like if we're having food, like we're eating things that we're intolerant to, maybe you can't get that exact number in, or that exact food item in the blood work. Erica Ballard (12:14): But I do think it helps really show same with magnesium, vitamin D cause there's different protocols, right? Based on different deficiencies that you have. And so to be able to task, versus just to think I provides a piece of mind that a lot of people want, especially going back to the high-performer piece, like your mind is always going, like you're going a thousand miles a minute, but if you can get paperwork that will show you what's happening and different ways to track, it can feel really nice. And it also can feel like an accomplishment. Karen Litzy: Yeah, I agree. And I think that it gives you, like you said, a goal to work for, to work towards maybe like, I know I'm like a big numbers person, so I really like to see the numbers. So for me, if I had like a blood test, let's say I was vitamin D deficient, which I am by the way. And then I was like, okay, well let me change my diet or let me take this supplement. And then I got another blood test in six months and it was better than I would be like, okay, this is a little bit more proof for me. This is what I needed. And it would encourage me to stay on that healthy path. Erica Ballard (13:09): Yeah. And I think there's nothing wrong with that. I think that that's why there's such beautiful things with all the tracking devices and blood work and the availability of multiple different types of blood work now to test all these different things, because what I always find, and this is neither good or bad, it just is. It's not a lot of folks are sicker than they know that they are. And because they're so used to feeling a certain way, they don't even know that they're in deficient levels or dysfunction. Erica Ballard (14:00): And so that blood work can also, as a practitioner help us show that there are different ways to feel better. Because going back to the vitamin D example, I mean, vitamin D was all the rage. And then it was then were told it was a crock of, you know, stuff. And then now it's coming back in and it's like, if we could just show here's where it should be, that was conventionally what we said. Right. And here's where we need to be. It just fosters an easier conversation. Karen Litzy (14:53): Yeah. I think you get better buy in, you get people like, Oh boy, I don't think it's, and I don't think it's meant to scare people, but it's just meant to be like, Hey, you know, something may be some of your symptoms. Maybe they're correlated with this. You know, it may not be causative, but maybe it can correlate and let's see if we can change some and see, Do you feel different? And then retest, it's just a test retest, right? Erica Ballard (15:03): It's yeah. And if one scientific method, if you will, I'm all for that. And I think when it comes to supplier minerals, nutrition, like nutrients, things like that, it's really helpful. I think the only place I would say, and I would be interested in what you think that it's not as wonderful as doing the test on yourself is food intolerance. Because I find that the best model or the best testing out there is 85% accurate. Whereas the gold standard I have historically found is to pull it from your diet for three to four weeks and then systematically add it back in. Which you can do anything for three weeks. Karen Litzy (15:40): Yeah. Yeah. And I've done that in the past. And it was definitely very, very helpful. Like I took things out of my diet for a month and it's felt a huge difference. I had some autoimmune issues after getting the flu shot. So I had an auto immune reaction to that and it was quite painful and it lasted nine months. Yeah, it's called erythema nodosum it looked like somebody kicked me in the shins 500 times of the steel toed boots. Like it was swollen and red and purple. And I remember I was at the time dating this guy that lived in Baltimore and it was on one leg and it was like over Christmas. So it was in between Christmas and new year's and it was on one leg. I was like, what? And I remember I showed his mom like, what, what do you think this is? Karen Litzy (16:28): And she's like, she used to be an EMT. And she was like, I feel like you should just see a doctor. I'm like, why? And she's like now. And so I just went to like a ready care place, you know, like a city MD. And they thought it was like a staph infection, which I was like, this is I've seen or cellulitis. I was like, listen, I've seen cellulitis this ain't it. And then the next day I woke up and was on the other leg and I'm in Baltimore. And I said to my boyfriend, like, we gotta go to the ER. He's like, I don't know where to go in Baltimore, Johns Hopkins, Johns Hopkins immediately. And I went in and the doctor said, I'm in the ER. And he looked and he's like, it's erythema nodosum. I was like, what he's like, did you have any, like, do you get any shots lately? Karen Litzy (17:08): I'm like, well, I got a flu shot a week ago. He's like, yeah, it's the flu shot. Don't ever get a flu shot again. I was like, okay. So that was over Christmas. And then it finally, all of the symptoms went away in September. And, what I changed in September is I did an elimination diet and took a whole bunch of stuff out. So I don't know what it was, but I mean, I mean, I stopped sugar, gluten caffeine, which I didn't drink anyway. Dairy, everything, like just took it all out. Yeah. And then within a month I was like, and even like my boyfriend, he's like, you're so much brighter and you're back yourself again. And so that auto-immune really like knocked me out quite a bit. And so I do agree there is something to that pulling stuff out of your diet and just see what happens. I mean, it's the easiest thing you can do, right. Doesn't cost any money. Erica Ballard (18:06): I mean, there's so many now alternatives and just the auto immune piece of it. I work with a lot of folks who have auto immune disorders and gluten. I mean, whether or not you have an intolerance or not gluten, for some reason always seems to aggravate these autoimmune diseases. And so we're disorders. And so when you pull that out for a few months, it doesn't mean it has to be gone forever, taking it out and then allowing yourself to see if it works or doesn't is huge. And like you, like, it's the sugar and the caffeine. I know it can be really tough for people, but the rest of the stuff there are alternatives for all. Karen Litzy (18:39): Yeah, absolutely. And I mean, I don't really have a lot of sugar and I don't drink caffeine anyway. So that was easy. The other thing was no alcohol also fine. I can handle that. You know, the gluten was a little hard in the beginning, but then like you said, like I just had gluten free bread and gluten-free POS I mean, it's so easy. It's not like I was like Jones and for tea, like a loaf of French bread or anything, you know? So for me, I felt like, Oh, this was super helpful. And I have not had the flu shot since. Erica Ballard (19:09): I wouldn't either if I had to. Karen Litzy (19:11): Horrible. Anyway, so we're talking about optimizing performance through food, right? And so I think the listeners can now get an appreciation for how food should be the first line of defense. Then move into if you need vitamins or supplementation or minerals and nutrients and when these work together, your brighter you're quicker. Like you said, you're moving from second gear to fifth gear. Erica Ballard (19:37): Yeah. And the thing that always it's interesting for people when they do this is they never knew that they could feel this good. And now it's what makes continuing it so much easier. It's both a mix of like, I feel this good. And then being quite honest is when you start to eat better, like take supplements, do those types of things. When you put in things that your body doesn't like, man, does it fight back? Like you just feel the pain, you feel the grogginess, you feel the lethargy and you don't do it anymore. Because a lot of times people will say, well, you're healthy. It's easy for you. And it's like, Oh, it's either I feel horrible. Or I take care of myself because I've done enough. I find that the body always is trying to talk with you. It's always communicating and it will slap you in the face. If it does, if you do something, it does not like, and most of us can't feel it because we've put it in such a stressed out state. So that it's always feeling so bad that like, it's just hanging on because we're in survival mode. But when you get into that parasympathetic nervous system, when you get into thriving, it will literally have as many communications and conversations as it can that you move in the best direction for you. Karen Litzy (20:53): Yeah. And it sounds to me like what you're saying is the body would prefer not to feel like shit. Erica Ballard (21:03): Yeah. That's exactly in a nutshell. Karen Litzy (21:05): Okay. All right. That's what I thought. Okay. So you brought up briefly, they're talking about stress. So let's talk about stress. I mean, we're still as we're recording this, I'm in New York city, we're still on lockdown. We're in the middle of a COVID pandemic. So stress is a real thing right now. And when we're stressed, I think that's when people are like, I'll take that piece of chocolate, I'll take this, you know, so what can we do to help overcome the stress without falling back on those cravings if you will. Erica Ballard (21:39): That's a really good question. And I heard something this morning that I think was brilliant. So I'm going to share it here is when we think about stress, the idea is just, how do you get back into the present moment and how do you get back in to finding joy? I mean, it sounds a little corny, but that is that's it. And so in quarantine, what can be really helpful is identifying things that you could do that you would do on your vacation at your house. So whether you take naps on vacations or you take long walks, or you listen to music in the morning, instead of a podcast, doing those things that transport you into a state of calm is really helpful. And we can do those things in our house. We just completely forgot that we could, because we're so used to only doing them when we're out there. Erica Ballard (22:36): So that's the first thing that just came to top of mind when you were, when you asked that question. And I think the other pieces are just looking for moments of not solitude seems like the wrong word right now. But moments of peace, because while some people are not at the office, we're there were so available now. And at least we had these cutoffs, right? You go into the office, you leave the office like, and that was that. Now everyone knows we're not going anywhere. So we're getting the emails, we're getting the texts, we're getting those things. And if we could work our way in defining moments where we can shut down, whether it's the walk without the phone, whether it's actually closing your computer and not opening it back up, putting your phone away for half an hour, those things are really gonna help bring you down. Even though we don't think that they do like you feel it in your body, like 15 and another phone, you kind of, you're able to sink down into that couch wherever you're at and just be. Karen Litzy (23:40): Yeah. And you know, I've been hearing that from a lot of my clients who I normally see patients in their homes. And so at this, right. Nobody wants somebody coming into their home and I don't blame them. But they're also working from home and what everyone's saying, they're like, you know, when I'm at work and we have a meeting, I get up from my desk, I walk to a boardroom, I sit down, I go to the bathroom, I talked to other people. I come back, I walk to work. I walk home from work. I go out for lunch. I come back in or at least I go to the kitchen and I come back to my office. And now I said, you know, I'll have a meeting from two to three. And they're like, Oh, you're available at three. We're gonna have another meeting from three to four. Karen Litzy (24:20): Oh, you're available from four to five. She's like, so all of a sudden my patient, she was like, I'm not leaving my computer. Whereas when I'm at work, I do. And I also have the opportunity to get fresh air, but now I'm 12 hours. I barely have time for lunch. And I'm just, and I heard that again and again and again, so you're right. It's that, that feeling of, we all have availability and for some people, their only option might be a five minute break, you know? Like they might not be able to take that half hour break if they've got people sort of like breathing down their throat. So do you have any advice for those people to do like a five minute break or a three minutes something to help at least ground them a little bit. Erica Ballard (25:04): Yeah. So there's two ways to do it depending on who you are as a person. So I think standing up planting your feet from on the ground and just breathing in and out in a really calm, amazing fashion and like feeling the breath go through you is just such a great way to literally move yourself into a very present state. The other way is to move your body, right. It depends on who you are and what you need. When I have five minutes between meetings, I'm not even going to hide it. Like I, right now, I'm here for the Jonas brothers. You can judge me all you want. I turn on the Jonas brothers and I like dance in my house. Cause those songs are only like three and a half minutes. So I will literally put it on and I will just dance around my house because a music makes me happy. But also it like moves. My body moves. My energy moves like that stagnation. And so whether it's squats for you going up and down the stairs dancing, whatever it is, it's just shaking off what was for what is. And I find that that is very helpful when you're chained to your desk for 12 hours on end. Karen Litzy (26:10): Great advice. Thank you so much. So now before we wrap things up, is there anything that we didn't touch upon or anything like, what is the thing that you want the listeners to leave this discussion with? Erica Ballard (26:24): I would say that if you want to get healthier and you're not where you want to be really taking a look at your food and at your stress and seeing which one is holding you back. Cause I pretty much guarantee it's probably one of the two and then make a few decisions and change as necessary. Karen Litzy (26:49): Excellent. And again, the good thing about this is that doesn't take a lot of money, may take some time, but it certainly is not something that's going to break the bank. And, and again, because we're in these uncertain times right now, you know, people might be a little less wary of like, Oh, do I have to, you know, go and leave my apartment or my home and go and do this and go and do that. But if there are easy ways, like you said, look at your food, look at your stress easy. Now, if you are the kind of person that needs someone to help walk you through it, that's where someone like you Erica would come in, you know, at being a health coach, like that's where you would come in to kind of not hold their hand, but be their coach and give them the game plan. Erica Ballard (27:41): Yeah. And, that is why if you do need help, I'm so huge on working with a practitioner because like at the beginning, it's an N of one, you are actually the unique snowflake you think you are. And so helping you figure out the right things for you in a safe space is really important because health is so personal and you get a lot of feels when he's searching to move, try to move in the direction you want to move. And so I do really believe people can do it on their own with a little bit of support from online programs and things like that. But if you can't, asking for help is the best thing you can do. Karen Litzy (28:26): Yeah. And I know you have a free resource for the listeners. It's the pantry playbook. Is that right? So do you want to talk a little bit about that? And just everyone knows, we'll have a link to that in the show notes at podcast.healthywealthysmart.com, but talk a little bit about it and where people could get. Erica Ballard (28:43): Sure. So I heard from clients all the time, I want meal prep, I want meal prep. I want meal prep. And I was like, no, you don't, they don't want it. But it's what they kept saying that they wanted. What they really wanted though, was they wanted it to be able to make really quick meals on the fly that tasted good because three days into the meal prep, if throughout all of their foods, they're sick of it. So I said enough, that's like, yeah. I mean, I don't like five day old food either. So I get it. And so what I did is, I was like, well, I don't ever meal prep. I don't. And so I was like, why