What are you willing to tolerate in your business? Substandard performance, misaligned team members, limited time to focus on your business, sacrificing family time for work, unprofitable company structure - these are all barriers to our goals. But they can only limit us and continue to do so for as long as we tolerate them. Inspired by Jocko Willink's quote in the book, Extreme Ownership: "....there are no bad teams, only bad leaders...." Nathan Shields sees that there is absolutely just one thing that is keeping us from what we want. The fact is our team, the economic crisis, the insurance companies, etc. are not the issue; WE are the issue because of what we tolerate.
I'll start this episode by apologizing. I haven't been on for a couple of weeks and we're getting back into the swing of things. I went on vacation and contracted COVID thereafter. I've been behind on a few things. Forgive me, we're moving on. This episode is not a guest interview like I typically have. It's a solo podcast episode. I'm flying solo because I want to talk a little about something that I've seen both in my own experience and in the coaching clients that I have. It's related to a concept that Will and I discussed a few episodes ago and was then brought up in a different way and in a different perspective. You know how that is. You're thinking about something and then you read it a different way. It gives you further thoughts and ideas. Maybe it even shines a light on what you were thinking of in the first place.
In my episode with Will, we discussed the five secret actions that PT owners take to make them successful. The fifth one that I brought up was impatience. Not that it's a successful action per se, but it's a characteristic that successful PT owners and small business owners have in general. At the time, I didn't feel comfortable with the word because it's not necessarily patience that the successful PT owners are able to make quick decisions with the data that they have. They're decisive. They recognize that there might be repercussions, but they make the best decisions with the data that they have, and do so in a rather quick fashion.
This concept was addressed in a book that I'm reading. Our Physical Therapy Millionaires Mastermind read together what’s called Extreme Ownership by Jocko Willink and Leif Babin. In reading that, this is what got my brain thinking a little bit, in page 54, he says, “As a leader, it's not what you preach. It's what you tolerate.” He goes on to take it a little further in page 55. He digs a little deeper and says, “There are no bad teams, only bad leaders.”
What I got from that was that Jocko and Leif are stating a better way of explaining that one of five secrets that I discussed and labeled it as impatience a few episodes ago. Jocko might call it intolerance. The idea being that improvement, growth, attainment require us to look at ourselves and our teams and ask, “What am I tolerating? What negative performance or actions am I tolerating that are keeping me from my goals? In spite of everything I have to say and all the values that I espouse, what am I tolerating that's going against those things?” I believe that answering that question and purposefully addressing it head on is the key to our ongoing growth and fulfillment and our successes honors.
It's not a one and done action. This isn't something that you look at now. Maybe you address a current issue and then move on. It's like that never-ending mountain that doesn't have a summit necessarily. There's never a summit to be reached in this regard. Tolerating marginal or negative behaviors in ourselves and others is the antithesis of growth. We’ll continue to be a stumbling block going forward unless we create or develop characteristics within ourselves to not be okay with those things that we're simply tolerating. We could get into a deeper conversation about integrity and character. For the purposes of this discussion, I'll just say that most of the time, the things we tolerate are counter to our stated and unstated values and purposes.What are you willing to tolerate to keep you from your goals? Click To Tweet
I want to share some examples from my own experience, the experience of coaching clients that I have to illustrate some of the things that are being tolerated. I'm not going to go through the consequences, but consider what those consequences might be if these scenarios are allowed to persist and continue. Usually we consider that it's a team member. That's the “issue.” Remember, there are no bad teams, only bad leaders. Consider what needs to be done as a leader in order for these issues to be addressed. I'll give 5 or 6 here. The PT that's not following train protocol to get full buy-in for the full plan of care at initial evaluation with a patient. Leaving the front desk and patient then to determine whether the patient should come once a week, twice a week, three times a week, and not taking a stand but saying, “You guys figure it out, whatever works with your schedule. We'll see you whenever you need to come in.” Consider what are you tolerating in that situation? What are the consequences if that continues?
What about the PT owner who finds out that, as I've stated here in my show or maybe found it in a different study, but less than 20% of patients complete their full plans of care? That PT owner does a little digging into their own clinic and individual provider statistics, and finds that most of one particular PT’s patients fall off after 3 to 5 visits and are in that less than 20% completed range. These patients are thus not reaching their goals or completing their full plans of care. When the PT is asked about it by the owner, he or she simply says, “I can't control if the patients are coming in or not. If they're busy, they're busy. I don't know what to do about that.”
What are we tolerating? What is the consequence? In that one, I'll tell you the average outpatient orthopedic clinic loses on average $150,000 a year because patients aren't completing a full plan of care. I'll give you that one. What about this? Front desk is found to be collecting only 50% of over the counter collections. That means only 50% of the copays, deductibles, and coinsurance are being collected at the time of service. Typically, this is struggled off by the front desk and maybe excuses are made that the patients forgot their purse or they don't have their credit card on them at the time or, “We'll just let the billing department handle it.” What are we tolerating? A lot of money and what are the consequences?
