Hindsight Wisdom! Special Post for #solvePT 02/24/15

Tonight’s #solvePT discussion revolved around the following question:

It just so happens that I’ve asked a similar question repeatedly over the last year in my interviews. I highly recommend that you check out the interviews. There are TONS of wisdom and lessons to learn from these shared stories and experiences. 

The question I asked was some variation of: “Imagine you’ve travelled back in time right after your graduation from PT school and are face-to-face with yourself. What advice would you give to your younger self?” I’ve listed the responses below.

Enjoy this special post for #solvePT!

Dr. Nick Nordvedt: LEARN and find a mentor. PT students and new grads that I meet are frequently surprised by the vast amount of knowledge still to learn after graduation. We graduate as generalists, but must find our practice niche after graduation. I think the best way to do this is through taking advantage of every learning opportunity available and find a great mentor that shares core practice values with you.

DR. MONIQUE CARUTH: LOL, shouting out loud to my young self…”You do not know it all!!!!”,  I would tell myself to welcome constructive criticism because those that offer it they see potential in you and care about you to take the time to invest in sharing ways and means for you to better achieve your goals. Those that don’t care won’t waste time even offering anything good or bad. Don’t beat yourself up about getting a B on an exam, no one cares what your grades are when you leave PT school as long as you pass your boards. Take a few business electives. Chat with managerial students. Meet and sustain relationships with great mentors. Engage in social media. Advocate more for our profession.

Dr. Ben Fung: Get involved in legislative issues – licensure defines practice patterns. PERIOD. If you want to truly be regarded as a primary care, provider of choice for neuromusculoskeletal impairments – one must be first licensed to do so to effectively penetrate the market.

DR. ERICA MELOE: That’s an interesting question because I gave up a financially rewarding career to go back to school. I would advise the student to pay attention to the trends in healthcare. When I graduated PT school, it was during a time when no one was hiring! The Balanced Budget Act was in full swing and the Medicare Cap was just instituted. There is no way as a PT Student you could have prepared yourself for that, realistically. I would also have advised myself to seek a mentor out, someone who was already established as a PT. Mentors are so important for both personal and professional development. And I think as a student in a field that was undergoing so much change, it would have been nice to see the field from a different perspective.

When I was at Stern in my last year of business school, NYU set up “informational Interviews” with alumni and they endeavored to match you both with regards to industry. These were very helpful in the sense that it opened my eyes to the opportunities in my field. When I was in PT school, I did not have that opportunity. I would urge students to request this if their programs were not offering it already.

DR. DAVID BROWDER:  Daniel Pink, in his book ‘Drive’ lists three things that drive intrinsic motivation.  1) Autonomy, 2) Mastery and 3) Purpose.  My advice is to seek opportunities to work in an organization where the purpose of physical therapy is embedded into the culture, and where they can gain mastery in the practice of physical therapy.  For those so inclined seek out mentors who can help develop management and leadership skills.  I believe that specialization is an excellent route to this.  Autonomy is more difficult and can definitely be found professionally, but for those that have the ambition and determination to build their own practice – I think there is no better place than private practice physical therapy to find the confluence of these three things.

Dr. Sandy Hilton: Be bold and take chances. You will need to be persistent to get what you want, do it with grace and kindness, but do it.

And publish your masters thesis, because you were right.

Dr. Erson Religioso III: Clinically: You don’t know it all, and for God’s sake, stop beating on people to make them move better!

Personally: Start working on your symmetry and stop with the huge pounding overstrides so you don’t have to quit running due to knee pain. Also, invest in something called google.

Jerry Durham:I would beat the following statements into my Younger head….

-Believe in yourself, your ideas and what you bring.

-Understand that YOU being YOU is the most Valuable thing you can do (Fuck others who say dont be YOU)


-Don’t be afraid NOT to be the smartest guy in the room…You can learn from Everybody

-Find a Business Mentor TODAY (this woulda helped on multiple fronts, not just starting my biz)

-Set up a financial plan and follow it..

-Your parents are right!!…(almost all of the time).

All of those played a huge role in my personal and professional development.  A couple of those came way later than others.  If those were beat into my head 20 years ago, my learning curve would have been far shorter!

(I would also mention to hold that Apple stock I bought at $14 a share…no joke.  But thats for another day)

TODD HARGROVE: Invest in Google and Amazon. Chicken wing consumption needs to come down.

I don’t regret going to law school at all, it was one of the best times of my life. But I do regret not getting started with my current career a little earlier. Is there a difference between these two things? It feels that way to me. If I had gotten started with this career earlier maybe I would have been more involved in strength and conditioning and sports performance.

BRUCE WILK: It was 1980 and it was my senior year of physical therapy school.  I was disappointed because I was hoping to learn about running injury management and how to keep people running healthy. It took years to reach that goal, but I finally made it.

My advice: Stay the course.