don't I meal prep? Oh, cause I have everything I always need on hand all of the time. Erica Ballard (29:25): And so I went to my pantry and started to look at, and then think about all what my clients do and me, and they're there, the special needs that go on and was like, Oh, I can create a list that if you always have on hand, it's going to be faster to make healthy meals than it is to go out and get takeout, because these are our options, right? We meal prep, we get take out or we make it home. And if I can help you make a fast healthy meal at home that cuts the meal prep and cuts the time it would take to get takeout. It works. So I have that resource for them and it'll be at https://www.ericaballardhealth.com/pantry-essentials-playbook. Karen Litzy (29:59): Thank you so much. And now onto the last question that I ask everyone, knowing where you are now in your life and in your career, what advice would you give to yourself after college? Let's say grad school Erica Ballard (30:12): That I love this question and I really, really wish I knew this, that you can do it your way. Karen Litzy (30:22): Mm, powerful. Erica Ballard (30:24): It's just with health. Like you go into people's homes. Like I go into people's homes via camp, like what, like, you know, zoom, you can do this thing. You were away. So don't follow someone else's rules. If it doesn't feel good inside. Karen Litzy (30:41): Excellent advice. And where can people find you social media website? Erica Ballard (30:47): Okay. So I play a lot on Instagram. So it's at Erica Ballard health. I'm actually on LinkedIn quite a bit. Website is EricaBallardhealth.com. And I had a new podcast that's actually dropping on June 2nd called the lies we've been fed. And it's an eight part series that walks people through the lies that we have been fed about food to give them a path forward. Karen Litzy (31:12): Awesome. It sounds great. I look forward to listening and thank you so much for coming on. This was wonderful. Thank you and everyone. Thanks so much for listening. Have a great couple of days and stay healthy, wealthy and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Kameelah Phillips on the show to discuss optimizing health during pregnancy. Dr. Kameelah Phillips is a board certified Obstetrician and Gynecologist, wife, mother, and lifelong women's health advocate. Since high school, she has been involved in local, national, and international organizations aimed at advancing women's health care issues through advocacy and direct patient care. In this episode, we discuss: -The impacts of COVID-19 on pregnancy and post-partum -Factors that impact the United States' maternal mortality rates -Six ways to optimize your health during pregnancy -The importance of interprofessional collaboration -And so much more! Resources: Calla Women's Health Website Dr. Kameelah Phillips Instagram Calla Women's Health Instagram A big thank you to Net Health for sponsoring this episode! Learn more about the Redoc Patient Portal here. For more information on Dr. Phillips: Dr. Kameelah Phillips is a board certified Obstetrician and Gynecologist, wife, mother, and lifelong women's health advocate. Since high school, she has been involved in local, national, and international organizations aimed at advancing women's health care issues through advocacy and direct patient care. Dr. Phillips graduated from Stanford University with a degree in Human Biology with an emphasis in Women's Health and Human Sexuality. After graduation, she worked at the San Francisco Department of Public Health in the AIDS office as a Research Assistant on HIV vaccine studies. She relocated to Los Angeles to attend the University of Southern California Keck School of Medicine. During medical school, she received numerous community service awards. She was privileged to travel to Ghana, Cuba, and Tanzania on health missions during this time. Upon completion of medical school, she attended a competitive OB/GYN residency at the New York University School of Medicine. She also served on an emergency medical mission in Port-au-Prince, Haiti to provide women's health care during the 2010 earthquake. Dr. Phillips is an educator, mentor, and expert in women's health issues. She loves to help women and girls feel comfortable with their bodies, so that they can be aware of changes or new developments. Her interests include Minority Women's Health and health care disparities, lactation, sexual and menopause medicine. Dr. Phillips is a member of the International Board of Lactation Consultants and speaks Spanish. She enjoys teaching residents and medical students. Her guilty pleasures include reality T.V. As a Real World Alumnae, she has used this platform to travel nationwide to discuss domestic violence, smoking cessation, and other health-related issues. She loves a good bargain, flowers, and deep-tissue massages. You can follow her on Instagram @drkameelahsays Read the full transcript below: Karen Litzy (00:01): Hi, Dr. Phillips, welcome to the podcast. I'm excited to have you on. And this is the first time I'm having an OB GYN on the program. I've had lots of physical therapists who work with women's health and pelvic health. So this is really exciting to get a different point of view on women's health and on pelvic health. And now, before we get into the meat of the interview, we are still living in a pandemic, COVID-19 is still here. It has not mysteriously disappeared or vanished. And so there are a lot of women who are getting pregnant, who are living through pregnancy at this time and who might be a little nervous, a little concerned about what can happen during their pregnancy is COVID affected. So what I would love for you is any advice for those pregnant women in the time of COVID? Kameelah Phillips (00:58): Yeah, absolutely. You know, one thing I really try and impress on patients that is absolutely unique to OB GYN is despite what's going on in the world, whatever chaos is going on, women still have babies women still go into labor. Women still take healthy babies home. So for us in particular we've made some minor, not, I shouldn't say minor there there's significant, we've made some changes in how we deliver care and the hospital setting, but for us, it's really been, you know, not so huge of a change because you know, hurricane Sandy earthquakes in Haiti, I've been through both of those, we still deliver excellent care to women. So one thing I would ask them to do is just really take a deep breath and while things are going on around us remember that their primary concern is to take care of themselves so that they can take care of their baby. Kameelah Phillips (02:11): I have told patients that a little bit of their OB care is changing. So we might have fewer visits, but really the important things we will always make sure that we hit the important time points and hallmarks of a pregnancy. So you won't miss anything. I've been telling them that labor and delivery has changed a little bit. And I think this changes pretty much coming across country, but whereas it used to be a time where, you know, extended family was welcome. It's important that they recognize now that only one or maybe two people will be allowed to be present for labor and delivery. And our hospital in particular, both moms and support family are being asked to wear a mask. We do check moms for coronavirus. We use the nasal swab. The extended family is not tested, but they're expected to keep their mask on. Kameelah Phillips (03:16): And most of the time our moms are coming back negative, but if they do come back positive, you know, we have a discussion and education with them as to what it's going to be like, knowing that they're now corona virus positive and going to be taking home a newborn. So we talk about those things. But for all intents and purposes, women are coming in. They're having healthy, safe deliveries, both C-sections and vaginal deliveries. Their hospital stay we've shortened a little bit in New York, we're going back to keeping women two days or four days, but other places in the country are, are shortening. The hospital stays in an effort to get women home safely and so that they can use hospital resources for the people that need them. But we're having healthy and safe deliveries. There was a panic, I think, amongst the pregnant community at the beginning of the pandemic, and everyone wanted to have a home delivery that still continues to not be the best response to this. Kameelah Phillips (04:28): It is still safest to deliver in a hospital or birthing center, certainly not at home to have best outcomes. We still recommend that women breastfeed that's the best way to feed your baby despite Corona virus, even if you were previously infected. And when women go home, I just ask them to be considerate of the new immune system in their house, right? So limiting visitors, washing their hands. If people come over, keeping them not being afraid to say, Hey, keep your face mask on while you're with the baby or around the baby. And really using the technology that we have to their benefit. So while it's not what we're used to, the grandparents meet their babies over FaceTime or zoom now. And that's not going to be forever, but you know, if you have people who are unable to quarantine and can guarantee that they're negative, I asked them to defer visiting. Karen Litzy (05:29): Yeah. Thank you. That's all really great advice. And I should have mentioned in the beginning that we are both located in New York city. And so right now it's different. Kameelah Phillips: Yeah. So obviously New York was the epicenter of the pandemic, certainly in the United States, if not the world at one point we have now our numbers have gone down, but the safety for the pregnant and new moms have, has not is right. Yeah. Right. So we are still on top of new infections, preventing infections in the hospital, the doctors, the nurses, the people who clean your rooms, we're all washing our hands, wearing gloves, keeping our mask on because it is our priority that you come in healthy and that you leave healthy. Karen Litzy (06:33): Yeah. Perfect. All right. Well, thank you for that. And hopefully if there's any pregnant moms or other healthcare practitioners that are working with pregnant women kind of give them a little bit more information to pass along or to kind of keep in their heads. So now let's switch gears slightly here. I'd love to talk about maternal mortality rates in the United States now in the United States. We know, unfortunately that we do have a very high maternal mortality rate amongst advanced countries, or what's the best word for that advanced countries? Is that the right developed countries, industrialized countries, like we know what you're talking about, you get it right. So the questions that I have are what populations are most effected. And then what, in your opinion, do you feel like needs to be done to improve those maternal mortality rates? Kameelah Phillips (07:32): I am firmly under the belief that we can as a nation, as a country walk and chew gum at the same time to make these rates better. So to answer your first part of your question we have plenty of data that show that black women, African American women in particular are most vulnerable during pregnancy labor and delivery. And postpartum times the rates of increased death can be anywhere from five to seven times higher than their white counterpart. And these rates are abysmal for a developed country to have such a discrepancy in healthcare is really saddening and frankly just discussing it's unacceptable. But there are other ethnic groups that are also at risk that, you know, we always talk about black and white and really this country is so diverse, but our native American population is also significantly affected by maternal mortality rates that are poor as well as Alaska. Kameelah Phillips (08:57): We always forget about Alaska. So African American women, native American women and Alaska women, and it's complicated. It is a combination of access to care. It's unfortunate that we seem like we're talking about the same things over and over, but access is a big issue. We live in the biggest city in the United States, but you know, Manhattan alone, what the Island of Manhattan has four hospitals there used to be more, there used to be more can you imagine? But some of our outlying communities that are more ethnically diverse or Latino or African American have far fewer hospitals. And certainly in those hospitals, the resources aren't comparable to anything that you would see in Manhattan. So along with, you know, access there's hospitals, there's doctors there's birthing centers, all of these are less often found in lower resource places. Kameelah Phillips (10:06): So access is a big one education both on the part of the health field and of patients themselves is a problem. I think we're starting to really get some traction on the African American population, helping them understand that this is a very critical time in their life. And so they have to be hypervigilant about blood pressure, weight gain, diabetes, all of things, all the things that can be triggers for issues in pregnancy. Those are the big things that stand out access and education. Karen Litzy: And do you also find that, and I find this in other aspects of healthcare especially when it comes to feeling pain that oftentimes women are not believed as much as men are. And, that is in other parts of healthcare, certainly true. Do you find that women maybe during pregnancy or even post pregnancy, like maybe that the day they gave birth, if they're there trying to explain things that are going on and perhaps they're not being believed and are just yeah brushed to the side so that I think is absolutely the case for a lot of the issues that women experience around the maternal period. Kameelah Phillips (11:22): And it's not limited to women. It also crosses ethnic and socioeconomic boundaries. We have a real issue and I'm part of the establishment, right? I'm part of the medical community. So I feel free to air up our dirty laundry, that we have a real issue with bias and medicine and we talk about racial bias and how that can impact black people. But we have a bias against women. We have a bias against women and, you know, she's being hysterical, she's being dramatic or pain's really not that big women in our discomfort in our needs are routinely downplayed and even by other women, because we've sort of ingrained in our head that, you know, women tend to be more dramatic, whatever. Kameelah Phillips (12:30): We downplay the needs of poor patients who come in, Oh, you know, she's just being loud for no reason or, Oh, that's just how they're. So this isn't just an issue of women. It goes across class, it goes across ethnicities. But for us, when we're pregnant, it has to be addressed and highlighted because when a woman is saying something isn't right. Something isn't right. And that should be taken seriously because in the postpartum period we get lucky a lot of times because women are generally young and healthy, but when things go bad in obstetrics, they happen quickly and then its big. So for example, if a woman was like, my bleeding is kind of heavy and say, maybe she just delivered a baby, a woman could easily lose one to two liters of blood in like a few minutes. So we had a really bad postpartum hemorrhage the other day. And I was like, this is impressive when you see what the body can do. Especially in labor, it happens quickly. And so it's incumbent upon us as healthcare providers to take women seriously. Karen Litzy (13:27): And then I would also think there is, and again, I don't know if this is true or not, but I know kind of where I come from more looking at the pain world and from my own experiences, as I personally would downplay my own pain. So as not to bother someone. Right. And do you feel like in the world of OB GYN, if you're going for pregnancy, like, do you have to kind of really educate those patients to say, listen, if you're feeling something doesn't feel right, like you need to speak up, right. Well, like you're bothering us. Have you encountered that? Kameelah Phillips: I have encountered that. And it's really incumbent upon all of us to relearn these narratives that we've picked up just growing up in the United States of like not being the complainer or not being the squeaky wheel, not rocking the boat. Like those all have negative connotations right. Kameelah Phillips (14:47): In the obstetric space. When you don't speak up, we can have really negative, horrible outcomes. So part of my experience with patients is to listen to what they're saying really repeat back what they're saying, like, okay, I hear you're having X, Y, and Z. Did I get that right? And if it's something that is quote unquote normal in the space of a, you know, a