E178 | The Future Of Physical Therapy With Kelly Starrett and Doug Kechijian

On episode 178 I am joined by Kelly Starrett of MobilityWOD and Doug Kechijian of Resilient Performance Systems.  We discuss and get into the future of Physical Therapy and where we see it going.

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Episode Transcription:

Danny: [00:00:00] All right. What's up, guys? Doc Danny here with the PT Entrepreneur Podcast and, tonight, is going to be a special night. I'm super excited to have these two gentlemen on. We got Doug Kechijian from Resilient Performance Systems and Kelly's Starrett from MobilityWOD in San Francisco and we're jumping on the podcast to talk about

 the profession of physical therapy and where we see it going and things within it that, that, we feel like, should change or not change in terms of how we standardize care or if we should standardize care. So this might be a little bit different than what many of you that listen regularly are you used to, I'm not going to teach you how to, get more people in the door.

How to get them to commit to you, how to build a business, anything with that. But you have to understand all of us that are on this podcast. First and foremost, you know, we work with human beings, right? We work with people, and people are messy. People are multifactorial and stop it. It's true.

Danny: [00:02:03] it's something that's going to be interesting to talk about is, is, you know, as a profession, Where are we at in terms of, are we doing a good job of getting people better? And do you, do we need more standardization within the practice of physical therapy? So here's what I want to do.

I'm going to kick it off, and I'm just going to let Doug go with this. I think he's the one that got the most heated in the Twitter conversation that he was having. If you guys haven't seen it, follow Doug on Twitter, and check out, you know, what he's been saying about standardization was in within the profession, but I'm going to let him start in terms of.

His views on physical therapy and, and, and whether he feels like it should be more standardized as it is currently

Doug: [00:02:42] Yeah. Thanks, Danny. Forever and beyond. I guess the, to answer the first part of your question, there's kind of this narrative on social media, on the internet that physical therapy is broken and the profession has to change and sort of being rescued.

And you know, a lot of times, like, people think that their problems are unique. I would imagine that most fields in medicine. Probably think that there are things that need to be fixed internally. So I don't believe that physical therapy is unique in that regard. And I'm not one of these alarmists who is like, and you know the field of physical therapy is so broken and has to be rescued.

I know for myself, you know, running my own business like I haven't encountered an issue where people, I was unable to achieve a, whether it was a clinical outcome or a business outcome. Because I'm a physical therapist now, people may have come from having previous experiences with other physical therapists. Still, they also had other experiences with different medical providers outside of physical therapy.

So I'm like, I'm not the judge of what good PT is, so I don't want to make it like, well. Physical therapy is so bad that I'm one of those guys that's doing it right. I don't think that's fair, and that's a little bit self-righteous. I guess like any other profession, and physical therapy has, you know, more competent practitioners and less acceptable.

And that's just how much that's going to change. Concerning the standardization question, you know that I come from a background in the military that combined aviation and emergency medicine. So I appreciate standard operating procedures as much as anybody. They serve a specific purpose. So like in a military sense, you have centered operating systems to sort of limit constraint and limit choice.

So like in emergency medicine, let's take a CLS, here's an ACS algorithm, because in an HCLs scenario. People are effectively dead. They're in cardiac arrest, and that's not the time to be using intuition to come up with a procedure to fix something now. In the military and aviation, as I parachuted in the military, I've been skydiving, and I had a parachute that was uncontrollable. I had to refer to my emergency procedure and go through a checklist because, again, that's not the time to figure out like, well, what should I do?

And my canopy is uncontrollable. But. Physical therapy is not emergency medicine, and it's not aviation. It's not this emergent situation where if you don't make a decision very quickly, you might have a catastrophic result. So there are different degrees of when you need standardization in medicine. I look at physical therapy almost more as coaching than I do as.

Trying to fix pathology in a medical sense because

Kelly: [00:05:16] and

Doug: [00:05:17] as physical therapists, in my opinion, we're not addressing pathology directly. We're working around pathology to maximize function and to improve movement. So we need to be respectful of it. But I, as a physical therapist, I'm not directly influencing.

Pathology. So I think that you need some standardization as far as like, having a, you know, common education, common licensure exam, and we already have those things. So beyond that, you know, how much denervation do we need or want? I value individual choice and provider discretion and, more importantly, patient values.

So. We're like, and we're not treating people who are in ventricular fibrillation where we don't really like in that situation, you don't care about somebody's feelings or their goals. You're trying to change their heart rhythm, so they stay alive. But if I have somebody who comes to me, it's not necessarily what I want.

It's about what they want, like why are, why are you here? And I always try to start back from somebody's goals and then just work within my scope of practice. So like there's an individualization,

Kelly: [00:06:18] let me jump in for a second because I think with everything you've said. Is, I believe every physio on the planet would completely agree.

So

Danny: [00:06:26] how did we get to this conversation?

Kelly: [00:06:28] What, because this, this is, the internet is wild and Twitter is a bitter, bitter battleground for physical therapists. It's only with that, and there are some big heavy guns out there who are very strongly opinionated in our field, and I'm probably missing them, but.

You know, some of the big water carriers are Karen. Let's see. And Greg Lehman and Peter Sullivan, Sandy Hilton for example. And these, I would say Adam Meakins is on there, but we don't follow each other anymore cause we fought too much. But how did you get? To this conversation, because I now really try to say not what's happening, but why are they saying this?

So when I go into any coaching environment, I see radical, brilliant coaches trying to apply their critical thinking to a new, unique, or novel problem. And I asked what problem are they trying to solve? And then I get less, less sort of sidetracked by tools, and I'm more interested in their critical thinking.

So I'm trying to apply that same algorithm, which has worked for me forever. Why is this working in sport? How am I solving this movement problem or this motivation problem or pain problem? And, and what problem is that? So what problem do you think got you into, got the three of us together in the first place to have this conversation?

Why is there a need, or why are people saying that standardization maybe even should be a thing?

Doug: [00:07:50] Well, yeah, cause I think that you know, now with the movement more towards valuing research, you know, somebody will come out and look at a systematic review that says, for example. Pick any controversial modality and PT, like I don't want to revisit the same old discussions. Still, somebody will say, Oh, the systematic review shows that such and such intervention is no right.

That leads to a discussion where people say, Oh, if only the profession could be standardized, and the implication there is that, well, I don't like modality X. Therefore because I don't like it, we should regulate the profession, so the people aren't doing it. And standardization then becomes a problematic thing because to me, unless you're willing to enforce that standardization, it's just rhetorical police.

So then there was a thread going on where people were saying, we want more standardization. And I'm kind of like, well, what does that mean? Because to me, standardization means, like in the military, if I deviated from a centered operating procedure. Like I could be kicked off the team. There were consequences for it.

So are you saying that like legally or professionally? If I deviate from the said standard and I work with an athlete or a patient and me kind of just do what I want to be based on my scope of practice without following like an algorithm that I can be removed from the profession or somehow canalized or punished. It's like, well, no, we didn't mean that.

So then what? It's like the kind of like,

Kelly: [00:09:07] well, if you're not willing to

Doug: [00:09:09] enforce it, and you do want people to have discretion. And you're just kind of saying, well, I just don't like what other people do. And in a way, it can become a form of brand spinning. Now, I'm not saying that some people aren't sincere, but like any physical therapist wants to profession to be right.

The question is, well, what is right? And that becomes a very tricky conversation because who is the arbiter of good? And if we're going to have standardization, who is the judge of what we're going to do? Who is the authority of what tests we're going to use? Because even if we say, okay. We're going to use it.