BRAD BEER: Great question. My advice would be two-fold:

1. To not ‘look side-ways’. Avoid the comparison game. The grass may appear to be greener but it rarely is!
2. Be patient. Success is developed through the navigation of an array of challenges and various learning opportunities that life both professionally and personally generates.The degree to which you succeed and progresswill be determined by the degree that you stop to evaluate your learnings and lessons.It has been said that experience is an OK teacher but evaluated experience is an even better teacher.

JESSICA MCKINNEY: Study, travel, and read more before you start your family and trust your gut in bridging pelvic health and your orthopedic manual therapy training. You’ll know enough to do it way earlier than you think.

DR. SETH OBERST: Having a reason for everything that we do as physios. Having a paradigm for progression/regression as well as using a test-retest model that exposes the client to the intervention based on your hypothesis and then gauges their response is crucial! It’s what separates the zeros from the heroes. The key is to recognize patterns and that means a lot of deliberate practice. Experience itself does not equate to expertise; deliberate, thoughtful experience while being driven by what we don’t know yields expertise.

Expose yourself to other ideas outside of physio. Yoga, massage therapy, kettlebells, Oly lifting, anything. We try to own these little silos of information without considering other, often very effective, schools of thought. Way too many PTs have no clue about training methods and movements which is rather ridiculous. If you yourself cannot pull, push, press, and squat how the hell can you expect to have face validity when calling yourself a sports physio or trying to coach a patient (and yes everyone should be able to perform those movements in some capacity). Because ultimately PTs are movement coaches so take pride in owning movement.

ANDY LODATO: This profession and your patients will humble you. They will humble you with their generosity, their complexity and their vulnerability. You won’t realize the power that you have to help someone just by listening and talking. The profession is a “Physical Therapist”, but all of those psychology classes you took in undergrad will be of great use to you. Also, remember to be have patience. Your career and development will take not happen overnight. All of the bumps in the road are part of the journey.

ANN WENDEL: I would tell myself that it’s all going to be ok. That no matter what happens, I can turn it around and make a really satisfying life for myself.

JULIE WEIBE: Change is an evolution, not a revolution. Be patient, and stand strong even when you are swimming against the tide.

Never stop learning.

Stop cursing like a sailor.

Stop dating that guy. Wait for the Canadian….(I would sort of trail that last one off into a whisper, then slink back into the shadows….)

Find me on Twitter: @Cinema_Air


Interview with Mike Horsfield, PT, MBA…

Mike Horsfield, PT, OCS, MBA, ATC of Bettendorf, IA serves as CEO of Rock Valley Physical Therapy. He has a unique and passionate perspective on the profession of Physical Therapy; in fact, he was invited to give a talk at the latest Graham Sessions. He is also one of few PTs to hold an MBA.

As usual, I learned quite a bit from the interview, and I’m sure you’ll get a lot out of it as well. Enjoy!

First, tell us about the first hour of your day. What is your daily morning routine beginning as soon as you wake up?

M-W-Fri I see patients in the morning.  I get up at 5:15, shower, have Greek Yogurt with peanut butter and granola for breakfast and then am off to the clinic where I am seeing patients by 6am.  T-Th are my administrative days.  I get up at 6:15, shower, start with the same breakfast and then I straighten my daughter’s hair (I am crazy good with a flat iron) and drive her to school those days.  Really enjoy those few minutes of one on one time with her.    

Give us the backstory of you find your way into the wonderful world of Physical Therapy?  

My story is typical of many PT’s.  I was became familiar with what Physical Therapists do after undergoing knee surgery from a football injury in high school.  In college I waivered between education, coaching and physical therapy.  After volunteering for a local PT practice I realize that effective therapists are also great teachers and coaches so I ultimately went down that path.  

Why did you decide to get an MBA? And, how has that impacted your business decision-making?

I realized after getting in way over my head in my first management opportunity that I had to do something to speed up the learning curve.   It was very clear to me that one high school business class in my 20 years of formal education was not quite enough.  Rock Valley was beginning to grow at that time as well so the management team saw the need to expand the organization’s business acumen so they supported my decision to take night classes to get my MBA.

The MBA has been instrumental in helping me get outside our clinical world and see our practice as a business.  When you are learning alongside people from John Deere, Caterpillar and United Airlines they help you look at your processes and business in a whole new light.  I realized that the fundamentals of business apply to all of us.  Organizations that build tractors are faced with many of the same challenges and opportunities we face everyday.

Learning and decision making is about knowing enough to ask the next best question.  Just like PT school provides us with the scientific foundation to begin our clinical learning and decision making process the MBA provided me with a similar business foundation  This has allowed me to continue to learn through the years by asking the next best question.

Tell us about the beginnings of Rock Valley Physical Therapy. Also, what was your role with the company, and how has that changed over the years?

