3 Lessons from my Car Mechanic.

I recently took my car into the shop for an alignment issue. Dan, the front office guy who has known me for years, greeted me. I gave him as much detailed information as I could so that he could effectively address the issue with my car. He said it would take a couple hours, gave me a rough estimate, and offered to drive me to a coffee shop or back to work so that I wouldn’t have to wait there. The shop is fairly comfortable and equipped with wifi, so I stuck around. When he motioned me over toward the desk about 2 hours later, Dan broken into a truly magical conversation that captured me as a customer. This is about that conversation.

First, in the initial greeting Dan was excited as ever to see me, and was familiar with our details, including history of our prior visits. This was remarkable considering I only see him 1-2 times per year for minor jobs. My guess is that he takes meticulous notes on his computer,  it either way – by memory or by computer notes – I was impressed by his mentioning of our previous visits.

Second, and most importantly, the words he mentioned when he motioned me back to the desk transported my experience in the mechanics shop to somewhere else… some place that made me feel like this guy has been paying attention to me since I first came to his shop. Here’s as approximation of what he said:

You know, I think you’re pretty good at your job, but I think you’re going to be much better. I can tell that you’re starting to pay attention to details more than before, and I’m sure it translates into your work as well.

What do you mean?

You gave me a pretty detailed and informative report of how the car was performing at highway speeds. It’s something you’ve never done so well in the past.

Ok, so this guy took my current experiencd, placed it within the larger arc of all my prior visits, and extracted an empowering theme with which he completely shocked me… and it makes me want to keep returning. This guy is actually paying attention to his customers as Human Beings, not simply customer #3842 with an alignment problem.

Third, he made a deeper emotional connection as we walked by a beautiful Audi:

Isn’t she pretty?

Yeah, looks nice…

Well, I wouldn’t buy it. It’s got problem after problem. Talk to me before you buy your next car. I’ll tell you what you shouldn’t be buying. And, I’ll tell you what to look for in the prospective car. This one is terrible…

Did this guy just offer me his time & experise (for free?) to help me make a smarter purchase on my next car?? He knows that it isn’t fun to keep bring your car in for major repairs/fixes. Of course he could make more money by me bringing in a terrible purchase for regular fixing, but he opted to help me get a car that wouldn’t require as much (if any) repairs or upgrades. With that, he said goodbye as I walked to my car with keys in hand.

  1. He remembered my history.
  2. He noticed positive big picture change in me and brought it to my attention. This made me feel really impressed by him.
  3. He offered something outside of the norm from a mechanic’s shop… for free, and most likely at the loss of potentially more income.

Customer service won me over, again.

How to be a physio extremist.

How to be a physio extremist. [applies to EBP-fanatics AND physio astrologers alike]

a. BE ABSOLUTIST. Take a side and commit to it regardless of individuals involved, evidence, or circumstance.

b. FAVOR TRIBALISM. Make Physical Therapy Great Again. Only you & your friends can do it right. Everyone else is completely wrong.

c. LOOK DOWN ON OTHERS. Use words that diminish viewpoints and approaches that disagree with yours. For example, a drastic reductionist perspective is that all “Manual Therapy” is the same. Even worse, use words to demean any “Manual Therapy” such as “tickle, rub, push, poke, prod” and the like. Equally ridiculous is the reduction of the biopsychosocial model to “talk the pain out of the person”.

d. BE SENSATIONALISTIC. Get the attention you know you deserve… because you’re worth it. Use extremist headlines because you know you’re a rebel. Show your rebelliousness to the world!

e. POLISH THE PEDESTAL. Use language that is inconsistent across domains: research vocabulary and clinical practice. Even better, start using arcane and unfamiliar phrases to convey simple ideas. It makes you look so very smart.

f. CLAIM THE ETHICAL HIGH GROUND. Always bring up any and all potential ethical faults to take the conversation away from the central topic of conversation. In fact, bring up your ethical concerns the same way a vegan would, and expect the other side to see things your way. One popular word in the world of Twitter-PT is “nocebo”. It’s the equivalent of dropping “Hitler” into any conversation: an immediate conversation dilutor that re-routes the conversation away from the main topic. You are a connoisseur of conversation killers.