Most people are reading, like exercise as good. It's not as controversial as manual therapy or some of these other things. Well, what does use even mean? Right? Because you can go to 10 different physical therapists. They're all going to do their X or exercise, but it's not going to look the same. Now, I don't think that's a bad thing.

Some people think some people do, but if you went to like, you know, a track coach and you want it to get faster like they're not all going to do the same program. If you're training in the hundred meters, they're all going to do things that resemble acceleration and maximal velocity based training.

And then maybe, maybe there, there are some bad coaches. We're going to have people running 10 miles to get better in the hundred, but that stuff kind of gets sorts itself out in the marketplace. So as long as people aren't dangerous, to me, I think individual discretion is a good thing. But

Kelly: [00:10:27], so do you think that this is more of a recent phenomenon of the internet is allowing us to suddenly.

Peer into each other's practice and that this, as you say, we'll normalize as we start to see who's getting good results because I think. You know, not only are we saying the intervention, the conversation started around the response, interventional kind of thinking, and you did bring up an excellent point, which I call it, it's the physical therapy zombie argument, right?

We're just like, Oh, here we go. Talking about valgus knee again, or rounded backs or say for, you know, X and such, or we didn't talk about pain or recognize pain in the brain. There are just some zombies that you can virtual signal like that, right? The virtual signaling is robust. But do you think that that may behave come out of a conversation that I know you and I run into, and I know you do?

I have run into a patient who has been given this enfranchising information. They've been told that they have a slipped disc, quote-unquote, that they should be afraid of any flection movement for the rest of their life. They haven't sort of been given a notion of unconditional positive regard and how robust their systems are.

Do you think that is what, this is a STEM from that we're seeing that some physical therapists out there are, we're running in doing a lot of clinics, cause I think underneath this is something that there's a neuro, physician out of, Australia who's a good friend of mine. And his, he makes a perfect

 point. I don't think he's very popular when the physical therapist, but he is a lifter, and he teaches a movement-based rehab center in his hospital. So it gets people moving again and sees that a lot of the problems is he's coming to me with a lot of questions. He sees our movement dysfunctions.

But his point is, how do we know if the physical therapies fail? And I think. Part of this scope of conversation is how do we know if someone has gone through their ten visits or hasn't met their goals? I mean, if we're talking about standardization, we have to know when physical therapy hasn't worked or when people have dropped off.

And right now, what's, let me ask you, Danny, what is your mechanism of reporting if physical

Danny: [00:12:49] therapy doesn't work. It's, it's so subjective, right? I think that's, I think for us, one of the things that we want to see is if we know no progression for us, honestly, within three visits, we're usually really quick at getting somebody's progress, and we want to see. If we don't, then that's obviously where we see, all right, well, we may need to get this to the next level of care, wherever that might be to get an opinion on if we're missing something in particular, systemic.

Right. And I think this is a. This is where we fit. This is where I learned where I meet in the military. Cause most people that we saw came in, and it was not a referral. Almost all of it was direct access, right? So within that continuum, we have to understand where we are within our, our, our kind of a skill set and where it may be something more significant.

But that being said, people are, like I said, very multifactorial, right? So you can have somebody. For instance, that is dealing with something that's very chronic and is depressed. It is going through something complicated, and all of a sudden, maybe we're not the right fit for them. They need to talk to somebody that's a psychologist, behavioral health specialist, wherever it might be.

All of a sudden, they come back, things are feeling significantly better, and they've done nothing else besides getting help from a mental standpoint, and then we can work on some of the physical things if they're even still there at that point. So for us, it's tough to say. I'm not quite sure we can standardize that.

We just know that, you know, if we see somebody for a couple of visits. And symptoms are not changing the way that we want. Then we need to get some of our, you know, what we call it, our dream team involved, which are potent providers that we've vetted throughout the city that will send people to that we have communication with directly.

So we have this sort of symbiotic relationship to see where

Kelly: [00:14:23] they're at. So, because I think Doug and I, you know, you and I have known each other for a long time. I knew I think I knew you even before you were a physio. You know, and I've known you, Danny, for a long time, and I both know how you practice, and I both know the communities that you're in.

Cause I'm an, I bumped into the same communities. I'm an office, and you're an office suite. We see each other. So if we're going to take the standardization question out. One of the things that I want our profession to be good at is to say, we did this, didn't work here, and no one talks about that, which for me is one of the roots.

I think what you're frustrated around, Doug is that there is zero transparency and how people, especially the people who are virtual signaling or, or saying, we should standardize. I can't for the life of me see what a session looks like for them. I can't, and I don't have any idea who they see the populations.

They see the volume of patients. They know the complication of the patients that see the variant of the cohort. So you're saying that this may work for an untrained middle-aged woman who, you know, some low nonspecific low back pain, not exercising and going through a divorce. Okay, great. I'm going to talk to the NFL.

I'm going to talk to these soldiers, and the only have one physical therapist and 5,000 people I'm trying to deal with this school. And all of a sudden even that standardization at that moment doesn't also fit the practice of this, the patients. So I, one of the hallmarks, I think what we've got to do as the next generation of physical therapists is continue to be so transparent about this was a failure and talking about it, because to your point, Doug.

Danny: [00:16:06] You know, the,

Kelly: [00:16:07] if the, if you're saying, let's standardize and we need to have this conversation out to the period, what does that mean? How many sessions should you get if someone has a raging hot shoulder from impingement, from doing crappy pull-ups and muscle-ups, right? If someone's heel striking is, I mean, how are you managing?

And, and if your layover, I think one of the classic sorts of type one errors on this is how many times a week are you seeing a patient. And for how long are you seeing them? Once every two weeks. And your eval was 30 minutes, and your followup was 15 minutes, and you're shoving them off, or are you like Kaiser where I got a 45-minute eval.

It took me three to six weeks to get him back in for a followup that lasted 30 minutes. And then I handed you some sheets with some stick figures saying three sets of 10 with zero follow up and zero connection and zero accountability. So I mean the thing that I see on the internet, I think that drives us crazy.

It's like, okay. We appreciate that we should be letting people know that this is a great practice model or the success of this technique. But what I'm getting at is I'm being shouted at from the virtue signalers who may not even be talking to me, but I'm, I'm pretending that they're talking to me. And again, I've been, I've been the.

The object of their opprobrium. I mean, just you can cloud into the internet and watch some of these physical therapists trashed me publicly, and there are some of their talks, and I'll say that, well, that doesn't show me what you did, how you did it when you did it. What you just said is, I don't know, like how he did it.

Right. And I think that's, that's the key. So. Outcomes are important. How do we tracking issues? You know, how do we know if something was a success and how long it took, and should we reproduce that? Because I think this critical thinking model is to your point, Doug, that at the very heart of this, I need a critical thinker who is an independent person who could say this is beyond me. I'm going to solve this problem uniquely for this person, which is to your point coaching.

Danny: [00:18:03] Yeah.

Doug: [00:18:04] Yeah. And then there's, there's a lot there. The first thing is, I would say that like. As an individual therapist, I don't feel compelled to justify what I do to other therapists. Like I don't treat to impress people on Twitter like I'm trying to get an outcome

Kelly: [00:18:19] in front of me. You're all about the follows, bro,

Doug: [00:18:21] right?

Yeah. But a lot of this stuff is driven by systemic constraints too, because in the insurance-based model, like, look, I'm not. I'm a realist about what the system is, but most physical therapy tends to be in-network with insurance companies. So if you know, as an example that you're going to get ten visits authorized for.