The Rock Valley story is a great example of how collaboration is many times a better option that competition.  In 1984 Mark Levsen and Steve Layer both opened private practices a couple of blocks away from each other.  After being in business a few short months Mark invited Steve to lunch and they realized they shared the same patient care and business philosophy and decided to join their practices together rather than competing with each other for the next 30 years.  This spirit of collaboration continues to be a strong part of our company’s culture.  We make it a point to get to know our competitors. In doing so we often discover that we share the same goals and this leads us to find ways to help each other by partnering or joint venturing.  Building these relationships has been instrumental in helping us grow from 6 to 25 clinics in the past 7 years.  This philosophy and has been the motivation behind  Midwest Therapy Network. This union of 16 private practices with nearly 60 clinics is dedicated to improving the practice environment for physical therapist owned practices in our States.

As I listen to the challenges of Private Practice owners across the country I often wonder how much better off we would be as a group if everyone was willing to walk across the street and truly get to know their competition.  I believe they would realize as Mark and Steve did that they have more in common than they may think.  United we are so much stronger than we are as single entities.  For us it has been a whole lot more fun figuring out how we are going to grow the pie for all rather than beating each other up for the one piece left.

I joined Rock Valley after graduating from the University of Iowa in 1993.  In 1997 I was given the opportunity to oversee a management service agreement with local hospital and nursing home.  In 2001 I became a partner in Rock Valley and in 2005 assumed the role of COO for our Iowa clinics.  Steve Layer transitioned from CEO back to full time patient care in 2010 and that is when I assumed the role of CEO.  Thanks to many great mentors along the way the entire journey has been and continues to be a wonderful learning experience..

Give us an example of some of the hardest challenges that Rock Valley PT had to overcome in it’s 30 years? And, how were they solved?

Five years ago we saw where health care was going and had to make a decision whether we wanted to grow or consolidate.  We understood if we wanted to grow in an environment where there would be vertical integration and risk sharing we had to be willing to consider alternative business relationships with providers and health systems.  That led to some great debate at our Board level.  A year later we eventually reached consensus on our “non-negotiable” principles that we still adhere to when we partner today.  We are fortunate to have a high trust environment where our owners can get into heated debates and then open and beer and move on.  We are proud of the fact that we have eleven business partners and have never had to take a vote on an issue.  We have always been able to reach consensus through thoughtful  discussion.

Share some of the most important entrepreneurial lessons you’ve learned over the many years of doing business.

Surround yourself with great people and then jump and grow wings on the way down.  One thing I am sure of is 100% of opportunities never explored fail.  Great people do great things.  Organizational systems need to be designed to encourage great people to fly as fast and far as they want but also build in the parachute to ease the landing if they fail.  Failure needs to be embraced in an organization as a great learning opportunity.  Do something!  Act!  It is too easy to be paralyzed by analysis.  If something feels right and the potential downside is not fatal then go for it and learn from the experience.  I have also learned to never underestimate the value of a relationship.  Relationships are long term investments and should be treated as such.

Imagine if you could pick up the phone and call your younger self right after graduating physio school, then what advice would you give him?

Listen better, be more patient and enjoy every step along the journey!

Tell us about HAVlife. And, how did you end up on their Board of Directors?

The mission of HAVlife is to prevent lost potential in kids by providing them the opportunity to participate in sports, music or the arts.  It was started by a friend of mine who lost his son Hunter Aaron Vondran (HAV) to a tragic accident at age 13.  HAVlife works through the schools and other non-profits to ensure children 10-15 years of age have access to the resources they need to be involved in these activities.  Since its inception 7 years ago HAVlife has given over $600,000 back to the kids in our community.

Rock Valley has been supporters of HAVlife since their beginning.  We are proud that the proceeds from a charity basketball game organized by our philanthropic committee was the first corporate donation to HAVlife.  We also organize a yearly special needs All-Star Football Camp with former Iowa Hawkeye football legends for HAVlife.  This camp is not only a highlight for the campers but is also a highlight of the year for the former Hawks and our employees who volunteer to help with the event.

After being engaged supporters of HAVlife for five years I was honored when their founder Mike Vondran asked me to serve on their Board.  It a pleasure to work alongside this 100% volunteer Board who is trying to impact the future of our community one child at a time.

I hear you gave a talk at Graham Sessions 2015 (#GrahamSessions2015). What motivated you to take the stage?

I was humbled and honored when Steve Anderson asked me to give a “What I believe” talk (and you can’t say no to Steve can you?).  The motivation for my talk came from the passion I have for our great profession and the values instilled in me growing up on a farm.  Like the land we farm I believe we have not inherited this profession from our predecessors but rather are borrowing it from our grandchildren. We need to take great care of it and leave it in better condition than we found it.  Reiterating my point earlier I believe collaboration among small practices in a “farm co-op” model is a way in which we can continue to keep PT ownership thriving in this time of industry consolidation.  I believe we need more owners not renters in our profession.