growing uterus or a growing body part of my job is to really provide education, to help them manage their expectations for what they should expect. Growing uterus, growing weight gain, swelling, what they should expect from their body. If it's the first time they've been pregnant or the sixth time they've been pregnant, you know, all the pregnancies are different. And if we have a clear understanding her giving me her complaint, me giving her feedback on what I think she's saying, and then giving her the anticipatory guidance, I think she needs, and we still have an issue. Then it's incumbent on me to escalate it and really make sure that there's nothing there that's going to hurt her. Karen Litzy (16:01): Yeah. Great. That's perfect. And I love the kind of handling of expectations and monitoring expectations because that goes such a long way when, especially if it's your first time or not, like you said, your first or your six times, but kind of knowing what to expect at certain times is very comforting. And so then as if you're the patient, then you can say, Oh, you know, she said, this might happen, but I'm not, you know, it's not happening or it's going above and beyond what she said. So maybe this is time that I reach out and contact my physician on this, there are times where you may need to reach out to your doctor. And so knowing when those times might be, is really helpful. Kameelah Phillips (16:53): Exactly. So when a woman leaves the office and you know, it'll be maybe a month before I see her again, I tell her, you know, this is what I think might happen. It's okay. If it doesn't happen to you, but in the next four weeks, you might expect, you know, your pants size to change general discomfort in this area. You might feel something fluttering in your belly, like giving her those points to look out for. And again, managing those expectations and I'll get a phone call, Hey, this is maybe more I'm having this. Plus this is this in the realm of normal. No, it's not come in. You know, we can really help women out by giving them education cause it's empowering. And it helps us do a better job taking care of you. Karen Litzy: Yeah. And it also keeps people away I would think from dr. Google or far down the rabbit hole of how many doctor Googles do you get? Kameelah Phillips (18:17): You know what, I can't anymore. Just so many doctor Google's with doctor said, I can't even more. Or my Facebook friend Sally said, Stay off. And it's funny cause when their partner comes with them, the partner inevitably just looks at him and like glares at them because they know that they're on Google or they're on these, you know, small chat rooms where everyone is on the T level 10 when the patient's issue is actually maybe a one or zero. And so it freaks her out. Yeah. I encourage patients to stay off of Google. Because yes, there are some times when it might answer your question, but really we're aiming for individualized personalized care and Google doesn't offer that to you. And so I really ask my patients to stay off of it. That's what their visits are for to write down the questions as they go. And honestly, it's so funny. They'll come in with like, say there's five questions just in the scope of time, given them the anticipatory guidance. Kameelah Phillips (19:17): Like by the time they actually get to the appointment, they may only have two questions because they're like, Oh yeah, she said that was going to happen. They know exactly, exactly. It helps to stay off Google. Karen Litzy: Yes, yes, yes, yes. And now I think we've touched a little bit, I think on this, but let's see if we can delve into this more and that are what are ways women can stay healthy throughout their pregnancy so that maybe it can contribute to a decrease in the maternal mortality rate, even if it's just chinking away at the tiny little bit, because like you said, it's a big bucket with a lot of stuff going into it. But if there are ways that women can, like you said, empower themselves to stay healthy and give themselves the best chance, what advice do you give to women to stay healthy? Kameelah Phillips (20:04): Yeah. So in thinking about this, I have six points that I usually share with patients. So I'll go over them really quickly. But my first point is to find a doctor that you trust. I'm really big on that. I'm really big on that. I tell people to find someone that they trust because inevitably, you know, most pregnancies are fine, but if we get into some mess, I need to know that you know that I am your advocate and I am on your side. And if you hesitate or you don't feel like you can trust me a hundred percent, I'm going to ask that you explore other op, find another doctor because I want you to the best experience possible. And I even say this with my GYN patients, like if I tell a patient, you know, I really think you need surgery for this. Kameelah Phillips (20:56): I don't sign them up for surgery that day. I've let them go into the world, do their due diligence, meet with three other doctors. And I promise you, I have not had a patient not come back because they trust me. So that's a big thing. Find someone you trust. I think it's really important that patients meet with their doctor frequently, meaning that you come to your visits, you got to show up, right? So we can get data from you like your blood pressure, your weight how you're feeling, checking the baby regularly, blood work, this data that we're collecting at every visit. And it might not sound like a lot 15 minutes, but it actually gives us a picture of where we're going with your health. So that's important. I asked my patients also to stay active and exercise. I am not sure why there's this misconception that you should be sedentary during pregnancy first trimester. Kameelah Phillips (21:55): I get it that progesterone knocks everyone out there on the couch. They can't, you know, they're nauseous. They don't want to, I get that. But for the most part, when you feel healthy in pregnancy, I need you take care of yourself. And that means exercise and eating healthy and patients are, Oh no, but the baby really wanted the chili cheese fries. No, no she didn't the baby requests. Yeah. Did she send you a text message to get that? So really encouraging, like if you would feed your six month old, you know, a Coke and chili cheese fries for lunch, that's a separate conversation, but you know, trying to do as best they can. In terms of staying active and eating healthy education is a big piece for me. Every time they leave, I'm like, okay, we're entering this phase. These are the major risks for this phase. Kameelah Phillips (22:53): So I need you to go home and look at this website and read two minutes about diabetes, cause you're doing your diabetic test and this is why it's important. Being flexible is huge. Patients, I think often have the misconception that physicians or that I control their pregnancy. And really, I see myself as just like a tour guide, ushering your baby safely into this world. And so it's important that they're flexible to whatever the results come back as whatever the ultrasounds tell us, however, the baby is behaving in labor, that they're flexible. In my industry, I'm not sure what the corollary will be with physical therapy, but people who come in with very strict demands as to how they expect their process to be are the main people who have complications as opposed to just letting us do our job, to get you guys to the finish line. Kameelah Phillips (24:02): So being flexible is really important. And then my last one is to not refuse life saving treatments. We were, it was in the, I told you the other day I had a postpartum hemorrhage and I might back of my head. I was like, this woman's going to bleed. So as we were pushing or when she got admitted, I was like, you know, this is the type of situation where I see XYZ happening and when XYZ happens and she lost all that blood. When I came to her about needing a blood transfusion, she was already on board to not refuse treatment that could possibly save her life. So not refusing like blood products or blood pressure management, those are increased surveillance. Those are the big things that hurt and cause women to lose their life. So really not refusing important treatment. Karen Litzy (24:58): Yeah. And I think thank you, those are great ways that women can stay healthy. And you know, as you were saying, they need to be flexible. And I always go back to movies where they show the woman going in and she's got a birth plan and it has to be this and it has to be this. And there's no flexibility around that. So I could see how that could be really dangerous if you're going in with that kind of a mindset of, you know, I have to have this baby without any drugs and have to have it vaginally. When in fact there might be some complications where that's just not possible and it's just not possible. And, or advised or safe. Kameelah Phillips (26:00): And again, we don't decide that, right. The baby's position, the mom's uterus, the pelvis, like all of these things that are outside of our control decide that we're just here to make sure you both come out on the other side. Okay. And I can't underscore that. Cannot underscore that. Like I don't have anywhere to be there's this misconception that doctors always have like tickets. So like I have to be at the opera tonight. No, we don't have anywhere to be we're here for your baby, but you know, we have to have some flexibility, like let us just do our job and we'll get you through this. Karen Litzy: Yeah. I think that's great. And then of course, I always love the third point, which is stay active and exercise and move during your pregnancy. And I think I'll give a quick plug for physical therapists. I think this is where physical therapists and women there are a lot of physical therapists who are pelvic health specialists and who work specifically with pregnant and postpartum women. And this is where I think we can actually maybe make an impact in that maternal mortality rate as physical therapists. Kameelah Phillips (26:54): Yeah. Yeah. I spent the first part of my career in a group dynamic and it was very hard for us to think outside the box with complimentary specialties that can help make this process of pregnancy, which is physically mindblowing. Like people, if you haven't necessarily been pregnant before or been in an intimate relationship with someone who's going through pregnancy, you can not imagine how physically difficult it is to have a baby. And so when I was bringing up the options of like physical therapy, no, no, no, she's fine. The body heals itself. I'm like, but it's not like, look at her walk. You know, I'm looking at her. Diane is like, like, let's think outside the box. So in my new practice, I'm making much more of an effort and actively establishing relationships with people that, okay, you're having this issue. Kameelah Phillips (28:07): Now let's connect with the physical therapist because you know, the hips give women the most trouble, the hips, maintaining flexibility labor and delivery, the act of pushing literally separates your pelvis. You know, it's not, of course you have issues with your pelvis afterwards. Lacerations, you know, women who undergo episiotomies that pelvic floor has literally hit the wall and back. So to not expect that pregnancy is a hundred percent, the most physical activity you can do with your body just really undermines and belittles the whole process. And so part of my process now is to send women to physical therapy, postpartum, even if it's just for one visit so they can have an idea of how to improve their core, how to keep their pelvic girdle in shape and engaged because most women have more than one kid. Kameelah Phillips (29:11): So that's a lot of, you know, trauma to the body. And we can do better. We know that it works, we know that it's available, but it's up to us to provide the education and the next steps for them to heal. Karen Litzy: Yeah. Well said, well said I love it. And now as we wind things up here what would be, what would you like the audience to take away from our discussion today? Kameelah Phillips (30:29): I think that it would be helpful to really understand that most doctors do their best to provide women with excellent obstetrical and Gynecological care. I think that a good doctor is really open to receiving information from other specialties in this case PT, physical therapy as modalities that can compliment what we offer. That's not in opposition to what we do so that if we could somehow strengthen the relationship between obstetrics and physical therapists, everyone would win. Like it's for all of us, the patient the obstetrician, the physical therapist the patient's family. It's, you know, pregnancy is the deal. It affects literally you physically, emotionally, psychologically, and sometimes the physical impact of sometimes a lot of times the physical impacts the emotional and the psychological and your sense of wellbeing and health is so impacted by like how you physically look and feel. And you guys have a direct, you know, you have the keys to helping us, you know, improve women physically. So if we could strengthen that relationship and not see it as so oppositional, I think it's a triple win for everyone. Karen Litzy: Yeah, I agree. And the last question I have is one that I ask everyone. And given where you are now in your life and in your career, what advice would you give to your younger self? Kameelah Phillips (31:41): So I'm out of residency 10 years, and I'm just starting my first private practice venture. And looking back, I probably should have done this five years ago. And yet I had a lot of other things going on. I was like birthing my own children and that kind of thing. But at the root of it, honestly, I was scared. I was scared of failing. I was scared of the unknown. I was scared of doing things that I'd never been taught before. Like formally I didn't consider myself an entrepreneur, all these like negatives, right? Negative, negative, never didn't have it. Shouldn't wouldn't, couldn't like, and I would give my younger self, like a kick in the butt to like, just get out there and you know, unless it seems so cliche, but you don't know unless you try. And when you're young, there's nothing to lose. Kameelah Phillips (32:53): Except the fear that's like this imaginary fear that's holding you back. It's a time to be brave and courageous and adventurous. And so I would probably give my younger self like the little push off the ledge the encouragement that I needed to have started this venture and experience earlier. And I would just tell her to be fearless. What do you got to lose? You can always, you know, move back in with your parents. That's what we're doing these days. Right. So like, why be afraid to fail like that just now it's so funny. Cause I think about it cause I'm in it now, but what did I have to lose? Nothing. Nothing. Yeah. Like time, but that would have been a learning, you know, you would have learned so willing to learn. Kameelah Phillips (33:52): So yeah, I would have jumped sooner. Karen Litzy: Excellent advice. Thank you for that. And now where can people find out about you about your new practice? Where are you on social media? Where can we find you? Kameelah Phillips (34:57): So on social media? My main page is drKameelahsays, my practice page is Callawomenshealth, like the flower. I love the like beautiful erotic nature of the calla lily. So that's my practice Calla women's health. I'm on the upper East side of Manhattan, but also available for telehealth visits, physical visits throughout coronavirus. I've been on the grind in this office. So taking new patients of course also happy to see them. Karen Litzy: And for everyone listening, we will have all of this information, one click straight to all of the practice and the social media at the podcast.healthywealthysmart.com. Under this episode, it'll all be in the show notes. So if you didn't get it, don't worry, you can get it that way. So thank you so much for coming on. This was a great episode and I think you've given a lot of wonderful advice to healthcare providers and to women who may be pregnant or want to be pregnant or maybe has already been pregnant. There's a lot of stuff here. So thank you so much. I appreciate it. And everyone, thank you so much for listening. Have a great couple of days and stay healthy, wealthy and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Susie Gronski on the show to discuss chronic pelvic pain syndrome in men. Dr. Susie Gronski, licensed doctor of physical therapy and board-certified pelvic rehabilitation practitioner, is the author of Pelvic Pain: The Ultimate Cock Block, an international teacher, and the creator of several programs that help men with pelvic pain get their pain-free life