Nonspecific low back pain, like there often isn't a lot of incentive to discharge people before those ten visits reimbursed.

Kelly: [00:18:48] You nailed it. Okay. So let's, let's circle that. We'll come back to that, or someone needs to put that on a problem list. Right. Here's our, here are our symptoms—irritability, nature.

Right? And that's one. So, okay, keep going. Cause I want, that's a big...

Doug: [00:19:02] It's huge because I mean, I think that a lot of times because people have this perception that healthcare is free, even though it's not free, that there isn't a lot of incentive to, to innovate. And I think in a way, the field is almost too standardized in my opinion, because.

Then, the experiences that I've had with patients who have had other experiences with physical therapy, like yeah, every, I did the same thing everywhere. So I'm seeing the opposite problem where people are doing the same thing, and it tends to be very generic. And I understand that in these clinics, they're working under the constraint of low reimbursement, so they have to run volume-based models.

And so the people who are coming in with back pain are going to do the back exercise sheets.

Kelly: [00:19:39] So

Doug: [00:19:40] in some ways, like. The cash-based model is a little bit more honest and is more conducive to innovation and driving, letting the patient be the judge of what good treatment is, because if they're willing to pay for it, right?

That's to a degree, it makes it, and it's not perfect, but it's to a degree, it makes it somewhat a decent product. And then people have, I find that amount of money in time, so when their insurance company is not paying for those ten visits, like, look. I can't spend X number of dollars per hour out of pocket for this.

So like, if you can't do this, get me a good result and put me on a home program, and I can do on my own and one to two visits. Like we have this expectation that and I get that, you know, some people are like coming off an ACL surgery. They're not getting authorized enough visits. I'm not talking about a post-op scenario.

I'm talking about like, you know, your knee hurts going up and down the stairs. No trauma. That kind of stuff. People will complain like, Oh, it was only authorized X number of visits. Well, what if someone gave you one tour or two trips for nonspecific low back pain? Like do you have resources in place, whether it's like YouTube videos, online progressions, things that they're not required to do something with you every second of the day?

Because if I went to the dentist, the dentist said, you've got to come in three days a week for the next eight weeks. I'd be like, and you're out of your mind. Like, I'm not, I don't have time for that. Even if, even if it's free like I don't want them to go to the dentist. Three days a week, like just because I do physical therapy as a career and I'm passionate about it, it doesn't mean that I expect everyone else to care what I do in this room here.

So, I think sometimes, you know, incentive incentives can drive ethical behavior and, and innovation. And I don't believe that the healthcare system allows for that right now. So a lot of this stuff is very constrained driven. It's, it's not just a matter of like on a micro-level what's going on.

Other things affect it for sure.

Danny: [00:21:24] Well, I think, I think you bring up an interesting point in terms of, you know, we, we've seen it from both sides. All of us, right? The insurance-based side, the cash-based side, where we have more time with people. Not only that, but they're also more pot committed because they've got skin in the game and, and they're actively seeking out what they consider.

Probably a little bit different of a resource, but the standardization, you're right, dude, regularly people come in to see us for. Pretty much anything under the sun. And they've already tried physical therapy in most cases. Very rarely does somebody come to us directly that hasn't seen physical therapy.

And I can tell you the same seven shoulder exercises they're probably doing for, you know, impingement. And then they come to see us. And yet no one's ever watched them do a pull-up. No one's ever watched them press or do a pushup. And then, all of a sudden, we apply this idea of the movement side of things in conjunction with some of these ancillary things they probably do need to do.

And all of a sudden, their symptoms are resolved, and they're back to their thing that they want to do. Right. So, you know, I think the inherent issue primarily, and this is I'm very passionate about the idea of limiting the utilization of insurance. I think it's not good for the consumer.

I think it's only good for the company. I think it drives PT mills to have, to have these high volumes, to maintain profitability. And most of them are owned by private equity. I get it, right? It's, it's, it is what it is. It's a business. But. The reality is they're treating, and they're, they're, they're treating the lowest common denominator, the Medicare and work for a top population that, who knows if they want to get better.

Right? They have a two-year-long ankle sprain because they're in litigation, and now you're talking about how does that get applied to these, these. The systemized approach, like how long should that take? Right? How, how, how long should an ankle sprain take if somebody falls off a cell phone tower and doesn't want to go back to work?

Like I remember that early on when I was a student, that's one of the first ankle sprains I ever saw. I was like, this guy's here for a year. It's cause he doesn't want to go back and climb climbing cell phone towers almost died. So like, how does that get rolled into this? And the other big thing is, I mean, I remember when I was at Baylor.

John Charles was my research director, and this is right when clinical prediction rules were, getting implemented significantly. And, and I remember seeing patients for back pain issues utilizing these clinical prediction rules and thinking to myself, okay, this person has to do traction. Like, I never thought one bit about.

What's this guy's home life like? You know, like, okay, yeah, he's carrying a bunch of gear around. He's in the army, but like it says he has got sciatica, Sal symptoms, you need to do traction. This is the clinical prediction rule, and I can tell you within about six months of graduating and utilizing that ineffectively, in many ways, I started looking for other options.

And this is honestly how I started getting into a lot of Kelly stuff going down the rabbit hole of YouTube. And I was like, Oh shit. Yeah, I have to watch a movie. That makes sense. So. I think we've tried some of that before. And I don't know if you guys still use clinical prediction rules. I highly doubt it, but I don't remember many, high-level clinicians that use clinical prediction rules still and, and, are, you know, are, are useful for the large population.

Maybe a small sliver of people that works for, but I just don't know if you can standardize it. I don't know. Kelly, have you ever used clinical prediction rules?

Kelly: [00:24:20] Oh, you talking about like Ottawa rules and red flags everyday sun. And you know, I'll tell you, I've had my mind blown off about standards of care.

So I

Danny: [00:24:31] thought about the

Kelly: [00:24:31] diathermy. I was responsible for a physical therapy school or the paraffin bath. I was responsible for his therapy school or the understanding of hydroxy later temperature. Things that were never, then we weren't allowed to plug these things in. Are those still things on the practice?

I don't know. No. what I'll tell you is that I was, I came up and was taught to ice. This is what everyone was doing. Well, guess what? There's no research to support that at all. So if you're, you know how in fact, there's a lot of resources so that icing makes things worse. So, you know, one of the things that I began to realize was that you know, some of these rules where, you know, if I did a sideline shear test.

All I was doing was confirming what I already saw. And I saw someone squad, which is where they had a super Wigley segment, and they didn't have any control to do that. And I think what's interesting is. You know, as we kind of feel our way through this, you know, if what we can never do as a profession is ever right within normal limits again, right?

What we need right, is, I'm not assessing this. It's not on my problem list. I won't get reimbursed for this. Okay, I'll accept that. But also there is this continuum that we feel like you have to be accountable for, which is children, recreational athletes up to the Olympians and sold. You have to be able to account for your thinking and all of that stuff.

And if there doesn't scale or doesn't count for an age group or a cohort, there's, there's somewhere that you've got some dissonance in your thinking. And one of the things that we saw, you know, with the icing, for example, is that we stopped icing and started decongesting and man, we were ahead of swelling within 12 hours after ACL reconstruction.

No swelling in 12 hours. Total neuromuscular control, full extension. I was like, okay, so what do I do for the first three weeks? Do you know? And if that's the case, you know what? Where is the place? What a, what's the mechanism for this innovation in there? And then B, where is the place where we can begin to have an enormous scope of conversation of, of recognizing that these clinical predictors are useful for helping me.