I absolutely love the way you worded that – “we need to take care of the “land” and leave it in better condition that we found it”. What were your biggest take-aways from Graham Sessions 2015?

I left Graham Sessions exhausted (mentally and physically) and inspired.  Our profession is in great hands. The talent, passion, and capabilities of the people assembled in Savannah was impressive.

Favorite books & authors? Reading recommendations? (personally & professionally)

Some of my favorite authors are Malcolm Gladwell, Daniel Pink and Jim Collins.  I am currently reading The Power of Habit by Charles Duhigg which is very good.  I love to read to learn but have never enjoyed reading “for fun”.  Always thought it was a waste of time.  Much prefer to wait until the book is made into a movie and then go see it.  More efficient and the popcorn is better.

How do you manage to maximize your life – professional & personal – given how busy you are?

I am blessed to be surrounded with people I love and respect in all aspects of my life.  I have the pleasure of working alongside my best friends and going home to a loving family every night.  I have learned that life is more about who accompanies you on the ride than what happens along the way or where you end up in the end. Perspective and gratitude = happiness.

Staying in the world of Physical Therapy, what important truth do very few people agree with you on?

One area where my thought differs from the PT establishment is that I believe we need to find ways to get closer to referring sources, hospitals, health systems and payers.  We have had such an inferiority complex as a profession that our fight for independence has taken our focus away from the bigger goal of interdependence.  Getting closer to these entities will enable us to show the true value we bring not only to the customer but to other providers.  This was never more clear to me than when I worked on the inpatient floor.  Inpatient therapists are in the best position to elevate our profession.  They have the opportunity to interact daily with decision makers and elevate our profession IF they choose.  It was so satisfying changing the image of the Physical Therapist  at the hospital we contracted with from “the people who walked patients” to the “professionals who coordinated the discharge planning”.  This only comes from accepting responsibility and treating all parties as a customer.  I am excited to hear what comes from the PPS task force looking into acceptable business models.  We need to find models that allow us to ethically partner with other providers and payers.

Another contrarian opinion I shared at Graham Sessions in Memphis is that maybe we get paid enough for the services we provide.  It seems that no matter what conference you go to the predominate “woe is me” conversation surrounds inadequate payment.  I would just ask each of us to step back for a minute and look where venture capitalists are investing their money.  These people know very little about our profession other than the economics and they are choosing to invest in physical therapy companies rather than put their money in tech, oil, etc.  Why?  Because we have a great thing going and a huge opportunity in front of us.  I understand that payment is regional and there are definitely some parts of the country that deserve to be paid more for their services.  However, the amazing reality is there are practices getting $65 visit that turn a 20% profit and other practices with $100 per visit income that are barely making it go.  We need to spend more energy and time focused on operational excellence and memorable customer experiences and less time complaining about payment.  A wise man once told me that no matter how much you make it is just enough.  So true.  

Given the choice of anyone in the world, with who would you want to catch dinner with?

I am a product of the 80’s and a big Steelers fan so I would love to be invited over to the Rooney’s for dinner.  I figure their house is nicer than mine and maybe they would invite Bradshaw, Franco and Rocky over as well.  The Steelers embody everything I would want for our organization-success, class, integrity and admiration from its team members and competitors.  It would be great to learn how the Rooney family has been able to maintain this balance over the years in the highly competitive world of professional sports.

Mike, what a fantastic read! Thank you for sharing your thoughts and passions. Look forward to more from you in the coming years.

Follow Mike on Twitter: @Mike_Horsfield 

And find me: @Cinema_Air

Life’s Inevitables…

What are Life’s Inevitables? Other than death and taxes?

Maybe Love, Loss, Disappointment, etc? In other words: “Highs & Lows”. If you’re reading this, then odds are you have at least a vague, but (and?) visceral understanding or experience of these Highs & Lows. So, maybe the Inevitables could be Death, Taxes, and Highs & Lows.

When it comes to Death, this article on The Top Five Regrets of the Dying is a must read. It’s worth your 3-5min to read the entire article, but I’ll list them here:

1. I wish I’d had the courage to live a life true to myself, not the life others expected of me.

2. I wish I hadn’t worked so hard.

3. I wish I’d had the courage to express my feelings.

4. I wish I had stayed in touch with my friends.

5. I wish that I had let myself be happier.

Thinking backwards from the ending makes me want to live life ending at the finish line without any regrets. Maybe this Top 5 provides a strong starting point. Simple, but not easy. Maybe John F Kennedy was onto something when he said,

We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard.

Is that how I should view this? A personal Moonshot mission? Maybe. Maybe, yes. Maybe the resistance – the not-easy part – guides a meaningful direction. All I know is I want to hit the finish-line regret-free.

Taxes are beyond my understanding and interest. So, let’s leave that alone.