back. In this episode, we discuss: -What is chronic pelvic pain syndrome/chronic prostatitis -Sociocultural barriers unique to men receiving pelvic pain care -Male expectations and reservations during a pelvic health treatment session -Strategies to increase patient self-efficacy -And so much more! Resources: Susie Gronski Instagram Susie Gronski Facebook Susie Gronski Twitter Treating Male Pelvic Pain Course for healthcare practitioners Pelvic Pain: The Ultimate Cock Block Book In Your Pants Podcast Men's Online DIY program: use code painfree20 for $20 off! One-on-One Intensive Program A big thank you to Net Health for sponsoring this episode! Learn more about the Redoc Patient Portal here. For more information on Susie: Dr. Susie Gronski is a licensed doctor of physical therapy and a board certified pelvic rehabilitation practitioner. Simply put, she's the doctor for 'everything down there.' Her passion is to make you feel comfortable about taboo subjects like sex and private parts. Social stigmas aren't her thing. She provides real advice without the medical fluff, sorta' like a friend who knows the lowdown down below. Dr. Susie is an author and the creator of a unique one-on-on intensive program helping men with pelvic pain become experts in treating themselves. Her enthusiasm for male pelvic health stretches internationally, teaching healthcare providers how to feel more confident serving people with dangly bits. She's determined to make sure you know you can get help for: painful ejaculation problems with the joystick discomfort or pain during sex controlling your pee without needing to be embarrassed... So whatever you want to call it, (penis, shlong or ding-dong), if you've got a problem 'down there', she's the person to get to know. Dr. Susie is currently in private practice in Asheville, North Carolina specializing in men's pelvic health. Follow her on Instagram, Facebook, Twitter, YouTube and listen to her podcast, In Your Pants, for expert pelvic health advice without the jargon. Read the full transcript below: Karen Litzy (00:01): Hi Susie, welcome to the podcast. I'm happy to have you on. And now as the listeners may know, I've had a lot of episodes about pelvic health, pelvic pain, but most of them were centered around female pelvic health and pelvic pain. And today, kind of excited to have you on Susie because today we're going to be talking about chronic pelvic pain in men. And I think this is a topic that is not spoken about a lot. I don't know if it's still considered taboo in many places. We'll talk about that today as we go through this podcast. But before we get into it, can you tell the listeners what is chronic pelvic pain syndrome or chronic prostatitis, which I don't know why I have a hard time saying that word and I'm looking at it and still have a hard time. But anyway, that's neither here nor there. That's my problem, not yours. So go ahead and just give us what is it? Susie Gronski (00:52): Well that's okay about the not able to say the word prostatitis because it is a bit of a misnomer when we're talking about male chronic pelvic pain syndrome. So it's okay. I wish that word wasn't used as frequently anyway to describe what we're going to be talking about. So the official definition that one might read in the literature is that chronic pelvic pain syndrome or chronic prostatitis is having recurring symptoms lasting more than three to six months without a known cause or pathology. And that typically results in sexual health issues, urinary complaints, and obviously a lot of worry to say the least. So that's the official definition of chronic pelvic pain syndrome. Susie Gronski (01:46): Now the NIH or the national Institute of health classifies, I put in bunny quotes here, prostatitis into four categories and briefly those categories are an acute bacteria prostatitis, chronic bacterial prostatitis, chronic non bacterial prostatitis, both inflammatory and non-inflammatory, which is the realm that physical therapist will work in. And then you have a category, interestingly enough, asymptomatic inflammatory prostatitis. And I think that's really important to stress that you can have quote unquote inflammation in the prostate, but you still have individuals who are asymptomatic. So when it comes to the word prostatitis and itself to describe male pelvic pain, I think it is a bit of a misnomer because a lot of cases are not bacterial related or infection related. And actually in fact 90 to 95% are not infection related or bacteria related. So I think we need to shift from using prostatitis as the main umbrella term. Susie Gronski (02:52): Because you know, it puts the blame on the prostate when we know that's not the sole cause or what we're dealing with in the long run. Karen Litzy: Got it. So that, that can be a little confusing for people. Cause I'm assuming if you're a man and you hear that diagnosis prostatitis that that's gotta be kind of unnerving to hear. Right? For one you don't know what it is. Susie Gronski: Yeah. It's like, well, and I don't want to stereotype, but I think when guys really hear prostate, anything, what's the first thing that might come to mind? Cancer, cancer. Right. And so now you're freaked out like what's wrong with my prostate? Am I going to have cancer? We know it's highly prevalent. And so yeah, I think it is a bit of a misnomer in terms of when you have pain down there especially without a known cause that leaves the fear of, well, they must be dismissing something. Susie Gronski (03:50): There must be something really seriously wrong that the doctors are not just finding. Karen Litzy: And what are some common symptoms? I know you mentioned a couple in the beginning there, but if you can kind of repeat those common symptoms that people may experience with chronic pelvic pain syndrome and is pain one of them. Yes. Right? Susie Gronski: Yes. Most often it is a sensation that is not typically pleasurable. It's painful. It may or may not be associated with urinary issues. In general. You'll have any sort of pain or discomfort in the abdominal or genital region. It could even be around the tailbone or even pain with sitting, sitting around, you know, around the sit bones in the groin. It may or may not be associated with sexual function. So for some men they might experience pain after completion or with an erection. Susie Gronski (04:46): They might feel pain with bowel movements. It might be testicular pain. It might be pain between the scrotum and the anus, typically known as the taint area. So there's a lot of overlapping symptoms that one might have. Again, everyone's so unique, but those are some of the common themes that one might hear in the pelvic health world. Karen Litzy: And so if you're experiencing these symptoms, let's say for more than a month, I mean, will people experiencing these symptoms for, let's say a couple of weeks before they go see a doctor or go to look up their symptoms and see what's going on? Susie Gronski: I think that varies on the person and their personality in terms of like their health and healthy behavior in terms of men health seeking behavior. We know that when you compare it to, for example, women, they don't tend to kind of seek out the help of doctors as women might do. Susie Gronski (05:50): Right. and I think that's across the board in terms of international standards as well in terms of the seeking behavior, health seeking behavior. I don't think I can have like a, I don't have a stat or factored on that, but I do think that men tend to kind of like watch and see what happens or you know, I think many of us do. Like if you feel something you're like, well that'll just pass. Right? I don't know if I gave an answer that fully. I just know that sometimes people wait and sometimes people go right away cause they're afraid or whatever the case may be. But I do think that the sooner that you can get reassurance for what you're experiencing in term, and I mean reassurance from not just take these antibiotics and come back and see me in six weeks, it should go away. Susie Gronski (06:42): Because that's typically what will happen when a guy will seek help. And I think the main one of the main barriers too is that where does a guy go get help from when something like this happens? Cause for females we have a gynecologist or a woman's doctor, right. But guys, like I know my husband just, he's like, I would have no idea where to even go. Who do I seek for help for this kind of thing. And so I think when we're talking about barriers for seeking help, that's one of them. I just don't know where do I go. And then you'll go to your primary care physician who may or may not be familiar with, you know, chronic pelvic pain or being able to differentiate, you know, whether it's an infection and what tests to do. Susie Gronski (07:26): A lot of times men are given antibiotics without even having diagnostic tests to see if there's an infection, which is unfortunate. And they'll do this for several rounds too. And so I think the longer that happens, the more that we're making the situation worse in terms of, you know, we know we've got microbiome, we'll plan to those pictures. Well it may or may not have been an infection that triggered this. We know the immune system plays a role in chronic pelvic pain. So, you know, I think having a well versed, fuzzy healthcare professional who can really help this person say, Hey, this is what could be happening. We know a multifactorial and multi-modal treatment approaches is very helpful for what you're going through and that, you know, these symptoms shouldn't last forever. Here go see a pelvic therapist if we know that's not happening. Susie Gronski (08:23): And I see guys several years later or years later before they even have an appropriate diagnosis, which I guess brings me to say that chronic pelvic pain syndrome is a diagnosis of exclusion. So, before they even come see or get a referral to see and see if they're lucky to get a pelvic health referral, they'll go through a lot of invasive tests. Cystoscopies colonoscopies. I mean, you name it. So I just think that by the time they do get the help, the right care that they need for the issues that they're experiencing, they've gone down a really dark rabbit hole by that point. Karen Litzy: Yeah, and that's sort of looking at, I mean, it's not that they're healthcare providers are intentionally doing them wrong, right? They just don't know. Right. So we're talking about, I guess this more traditional view of a medical process for men who are coming in. Having these complaints is saying, well, let's check this, this, this, this, this, and this. Like you said, a diagnosis of exclusion. And then years down the road they come to see you and I can't imagine, forget about their physical wellbeing. I can't imagine their mental and emotional wellbeing is doing all right either. And now the pelvic physical therapist has a whole lot of comorbidities to deal with. Susie Gronski (09:21): Absolutely. Absolutely. And with any type of persistent pain, not just chronic pelvic pain syndrome in men, but I think with any type of persistent pain, we really have to be looking at the psychological and sociological aspects of that person's experience. Because at this point now we're dealing with an emotionally driven process versus a purely nociceptive in nature. You know, it may have started that, but now we're dealing with this like this cat yarn, I don't have cats, but a kid, I know they like to play with yarn and you have this big ball of yarn that you're really just taking one strand out at a time to really unravel and everyone is so unique and very different. Susie Gronski (10:30): So yeah, I think that's where we're dropping the ball with getting quality pain care for these individuals. Number one, just getting rid of some of these barriers of a lack of education on the practitioners, you know, perspective of what do I do in this situation? Why do we need to have all these invasive tests done? In my opinion. I don't think we need to do that, but they're really not getting the referral to see qualified, you know, pelvic therapists who can really rule out, you know, biological triggers and even work with the psychological and sociological aspects of that person's experience. Just to, again, calm things down. And to reassure that person that things are going to be okay. And to that extent, I think this would be worth noting as well is some men do not have positive medical experiences in that they're not being validated, often being dismissed. Susie Gronski (11:23): And no one's really actually looking at their genitals. To this day, I still have men say it's all about just finger, finger in the butt, checking out the prostate, and no one's really addressing like, take a look at my testicles, look at my penis, like treat it like any other part of my body. And then you're then that kind of plays into the blame and shame of one's body. And just again, not knowing, no one's really looking at it. I want somebody to look at it to tell me I'm okay. And I think that's really being missed as well in those early encounters with medical providers. I think that's so important. Karen Litzy: And you know, you had touched on it a few minutes ago talking about not just what we see from a physical standpoint, but a socio cultural standpoint as well. So what are some common barriers that are unique to men from a sociocultural standpoint when receiving care for chronic pelvic pain? Susie Gronski (12:25): Well, the first one that I touched base upon as you said, was having an outlet to get medical care. So there isn't a, you know, male gynecologist per se for men. And so I think just having a lack of that awareness of where does a guy go get help for these types of things. Where would be the best physician, let's say for health urologist or urologist. But that isn't usually the first line of the encounter. It's usually an internist or primary care physician. And sometimes it could be even other healthcare professionals like a massage therapist or a chiropractor, an acupuncturist who's hearing these the symptoms or men feel comfortable enough with the trusted provider that they trust to talk about even what they're going through. Cause I think that brings me into the second, I think barrier is I think if I can say this, the masculine side of culture, right? Susie Gronski (13:33): Like, what should men like mentioned man up and not have these issues and what if something is going on down there? Like, you know, guys aren't really talking about their private parts in the locker room per se. And I speak, again, I'm speaking for the heterosexual male, but like, you know, I think it's just uncomfortable in terms of how the society that we live in to even have that conversation be brought up so that being one of the barriers is just, we're not really talking about sexual health issues and what could go wrong unless it's like, you know, erectile dysfunction. Right? Karen Litzy: Well, that's all over TV, so you can't miss that one. Right, exactly. Here's a pill for that. We know how to fix that. You know, you got Snoop dog talking about like male enhancement products, Pandora. Yeah. And I think, I think in terms of, you know, what are the conversations that we're having around men's health and really comes down to what's selling and what's not selling, unfortunately. Susie Gronski (14:38): But yeah, I think that that's one of the biggest barriers as well as just we're not talking about it outlets. There are no you know, taking a stand for men's health essentially. And the second thing too, or the third thing is when a guy has pain down there and they look it up on the internet, cause that'll probably the first thing we do. Absolutely dr Google will be first they're there and to get help, everything is women's health, women's pelvic health, a women's clinic, baby and mom, you know, like things like that that are coming up where that in itself is like, wow, this is a quote unquote woman's issue. Why am I having it? What does that mean for me? Because again, guys and everyone, I think unless something is going on down there, like we really don't talk about our pelvises or how things work and we're not taught, we're not really taught about like you know, what to expect and how things work and that you have actually pelvic muscles down there. Susie Gronski (15:39): So until you know, something goes South literally and then you have to like look things up and there's enough of crap out there to scare anybody. And so I think, you know, again, I think Google is helpful but it also can be harmful because we know, we know that anything can really shape someone's prognosis when they're seeking treatment and you have scary forums and you have people talking about how I'm living with this for several years. And then you have this person who's just starting