That's a tertiary output of a, of an algorithm that helps me make better choices, but isn't, shouldn't be defined dead end. Right? Like, I start to see, I mean, how many times did you hear this in physio school, Doug? As an expert, the clinician ship is ultimately about pattern recognition and expert level pattern recognition.

And you know, one of the things that happen I think is unique about all our, all our experiences are that I didn't see one patient. Every hour or ten patients a day for, I suddenly had 400 athletes in my gym four to five times a week. I was going around and seeing such large patterns that I saw that induction, but I was recognizing it for what it was and usually seeing that there was a movement-related issue to it.

But I get where this is coming from, you know? And I think we always can be having a better conversation about the language that we use, about, you know, not fearmongering. I agree with that 100%.

I'm thrilled about that. She's writing a book about her pelvic floor model because, you know, show us, show us what's working for you, not what this end of 10 small research piece did. Because I feel like it doesn't fit in with the people that I'm seeing and how it works. So. There's a mismatch, and if right now today.

You had to say, are you a physical therapist? I'd be like, well, according to the internet, I'm not, you know, and my wife, who's a CEO, you know, but she was straight as an attorney. Is she an attorney? She's not practicing attorney, but she indeed uses attorney skills. So is there time in case for, you know, this specialization, but why can't you speak to all these cohorts?

Cause we see a lot of things in our gym clinic just like everyone else does, but we're always relating it to—functioning capacity. So we come back to this within normal limits idea, and I say, well what? How do you define normal limits? Cause I had to memorize all the joint ranges of motion. I think you did too.

And how was that expressed in movement? Because that's the thing, right? Not can I passively assess you on the table? That's my confirmation. The idea that matters most is. Not know how I grade you as you roll out of bed, but can you fucking get out of bed by yourself and walk around independently, comma, that's pretty low level.

Ultimately, do you have a full range of motion, your hip, and is that a component because, and how are we assessing that? Not do you have the parts? To function. But do you have the function? And I think we have done, and I'm just going to swear here, sweet fuck all around helping people understand what is normal and what's not healthy.

And by that, I mean normative. I mean full. I mean, the thing that we all agree on is a full range of motion in the shoulder joint. Not, Hey, everyone's a unique snowflake and. Every compensation is just a unique solution to a new movement problem. Like that's horse shit. And otherwise, if we apply that thinking out, it doesn't work.

We teach kids to swing a tennis racket a certain way. We teach batters to sit a particular style like we teach the technique to people somehow with movement. It doesn't seem to matter.

Doug: [00:30:00] Yeah. And to piggyback on that, and Danny like to your point and your question, I'm not opposed to clinical prediction rules or protocols.

I think they do serve as a good guy from which you can deviate. Its kind of like the saying like all models are wrong, but some are useful. It's like just the Northern limitation of the model. I looked at it a lot. Periodization. People were like, Oh, well, periodization isn't a thing. Still, like, I mean, it's good to learn about linear periodization and lock periodization, but where I'm opposed to is compelling that somebody adheres to a block periodization model without looking at individual factors.

I'm opposed to comparing

Kelly: [00:30:37] people. Yeah.

Doug: [00:30:39] Good. Here to a clinical prediction rule. So I'm saying you can have all these things, but it's not, it's a definitional issue. I don't consider a standardization until it has teeth. Until you say, look. If you don't do this, then you're, then you're not a part of the profession.

Kelly: [00:30:54] And it doesn't have to say that. So are we at, and aren't we at odds with this complex bio-psychosocial model that we are complex cycle emotional beings and does that clinical prediction model work when that person's going through a divorce, is an alcoholic, refuses to move, sit all days sedentary?

And at what point, who was responsible for that? And, you know, giving someone a sheet or passing just, you know, Hey, by the way, this is probably in your brain. It's not really in your back, and you're just stressed. That's not helpful. But I'll tell you. We're going to have to reconcile that dissonance.

Exactly what you're saying around, you know if we want to give credence to the fact that people are in different places in their life. And by the way, this is the core tenet of being a coach, actually working with athletes, trying to do something. How are you feeling today? What's going on? How are we managing your volume?

Hey, do you look like you're fried? I mean, we don't have any of those coverages. I just don't think our profession is set up to have that conversation. People talk about nutrition, talk about sleep hygiene. You know, we don't, we just say, Hey, look, here's, here's a book. I don't know what to tell you, but you know, this manual therapy isn't going to help you.

Right. And, you know, so how are we going to reconcile these clinical prediction models, which is a form of specialization. And the fact that everyone who walks in a slightly different is as a snowflake, you know, tell me, how do we solve that?

Doug: [00:32:16] Yeah. And then the difference is like if people want to use clinical prediction rules like I'm not telling anybody not to make the differences.

Some people are telling me that if I don't want to do what they're doing, but I'm doing it wrong, and I'm not, I'm not telling anybody they're doing it wrong. Like there's a lot of ways to get a good result with a patient. And like I said, I'm not the judge of that. But I think there are some people where it's like when they say standardization unless they're willing to enforce it.

When you're, what you're effectively saying is. If you're not doing it my way, then you're wrong. Which there's always a fine line between activism and self-righteousness. And I'm not like in some way, in some aspects, they can be right about certain things. Still, there's a fine line where you know, if you're not willing to be transparent and because if we speak in the abstract as we can, we can agree on most things, even people who maybe don't practice on a practical level as we do.

But when it comes down to like, all right, well, what is, what does this generalization look like? Then I've got to see an interaction with a patient and a case study. and until

Kelly: [00:33:13] people see like 10 of them, I'd

Doug: [00:33:16] be happy with one. Right. But it's like what is just even thought process? Like, what do you do?

What did you do with this one person? And assuming that like hippo was complied with, like, like film my treatment session because these abstracts are meaningless until we see how this is applied. It's, it's the application again, in theory, most people can agree on these things, but it's like, what do you do?

This is not, and it's not a research paper. This is like an actual patient

Kelly: [00:33:40] encounter. Yeah. Yeah. You know, Adam Meakins, made a perfect point in a, in a publication. He's good at pointing out our fallacies and our holes in our thinking. Like, you know, physical therapy would be worse off if we didn't have someone like Adam making to detest me.

And what I'll say is I'm so grateful for his critical eye because what I, what I, every time he throws the, an internet fit when I think to myself is, Oh, I'm sure he has a point here. You know, I remember how he delivers it is sometimes less useful. And he shuts off a lot of people who could, you know, who could benefit from his thinking and benefit from his in his rationality nation.

But one of the things he's saying is, you know, Hey, manual therapy is terrible for low back pain for chronic low back pain. And one of the things that I, you know, they're not a fan of that, and it's hard to standardize that. And I was like, well, I, you know, I think manual therapy is a rural will tool. You see, it's not my go-to tool.

And then I thought about people who have chronic low back pain in my clinic, and I don't use any manual therapy on them. And so I was like, okay, well wait a minute, why am I defending manual therapy? What am I doing to make someone feel better or have some input at home or teaching technique? Or the first thing we do is each movement and breathing talk about how resilient they are and how they're going to, and I was like, okay.

So I think I'm 100% in line with his thinking. But to your point around, I still haven't seen how he treats, and I haven't been to one of his courses, and I liked it. That's still not the same thing as coming in and watching. Start to finish soup to nuts. How someone is handling these things, and what point do you discharge or point to what are they doing?

Intercession change. Danny is something that we've obsessed about and no one, if we're talking about chronic low back pain, I can see how total hip range of motion matters less, but if we're talking about your low back pumps out, and you don't have any hip extension and your gains athletes. That's a problem.