The Highs & Lows. I think experiencing this is also inevitable. The Lows seem to leave a much stronger impression than the Highs. At least, that’s true for me. It also seems to be true for Andre Agassi:

I feel, in fact, as if I’ve been let in on a dirty little secret: winning changes nothing. Now that I’ve won a slam, I know something that very few people on earth are permitted to know. A win doesn’t feel as good as a loss feels bad, and the good feeling doesn’t last as long as the bad. Not even close.

Is it possible to have the Highs without the Lows? I don’t know. Maybe we need the Lows to appreciate the Highs. Brian, from the movie “Vanilla Sky“:

Just remember, the sweet is never as sweet without the sour, and I know the sour.

Could the Lows be more meaningful and impactful than the Highs? Maybe it’s our response to the Highs & Lows that matter most. Dr. Victor Frankl:

“Everything can be taken from man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstance, to choose one’s own way.”

I hope I respond to Life’s Inevitables with determination, applying lessons learned to make the most of our time, and breathe the breaths of a regret-free peace of mind. I hope to live a life true to myself, work to live – not live to work, not hold onto bitterness or resentment, keep my closest friends closer, and choose happiness over comfort.

Gerard Way:

One day your life will flash before your eyes. Make sure it’s worth watching.


Interview with Scott Epsley, PT, RMSK, SCS

Some of you may have heard of Scott Epsley, many of you haven’t – and I think you should! Scott is a Physical Therapist with experience in private practice, research, sports PT, as well as strong interests in the use of diagnostic ultrasound in PT, Dry Needling, and more. He currently works as the Physical Therapist for the Georgetown University Athletics Department. You can read a short bio here

The world of Physical Therapy is studded with remarkable individuals, and Scott is one of them. I learned a lot from this interview, and I believe you will as well. Enjoy!

Let’s start with your professional beginnings. What drew you into the wonderful world of Physical Therapy?

I think it’s fair to say that Physical Therapy found me.  I’ve always loved biology and the human body.  In Australia Medicine used to be a six year undergraduate degree.  I intended to do Medicine however the year that I graduated High School Australia switched to a US styled post-graduate Medical degree.  The truth is I didn’t put Physiotherapy on my University application.  At the time it was the most difficult degree to get into at the University of Queensland, my Alma Mata, and required the highest graduating score from High School.  When I achieved the entry criteria I called our Career Guidance Officer immediately and changed my application to put Physiotherapy number one.  I still intended to return to Medicine after practicing for a couple of years.  However I began working with professional and representative teams and had an aptitude and passion for it.  The rest is history as they say.  I still haven’t ruled out Medicine one day.  If ever I lose the passion and don’t feel sufficiently challenged it’s time to move on.  Needless to say I’m still finding plenty of both as a Physical Therapist!

You had your own physio practice in Australia for about 6 years. Given the benefit of hindsight, what were the biggest lessons you learned from those years in private practice?

 I read a lot of marketing books.  I came across the concept of “Surpetition” by Edward De Bono.  The premise is that one doesn’t attempt to compete with others, but focuses on being better than oneself, while still being aware of what your competitors are doing.  This has since become not only my philosophy in business, but in life.

I learned a lot about people and teamwork.  I discovered that if you find someone’s gift and give them responsibility they will usually surprise you with their capability.  This requires anyone in a leadership role to be very secure in themselves.  It is also important to support them if they make a valiant attempt and things don’t go quite as planned, because confidence is a great motivator of future efforts.

We never made any decisions purely to try to make money.  We made decisions that led to better patient care, improved customer service, and the highest level of practice possible.  Our mission statement was to give each and every person the same care afforded to the Olympians we treated.  As a result we averaged 25% growth per year and had a very profitable business.

William Osler said “The value of experience is not in seeing much, but in seeing wisely”.  I hired young therapists who were passionate and demonstrated sound critical thinking, and then trained them well.  I’m far less concerned with how many years someone has been practicing than how they think.  Young therapists are the future of our profession.

Finally, success in business isn’t in the deals or things you do, but in those that you don’t do (which is over 90% of things that come your way).  I felt so validated when I read that this was Steve Jobs’ philosophy!

You’re lucky enough to have worked in both Australia and the US! What are the biggest differences you’ve noticed? And, what can the American Physical Therapy Association learn from its Australian counterpart?

This question is perhaps a little unfair if considered in the context of a profession functioning in isolation of societal and political influences.  Many of the differences I believe are reflections of different public attitudes toward health care and the healthcare systems themselves.  Furthermore understanding that there are distinct sociologic differences between the two countries is key to understanding the professional differences.

Australia is a very egalitarian society where people in positions of authority such as politicians and doctors are not revered quite as they are in the USA.  It is also a society where invasive (eg. surgical) or pharmacologic intervention is generally less adhered to as the “gold standard”.  This has helped Physiotherapists become high profile providers of direct access medical care.  The USA has long been doctor-centric whereby allied health may be seen more as an alternative to medical or pharmacologic intervention rather than a primary intervention in and of itself.  This attitude is changing however.