g. LET SELF-PRESERVATION BE YOUR GUIDING LIGHT. A crowd of similar beliefs & opinions offer warm comfort – who cares if those beliefs &/ opinions are weaponized?! Stay warm in your crowd. Never mind the existence of the other crowds who may hold different perspectives than yours – they are wrong. They always have been, and always will be. Enjoy the warmth of your echo chamber.

h. EVIDENCE SCHMEVIDENCE. Arm yourself with a quiver of research papers that you can quote/link in your Twitter arguments… I mean “discussions”. After all, arguing is supposedly nothing but constructive & positive… right? So, why not come prepared. Come prepared to win, not to learn. While you’re at it, feel free to take 1 of 2 opposing sides; either you are a qualified physio who functions in a world of religiously peer-reviewed and statistically approved physical therapy where nothing you do in the clinic is without the complete blessing of the research gods, OR you choose to believe that all research is inherently flawed from beginning to end… and you no longer hold any faith in the existence of math. Go ahead, choose your side and guard it with every fiber of your being whether you’re ultimately right or wrong. And by all means, never ever look up the word falsifiability.

i. ABOVE ALL, FORGET THE MAIN THING: THE PATIENTS. It’s about you being right, not about you being right for the patient in front of you.

Now that you’ve chosen your side, remember: there is no middle ground in the world of an extremist. You’re either with “us” or against “us”.

Approaching multiple climaxes in PT.

What are the odds that we are reaching multiple climaxes in the world of PT? Student loans, declining reimbursement, more PT students graduating every year, combined with a weak professional moat and big data all point toward a significant shift in the industry.

Add venture capital into this already volatile mix, and there’s now more fuel to combust. The entry and increase in PT venture money is somewhat surprising given the trends in industry reimbursement dynamics. Not only does it expose physio’s to unseen financial risk, but it also fuels an insidious race to a commoditization of our profession.

In an effort to battle this ongoing commoditization, some adventurous physio’s are branching into niches that weren’t on the radar 15-20 years ago. PT business models are adapting into new environments focusing on specific clienteles based on their needs, as well as the ever-growing number of physio’s specialties. 

Catering to these changing dynamics, some physio’s have even built enterprises with the intent to educate other physio’s. As a result, the realm of Continuing Education has transformed into an immense mess of a financial boon.

PT ain’t what PT was. The internal dynamics are shifting, and have been shifting more intensely for the last decade.

I wonder when it will reach critical mass. Even more so, I wonder what’s on the other side of this critical mass.

When do you think this’ll happen?

What shifts in the industry have you noticed? What shifts are you expecting in the near & far future?

How are you adapting? What prophylactic measures are you taking?

How is it affecting You?

I’d love to know.

Our Inner Tribesman (or Tribeswoman!)

It’s hard to challenge what have become your core beliefs. You’ve made a stance in the past and don’t want to look like someone who wasn’t right from the start.

Good news: most of the greats weren’t right from the start. The adapted themselves and their ideas to the world around them. They let go of crowded thinking and mob mentality to forge a future only they could foresee.

Tribalism puts blinders on your ability to adapt. You feel caught in the spirit of the times, cementing a sense of certainty, and discounting the costs & consequences of being wrong. We do this by ignoring signs, ignoring opposing evidence, continuing to invest in sunk costs, and downplaying any counter-arguments with cries of biases and clever belittlement.

Let go of your inner tribesman. It hampers your adaptability & hijacks your future. 

Our hidden biases betray our true incentives. Uncover your hidden biases; the ones that you dare not admit to the world. Ask yourself: “what is something I believe that most of my tribe would have strong disagreements with?” Why do you have these differences? Are you trying to feel the warmth of an agreeable crowd or are you thinking for yourself? [hint: neither option is ideal. You ought to be serving something greater than yourself. If not, then you may be lying to yourself about your hidden biases and true incentives.]

Find your hidden fears. What negative impacts would you suffer if you were wrong? Explore these fears. Test these fears of being wrong. These fears are very likely tribal & misguided… weighed down by the distant and recent past.

Don’t pin yourself to the past. Don’t hang your hopes on a confirming future. Free yourself from tribalism and allow yourself to adapt to the changing terrain of the present.

The Diagnosis Trap

Beware believing or giving a definite diagnoses. 