So I can see how suddenly we're talking past each other around this standardization idea. You know, one of the things I think we forget is physios. As we move, this change you're talking about is the result of physiology. So. You know, I was talking with Sean McBride at our gym just about this conversation standardization.

And he was like, man, and I came out of a generation physical therapists who rejected every modality out of hand. We're like, screw it. We don't use patterns. Modalities are not the same thing as coaching, teaching, touching, right? Reinforcing, giving input in. And I think we missed the opportunity on a couple of things.

There's some, you know, maybe, some of the stuff is, is on the edge of valid and some of the things. So movement is a big deal. So I have a neighbor who had a blaming hot elbow, and he doesn't play tennis, and he doesn't golf. So I don't know what it was—some kind of IDAs of his elbow that had been going on for months.

So obviously it's not itis, but he's in considerable pain, and he's talking about surgery, and he fought. If you tell, it's wrong, cause he's finally asked her help. And I said, Hey, first thing, here's this, here are the things I'm doing. You'll be okay. But first of all, let's control just. Fluids in and out, you know?

So I got him a Marc pro. And all I had him do was a pump, which is the same thing as wiggling your hands. So you have silver surgery, and you squeeze the ball. That's the same thing. So peak was able to do that for two and a half hours, and he woke up the next day, and his pain was one out of 10 so what's the, what's the mechanism there?

Was it a conversation? Is that placebo effect? Did I decongest? You know, and

Doug: [00:37:03] my, so the mechanism is really, you

Kelly: [00:37:05] know, that's my point. My point is I would discharge him. He's like, God, I'm

Danny: [00:37:09] good.

Kelly: [00:37:09] I, I've solved this. It'll go away now. So when is physical therapy successful? When does it not successful? I didn't do manual therapy, scraping tooling, massage Buddhists.

I didn't do any of that. We just had him move more, but passively move. He just lay there and flexes his arms. Right. And so. How are we thinking about, cause I think one of the things that came up with this, this conversation that happened tangentially with the conversation about the British journal of medicine talking about this, it standardization of it band practice, was that the, I may have been the kernel of this, but what I saw was a bunch of things that I would have never done for it.

Band syndrome. And have never done for IT band syndrome. And that was the practice care. And I was like, wow, I wonder why my people get better, even though I don't do the standard practice of concern and why I usually see them less than two or three visits for this and I don't, I don't get it. How is there such ships in the night around this?

So that's, that's why, and, and I think to the heart, what you just said. At some point we're going to have to say, look, here's what's working. Come on over here. Instead of shouting at the model, you'll never, I'll never change your practice, but I'll show you that my method was more effective or got better results faster, or saved your hands and had happier patients who came back, or I got rich. You might go over, be interested in what I'm doing.

Right? That's the Buckminster fuller model.

Danny: [00:38:29] Well, I think, I think the other important thing to keep in mind is that. There are so many ways to help people, right? And you could make a strong case that in manual therapy, in many cases, we're mostly just proving to somebody that we understand how to manipulate paint in a way to gain buy-in, to gain trust, and then move on to these things that we know are going to create long-term positive changes, right?

Like in my opinion, I look at manual therapy and that way a lot, like they're coming in, they're vulnerable, they've seen all these other people. Maybe they've had years and years of issues going on, and all of a sudden, if I can. With a test, retest, intercession change show. Like all of a sudden, Oh man, like my Ford band, is like half as painful.

Cool. Now you're going to do the homework that I know is uncomfortable that I'm going to teach you how to do so. Sure it is. Is this the science, Adam? I don't fucking know, but I'll tell you this much. We get a lot of people better to go to a lot of other places, and they're thankful that they came to see us, so I don't care.

So when you can look at standardization though, I think that's. The one variable that I don't know if you can dispute this fact is unless it's something just random like your neighbor is that most of these things that we see, we can drawback to some sort of. Movement issue associated with that, right?

How many people have you seen for elbow issues that are tennis related elbow issues? And people just don't, and they'll needle the elbow, their elbow, they show them all these different exercises to do, but yet they never talk about their swing or get somebody to look at their swing that knows what the hell is going on.

So if we look at standardization, there needs to be a robust and compelling element for movement associated with that. Because I think if it's if it's not. Add, I didn't learn this stuff in school. I don't know. I'm sure you guys didn't either. Like my first, healthy kind of, the element of, of movement analysis, came from delving into Mo to Kelly to your stuff, like early on.

And then all of a sudden I was like, dude, I'm missing the boat on all this stuff that we didn't learn in school. So if that's the case, and I think as a, as a bigger question, it's probably. What are we not learning that we perhaps should learn that can make our profession better instead of standardization?

What are some key elements that we just are missing? I think of movement. I'm sure you, too, Doug, knowing your background, like a lot of what you do, it doesn't look like conservative physical therapy and I, in many cases, I don't know if you guys feel this way, but I don't fit. I don't feel like I fit in with my peers, who are other physical therapists.

I see. I seem to get along better and fit more in. Coaching environments, training, conditioning environments, so I'm not quite sure where we meet. I don't know if it's physical therapy as much as it is this hybrid kind of approach.

Kelly: [00:40:57] Well,

Doug: [00:40:57] at two points. The first is a lot of the people who are calling for the standardization, I w I'm just, it's conjecture.

If you watched what they did relative to the people that they're critical of, they're probably pretty much doing the same things. The differences, the essential people maybe have more robust. Theoretical explanations for what they're doing. The workaround for this is okay. Like most of what we do don't know how it works, so let's just not speculate about why what we're doing is working or not working and just say, look, like as far as I know, this is safe, a lot of what we're doing is trial and error test, retest.

We're going to try this and see if we get the results that we want. If not, we're going to do something else. So, you know, and then, and this way you don't have to say, well, where we're, decreasing ion channel sensitivity or we're sensitizing the nervous system or breaking up scar tissue. You don't need to say any of those things.

Just say as you have, you want to get to point, you know, point B, you're at point a, we're going to try to get you there systematically, and we're not going to speculate unless you want that kind of information. Then I'll give you stuff to read because that's not why we're here to go over that.

So that's, that's the first point. The second one is, I mean, there are a lot of problems that I encounter in the clinic where, as you said, I didn't get the answers anywhere in my formal PT education. Such a perfect example. Today I was working with a high school sprinter. He's a senior, is being recruited by some high-level D one schools.

He had a grade two hamstring tear. Two months ago and he's been going to other providers or those physios. He hasn't done anything that's resembled running and two months, nothing. I mean, the the the most aggressive thing that he's done is lift, which lifting is excellent, but that's not going to get you ready for sprinting.

This season starts in two weeks. And he's had, multiple medical providers. Tell him, and I think you'd skip your entire season for a grade two hamstring strain that he has no pain at rest on the table. He looks fine. So today, what we did was stuff that I learned from all this Derek Hanson, it's sprint progressions.

So it looked more like a track practice than it did a physio session. But if I had done whatever the professional standard is. It's

Kelly: [00:43:04] not getting, it's, it's

Doug: [00:43:05] basically, it's hot, it's hoping that we do something unrelated to his goal and that he let that by luck. It works out, but it can run again.

You are coming from a military background like I don't believe in luck. I think in preparation and not, you know, no false confidence. So like, all right, if you've got a sprint and max velocity, we're not going to do that today for the first time in two months. But we're going to do, you know, resistant acceleration.