In the context of universal healthcare in Australia it is important to know that except for a select few conditions (where a limited number of treatments are approved) Physiotherapy is not covered.  Patients with private health insurance are afforded some coverage as an amount of the total treatment cost, with the remainder being their responsibility.  The predominant provider of outpatient care is private practice, and a large percentage of that is direct access.  Public choice of a provider is therefore partly driven by the cost-benefit theory of economics.  Therapists need to offer a better service in order to win business, thus improving the standard of the profession as a whole by increasing intra-profession competition.

In the USA improving the status of Physical Therapists to a highly sought-after member of the medical fraternity with the reputation for being the premier musculoskeletal experts should, I believe, be our goal.  While I understand the move to a DPT from a political perspective, this is an extrinsic change.  True change has to occur within the profession, enacted by each and every one of us.  It means no longer seeing ourselves as subservient to referrals with incorrect diagnoses and requests for outdated interventions.  As in any relationship, we will be treated as we wish to be treated.  It means raising the bar for ourselves, and then proving we can live up to that standard.

In my experience across two continents the formula for achieving this is the same despite the different social and political environments.  Why?  Because people are essentially the same anywhere in the world.  We can all begin today by building better relationships with our medical colleagues and our patients.  It is up us to engender trust, and trust I believe will fan the fire of change.  Fire purges and allows for new growth.  Let’s be the spark in our own communities and before you know it we will have an irresistible inferno!

RMSK. What is it? And, why are you so passionate about it?

RMSK (Registered in Musculoskeletal Sonography) is the credential in diagnostic ultrasound earned by passing the certification examination through ARDMS (the American Registry for Diagnostic Medical Sonography).  To date this is a credential attained by only a handful of PT’s in the country of which I’m proud to be one.  It’s fair to say that I’m passionate about ultrasound as a tool for improving practice, and the RMSK is a vehicle enabling me to be credentialed in this area.  Therefore I will direct my answer more specifically toward the question “why am I so passionate about ultrasound?”.

Ultrasound is a non-invasive, low risk tool for imaging musculoskeletal tissue in real time in order to aid rehabilitation, provide for early appropriate referral, assist in clinical decision making, and improve the efficacy and safety of interventions such as dry needling.  It has the major advantage over all other imaging modalities of being capable of providing for dynamic assessment.  As experts in movement the ability to perform dynamic imaging fits perfectly well within our scope of practice.

As a direct access practitioner and one who works in an elite athletics setting the precision in practice provided for by the use of ultrasound as an adjunct to a thorough examination enables me to improve outcomes and better manage expectations.  By developing my skills with ultrasound guided needling I have been able to treat conditions and obtain outcomes previously unattainable.  Rehabilitative ultrasound has aided in identifying unique patterns of muscle dysfunction that one is otherwise unable to appreciate, and induce a positive change where other methods of exercise have failed.

In short, proficiency in this skill further supports and improves our position as musculoskeletal experts.  This is why I’m so passionate about it!

“Evidence-Based Practice” has been the physio mantra for the last few years – and rightly so! Given your experience in research, private practice, and working with very high-level athletes, what are the limits and short-falls of being 100% EBP? (Also, is it possible to be 100% EBP?)

If one wishes to be 100% EBP then stay home, grab a cup of coffee, and enjoy your Netflix subscription!  If you look at the Cochrane Collaboration little of what we do has much if any effect.  Systematic reviews and meta-analyses, although considered the highest level of evidence, can dilute the value of good individual RCT’s.  RCT’s unfortunately  negate the clinical decision making process used when determining an intervention by reducing conditions to a defined set of symptoms, and treating those identically.  And finally case series’, while a great way to present consistent clinical observations, are not scientific evidence of a true treatment response.  They do however help the clinic to drive research and as such are incredibly valuable.

When I’m considering my own treatments I look for them to fulfill two criteria: i) A valid physiological basis for how the intervention may work, and ii) uphold the existing evidence.  If there is evidence without a sound physiologic basis, or a sound physiologic explanation that contradicts all existing evidence, then I would question the validity of that treatment.  I don’t however believe that a treatment is invalid because there isn’t an RCT or systematic review supporting it.

One final note.  I firmly believe that there exists an intangible “energy” interaction during treatment.  It is for this reason that two clinicians can administer ostensibly identical interventions to the same patient and get two completely different responses.  While I am a seeker of evidence from the physical sciences to support my interventions, I cannot discount the metaphysical.  The best scientific explanation I can muster for this lies in quantum entanglement, but this is purely supposition.

“Are Biomechanics Obsolete?”

I love this question, thank you!  It has been said that “to someone with a hammer everything looks like a nail”.  That is how our profession has become.  We are very good at addressing biomechanical issues, therefore everything has been reduced to biomechanical causes.