to experience these symptoms, reading through these forums and looking at, you know, it could be cancer or it could be this or that. You know, it's like a life sentence. And that's really scary. And that I think is what part of the picture that takes things from acute to chronic in my opinion. Karen Litzy (16:48): Yeah. And you know, when people are involved in, and this isn't across the board, but oftentimes in those kinds of forums, it's people are writing about their experiences that have gone wrong, right? Or that you said, I've been experiencing this for years or I tried X, Y, and Z and it was horrible. So when you read those kinds of forums, cause I've gone on those, I think we, you know, a lot of healthcare practitioners should go on some of these forums to see what's being spoken about. But I've gone on them for like chronic neck pain and you're like, Oh my God, goodness. Right. This is, this is frightening. It's really scary. And so I can't even imagine someone going on there who is experiencing, like you said, some of the symptoms that you had mentioned before. Maybe they've been experiencing these symptoms for a couple of years or a couple of weeks and they look on these forums, they're like, Holy crap. Yeah. Like this is what my life is going to be now. Susie Gronski (17:35): Right. I mean that is really scary. Exactly. Exactly. And that we know, doesn't matter what body part we're dealing with, right. Tends to make the situation worse. Yes. Just cause of that. And so I think I'm a huge proponent of, I don't think I am a huge proponent of having good information knowledge. And like I said, reassurance for this group of people to say like, Hey, this isn't forever. This is what you can do about it. We can really work with this. It's more common than you think. And, it happens in this area, just like any other part of our body, you know there's muscles down there, there's nerves down there, there's everyday function that happens, like pooping, having sex, you know, all these things are quite normal. And I think just even experiencing some discomfort down there, just like you would have some back pain once in a blue moon is not, you know, something that needs to be perpetuated I think for many, many years. Susie Gronski (18:41): But I think we're talking about is that it's unfortunate because they will go down a rabbit hole of, well we've checked everything, we've done every scan under the sun and there's nothing that's showing up on scans. I just don't know what else I can do to help you. And then at that point the conversation is, well now it's all in your head and then, and I'm a goner. Like I'm doing. Yes, I'm doomed. Like and then, yeah. You know, when we talk about the interpersonal context of pain for that individual, it's am I going to be able to have a family, you know, if they don't have any, you know, or be in a relationship or to have kids or how about my job, I have to sit for my work. I can't do that. Or what about my sport that I want to play? Susie Gronski (19:27): Does that mean I can't do that anymore. I mean, there's so many like what ifs and uncertainty and that's one of the themes that men will talk about it's this uncertainty, this roller coaster ride of the symptoms that they experiences. It's fine, you know, one week and then it's terrible the other week and they just don't know what to expect because there's no rhyme or reason for it, for their triggers. And that's really, I think that's a really hard mental, yeah. How do I say that? Like a lack of words. It's really hard. Mentally. It is. Karen Litzy: Yeah. You know, you're absolutely right. And now let's say one of these guys they've been having these symptoms, they've gone to their doctor and miraculously their doctor said you need to go see a pelvic health therapist. Right. Yay. The doctors know what's up. So what are some reservations men might have before seeing that pelvic health therapist? And then we'll talk a little bit from the therapist background point of view after that. But let's talk about the men's point of view first. Susie Gronski (20:26): Yeah. So, the point of views that I'm going to be talking about are actually from the people that I've worked with. So I'm just reiterating or paraphrasing from their experience. But the number one thing is what is it? Cause the doctors aren't really telling them what to expect. So again, they'll go on to Google and they'll find like, you know, this is a woman's health issue and why am I going here? And you know, again that psychological aspects of I guess gender in general of what that means for me as a person. And that experience in itself might be one reservation. Susie Gronski (21:17): Like you know, this is a women's health issue. Like I don't want to go there. And so they might put that off. Which is common as well. I think the second thing is the actual procedure of having internal work or an internal examination. And this is one message I'd like to kind of get across to people is that you don't have to do internal work to get better. And I think there's this huge misunderstanding of like pelvic therapy being like, well, it's all about moving the genitals out of the way and just going for internal work and chasing trigger points. That's not really what it should be an in fact, I think unintentionally of course, I think that's more harm than good because we aren't really asking. Like if you ask the guy in front of you like is this something that you really like? Susie Gronski (22:06): First of all, what would be the purpose of doing internal work? Or even having that assessment, like why are you doing what you're doing? And number two is that in alignment with what that person wants, is that a goal of theirs? Is that functional for them? You know, why are we doing these things? Because we don't want, as for me, I'm speaking for myself, I don't want it to be another person to create medical trauma. I don't want to be that person that says, well this is what you need. When in fact like they're sitting up there on the table, you know, cringing and guarding and tensing. And I think it's funny for me, like it's not funny for the person on the table, but I think when they're pissed we'll say, Oh, you're really tight. You know, you're really tight. Susie Gronski (22:51): It's like, yeah, this is tightest I've ever seen. And I look at me and I'll tell my patients, cause they'll be told that. And I say, well, how did you feel on the table? Were you comfortable with what was going on? And they're like, no, you know, no. And I said, well, no wonder your muscles are tensing. And that would happen with anyone, you know, I'm like, but that doesn't mean that you're broken or that there's something wrong with you. And I think that's the message that's going across, not for every therapist. And I'm not speaking for every therapist, but it's just a theme that I see with men who come into my office who've had therapy in the past. And that's something that I think might be a huge reservation for someone seeking care as well, is having to have an internal assessment done. Susie Gronski (23:36): Although it is common, it doesn't have to happen. And if you're doing an internal, so now let's kind of go into the pelvic health therapist point of view. So this patient comes in, they've had chronic pelvic pain for, we'll say several months and why might you do internal work in or an internal assessment if the patient was okay with it, obviously. So what would a therapist be looking for? So if the person is agreeing to have this done, number one, I think it's, they want to have a thorough evaluation by a professional who works in this field. So that's reassurance. So you would do that because they're asking you to do that, to rule out whatever's putting their mind at ease, right? Again, if that's what they so, so want, I think that's the first thing that we're doing. Susie Gronski (24:35): Number two, if there's like pain with bowel movement or let's say that person's sexual preferences or pleasure has to do with anything anal that would also be applicable in order to just map out areas of tenders, tenderness, and then see if we can change that. So we're not, they're looking for golden nuggets, trigger points. We're there just to see, okay, can we change what you're feeling and can we give that person an experience of, Hey, it doesn't always have to hurt this way. And there are things that we can do to change things and essentially giving them back a sense of control of their own body. But I like to preface that it is a very awesome teaching opportunity for the person because you can say, well, how does it feel when somebody else touches you versus when you try to do this yourself and right then and there during the assessment, I will actually have, we'll compare, I'll say, okay, I want you to touch those areas at home and tell me what you feel. Susie Gronski (25:39): And then I'll say, if it's okay, I'm going to do the same thing and that might be my own individual hand. It might be hand over hand with that person's hand. It just depends on, you know, again, their comfort level. But essentially I'm just there to see if we can change their experience in their body and to prove that you don't have to hurt all the time and that things are changeable. So I love those moments. So that's the reason that I would do any internal work or any external work for that matter, is to see if we can change that person's experience in their body to create more safety and less danger. And so it makes sense. That's what I would do. So yeah, that's essentially why do that and it's not an hour long treatment session of you know, internal work. Susie Gronski (26:31): But, men do appreciate that you take the time to actually talk to them to address their body just like, or this part of their body just like any other part of their body. And that's a theme across every single man that I have worked with. I came into my office, you know, they'll say, I really appreciate how you just worked with me and worked with my intimate parts of my body but just considered it just like any other part of my body, like my nose. And they just felt like the sense of like they can feel vulnerable, they can be safe. They feel heard and validated because somebody is actually taking the time to work with them to ease their essential suffering around what it is they're experiencing. Karen Litzy: And I think that's really important. And so if you are working with a patient with this diagnosis and they are not comfortable with internal work, cause like you said, you don't have to do it. So what might be some other evaluative procedures you might do as the therapist to help this patient? Like you said, feel more comfortable in their body and get a better sense of understanding of what's happening. Susie Gronski (27:45): So the first thing is really just getting to know their story. So going back to giving them time to talk about what's going on for them. I think for men, having an outlet to be heard is really important because men don't typically kind of talk about these things. So once they know that you are accepting and you're there to offer that space for them to express themselves and the difficulty that they're going through with this, I think that's therapy right there. Just to give them that opportunity. So, having a supportive outlet. And the other thing is just if it's movement related, if it's an activity that they're having difficulty with, for example, sitting as a very common one. I have all sorts of like gadgets and toys in my office and I just bring some playfulness into the conversation. Susie Gronski (28:39): I have them sit on various different surfaces to see what would be something they like would actually explore, you know, again, I'm trying to see if we can violate the expectancy of, well, it always hurts and it's constant. I can't change anything. And so my role is really to see like can we change things and if we can, let's do more of that. So I try to bring a little fun into it. I try to incorporate like the passions, their hobbies that they once had done but have stopped since because of all this happening. Sometimes we don't even do any hands on work or any, even a formal assessment on the first day because we're really going through the story and we're reestablishing a sense of that person, a sense of what that person, who that person is. Because a lot of times you lose who you are. Susie Gronski (29:38): You know, when you have pain, persistent pain, you've gone through something. So life changing. So I think, you know, for me and for that person is establishing, well, what would life look like? What would life look like if this were no longer a problem? Who do you want to get back to being? And so I do vision boards. I'll do some sort of visioning exercise of where we can get to like the why, you know, why is this important for you? What do you want to get back to doing? How do you want to feel in your body? And then that becomes essentially the treatment plan or the plan of care. Anything that we can do to collaborate together in more of a coaching relationship to help you move forward, to attain I guess living in a way that you see yourself living, but also a values based type of approach. Susie Gronski (30:28): In terms of treatment. So I know that was like a mouthful, if it's the Bible, you know, I'm doing a bio-psycho-social approach, but I'm really, really having a being patient centered and patient led and I'm just there guiding them. So for some people it is really more of this, I need to figure out who I am, I need to start doing something. Well we figure that out before we go on the table. Cause there might be a lot of fear with that or they might have had certain traumas associated with, you know, medical experiences that may have had that may be negative. And so there might be a lot of reservation. Karen Litzy: And I think we as therapists need to recognize that that person might say yes, like yes, that's okay for you to do all these things like with touch. But we should also be responsible of actually paying attention to what their body is doing, what their autonomic nervous system is doing while you're touching them. Because they might say, yes, and I'm guilty of this too. I'll go for a massage and that person's touches firmer than I'd like. And they'll ask me, you know, how's my pressure? And I'll be like, Oh, it's good, it's good. Susie Gronski (31:37): That's my point. Exactly. That's what the person that you're working with is going through the same thing. And I think it takes a sort of a bit of a skill to recognize or to be more mindful of, you know what, this isn't necessary. I noticed that you're sweating a little bit more, that you're tensing up more. I see your facial expressions, what are your eyebrows doing? And then I'll say, you know, we don't have to do this. I don't think this is right. You know, your body is saying one thing and I know you, you know, I know intellectually, yes, they want it. They want to make you happy. They want to please you, they want to make you happy. And I think part of the treatment too is giving them permission. That's self-efficacy, that's giving them a sense of agency to make that decision for themselves. Susie Gronski (32:21): Do I want, you know, I want to be able to say no. You know, and I tell them right off the bat, you know, that may know I have a lot of tools in my toolbox and if we try something where you're willing to try something and it doesn't work for you, just let me know cause there's many other things that we can do and try out. It doesn't have to be this one size fits all, which we know never works. So yeah. Anyway, I guess in the long run it just depends on the person who is sitting in front of me and essentially what they're telling me they need. And they'll actually, I have a very long intake form, but it's more reflective, very open-ended. And so I'll know from that of like what they're telling me. It's just so it's this awesome cause you can see it like they actually write it out. Susie Gronski (33:04): Like this is what I need. So I think is happening. Great. Well I'm going to facilitate this process and we have a conversation around that. Karen Litzy: Yeah. And I think that's great. And I think it gives the listener, certainly other therapists listening have a better idea as to what a session treating someone, treating a man with chronic pelvic pain might look like. And now you had mentioned self-efficacy and we all know that as physical therapists one of our biggest jobs is to give people a sense of self efficacy and control over their body. So do you have any helpful strategies that you give to your patients for them to increase their self efficacy and to be able to manage their care when you're not there? Susie Gronski (34:02): Hmm. I love that question. So as you know, it probably