We're going to do tempo runs, and we're going to work on mechanics. We're going to work on, make sure you don't overstride, and put more stress on your hamstring, permanently. But these are things that were not part of physio education. But if the job is to solve problems and you've got to go to whoever's going to help you.

Solve the problem. And so that's where the standardization thing can be problematic because who in physical therapy is the print progressions? Right?

Kelly: [00:43:51] Problematic. Show me the research to show that your tempo is run foot contact queue as effective. This dose at this stage, after two months of being a high school athlete in Cheetos and laying on the bat and cat, and I mean, it doesn't work.

So, that argument is spacious, and it ultimately falls apart under any examination to your point. Right. You know, and thus, you know, I, I, ironically, I'll see a sprinter tomorrow at a high school. He's the best form in the school. He's been dealing with this hamstring thing for 18 months. No one's not. So guess what?

I'm like, well, Hey, do you have any, a hip range of motion? I'm not. You look at your hamstring, let's just talk first. You know, and the kid is trying to do the right thing. He's got a great coach. He has his hip locks at about 88 degrees, 85 years, and it's not a bone. It's just stuff. Right? And what you can see is, boy, in the primary engine that hamstring is crossing, you don't even have a full range of motion.

So where does looking at a hip range of motion fit into this sequella of issues, right? You know, where does the conversation about warming up before you play tennis? Danny fit in or cool down fit in where I didn't learn those protocols, and they only know what the standardization protocol is for those things.

Danny: [00:45:07] Yeah, I mean, how do you do it? It's such an infinite amount of things that can be causing, B is the root cause of a problem. Let's, let's put it that way because in most cases, the things that we're learning are symptomatic. Like for instance, I remember treating somebody via the clinical prediction rule for a referral.

You know, pain down the leg for back pain, put them on traction machine feels better, goes back out deadlifts, like a douchebag comes back in and then figure his back is hurt again. So it, it took me realizing, Oh crap, we're missing out on this, this element of. What is probably causing your symptoms to begin with?

Because I'm blinded by this idea of this clinical prediction rule that says you're supposed to do traction and then like four weeks, this is going to be better. But yet we don't resolve the root cause of the issue. So I think it gets challenging. And the other thing is research. I think we can all agree, and I'm not trying to sound like a conspiracy theorist, but like research can be very biased.

You know, I've been involved in a lot of research at Baylor, and these are, these are. Large projects with a lot of money behind it. And I've gotten into SPSS with instructors and thought to myself, how in the fuck are you manipulating this to find something that looks like this is, you know, no results or the same, and all of a sudden we find something that's barely statistically significant and now all of a sudden they've got a publication.

So I think that inherently researched is somewhat biased. You can say that it's not, but when you have a bunch of money and time behind it, look, you don't want to. No, you don't want to waste your time in the process. And it depends where it's being done, who's backing it, all kinds of things. So I'm not quite sure that you can just bank on the fact that research is, is going to tell you the right thing.

Not only that, how often do you see the research that just disproves other research? Constantly. So yeah.

Kelly: [00:46:45] So you talked about being a Baylor incredible work going on there, and they're pretty transparent about some of the innovative things they do, which is one of the hallmarks of that. But to your point, Doug, if we're talking about specialization through.

How is it that I have a school that comes out? So my physio school was Samuel Merritt University. At the time, we had heavy-duty manual clinical therapists. Everyone was a superstar. Right out of Kaiser Valeho right out of that P and F  program, we had NDT specialists. We had muscle skill experts from Kaiser.

All the time is integrated, I think it is an excellent as education as I could get. And yet what I've heard from the internet is that my rationale and the theory through the entire school was bullshit. And actually, that rationale and way of critical thinking didn't fit anything. And I dug, I think you've got a patient and like five minutes, don't you?

So.

Doug: [00:47:43] Lowering the, lowering the music in the gym.

Kelly: [00:47:45] Okay. So what I think is why aren't we going to have to have a conversation, even about standardization at the physical therapy school. I mean, I think we're all teaching to this test. Theoretically, can we pass the board exam? But I spent a weekend studying for the board exam.

It just wasn't a, and it wasn't a big deal. I just, I, you know, I was well prepared. I spent a weekend, and I passed the

Danny: [00:48:09] kids too. Didn't you get a fucking business? The kids,

Kelly: [00:48:12] Juliet is looking at me in the back room. She's like, you're such a jerk. My point is. That wasn't, you know, that wasn't already helping me solve the issues.

And the school did a good enough job to prepare me for that. Is that validation school? So the schools are all accredited. And what I'll tell you is that the, the staff at the time, you know, including our Dean, Terry Nordstrom, you know, was heavily involved, a PTA, really advocating for physical therapists.

And. Is that a standardization issue there, Doug? I mean, you and I went to two different schools, so we're going to have it for bias as well. If you came to some of McKenzie school in Texas, what if, you know, we have a patient, we have therapists, students who go and do these little services with us or small blocks of time and they haven't done anything, and now they're actually at Yusef making like things like ortho is a, or understanding mechanics is an elective.

So people aren't even being trained as generalists anymore in physical therapy school. So I think we have some real issues. We're going to have to think about us as a profession. What does it mean to be a physical therapist? How do we define that, and what is best practice and is best practice different than specialization?

Because what I do is I go, Whoa, this person is getting crazy results. You know, you and I have been to Altice, Douggie, and. You see, their therapists are 10 feet from the track, and their lipid sprinters run, and then they come over, and they change something, and they run again. I mean, it's that close conjoined between performance and restoration or improvement in mechanics.

So, you know, w where are we.

Doug: [00:49:47] Yeah, that's cool. I mean, I don't know how conducive physical therapy is to the kind of standardization that some people are calling for. It's not like treating a lethal heart rhythm where like, that's the only thing you care about because if you're treating pathology, you want to fix the pathology because we're not treating pathology directly. We're managing function, and you know, basically trying to get someone to achieve their functional goals.

That involves so much discretion where at best, all we can, I think, to do is standardize. Concepts that we feel are important. So like progressive overload, I believe, is a concept that pretty much anybody can agree on. But then the more you try to like narrow that down into, well, an a, a concrete recommendation becomes problematic.

So I'm not, I'm okay with it the way that it is. Just whatever, you know, the curriculum needs to be, get people to pass the boards, and as long as they're safe and not volleying scope of practice, like I don't think variation and treatment isn't necessarily a terrible thing. And with the right incentives in the marketplace and the health care system, I think that that'll drive innovation and improvement.

But like, if I was in a profession where they said, you have to practice this way and follow algorithms and clinical prediction rules. I, I don't, I don't think I'd want to do it. I do something else,

Danny: [00:50:58] frankly. Yeah. Yeah. It sounds boring, right? Like, it sounds, like too much structure and every single, all three of us have our businesses and us, we sort of.

Thrive in these situations where, I mean, I mean, Doug and I, it's interesting, we both spent time in the military where there's a lot of structure, right? And I don't know about you, but I kind of figured out how to do my own thing within those borders of, of the structure that I was given and enjoyed in many ways, my jobs where I had more autonomy, it was in the military versus when I was like stuck in a staff clinic.

But you know, this, this idea of, of. Having the creativity to do things or, you know, I mean just talk to people differently, right. I mean I, I had a mentor that people would like to break down on this guy cause he was very stern. And when they would cry, he would just leave and walk out of the office until they were done.

And I thought to myself, and I was like. This is a weird human being. This is fucking crazy. This person is like crying in your office, and you just leave, and you leave me in there who's like 20 years old. I'm still in school, and I'm talking to them about that. That's going to be okay. Do you know? It's like,

Kelly: [00:52:05] and like.