For those who don’t know, my research has been into Medial Tibial Stress Syndrome (MTSS).  I have read hundreds of papers pertaining to this topic.  Contrary to colloquial wisdom there is very little evidence for any consistent biomechanical “cause” of MTSS.  If you have seen enough athletes, especially very good ones, you would have seen a huge variance in mechanics even at an elite level.  Mechanics themselves don’t cause injury (short of catastrophic tensile load to failure such as an ACL rupture).  The biochemical response to tissue load is the cause.  Understanding mechanotransduction (how cells regulate protein synthesis in direct response to tensile, compressive, or shear forces) and the chemical pathways that ensue is the only complete way to describe and consider injury.

This is why I have coined the phrase the “Biomechemical” approach to injury.  It is how the mechanics cause the upregulation or downregulation of proteins that is the ultimate determinant of injury.  If you do not exceed the body’s physiological ability to adapt, or happen to have the right physiology, you will not get injured.

Truly understanding injury means extending our paradigm far beyond biomechanics and returning to basic science.

Favorite books and/or authors?

My favorite book and author are in kind.  “The Alchemist” is my favorite book, by my favorite author Paulo Coelho.  It is the story of Santiago a shepherd boy who goes in search of his dream, facing many challenges and the temptation of an easier life but persisting in order to realize his “personal legend” or life’s purpose.  I feel a deep connection to the parallels drawn by this book to my life.  In his many works Coelho articulates almost cathartically the struggles of humankind across the ages, while placing meaningfulness to the pursuit of Love, self awareness, and providing for a spiritual context to life.

I’m also very interested in the reconciliation between science and spirituality.  This has lead me to explore quantum physics and Buddhism.  I’m currently reading “The Quantum and the Lotus” by Ricard and Thuan.  The gap between science and spirituality seems to me best explained by quantum theory, and while I no longer identify with organized religion, the tenets of Buddhism blend best with my scientific mind.   Other books that I have read in this vein include “The Universe in the Rearview Mirror” and Deepak Chopra’s recent release “The Future of God” in which Chopra proposes a new model for God that transcends religion.

High Intensity Interval Training, Crossfit, P90X, and other extreme exercise routines are are the rage these days. What are your thoughts on such aggressive training?

The businessman in me thinks there should be more of it!  It’s great for job security!  Seriously though, I really think the appropriateness is as much dependent on who attempts these programs as the regimen itself.  I firmly believe that not everyone is designed to run marathons, and not everyone should be snatching hundreds of pounds.  Exercise pursuits tend to self select individuals.  For example a person with hypermobile shoulders is likely to gravitate towards swimming and away from football (if for no other reason but that they keep dislocating their shoulders playing football!).

One of the key considerations missing in the decision to undertake such exercise is past training history, childhood activity levels, and “training age”.  Physiologic changes occur in the musculoskeletal system beginning in childhood that determine how we respond to exercise later in life, and many of these also pertain to future injury risk.  This ranges from bone density to the responsiveness of muscle to training, and the sensitivity of tendon to load.  Someone who has been inactive as a child or adult for an extended duration should be much more cautious about participating in aggressive training of any kind than someone with a lifelong history of relevant exercise.  By relevant I mean that the training history should be somewhat consistent with the type of exercise to be undertaken.  In this sense I don’t think that the exercises themselves are necessarily inherently bad for the right individual (if performed correctly of course).

Finally one needs to understand that not all exercise is necessarily “good for you” and there may be repercussions that persist years beyond cessation.  I think the obsession with these forms of exercise frequently has little to do with the physical and more to do with the psychological.  Excessive exercise is socially acceptable, alcoholism isn’t, and yet both can be abnormal coping strategies or manifestations of other organic disorders.  In these states one frequently is blinded to future consequences, and there is positive societal reinforcement for the behavior.

Speaking of exercises, how many exercises do you usually include in an HEP? Why?

Three, maybe four, tops.  I mean, if you have an ACL reconstruction you have to have the gamut.  But I’m against giving exercises for the sake of it.  I work with division one college athletes in a highly academic school.  They have class, lift, practice, games, treatment, homework, internships etc.  The last thing they need is to be overburdened with exercises.  However I extrapolate this philosophy to treating all of my patients.  Your exercises should be addressing neuromuscular control, strength, mobility, and pain.  Giving one exercise for each of these categories and then progressing them appropriately is far more effective than a generic program.  I see far too many patients with redundant exercises.  In contrast I am very specific and targeted.  Furthermore there is much written about compliance.  I believe this optimizes compliance.

Staying in the world of Physical Therapy, what important truth do very few people agree with you on?

This was perhaps the most difficult question to answer.  I tried polling my colleagues, but of course they weren’t game to tell me even if they did disagree!!