It might ossify your approach & (by default) your treatments.

Ossified Diagnoses : Everyone Loses.

Adaptive Diagnoses : Everyone Smartens.

The Physical-Therapy-Education Bubble-Market

Recommended Reading: November 2016 edition of the Journal of The American Physical Therapy Association. It refers to something I’ve been warning about for the last 5 years: there’s a coming inflection point in our industry that could be triggered by a number of things. One of them is the intersection of declining Insurance Payments and increasing costs of Physical Therapy programs across the US.

The University of Saint Augustine (USA) was recently sold to Laureate International Universities. Laureate – the world’s biggest for-profit educational outfit – intends to transition into a Public Corporation (for ~$1 billion) and list on the NASDAQ. You can read the Initial Publics Offering (IPO) here. Laureate’s IPO comes with enough controversy to orchestrate a rocky IPO. The current cost of attendance at USA’s Florida campus is ~12.5k per semester. For comparison it was about $6k 10 years ago.

Has the cost of anything else (maybe, other than your health insurance premium) increased 100% in the last 10 years?

Have Insurance Payments increased? Both of us know the answer. Insurance payments continue to drop across the board. Some insurance pay so little that PT’s actually lose money by treating folks insured by these particular companies.

There are more PT’s graduating in the US now than ever before.The number of PT programs have expanded across the US. In fact, from 2000 to 2016 there has been a ~25% increase in the number of PT programs. Presumably, this is intended to not only fill the supposed demand for more Physical Therapists, but also because it is lucrative business. The total cost of these programs range from $60k to $188k. There are also more applicants than ever before. And, why not? Based on the Bureau of Labor Statistics, the demand is expected to grow at 34% per year.

Combine the growing number of PT’s with down-trending Insurance Payments and imagine what you get?

Is it any surprise that salaries for Physical Therapists have (on average) dropped 2.3% in 2015. This is something that I’ve been expecting for the last 5 years. From a completely objective perspective, this is to be expected. Graduates schools are money-making machines. Guess who isn’t making as much money? You guessed it, the graduates.

Yes, the average salary of PT graduates sounds great, but what about those pesky loans? Potential graduates are considering the impact of rising costs of PT programs more & more. The number of law school graduates at lower now than they were 10 years ago. Could this happen to PT? If it could, then what would drive this trend?

Lower insurance payments has already pushed hospitals to hire more Physical Therapy Assistants than Physical Therapists. PT’s do patient evaluations, and PTA’s carry out treatments. I don’t imagine this trend slowing down any time soon.

Student Loan Debt is by-no-means limited to PT Graduates. In aggregate student loans are reaching climactic proportions. The last time something increased at such a persistent trend was the cost of housing in the 2000’s. We all know how that ended: the harshest economic melt-down since the depression.

This time the amount of money involved is significantly higher. Here’s a graphic pulled from tuition.io:

tuitionio

What pricked the housing bubble? Things started going south when the number of defaults exceeded expectations. So, where are we in terms of Student Loan payment delinquency? Well, it’s not very pretty. The number of Student Loan delinquencies has now eclipsed the number of Credit Card delinquencies.

STUDENT-LOANS-VS-CREDIT-CARDS_0.jpg

Here’s what makes these delinquencies insidiously worse: student loans cannot be cleared in a bankruptcy. That’s right. What was the “best loan to have” can quickly transition into the worst loan ever. The bubble is set to pop. The question is when.

WHAT ARE YOU TO DO??

First, let’s get the obvious out of the way: Explore Income-Based Repayment Loan Forgiveness Programs. Do your research online. Then, talk to at least 5 different individuals about your options and the best course of action for you.

Now the stuff that takes a bit of elbow grease…

You have something truly priceless: YOU. That’s right, your best investment is in yourself. Let’s make this a bit more actionable.

  1. If you are a recently graduated PT, then I strongly encourage you to consider entering a residency/fellowship program to sharpen your clinical skills.
  2. Ensure that you experiencing personal growth on a consistent basis. If the week went by without any change in your thoughts, perspectives, understandings, or performances, then you are doing yourself a disservice. Get better. Now. The most successful individuals have an insatiable curiosity for something. Uncover your curiosity. Explore it as completely as possible. Read everything you can on the topic. Talk to and network with anyone that feeds this insatiable curiosity. I was (and am still) very interested in sharpening my Manual Therapy skills. I also have a couple other curiosities that I’m fostering and exploring right now.
  3. Make sure that you work for someone you admire. This is especially important in your early professional years. Nothing beats having a strong mentor who guides you in a direction that will likely skirt the pain of monotony and stunted professional growth.