depends on the person, but everything that we do together in a session, I make sure that they walk away with, well, here's what you can do for yourself. And it's really just a suggestion for them. I really want them to take it to experience it. So for example, I might say, you know, let's do some pleasure hunting. Probably if they've had experiences with you know, having an erection or participating in sexual activity, that was painful. We know that it's like all it takes is one time for things not to work and for things to be bad, to have a bad experience, to be worried about the next time and the next time and the next time. And unfortunately that's really strong for men and their, I guess their penis function, you know? And that's not uncommon to experience when you have pain down there. You know, the last thing you want to do is be like, yeah, I'm ready for sex. You know, it's a threat. Absolutely. and I think it's just educating, educating the person about like, this is completely normal what you're going through and it's common and it's not forever and let's see what we can do to start getting you to feel comfortable in your body again. Susie Gronski (35:05): And so, yeah, I think just having that kind of conversation, not being afraid to ask the questions and then asking them, well, what is it that you'd like to do or start with? Cause there's so many things we can do. What is it that you think is the most important thing to start with onto your recovery? Like I said, it could be sensory integration. So touching one's body, touching oneself and not being afraid and then having a recovery plan or a flare up plan. Cause we know that's common as well. So having some sort of structure around if I experienced this discomfort well what can I do next to help myself in this situation? Whether that's breath work a stretch you know, talking to a friend meditating, whatever it is for that person. Then we kind of put that into a plan to say, okay, next time, you know, if you try this cause you can't really, it's really hard to just, I think applied graded exposure techniques or graded activity to sexual function. Susie Gronski (36:08): Like you know, erections and having an orgasm and you're ejaculating. You can't like stop halfway. Like coming back from like, once you hit that climax, you know, and I think just letting them know that this is the process that happens in your body when you're having an erection and when you're ejaculating and here's what you can do to help yourself post. So, you know, I usually give things like recovery plan, but it's really collaborative with that person cause you know, everyone has their own way of living and their own lifestyle and whether or not it depends under relationship dynamics and sometimes we have to have a conversation around that. And then, you know, if any of those things are kind of coming into play, then we have to reach out to other, you know, a network of team members to help with all those dynamics that might be contributing to that person's experience. Susie Gronski (37:01): So, you know, like sex therapist or couples therapy or, you know, that sort of thing. So it just, you know, again, it depends on the person. So I actually want to do, I do want to make a comment about, you mentioned you know, so what is it that you give to your clients or to your patients? I think the other thing that I want to mention is that for therapists not to be afraid to address the genitals, this is one thing that I think is still common where female therapists will want to I think move male genitalia out of the way and just go to internal work. I think it's really important not to be afraid of, you know, addressing, we're touching a testicle or touching their penis. Because for them it's really important that you're doing that and then you're showing them what exactly, you know, showing them techniques or sensory integration techniques that you can do that they can do for themselves. Susie Gronski (38:03): So you don't have to do things. You're just showing them and then you're saying like, this is all completely normal or you know, or this is what we can work on. And having them experience, have an experience in their own body that's completely not sexually related at all. But I think as female therapists, we're afraid of like, well what if they have an erection right in front of me? You know, or like, and that's happened. You know, that does happen. I think that's one of the reservations is like, and speaking of reservations for the guy on the table, they're also afraid, maybe more so than you, that they're going to have an erection. Oh my gosh. You know, and then I always, I'm very candid about that too. I'm like, you know, we're touching parts of your body that have nerves and sense things and physiological reaction may occur. Susie Gronski (38:47): No big deal. If you need some time to yourself, I'll walk out of the room, you know? But you kind of address it before they even have a question about it. To put things at ease. So, sorry, I went on a tangent with that. Karen Litzy (39:20): I think that's important. That's really important to mention for sure. No, this is great. I mean, what great information. And so if you were to kind of take this conversation from let's say from the point of view of a man suffering from chronic pelvic pain syndrome, what would be your big takeaway for them? Susie Gronski (39:23): Big take away. How can I put this in one sentence? The big takeaway would be that this doesn't have to be forever. Like that this isn't permanent. That if there is something going on down there, don't be afraid to talk about it. I know you may not be surrounded by people who are very candid about talking about poop pee and sex. Like, you know, us as physical pelvic therapists. Anyway, we're so comfortable talking about that, that we forget that people, other people have reservations about talking about private parts. But yeah, not to be afraid to just, you know, reach out to a professional who understands what you're going through and who can relate to you because it doesn't have to be a lifelong sentence and a death sentence per se. Susie Gronski (40:27): You can get help for it and there's help for this. And yeah, I just, I guess that would be the main thing, just making, you know, having support and having that outlet for them to just be themselves and know that they're not alone. Karen Litzy: And what about to the physical therapist who, let's say you, if you are a pelvic health therapist, you're probably a little bit more informed about this, but what if you're not a pelvic health therapist and someone is coming to you with these symptoms, what advice would you give to them? I mean, outside of, I have some that I could refer you to, who is more well versed in the treatment of this, but what advice would you give to the physical therapist? Susie Gronski: You might be seeing a patient with chronic pelvic pain syndrome. I think just having more knowledge about what it is and what it isn't just as a practitioner so that you can have a conversation with this person who is experiencing pain because it in fact, you know, if the person you're working with has groin pain or the tailbone pain or sit bone pain, I think just being aware of like, there are other things that might be involved and asking questions, really not being afraid to ask questions. Susie Gronski (41:48): Maybe you put it in your questionnaire. I think there used to be Oswestry used to have a sex question in it. They took it out. So get the original one, keep the original one. But, yeah, just not being afraid to ask those questions and really just asking the person like, you know, I know asking permission without giving advice to, you know, just saying like, you know, I know a little bit about this. It's not within my scope, but how do you feel about having a consultation with a colleague of mine who works with men? Or who works in this field that can really help you out, we can really work together. It really is just opening up the conversation to say, Hey, you know, you're having these symptoms. There's something that we can do about it. Susie Gronski (42:36): It doesn't have to be, you know, it doesn't have to be like, well I don't know what to do for you, you know? Exactly, yeah. I think that's what it is. Like, you know, give them a resource or give them a website. There's so much free stuff out there. Like my website, I have all sorts of like blog posts and many others who work in this field have a lot of great literature on here's some things that you can do to just open up the conversation and what you can do to help yourself. So I think that's really the key. I think for PR professionals who are not pelvic health therapists but working with people who have pelvises that make a difference, you know, and you know they might be coming to you for low back pain but we know that low back pain and pelvic floor dysfunction and pelvic issues are correlated, highly correlated and in fact you know a lot of testicular pain can or can't originate because of low back issues and vice versa because of the connection there. Susie Gronski (43:31): And so just I think just having that conversation with your patients of saying like this is why it's all connected and this is what I think is what else is happening. How do you feel about getting, you know, getting a consult from so-and-so related to this because they might be, that person might be having many other struggles down there but not talking about it. Right. The first and foremost thing to do from a therapeutic perspective is let's have a conversation because we don't know what else might be going on for that person. And we can certainly be that gatekeeper, that liaison that says, Hey, I know I can get you to see so and so to help with these things issues. You don't have to just live with them. Karen Litzy: Yeah. Great. Great advice. Thank you so much. This was such a good conversation. I think from the standpoint of the therapist and the standpoint of a man maybe experiencing some of these chronic pelvic pain symptoms. Thank you so much. And now last question is one that I ask everyone and that's knowing where you are now in your life and your career, what advice would you give to yourself as a new graduate out of PT school? Susie Gronski (44:52): Oh, that's a good question. Okay. So what advice would I give myself as a new graduate from PT school? Hmm. You don't have to be so serious. I think that would be the advice of knowing that we're humans are all very different and we're built differently. And what we thought was once quote unquote true is always evolving and just use your own experiences to make those determinations. Like you don't always have to be, I don't know, taking word for word when everyone tells you, experience it for yourself and then make that decision. Karen Litzy: Excellent advice. So now let's talk about what you have coming up. So you've got podcasts, books, courses. So tell the audience where they can learn about what you're doing so that they can in turn help their patients or help themselves. Susie Gronski (45:52): Well, thank you for this opportunity to have a shameless plug. Here I am. Well, I'm currently working on the second edition or revised edition of my book, pelvic pain, the ultimate cock block, which is written for, you know, the average Joe who is suffering from pelvic pain. I have a podcast called in your pants that's also on YouTube. And I have several programs support programs for men who are suffering, who suffer from pelvic pain. Some are online DIY programs, others are support programs where myself and a psychologist and sex therapist have collaborated on. And I also have a course that I teach. It's called treating male pelvic pain eight bio-psycho-social approach. So I'm very busy. I have a lots of things go. It's awesome. But where can we find all of it on my website? drSusieg.com. I'm on Instagram @drSusieG. I'm also on Facebook and Twitter. Same handle. Susie Gronski (46:54): Awesome. Yeah, and we'll have the links to everything at podcast.healthywealthysmart.com under this episode. So one click will take you to all of Dr. Susie's really helpful information, whether you're the person living with a chronic pelvic pain syndrome or you're a health practitioner that wants to learn more. So Susie, thanks so much for coming on. This was great and I look forward to your revised book and all the fun stuff that you have coming out. So congrats. And everyone, thanks so much for listening. Have a great couple of days and stay healthy, wealthy, and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Jennifer Hutton on the show to discuss Anti-Racism & Allyship. Dr. Jennifer Hutton, aka Dr. Jpop, is a pediatric physical therapist from Nashville, TN. As a Black woman, Jennifer knows what it is like to identify as different, and it has helped in her quest to be an ally for children with disabilities inside and outside of the clinic. Now she is educating others on how to be effective allies to BIPOC and furthering her desire to create a diverse and inclusive space she calls Dr. Jpop's Neighborhood. In this episode, we discuss: -How racial trauma impacts the biopsychosocial determinants of health -The difference between an ally and a white savior -Implicit bias in healthcare -The lifelong process of Allyship -And so much more! Resources: Jennifer Hutton Facebook Jennifer Hutton Twitter Jennifer Hutton Instagram Jennifer Hutton Website Anti-Racism & Allyship for Rehab and Movement Professionals A big thank you to Net Health for sponsoring this episode! Learn more about Four Ways That Outpatient Therapy Providers Can Increase Patient Engagement in 2020! For more information on Jennifer: Dr. Jennifer Hutton, aka Dr. Jpop, is a pediatric physical therapist from Nashville, TN. She became interested in PT when her youngest cousin was diagnosed with cerebral palsy. Jennifer spent time observing him in different therapies, and subsequently determined that she would work with children in a similar capacity. She graduated from Loma Linda University with her Doctorate in Physical Therapy in 2008, and moved back to her hometown. She spent two years treating in an ortho setting before finally transitioning to her dream job with children. Jennifer enjoys treating the developmentally delayed population, as well as children with neurological and orthopedic diagnoses, both congenital and acquired. While the world reminds children with special needs of their limitations, she believes they are all capable of the impossible and helps them see that their special gifts will help them be their best selves. Jennifer loves to showcase her "pop stars" and share creative treatment ideas on Instagram. She is also an instructor for RockTape and is currently working on her own educational content for pediatric movement specialists. As a Black woman, Jennifer knows what it is like to identify as different, and it has helped in her quest to be an ally for children with disabilities inside and outside of the clinic. Now she is educating others on how to be effective allies to BIPOC and furthering her desire to create a diverse and inclusive space she calls Dr. Jpop's Neighborhood. Read the full transcript below: Karen Litzy (00:01): Hey, Jennifer, welcome to the podcast. I am so happy to have you on. And now for those of you who are, maybe don't know you by your full first name on Instagram and social media, she is Dr. J Pop and last week you gave a wonderfully informative thought provoking webinar, and we will have the link to that in our show notes. Cause people can still watch the replay to that, correct? Yes, the replay is up and it will be for the foreseeable future. So what I'll have you do quickly because I don't want to put words into your mouth, but I would love for you just to tell the audience a little bit more about what that webinar was about and why you did it. Jennifer Hutton (00:58): Yeah, so it was anti-racism and allyship for rehab and movement professionals. And I went through from the beginning, literally started with the history of white supremacy in healthcare, through slavery. The Jim Crow era talked about racial trauma and the effects that it can have psychologically and physiologically. Then I went through the stages of allies and all of the things that you can do in each stage. And then I have portioned it out for the examination phase and for the action phase and kind of let people know in their different settings, be it education, be it healthcare or fitness, the action steps and the questions that they can ask themselves to be a better ally. I just, I wanted to do it. It's been a passion of mine for awhile talking about cultural competency and diversity, and I could tell people were awake in a way that they've never been awake before, so they were ready to receive the message. Jennifer Hutton (01:57): So when everything happened with, you know, Brianna Taylor, I'm not arbitrary and George Floyd, it was kind of like the cherry on top that everybody now is ready to listen. And so I found this was a great way to just get my thoughts across. Karen Litzy: And obviously we're not going to have you retell that entire thing because people can go and watch the replay. Like I said, there'll be a link in the show notes but for me after watching it and I also watched the replay, so I sort of like went through it twice. Just because, you know, I want it to be really clear on what I didn't know. And good. Yeah. And so we're not going to go through all of it, but what I do want to touch upon today is, and you mentioned it in your description just now is racial trauma. And I also want to talk about allyship. So what can people specifically in healthcare do to be allies to our BIPOC community in healthcare? Jennifer Hutton (03:00): Right? So we'll get to that. But first, what I want to talk about is racial trauma. This was a very, very powerful part of the webinar for me. And it is certainly part of our social determinants of health. And as physical therapists, if we are treating under a bio-psychosocial lens, social is part of it. We need to be aware of what racial trauma is and how that may affect a person mentally, physically, and emotionally. Jennifer Hutton (03:47): Racial trauma is basically the cumulative effects of racism on an individual's mental and physical health. And I thought it was really important to highlight because we do a great job of talking about healthcare disparities. We do a great job of, you know, singling out the races and what you will see in the trends and the diseases. But we don't really look at the root cause of why this may be something that is more prevalent in different communities. So I kind of explained that racial trauma is likened unto PTSD. The only difference is we cannot separate ourselves from that toxic environment. So you start to see the manifestation of that stress. The weathering is one of the terms that you will hear when it just breaks down the body because of all of the stress that you are feeling and seeing. So you start to have increased suspicion, sensitivity to threat you know, physiological symptoms using other mechanisms like alcohol and drugs, increased aggression no thoughts of future. Jennifer Hutton (04:54): And I also have looked at research that where they look at the Holocaust survivors and how they actually saw changes in their DNA from the stress that they went through. And that's what they're starting to look at with our DNA as well, seeing that we pass these things down through generations, which is why it's called generational trauma. So to just say, Oh, well this, the African Americans are most likely to have these diseases. It's like, well, what are they dealing with outside of your clinic walls? That would cause this. And it was funny cause the students loved that part. The most, those were actually in professional school. Cause they're saying this would be extremely helpful to relate to patients when I actually go into the clinic or healthcare setting. So I focused on that and I also kind of showed way that you cope with racial trauma and all of the ways that you'll see in the communities is racial storytelling. Jennifer Hutton (05:58): So being able to tell you some of the experiences that I've had in this America validation, naming the trauma, understanding that the microaggressions that you're feeling are a part of the racial trauma that you're experiencing it. And the problem they're finding, even with some of these coping mechanisms is great for the moment. But what happens when the next event comes around, they're going right back through those stages of grief and stress. So I think it's important to see in every facet of life, there are the effects of racism, the effects of white supremacy. And so if you're hitting that on every facet of your life, you're more likely to present with physiological issues. Karen Litzy (06:44): And as a, let's say, as a clinician who might be treating someone who let's say does have high blood pressure or heart disease and is part of the African American community or BIPOC community, is it part of our job to then educate our patients on this? So cause they may say, well, you know, it runs in my family, right. I don't know why it runs in my family. So where does our job come in as the healthcare provider? What is our duty to those patients to address? Is it our duty to address that and to help with coping mechanisms? Or is it just a referral to someone else? Jennifer Hutton (07:25): Right. I think it's definitely our job to consider it when we are approaching different patients to consider that this may be something and a lot of times you'll hear it in their rhetoric. I think I had a student in the chat during the webinar say I have someone who said, he's afraid that if a cop actually comes and he can't put his hands up, that they'll feel like he's resisting. And it was because he couldn't get enough external rotation. Did you read that one? Karen Litzy (07:56): Yeah, I read that too. Yeah. Yeah. Jennifer Hutton (07:58): It was like, see that, that right there. That is something that probably wouldn't have come to your mind when you were thinking about his plan of care, but now maybe you need to change your approach because you're actually tapping into something that makes him feel outside. You feel something that just about the pain that outside and his wife. So I think we definitely have to keep it in mind and consider it. I also think we have access to and knowledge about so many different ways that we can take care of our body. So even if you were to start incorporating some of those into the treatment plan so that they can understand, these are things that you can use and you don't have to name it for them, you don't have to say this is because of racial trauma or give them all of the facts. But you, as a clinician recognize it might be something that's beneficial to them. So that's why I say to my Pilates instructors, to my yoga instructors, you know, you're a key to coping. You're a, something that could be helpful for them. And if they don't know that it, yeah, it is your job because you know about these things. So you can give them as a resource. Karen Litzy (09:02): Excellent. Thank you. And now, let's move on to the concept of being an ally. So before we start and get into how to be an ally certainly within the realm of healthcare, I would love for you to just, can you just define what an ally is? Jennifer Hutton (09:25): Yes. So an ally is a person group or nation that is associated with another group or others for a common cause or purpose. So that just means no, this is not something that affects your daily life personally, but you see that it does affect the way someone else's life is and you want to help make it better. So where you're using your privilege and your position to help further the cause. Karen Litzy (09:51): And how is that different than white savior racism? Jennifer Hutton (09:56): Yeah. So white saviors and still comes from the perspective that you are superior, that if you were not doing the work, then it would not be done and that you are absolutely needed. And I agree your voice is needed, but if you're still approaching it from a superior mindset, because you haven't done the work through those stages of allyship than it actually is a hindrance and it's not as effective. Karen Litzy (10:25): Got it. All right. Good, good change. They're good. Because I think oftentimes we maybe think we're an ally, but maybe we're not. And the concept of white saviorism, is that something that someone is consciously thinking or could that be an unconscious thing? Like you really think that you're there to help and you're trying to do your best, but you're may not be helping in the way you think you are. Jennifer Hutton (10:58): Right. And that's, to me, that's where the self-examination comes in. That's where those questions that you ask yourself about your upbringing, what you believed about black lives matter before all of this happened, what you thought about the killings that were happening in the people that were speaking out against them. How you viewed other races, the things that you said, the things that you've heard, because now you are able to see, yeah. Maybe you're not a racist, but you may have biases that are affecting your thought process, affecting your decisions. So I always say, check your intention. Like, don't just say, well, I intended to do good. Look at the impact that it had. If the impact does not measure the intention, then maybe we need to go back and do some homework on that intention. Because if you're doing something only to make yourself feel better, like, okay, I'm doing it. I'm that good person, not the best intention if you're doing it because like, Oh, they need me, like I talked about thinking that you have to give scholarships to all black people. Like they don't have the money to pay. That's why saviorism that is still coming from a bias mindset of, they are poor. They have less, they don't have the resources and I need to step in and save the day. But I don't think it's ever intentional. I still think it's just coming from your perspective and you really gotta check your perspective. Karen Litzy (12:19): Yeah. And I think we also hear the word implicit bias thrown around quite a bit. So do you want to define that and where that comes into play within this conversation? Jennifer Hutton (12:29): Yeah. So the official definition would be attitudes and stereotypes that affect your understanding, your actions and your decisions in an unconscious way. And I talked about thought viruses. And the way that I give a great example is the older person who only saw whites only signs and colored only signs everywhere that they went can, do you really think they couldn't have made some type of decision or thought about how black people are, how white people are based on what they experienced in their environment. So everything that you were taught and the things that you saw, the things that you heard, it forms your biases and that's on all sides and it mobilizes you. And it's how you act. So if you were surrounded by people who were racist, even if you think of yourself as a good person, you still may have things that were thought viruses that were planted that you have to check. Karen Litzy (13:28): Yeah. All right. Great. Okay. Now let's get into the stages of allyship. So stage one awareness. What does that mean? Does that just mean, Oh, I'm an ally. I'm aware. I'm sure it's much more complicated than that. So I'm just trying, I'm pointing out like the total ridiculous side of it, because that might be like what people think like I'm aware I watched the news. I know what's going on. I'm going to be an ally done. Yes. Jennifer Hutton (13:57): So awareness is that you see that there is a problem. You see the problem and you acknowledge the problem. You also acknowledge as an ally, your privilege in this world, the fact that you are viewed as different and sometimes better in your spaces. And then you say, I want to make this better. So the end of awareness is still an action step of committing and deciding and holding yourself accountable to learning and unlearning all of the things that have made you think this way so that you can be an effective ally. So the awareness, isn't just, yeah, I'm an ally. It's Oh, there's a problem. We got to do something about this. How do I help? Karen Litzy (14:52): Yeah. And could an action step in this awareness phase, be, you know, watching your webinar or watching 13th or reading a book or having conversations. And does that, would that fall into this category or is that sort of weave through? Jennifer Hutton: I think awareness is probably the step that you will visit the most. That would, that's the thing because you, the more that you educate yourself, so webinars, podcasts, Ted talks, documentaries, those are part of your education. Just like any, I think I said, create your own curriculum. Just like you would learn anything. You have to go through all of the information, but as you learn, you'll start to see these things in other spaces and that seeing those things is still your awareness. So I always say, don't think that you're going to escape the phase I'd be done and not come back to it. You're going to start to see these things in all the facets of your life on it. So not just awareness on, like I took a week off and now I'm more aware it's being aware on a daily basis of what you're seeing in your community, within your family, your friends, your peers, your colleagues, and then just do so are you aware of it? And you just make a little mental note, or it's more of a high and it sticks because if you're educating yourself, then what you see will help you process. If that makes sense. The scenario that you are placed in the things that you watch, you'll be able to refer back to. Oh, I remember when I watched, Oh, I remember when I read, when I heard this person say, now you're connecting that after you've educated educator in the process of educating yourself. Karen Litzy (16:02): Yeah. Yeah. And then we sort of jumped the gun. So you've got awareness and education. Is that kind of second stage or do those just sort of inter sort of weave together? They can't have it. Can't have one without the other, right? Yeah. You cannot. Okay. And then next, so kind of moving through these stages here, here comes this, this is a tough one. Karen Litzy (17:00): Here comes the sticky one self interrogation. So can you explain that and also explain why it's sticky it can be difficult. Jennifer Hutton: Yes, the reason self interrogation, this is when you really start to ask yourself a question, cause you're now trying to strip yourself or unlearn the things that have caused you to think the way that you have. So you really have to put your ego aside. And I always say, tell yourself, you're not a bad person. You just have thought viruses that you're trying to change. So you're asking yourself those questions. What were you taught about black people and people of color? Were there any times that you were in, you know, scenarios where there was racism and you didn't speak up or you feel like it was important to speak up? Have you allowed your privilege to mobilize you, but maybe not help someone else? Jennifer Hutton (17:56): Do you have friends of color? My favorite is, well, what were your thoughts about black lives matter 10 years ago in 2012, maybe when Trayvon Martin happened, what were you thinking about these same protests and these same people speaking out? Because if you can truly answer those questions, then you'll see that's where my bias is. That's where that was my blind spot. That is something that I didn't realize it was coming in, but it has affected me. So those were the personal questions and those are hard because it is really, you have to strip yourself of what you consider a part of you. A part of who you are a part of your upbringing. And if you're having those conversations with family members, I mean, I've heard people say, I didn't expect my parents to say the things that they said. Jennifer Hutton (18:47): I didn't expect my best friend to feel the way that she did about me posting my black square. And the conversation that we had was extremely uncomfortable for me and hurtful because I thought we were on the same page. So that's where the discomfort lies. And then it's in deciding, is this that important for me to continue? Even if other people don't continue with me asking yourself, that question is hard. Because you can't, you can't let go of family. That's not how it really works. I mean, of course, if it's toxic, I understand, but you really have to say, I might be doing this by myself and it is a tall task, so are you really ready for it? So that was the personal self interrogation. Karen Litzy (19:34): Yeah. It's sort of this cleaning out your cupboard, if you will, you know, and trying to see if you are ready to change your thoughts and your beliefs and what if you go through these questions and you're not ready. Okay. Jennifer Hutton (19:59): It's always comes back to the question. Once you get to that point of discomfort, you have to ask yourself why you're uncomfortable. You can't just escape the situation because you're going to end up coming back to it. If it was a part of your awakening, once you're awake, it's hard to not see things. It is really hard. So I always say, it's fine if you're not ready, but maybe the reason you're not ready is because you had an upbringing that taught you something that you can't shake. Maybe you need a therapist. Maybe you need to talk through some of those other things to actually help you get past this stage. Karen