That, what the fuck do you standardize with that?

Danny: [00:52:08] Like how not to be an asshole? Like there's a lot of things that there will be, there'll be challenging. And I think that's, you know, the fact that we have the autonomy to figure things out the way we want. It's what makes the feel exciting as well and allows us to have created within it.

Because I do think this, if it was just like, you know, I don't know, my brother's in emergency medicine, it's like, okay, if somebody has this, this, and this, they get this test, they get this medicine, and they memorize these things. And that sounds incredibly boring to me, honestly.

Kelly: [00:52:35] Yeah. And you know, I just jump in and say, you know, I think our standing operating procedures and guidelines are tissue healing times, right?

I understand what phase of the injury Personism and, and I understand, you know, you know when a physician hands me a protocol, you know, they're not trying to constrain me. They're like, dude, don't pull this. Don't pull this repair out and trying to limit this. And I'm like, okay, well, so all of this, so it helps to have.

The boxes, I understand what the function is. And coming back to what you're saying is the what is, what is the goal? So, you know, I think you start with Doug is like what's the patient's goal? And if that goal is just to be out of pain, then that looks very different than, you know, telling me that what I'm doing is wrong.

When my guy just snatched the American record and wasn't pressurizing, or I'm trying to manage a team and improve a group like all blacks. And at some point. You know, we try to be transparent in who we're working with. And again, I don't think it's always about me. I think we need to, we can continue to support and show people other models of understanding, but we're pretty transparent about how we get there.

And it's not a gimmick, you know, it's, it's, you know, these are our, and in our level two courses, you know, Danny, we have clear guidelines for what we think is. Full movement capacity, not within normal limits, not a movement screen. And those things may not even be relevant to you, but if you are missing your overhead range of motion and you have excellent compensation strategies, and you're a swimmer. You have shoulder impingement, and I can come up with a rec, a rationale for that mechanical dysfunction.

Right? And I understand that you're able to buffer it when you were well-rested and well-loved and were having sex and eating like an engine and had excellent life support. But as soon as one of those things went by, your mom came up to the surface. And so, you know, there is a lot to cover, I think, I saw a great book, or just finished a book called the short history of everyone who ever lived.

It's about sort of the common, the contemporary look of genetics by Adam rather who Adam Rutherford. And there's a quote in there that says, for every complex problem, there was an equally simple. An elegant, straightforward solution that is wrong. And I think, you know, that is what I believe to the heart of what you're saying, Doug, is that if the brain is the most sophisticated structure in the known universe, most complicated thing in the known world, and we attach a body to it in a complex society.

Why should the answers be straightforward? Why aren't they dynamic, and why isn't it a change? So I think it is, these are existential questions that we really should be having out in the open and not in the ran core of, I think you're doing it wrong, Doug, and how dare you? Because you don't have the moral high ground, you know, you're going to turn me off.

And what we're going to do is we're going to continue to work the way we're working anyway within our scope of practice. And I'm happy to show you my results, and I keep inviting everyone to come to the gym, and I'll show you the way we think and why we think that way.

Doug: [00:55:29] Yeah. And I think if people just worried about themselves as individuals and everybody had that mindset, then the profession as a whole would be elevated.

So it's, I mean, it's like the amount of time that some people spend being critical of like,

Danny: [00:55:40] you know, the

Doug: [00:55:40] broken profession. It's like, you know, just improve yourself, show people what you do. And like you can't always force this stuff that's going to happen organically. So do a better job as an individual and show people what you do and hope that collectively,

Kelly: [00:55:53] I mean.

And let me start that again. Show me what you do. So, Doug, you get, you're in a lot of places. I lecture, and I see you, and I always have to clean up your hot mess. Everyone's all confused, right? I'm just kidding. A lot of the therapists, I know Danny, you just wrote a book about what's working for you and about ways that people can experience that mom themselves.

Write books. Don't just talk about your blog. And I need to see a real video of how you move. And what I'll say is, I understand I have a personal bias. There's this, cause I have over 5,000 videos in the world. Showing how I think and what I do every day and exposing myself

Danny: [00:56:26] to

Kelly: [00:56:27] the criticism. You know, and one of, you know, we get all these zombie arguments, there's no such thing as an adhesion.

Well, if your skin doesn't slide over your cow, Caney, or you know, their fibular head and it's an order, it adheres to the tendon, and then I move it and then your range of motion improves and then your pain decreases by eight points on the scale. What was that sticky spot? What do you call that? An extracellular matrix, you know, dysfunction, disordered conjunction.

I mean, so maybe you don't like certain words. I appreciate it. But if you're, like you say, if we're going to going to have standardization, if I can show you an outlier, then that standardization no longer works. So that standardization has to be pretty robust, and it has to account for all phenomena.

Cause if I can come in and show you a different model or an outlier in that thinking, in that process. And your standardization doesn't work anymore. And I think that's important. Understand, is that people are sufficiently complex and we need the creativity and the autonomy to help solve and manage a treatment inside the context of someone's

Danny: [00:57:29] relapsed.

Yeah. Yeah. And I hear, here's the other thing. I want people to, also, keep in mind, like there's going to be a lot of physical therapists and listen to this and, and, you know, hopefully, though they will. Form their own opinion on what they should or shouldn't be doing. But one thing that I want to be at least clear about is the fact that I feel like our profession has helped me significantly within, within, within my career.

I feel like it's helped all of us and this idea that. Physical therapy is broken, is silly, right? Negative people find negative things in anything, you know, positive. People with an abundance mindset find the positives and thoughts, and they expose that, and they use it, utilize it to their, their advantage.

So, you know, I know for me, I've met a lot of PTs that have gone to school or students that are in school because of, you know, Kelly's work in particular. And. It's interesting to see them when they're there, and then, they come and see us for maybe like a day in the clinic, and they're frustrated because they're stuck in like a high volume clinic, and they're like, should I have even gone to PT school?

Like it seems like, you know, it's not, it's not going the right direction. They come to see us, and they're like, Oh shit, this is awesome. This is what I thought I was going to be doing. But then they would, they learn in school. Maybe it's not exactly what they're going to do. And that's okay because like you said, they're there to pass a test, but I wonder already listen to this, to also understand that like.

We're very, and I'm very positive about the profession of physical therapy. I think we get who else gets to works with, with bad-ass people, solving problems to help them have better lives without having to do things that are negative in terms of unnecessary surgeries or get addicted to medicine or avoid stuff for the rest of their life.

Right? Like, Oh, you just can't run anymore. Like, dude, what the, what if a dog chases you? What the fuck you should be able to run away from a dog if you need to. So, you know, we get the opportunity to work with really. Amazing people and use our skillset to help change their lives for the better. And I think it's something that we should be very positive about.

Not negative, which I see too much of this in particular on social media because it's accessible to. It's easy to get a reaction. It's easy to get a lot of likes when you take a stance and be very harmful to things. And I can tell you, I think to your point, you know, for the number of things that you've done for our profession, it's straightforward for people to point their finger at you, to disagree with you to help build their platform.

And, and what's the phrase? Heavy is the head that wears the crown. Like when you put yourself out there, and you've done so much, I think inherently you're going to get people to try to build themselves up by. You, I'm trying to bring you down in the process. So this idea that you know, PT is going the wrong way and it's broken.

I just don't see it that way. I think it's only a cynical view that people take. That's just, you know, isn't, it's not accurate. So anyway,

Kelly: [00:59:55] we're sending more people to physical therapy school than ever before because it's not broken. I'm like, Hey, people really who want to be good coaches and help solve movement-related issues.