If you are working for a company, then make yourself indispensable.

  1. Learn the company’s ecosystem inside and out. What drives the company and it’s leaders? How can you add fuel to their drive?
  2. Volunteer your time and efforts to take on additional responsibility. This has the dual benefits of learning a new role and embedding yourself in the execution of these roles. So, when they need someone to fill a similar role guess who they’ll turn to? You.
  3. Put yourself in the owner’s shoes. Look at the entire clinical operation from the perspective of an owner. Make decisions (as little as they may be) as if you are the owner. Got an idea to help the clinic owner spend more time away from the clinic without worrying about the day-to-day clinical/administrative routines? Lay it out for him to adopt. Time is valuable to everyone. Be the individual who makes it clear that you are the one who is saving the company and it’s administrators time and money.
  4. Once you’ve managed to pull-off steps 1-3 you’ll have the leverage to increase your paycheck or even better: get on a path to generate your own income.

 

CEU Review: DN-1 & DN-2

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I recently attended DN-1 & DN-2 by the Spinal Manipulation. The courses were fantastic experiences and have provided me with new means of addressing a variety of conditions in the clinic. Both courses surprised me on two fronts:

1. The Research. I wasn’t expecting so much time spent on discussing the research and how it guided their approach. The amount of research presented simply blew me away. Research is research regardless of which geographical region of the world it was done and in which professional journal it was published. And so, they pulled research from all over the planet and thought a decent variety of disciplines. This was strangely refreshing. The lectures were quite heavy on the current relevant research; and, it was presented fairly in that both positive and negatives were mentioned. I don’t know about the nuances & specifics of these studies, but the fact that they exist and haven’t been explored in other courses is very interesting.

2. Pain Science Lectures. Yes, I know what you’re thinking…it’s a dry needling course and they’re presenting lectures on pain science? Oh, yes they did. The phenomenal lectures on pain science as it relates to Dry Needling also caught me completely off-guard….in a very good way! I gotta admit: pain science talks in both courses were in-depth on biochemical and mechanical levels as related to dry needling. It was fantastic and convincingly presented. Very convincing. Tommy presented a very detailed & balanced lecture, and Ray bled passion during his lecture.

Now onto specific critiques on the courses themselves, as well as recommendations for future attendees.

The Negatives.

About 40% of the manual was summaries of research reports. While this provides a nice foundation of research on which to base Dry Needling treatments, it could easily be converted into a PDF to be emailed and downloadable to course attendees. Another issue with the current manual (DN-1 2016) is that it didn’t always correlate with the material presented. In other words, material was presented that wasn’t in our course notes, and there was no way to obtain an updated manual. Why? Apparently the new manual wasn’t yet approved for publishing. It would be fantastic to make this information accessible to 2016 course attendees (with a reduced price) when it is available. Maybe you could save paper and simply email/download it in PDF form; printed manual could be an extra charge.

The manual had a couple more short-comings. 1) There was very limited space to take notes. 2) The semi-standard protocols weren’t to be found; however, there is ample instruction on palpation, needle placement, and needle technique. It would’ve been nice to have drawings/pictures of the protocols alongside written instructions for future reference within the manual itself.

When it came to lab time, there was often ran into extremes of either excessive or short practice periods. This was the first Dry Needling course for a number of attendees, and spending a little longer on basic needling practice would’ve been more beneficial. Then again, maybe I was just too slow to get comfortable before moving on to labs 2 or 3. DN-2 did a much better job of managing lab time.

Finally, there should’ve been more time spent on the technicals of employing Dry Needling in the clinic – things like how to bill insurance for it, how it’s incorporated into a cash practice, orchestration of Dry Needling into the Plan of Care to address questions of stretch after/before or skip exercising entirely. All these items should be addressed up front and as clearly as possible. I had these questions addressed in DN-2 by asking the instructor during lab time. Be sure to ask this question to multiple folks – instructors & other DN practitioners.