Litzy (20:34): And was there a point for you growing up where you had your first encounter with racism? Jennifer Hutton (20:50): My very first that I can recall it was mother's day out where you went like three days a week and I wanted to play with like, it's a daycare. It's kinda like daycare, but you don't go every day and you still learn things. So it's like a preschool thing pre K through year four or whatever you call it. But I wanted to play with the kids and I think there were two black kids and the entire mother's day out or my class. And I was told, no, we don't play with Brown kids Jennifer Hutton (21:29): I had another four year old. And so apparently went home. I remembered the act. I remember the kid. I could actually see his face even now, 30 something years later. But apparently I didn't want to tell one parent because I thought that parent would get upset and do something at the house. So I told my, I think I told my mom and that was when they first had to have that conversation of people are not going to like you because of your color and explain it. You imagine having to explain it to a four year old, like they're still processing how to count, pass a hundred, like, and you're telling them it's going to be a problem. Something that they identify with, that they see in the mirror everyday, they cannot shake is going to be a problem for people. So I think that was definitely the first time that I remember. Jennifer Hutton (22:24): And then I also remember the first time I said, Oh, this is unacceptable. And at that point I was like 14. And I had had an incident with a cop where I was profiled. And it was evident because I had white friends around me that were not treated the same for the same regulations I was given. And it was at that point that I said that I'm a fighter, it's time to go. I'm not going to accept this. And I'm not going to not be in these spaces because you don't like it either. I'm going to show up and you're going to see me and I'm going to speak and be loud about how I feel. Because I think my voice is extremely important. Karen Litzy (23:05): Yeah. Wow. I mean, I grew up in the most non diverse town in Pennsylvania and I went to a very non diverse school for college. It's much more diverse now. And when I moved to New York, so I'm in my twenties and it's the first time that I had a friend that I worked with. And he's awesome. But that's beside the point. And we were at work and he had said something about like he had to drive. He hated driving back out of the city at night. Sometimes I said, well, why I was like, is it, I was like, see, it wasn't a drinker or anything like that. It's like, he's drinking and driving. And I couldn't understand. And I was like, well, why wouldn't you, like, why would you worry about driving out of the city at night? Karen Litzy (24:05): And, and he was like, well, I wouldn't want to get pulled over. I'm like, why would you get pulled over? This is how like, night and I was not doing it. Like I was seriously wondering, why would you get pulled? Like, do you have a broken tail light? Did you do speed? And he was just looking at me and he was like, no, I'm like, well, why would they, why would the police pull you over then if you're doing everything right. And he was like, well, you know, when I was like, I don't, I don't know, like tell me why. And he was like, well, you know, because I'm black. And I was like, what? Yeah. And that was the first I was in my twenties. And that was the first time. And I was like, it's funny. I had a talking about, so that was the first time I ever had a conversation about that type of, about racism and how it affects someone who I only knew as like these. Awesome. I love him. He's my great, he's a great friend. He, to this day is still a great friend. And I just was like, I don't, Karen Litzy (25:08): I don't get it. I don't get it. Yeah, yeah, Jennifer Hutton (25:10): No, I didn't get in there. And I think part, my brother said it perfectly sometimes when you're in the same spaces with people, you think your experience is similar. So even if you had a black friend that was with you through all of those, you know, non diverse schoolings and situations, scenarios, and things that you were part of, you would still think our perspective has to be the same. Cause we're getting to do the same thing. So it kind of makes it harder for you to look outside of your experience. Karen Litzy (25:43): What a world. So that's a little bit on the self interrogation and what those questions when I asked myself those questions, I remember that incident. So clearly now and looking back on it, I was like, Oh boy. Yeah. I was just didn't know, I didn't know what I didn't know. And now I do. And now I do. Yeah. Period. Now let's go on. So we talked about self interrogation serve as a person, but let's talk about it now under the lens of being a healthcare provider. So how does that work? Jennifer Hutton: So the self interrogation as a healthcare provider, to me, just like I said, we're educated on health disparities, but not with them. What was your professional opinion? How did you form your professional opinion based on the things that you were taught? Jennifer Hutton (26:44): And this can even a great example is when you hear the word Medicare, what do you do mentally physiologically? Do you grown? Because it's like another Medicare patient. If you're a clinic owner, or even if you are a clinician Medicare, Medicaid, workman's comp, like, what are your thoughts when you see that come through the door, chronic. So that kind of pain. What do you think about chronic pain? People like that? These are you've formed a bias. And how does that bias actually shape how you treat shape the way that you develop plans of care? Are you able to actually change things based on what you see? Just like that student said, well, how do I work on external rotation? There's a million ways that you could actually work on it without it triggering them. So those are the things that you really have to ask yourself and then privilege in outside of just the clinic. Jennifer Hutton (27:34): What is your governing organization look like when you are a part of these masterminds and part of these panels and these groups and discussions, do you see other voices? Do you see other people that don't look like you in the room? Are there ways that you could leverage your privilege to actually open the door so that there are more voices in the room? And then how do you view the table? Like there was one person I was talking to last week and she said, you know, even the thought of saying, let's give them a seat at the table said that you own the table and you don't, none of us do. So you want to create a diverse perspective or diverse group of people in all of your spaces. And so you really want to ask yourself, how can I do that? And then patients like nonverbal communication, when you are working with them, when they are hearing conversations that might be triggering or how do you respond? Do you want to just go in a corner and not say anything? Do you want to just ignore it and shift it to the side? How does discomfort in your coworkers look when you are talking about certain things. So that's some of the self interrogation you can do as a clinician. Karen Litzy (28:43): And, you know, you sort of mentioned, well, if you're having conversation with patients, what happens when let's say a patient in a clinic, whether you're one-on-one or you're in a gym with a lot of people, if they say something that's just not right. Right. And if they sit there talking racist talk, or even saying things that maybe aren't blatantly racist, but still you're like, yeah, no, that's not right. What do you, what do you say? No, we spoke about this a little bit before we went on the air. And we said, it's a little different because we can, we were talking about coronavirus before we got on the air and how, you know, cases are going up in some parts of the country. And it's not just because of more testing it's because more people are sick and you can point those facts and figures. So someone says to you cases, aren't going up, it's the testing you can say, no, no, no. Here are the facts and figures here it is. This is the truth with this. It's a little more abstract, right? So how do we handle those situations as healthcare providers? Jennifer Hutton (29:53): I think just like you handle your patients, it's going to be a case by case situation. I can't give you a cookie cutter copy and paste way because everybody, even if they present with an implicit bias, it's still going to be different from the next person. So depending on your position, if you are a clinic owner, then if this is something that is explicitly, someone's explicitly racist, then you have to make it clear what your business stands for. That is extremely important first. I think it's important to have procedures and policies in place. And maybe even we tolerate everybody like this. Isn't an open space. This is, we accept everyone as they are. And that's something you can give to them. The first time they walk in the door. Cause that lets them know, I don't know who's coming in here is clearly a diverse population and they are tolerable of everybody. Jennifer Hutton (30:48): So it sets the standard sets that precedence before you even get started. And then it's those simple conversations. No, you can't spend your whole session educating them on, you know, the history of healthcare. But you can say, you know, there are some resources that I've read that have helped change my perspective. And if they are open, then give them to them. If they are not, then you need to have something in place that says, Hey, I understand that everybody has different perspectives, but here we respect everyone. And we don't want to trigger anyone in how in our speech. So we would really appreciate it if you would respect that. And honestly, they're gonna be some people who don't like it. And that is this journey. This is literally the journey of being a black person and being an ally. There are not going there going to be people that don't agree with you. And you just have to decide what your stance is and continue to go inside for that every time you face these situations. Karen Litzy (31:48): And I love, and I want to point out that the responses you just gave did not, they weren't accusatory, they weren't aggressive. It was more, Hey, I found this for myself or this is what we, as a clinic, believe it wasn't you. Or how could you say that? Don't say, I mean, that is just the wrong way to go about it. Jennifer Hutton (32:12): Especially the clinician is not professional. Got to that point. You do, you might have to say, you know what, we might have to end our relationship and maybe able to give you some clinics that would be more suited for you. But this, if you are, if you continue to look at this as person against person, we're not going to get anywhere to me. If you look at it, as these are thought viruses, I'm trying to change, it's a lot easier to have grace for other people as well. Karen Litzy (32:44): Yeah. Excellent. All right. Now that was a little bit of an action step, right? So let's talk about a very, very important step in allyship and that's action. So that was one and that's a great action, but what are some other things that would fall into the action category? Jennifer Hutton (33:01): So I split them up into immediate action and longterm action. And mainly because we're telling you slow down, educate yourself, and that can be hard cause like, well there's stuff that needs to be done. So your immediate action is you're protesting, signing petitions in the emails informing yourself about, you know, the politicians that are statewide local, all of those. And then speaking up against remarks. If you hear them now, one thing I want to say do not wear yourself out in the comments section of social media, because I'm sorry that anyone who comes into those comments extras, they're really not looking to learn anything and you're not going to teach them. So you have to let the energy out of it. Karen Litzy (33:45): Energy vampires, it's not worth, it's not worth it. Jennifer Hutton (33:48): It's not worth it. So that's not the action I need you to take. I need you to take that off the dock. Long term action would be continuing to having those discussions in your clinics, in your gyms, in your educational setting, to see where your blind spots are and what you really would like to do to move forward. I think I said earlier, you may get stuck at a step. And if you feel like it's something deep, rooted, get a therapist to actually help you talk through these things recognize it's a learning process, encourage others to do that work that you are doing. And if we're doing it already as healthcare clinicians, we learn things. We believe things. And then we use them in our practice, whether it be something in the biopsychosocial model about chronic pain, about certain, you know, systems that we use, we do it already. And you just have to decide that this is something that's important to you. And that honestly will be your guide when you get to that longterm action. Karen Litzy (34:55): And something that you'd mentioned in the webinar that I want to bring up again, is that when you're talking about these, this longterm action that it needs to be authentic and then you don't want it to do, you don't want to subscribe to tokenism. So we didn't really define tokenism. So why don't you define what that is and why we want to be authentic and not subscribe to it. Jennifer Hutton (35:18): So tokenism, the long and short is you are going to get that one person to represent diversity. I think I said, when we were talking before we started recording about if you are in an all white community, don't just go get a black person and say, that's our representation that is not authentic and it's probably not comfortable for them. Would you need to be able to identify that? So if you're just picking the black person or the person who's Mexican or Asian to say you have that voice, that would be your tokenism. Karen Litzy: Yeah. And, I think that we certainly see that in a lot of facets of society. Definitely. Definitely. All right. Any other actions that you want to cover or do you think we've hit everything? Jennifer Hutton (36:20): I think, I think we've hit everything. I know I did a lot of steps for examining in the webinar, which if they wanted to see it by setting, they're definitely able to go in there. But my biggest takeaway from this is, I know we're in a manic period still where everybody is happening on this quote trend. So don't burn yourself out. It is a marathon, not a sprint. And so it will, it might be sticky. It might be difficult. It might be uncomfortable, but you have to decide whether this is what you believe in to keep going. Karen Litzy: Excellent. Well, thank you. I was just going to ask what are your final thoughts and beat me to it. So thank you. Okay. Well on that, I have one last question that I ask everyone. And that's knowing where you are now in your life and in your career. What advice would you give to yourself straight out of physical therapy school? Jennifer Hutton: Be patient be patient. I came out with the idea, I'm going to be a PT therapist and nothing's going to stop me and I'm going there and I'm doing this. Jennifer Hutton (37:18): And I had to take detours from the minute I graduated. My life did not look like what I thought it would, but where I am right now. I'm good. So it worked out how it was supposed to, so I would say, be patient. Karen Litzy: Excellent. I'm still need to learn that one. I feel like things still need to be done yesterday. Thank you for that advice. And now where can people find your webinar? Jennifer Hutton: Yes. So if you go to Instagram, dr. J-Pop, I actually have the link in my bio. I am probably by the time this comes out, it will be on my website as well. That replay is there and it will be there until that platform doesn't exist. So hopefully forever. Karen Litzy: Excellent. Well, thank you so much. I appreciate this. Like I said, I learned a lot, it was very introspective for me to go through your questions and to kind of understand the privilege that I came from, just for the fact that I was born with the skin that I have. Right, right. And it has nothing to do with, you know, just that one singular thing. It has given me privilege and listening to you and educating myself has really allowed me to, to see that, that very singular fact very clearly. So thank you very much for your webinar and for coming on. I appreciate it. And everyone else. Thanks so much for listening. Have a great couple of days and stay healthy, wealthy and smart. Thanks for listening and subscribing to the podcast! 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