I'm like, you need to go to physio school. Like, if you want to know what you know, a duck can think or how we feel, or a way of thinking, you know, you know, I was a geography major and at fizz at school, at college in a geography major as a way of seeing the world. It's a way of understanding. It's if you've ever read guns, germs, and steel by Jared Diamond, that's the same way I think about the body in its environment.

It's not an accident that I came into that as a broken athlete, but also understanding that context matters to this. And you know, to your, to your point, Doug, just initially, you know, a. Aye. I am thrilled with the current model. I'm down, and I'm down to keep talking about what, how do we become more effective at our profession, and move our business into the limelight where it belongs.

You're saying, Hey, exactly what you're doing, but if expert clinician ship was always a compromise between what you think is best for the patient and what the patients believe best is for themselves. Well, you're at a, you're in a district, you're going to lose your best practice from the start, and you, once again, you were at odds with yourself because what you think is the best based on the guidelines, the patient's like, I'm not doing that or I'm not going to do it 10% of the time.

I mean, what's adherence in physical therapy in the 30s. 27% I think, you know, so, I mean, there are, these big holes in our thinking all over the place, and if we're going to standardize or improve, then we're going to have to show our outcomes. All of them all is, we're going to have to own failed issues.

And I don't think failed rehab, rehab, rehab, failed rehabilitation syndrome is something that some of the doctors have pointed out at us and saying that we don't have to ever. Except for responsibility for putting wrong physical therapy through, and then someone ultimately has surgery. So how do we wrap our heads around those things?

And then, one importantly, how do we continue to press push positive on this? And I, you know, there are a handful of therapists and all the people that I named called and tagged out there, I follow for a reason. Because they helped me clarify why I believe what I believe. And I think that's important.

So even if you are out there as a physio and you're listening, and you're like, man, I don't treat like that. You should be understanding how does someone operate that way? What problems are they trying to solve? Because that is the model that all the best coaches in the world. We're going to put up, and I'll tweet at it just in a second. If you haven't, I think Doug, you might've already re repurposed it. It came from Stuart Macmillan, and it's this idea about critical thinking. A little ebook came out of Altice, which is really what we need more of is we have so many tools, but not enough critical thinking.

You know,

Danny: [01:02:25] I'll put that up on that

Kelly: [01:02:26] ebook, or I'll even send you and maybe put it in the show notes and just as a reminder that people are solving the same sets of problems. Yeah.

Doug: [01:02:34] Yeah. I mean, for our broken profession, I would say it's afforded me some pretty incredible, incredible opportunities. And I'm happy with the career decision.

I don't feel limited or constrained by the professional choice that I made. And to come full circle, like what originally started the standardization, the question on Twitter was somebody made the point that some of these more systemic macro-level issues in healthcare. Artist's way more important than the things that PT is fixated on, like whether it's cupping or dry needling or manual therapy, and somebody can't counter that and said, no, I think the cupping and the manual treatment and the dry, I need to link those are a big deal because they're not good.

We should standardize the profession. But again, I think that these assistant systemic things do matter, and there's no perfect way to measure physical therapy outcomes. And again. You know, a lot of these are going to be driven by, well, do physical therapists determine how, you know, how they should be gauged or do health insurance companies?

I think it should be the patient. So the more that the system incentivizes patients to look out for their health, I think ultimately that might, you know, create a better answer than what we have now. Because

Kelly: [01:03:43] I

Doug: [01:03:43] think the goal should be for the same problem, whether it's low back pain, knee pain, the less money the patient spends of.

His or her own or of health insurance companies, the better. So it's not a perfect metric, but if we can get people to spend less money for the same thing. I think that's a good thing. And if we had a system that incentivized that type of behavior, I think it'd be better for everybody. So that's kind of my

Danny: [01:04:06] parting shot.

Yeah. Well, I mean, yeah, you're getting, you're getting at the root of the problem with, with a lot of the ways that, you know, we get reimbursed or not reimbursed for certain things that, that, which is one of the reasons why this idea of, a cash model or an out of network model or speed for service model, whatever the hell you want to call it, is, is such an exciting sort of elegant solution to, it's a

You and I were deciding, are you interested in doing this? If so, this is what it costs. We'll take these other people out of the equation and let's solve, let's solve this problem together, right? No biases, nothing like that.

Kelly: [01:04:40]It's all the outcomes, solutions. I'll put my money where my mouth is.

Fire me. If you don't, right, and you guys just can't do that. I'm at 5% left on my computer. Go on. But if I go away, I appreciate everyone so much, but I'll talk to the end.

Danny: [01:04:53] Yeah, no, let's, let's, let's wrap it up so that, know. People can finish this in a commute there, and you know, to work and back depending on, well, maybe it depends on if you're in San Francisco or Atlanta traffic, it might be just one direction.

Well, New York, just in Baton, their mind, all of us probably do someone, in one trip. So,

Kelly: [01:05:08] no, this was, this is,

Danny: [01:05:09] this is a fun talk. This is something that's, you know, hopefully. You know, people can, maybe you need to listen to this more than once, you know, synthesize some of this information. I think these are like, and this is some high level, stuff that's essential conversations to have.

It's one of the reasons why I wanted to have this conversation. If, when, when Kelly or Doug, you know, emails me or texts me and says, Hey man, you want to talk about, you know, whatever, it could be anything. I'll say yes. Like literally anything, I'll say yes. Because I think they're brilliant. They're incredibly passionate about our profession, and I think they've done nothing but.

Positive things for the profession of physical therapy performance in general that are wrapped together within our business. So, you know, for you guys are listening to this, here's what you should do. You get involved in the conversation, you know, follow these guys on social media.

Follow them on Twitter. Get involved in the conversation to see how you feel. Talk to your peers about this. Talk to your, your, your mentors about this, and challenge what they're saying in particular. And not in a, not in a negative way, but just tell them, you know, Hey, this is what I think about this, and this is the way I view this.

These are the problems that I see because you might be new to the profession, but it doesn't mean that you don't have ideas that are positive and, and can, can help us. That's, that's how it progresses. That's how we. Prove proven new model. So, anyway, I just want to say thanks so much for your time and I both you guys, I appreciate it.

I know you've got lots of stuff to do. Doug's be busy treating everybody in New York City. Kelly's probably in his, whatever, the fifth, fifth, seventh book, whatever it is at this point. I'm trying to raise two awesome daughters. You know, you've got a lot of shit going on, so I appreciate it. And, anytime you guys want to talk, we're down.

And as for you guys are listening to this podcast, thank you so much. We're listening. If you like it, let us know. If you don't like it, I don't fucking care cause I'll still do another podcast like this. It's my podcast you've fucking want ever, and if you haven't yet, go check out F Insurance.

I guess you can say at this point if you're interested in doing more of a patient to provider model and taking some of these things out of the equation that makes us have to make bad decisions. Just take them out of the equation and commit to your patients. And to do that, you have to be able to have a conversation with people, get the results, commit to it.

Because if you're wrong, guess what? They still paid you. Do you know? And that's a tough place to be. So I think it makes us better. So anyway, guys, thanks so much for your time. I appreciate it. And as always, guys, thanks for listening to the PT entrepreneur podcast.

Do you want more cash, PT, biz help? If so, get a copy of my book. Fuck Insurance. It's your playbook—so successful performance, PT practice, and never having to deal with insurance again. You can get a free copy at Finsurancebook.com. Inside this book, you'll learn the direct techniques that we've used to become one of the fastest 100% cash PT practices in the country.