Some Tips & Recommendations.

Take lots of pics from a variety of angles – at least 2 different angles. This will allow you to get a better appreciation of needle placement when you’re practicing it on your friends, family, and coworkers after the course.

If you’re a visual learner like me, then it might be a smart idea to sketch out the lab demo with all the insertion markings. It might also be useful to re-create this on your own after the course is over. This way you feel more confident about inserting the needles, and know exactly what you’re doing before you start poking your friends, coworkers, and/or family members.

Let’s stick with the lab demo for a bit longer. As I mentioned earlier, the course manual provides very little room to take adequate notes. So, it’s a really good idea to jot down instructions/sketches during the lab demo into either a separate notebook or sheets of paper. Using a clipboard with unruled sheets of paper works best for me. This allows freedom to sketch and jot down info as it suits my visuals without the constraints of ruled pages.

Consider reviewing the relevant anatomical regions prior to taking the course. Here’s how I would’ve done it: cover the insertions of major/important muscles and their innervation, trace major nerves (for DN-1 think brachial plexus), and, finally, roughly familiarize yourself with the “spaces” (for example, the quadrangular space) that are created by the framing muscles and/or other structures – no need to be very meticulous about this, just consider the obvious ones.

Finally, bring some cash. They tend to supply needles like your grandmother would supply dinner items: better too much than too little. This allows you the opportunity to purchase some needles right after the course and start practicing right away. $50 worth of needles should be a nice start.

The Positives.

Their conceptual application of combining spinal manipulation and dry needling certainly peaked my interest. It made me want to explore these “segmental effects” deeper on my own prior to taking a spinal manipulation course. I really appreciate the work behind creating these protocols (much of which was lifted directly from research articles).

Both instructors were knowledgeable, presented the material well, AND presented it fairly. They pointed out studies that showed both sides of the argument. Their perspectives on utilization of the literature was refreshing and made me open my eyes a bit more toward how some (many?) folks view the literature through tainted lenses while wearing blinders. 

This course provided me with incorporable content and manual intervention options that can dove-tail nicely with my current clinical framework. While I don’t think wearing the “osteopractor” label is in my future, the concepts were intriguing and definitely warrant more of my curiosity.

Final Take.

I came away from this course with much more appreciation of an intervention that I had ignored just 4 years earlier. Dry Needling seems to have the potential to address multiple fronts at once: save my hands, access structures that are difficult to reach/treat with manual palpation, provide another route to address chronic pains, and provide me with another differentiator with which to market my services for the benefit of my future clients. Good content. Engaging instructors. Worth the time.

Fund #GetPT1st Now!

Many of us have enjoyed the benefits of the efforts of Sean Hagey in coalescing the profession behind #GetPT1st. Some folks were a bit skeptical about it in the beginning, but their skepticism faded as #GetPT1st stayed focused on its message and continued to deliver content that you, I, and our fellow PT’s have shared with colleagues, friends, and family.

Here’s the crazy part: Sean managed to rally the profession while working his regular job and devoting extra hours (and finances!) to the #GetPT1st campaign…his “pet project”!

Let’s rally behind Sean. Check out his video and donate by clicking here.

Who could have predicted #GetPT1st 5 years ago? Certainly not me. #GetPT1st turned into a powerful medium to spread the value and power of physical therapy, and I strongly encourage you to take part in the movement.

What’s not to like? Do it for your patients, do it for your profession. This might just be the most fulfilling money you’ve spent is some time.

Join me in supporting Sean by funding #GetPT1st here.

 

Premature Accumulation

I once heard a well-known founder of a Physical Therapy specialization certification program state that some clinicians who passed the Certification Exams prepared merely for the exam, and the process of preparation didn’t necessarily make them better clinicians. This made me wonder about those individuals who have accumulated a string of acronyms after their name, but weren’t able to efficiently integrate their achievements. It also reminded me of those clinicians with 1, 2, or no certifications who applied their learnings and are, consequently, more integrated & effective in the clinic.

Letters, titles… For what purpose? Why & for what goal? How has it changed you & your outcomes?

Most clinicians sacrifice time & energy to attain their titles with the intention of sharpening & expanding their clinical skills with the goals of achieving better patient outcomes, and, consequently, greater job satisfaction – among other things.