One of the paths our profession has chosen to take is that of “Clinical Prediction Rules” (CPR’s).  Perhaps this is one of the things I am most vehemently opposed to, and certainly an area I have had many disagreements with colleagues over.

Phil Plait is credited with the quote “Give a man a truth and he will think for a day, teach a man to reason and he will think for a lifetime”.  In this way teaching young therapists CPR’s stunts their clinical reasoning, perhaps irreparably.  It is not the rules themselves that are the problem, they can be a great informative guide for an experienced therapist.  It is how they are taught and implemented, and when.  Clinical reasoning is like a developmental stage.  If one does not learn it at the appropriate time I have observed that it is very difficult to teach later.  The appropriate time to foster this reasoning is in the education system.  By relying on CPR’s at this stage, one will have great difficulty moving beyond them.

Today there is much less value in teaching facts because information is so readily accessible.  The true value of education for the future will be in teaching people how to think.

You’ve just traveled back in time to when you were 20 years old, and are sitting face-to-face with yourself. What advice would you give yourself?

I doubt my 20 year old self would listen!

I think one of the most difficult things to come to terms with in Sports Medicine (and perhaps life) is that no matter how much you know, how hard you work, how technically sound you are, or widely read you are, not everyone is going to be happy with your advice.  There are many varied personalities, from coaches to trainers, athletes, parents, and other medical professionals.  It comes as no surprise that not everyone involved in athletics is always rational, and you can’t logically reason with irrational people.  Therein lies a common source of contention.

People generally behave irrationally in response to uncertainty.  Being  comfortable with uncertainty requires a strong sense of self, but does not insist that those we interact with have yet similarly evolved.  Our response to this is key in determining the outcome of such conflicts.  If one acts indignantly or feels insulted you are likely to lose traction with your argument.  Accepting that rejection of our advice or treatment plan is not a reflection of the advice itself, but of many other factors, is key to moving beyond such disagreements.

Not everyone we can help necessarily wants the type of help we desire to give.  If I’d learnt to accept this at a younger age I would have significantly diminished my sleep debt!!

Life is an adventure. Tell us about one of your most memorable adventures so far.

My most memorable adventure was moving countries and re-establishing myself professionally on a different continent.  This is why I identify with the book “The Alchemist”.

Since my first trip to the USA playing basketball in 1995 I had a sense that I would someday return.  After being encouraged by a number of Australian professional athletes that resided here but would see me when in Australia for treatment, I decided that it was time for a new challenge.  I had conquered private practice, worked at a professional, national, and international level in sport, all by the time I was thirty years old.  I had no idea the trials that awaited, which is just as well, because if I had I probably wouldn’t have  embarked on the journey!  People see me treating professional athletes or lecturing around the world, but very few know what it took to make that dream a reality.

Firstly there was the loss of my identity as a Physiotherapist when I was unable to get my license to practice here initially.  I sat six CLEP exams, taught myself economics, and attended a night chemistry class while working by day, all in an attempt to fulfill the requirements.  Despite that I was again failed by the Foreign Credentialing Commission by 1/4 of a point.  An eleventh hour trip to the DC Board who subsequently gave me a license meant that I remained in the USA.

My first job here was not a good fit and after many months of distress, having lived in the USA for only one year, I made the decision to return to Australia.  I believed so firmly in my heart that I was meant to be here, but between the job and difficulties obtaining my license I was faced with the possibility that I had been wrong.  At the time I was volunteering in the athletics department at Georgetown.  Upon hearing of my imminent return to Australia they advised me that they were unable to hire me due to budgetary constraints.  Two weeks before I was due to leave, my belongings booked to be shipped to Australia, a moment occurred that changed my life forever.  An interaction with the head basketball coach, and his subsequent intervention, (perhaps buoyed by a recommendation from a former Secretary of State), saw them create a position for me.

After cancelling the shipping and placing my belongings in storage, I returned to Australia temporarily to obtain the appropriate visa.  When I next landed in Washington DC I had the strongest sense yet that this was home, at least for a while, and that my dreams could become a reality.

From this experience I learnt some of the most important lessons in life: 

  1.  If you have a dream, hold onto it, believe in it, and don’t let it go, even when everything before you seems contrary to your vision.  It only takes one little miracle and it can all change in a second.
  2.  Be willing to forgo who you think you are to be who you want to be.
  3.  Persist, and when you are done persisting, persist.  It is likely that this is when the breakthrough is nigh.
  4.  Making the right decision for you, even if it seems like a step backwards, is often the inertia that the universe requires to bring about the positive momentum to move forward.

I’ve still many dreams left to fulfill, but I’m living the life I imagined!

Scott, thank you for this fantastic interview! I appreciate all the knowledge and lessons you shared. Maybe I’ll see you in class sometime!

Follow Scott on twitter: @ScottEpsley

And, connect with me: @Cinema_Air