The decisions of which philosophy and framework of practice to pursue often bottleneck down to whether or not “the juice is worth the squeeze”. “The Juice” is usually some blend of curiosity, cost, continuing education credits (poor reason, but it is unfortunately the only reason for some), and clinical application.

One route some clinicians travel involves certain Clinical Specialties requiring sitting for a computerized exam. One example is the OCS – Orthopedic Clinical Specialist.

Allow me to rant about the OCS for a bit. Feel free to skip ahead…


The OCS is a regurgitation of dated material. I know this to be true because I was preparing for it last year. Although I decided to put it off until some time in the future, I appreciate the amount of time & effort it takes to memorize the required information for the test. Now, why anyone would want an OCS rests mostly on 2 legs: 1. Public Perception 2. Requirement for APTA Credentialed Residency programs. I find both of these reasons false & inadequate. Let me explain.

When it comes to public perception, it misleads the public into thinking those without an OCS are incapable to evaluating and addressing orthopedic concerns. This is blatantly false considering that a majority of our training in PT school is geared toward orthopedic assessment & treatment. Moreover, memorization and regurgitation DO NOT equate to better clinician reasoning skills. This might be one reason many (but, not all) folks are not better clinicians after attaining an OCS.

As it pertains to APTA Credentialed Residency Programs, the last thing you want as a requirement is rote memorization. It should be geared toward clinical reasoning and patient outcomes. An OCS does a mediocre job on this. How can studying for 1 weekend exam compensate or replace the achievements/efforts of year(s) of dedication and practice? It simply can’t. However, it is a nice recurring revenue generator to require Mentors have an OCS in order for a Residency to be APTA credentialed.


Given the benefit of retrospection and conversations with colleagues who have taken a fair number & variety of Continuing Education courses, I feel fairly confident with what I’m about to say.

If the contents of the course do not add to your clinical effectiveness or efficiency, then it probably wasn’t worth your time & investment. Additionally, if it didn’t inspire you to become a better (how ever you define better) Physical Therapist, then it most certainly wasn’t worth your time.

Maybe you’ve just experienced a life-altering Continuing Education course, and you’re excited about representing a movement that drives you to practice at the peak of your licensure. Now you’re nervously excited about the certification exam and are wondering if you really should pursue it.

Ask yourself: What are those letters after your name worth to you? To your patients?

Maybe the answer is, “those letters mean nothing to me. All I want is to learn the content, help my patients, and improve my clinical practice.” If that’s your response, then congratulations! You just saved yourself a shitload of stress and expenses by avoiding the brain-bending experience of studying for a certification exam.

If your response is, “I want to know that I’m applying the content effectively and at the highest level possible” then the letters might be worth the effort. If you believe the letters will provide you with leverage in clinical outcomes and evangelizing the Physical Therapy Gospel of the potential to live functional lives with zero-to-minimal involvement of pharmaceutical drugs and surgery, then the juice might be worth your squeeze.

The practicality of accumulating letters can distill down to a signaling mechanism that shouts “I know what I’m talking about!” Or maybe it says “I still haven’t found what I’m looking for!” (say it again with your best Bono impression). Maybe s/he is a genuinely curious individual with a passion to learn & grow as a professional.

Me? Well, I would go with the “Bono option” – I still haven’t found what I’m looking for… In retrospect, my certifications (so far) have been a boon to my clinical practice and experience. It’s been a cumulative and catalytic accumulation that provided me with a foundational conceptual framework on which I can mold my future professional growth.

I’m sure you’ve met individuals with an alphabet soup of letters after their name who do not practice at the top of their licensure/certifications. Even worse, they might have completely abandoned the teachings of these certifications, but continue to grace their business cards with these aching acronyms. False advertising, perhaps. Or… a premature accumulation of efforts with nothing to show for it other than limp advertisement.

A possible cure for this premature accumulation: finding a framework that you believe can last the test of time. This is significantly more valuable than a random accumulation of certifications.

P.S. – As many of you are well aware, I enjoy reading books. Early March 2016 saw the first edition of my Quarterly Readings Newsletter. It is an update on some of my favorite reads of the quarter. Email me with “I love to read!” in the subject line, and I will add you to the email list.