How about this? This might be a little bit more relevant to our situations. Six months into this economic downturn, there's a clinic that is overstaffed. Reserves are depleting and there's no immediate increase in new patients on the horizon. How much longer do you tolerate the overstaffing and negative profit margins? These next few are owner-specific. An owner has a team member that complained about their pay, their hours, even asking if meetings are on the clock or not. It's gotten to a point and sour the relationship to a point where this team member now avoids interaction with their supervisors and even the owner. However, they're productive and their patients have no complaints. Is that conduct tolerable? Are we tolerating something? What are the consequences?
The last one I'll share, all of your physician only marketing efforts have led to a stable yet a plateaued number of new patients that come in the door. You, the owner wants to expand, but you don't know what to do and don't have the time and effort to do it because they’re too busy treating patients full-time. You don't have the time to necessarily assess the alternatives because that takes even more time away from hobbies, family, etc. What are we tolerating and what are the consequences?“There are no bad teams, only bad leaders.” – Jocko Willink & Leif Babin Click To Tweet
Most of these are real situations. Some are mine. Some are clients’ situations, but in each situation, I can promise you that the owner is tolerating the inaction of the employee or of their own that goes against their clinics, values and purposes. It’s going against what they preach. Remember, it's not what you preach, it's what you tolerate. That's where this whole conversation came from. Successful owners who have gained experience and have learned over time, they don't tolerate the affirmation scenarios.
They usually follow up pretty quickly with a four-step process and don't drag things out. Number one, they assess, revise and update any training or protocols that need to take place, and assess the situation to see what was missed in the training, what was missing in the protocols, or if the employee simply didn't follow through. Number two, they commit to change and improve both personally and as a leader of their team. Number three, they commit and expect higher levels of performance of themselves and others. Number four, they follow those commitments up by acting according to a higher standard and tracking the statistics that are related to them to that higher standard, and doing regular assessments either with themselves or with team members or in their leadership teams.
In the book, Jocko Willink says, “When setting expectations, no matter what has been said or written, if substandard performance is accepted and no one is held accountable, if there are no consequences, their poor performance becomes the new standard. Therefore, leaders must enforce standards. Consequences for failing don't need to be immediately severe, but leaders must ensure that tasks are repeated until the higher expected standard is achieved.”
What we tolerate leads to poor performance and that poor performance becomes then the new standard. The question is, what can you see in your clinic or in your own personal lives that you're tolerating that needs to be addressed? Simply address that now for immediate improvement. That's the challenge. I can think of a few things myself and they're not easy solutions. Nevertheless, if addressed, I can see the possibility for growth, fulfillment and attainment.
That's obvious if I simply address those things appropriately. I offer you that challenge. Open your eyes, pull your head up as the leader and be honest with yourself. What are you tolerating personally and professionally? Make a plan for immediate correction, including putting on your calendar exactly the hour and the day of when that item will be addressed. This is how successful leaders operate. They act quickly and decisively. They don't tolerate substandard performance.
If you are treating patients full-time, that doesn't give you the opportunity to assess and address your business accordingly to see and act on those things that you're tolerating. I challenge you to do those things. Hopefully, everyone's doing well, especially as we're recovering from the pandemic. I hope to see you here in the near future with another exciting guest, some great resources and content coming up. Stay tuned. I'll see you next time.
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In 2019, Ben Larsen, PT, DPT, co-owner of the Teton Therapy Cheyenne Location, had great goals of increasing his number of total visits per week by year-end to well over 200. Little did he know that by making appropriate, time-honored decisions he would hit well over 300 visits per month come 2020! His path to success wasn't based on a new treatment technique or referral source. Rather, as Nathan Shields and Ben discuss in the interview, Ben hired people that were in alignment and he implemented what he knew he should be implementing (things he learned from his consultants and coaches in the past), and started tracking stats and training his team (future leaders). Suddenly, patients started coming in greater numbers than he had ever seen before and he wasn’t treating most the time! A great story of small and simple actions generating great results.
I'm bringing on one of my friends and coaching clients. I hope it doesn't come across self-serving but I had to bring this guy on because he has made incredible gains. I wanted to talk to him about what he's done and what were some of the specific actions that he took that got him to see such significant gains. From what I recall from the discussion is that nothing new came up. We talk about hiring the right people, having the right mindset, figuring out your purpose, stepping out of patient care, taking control of your environment, all things that can be seen in Ben's growth. My guest is Ben Larsen. He's out of Cheyenne, Wyoming, and making great strides and looking to grow and expand. Hopefully, I'm along the ride with him as a coach but he's implemented many great things and made all the right choices so they can see significant growth and hopefully continue to see it going forward. Hopefully, Ben's story is an inspiration to you as well and it gives you some ideas about the next steps that you need to take to see your goals and dreams come to fruition.
I'm excited to bring on a friend of mine that I’ve known for some time and has become a coaching client, but he's had such tremendous growth. I wanted to share his story and talk about some of the things, especially the successful actions that he's done to double his growth in his clinic. First of all, the guest is Ben Larsen, Co-owner of Teton Therapy in Cheyenne, Wyoming. Ben, thanks for joining me. I appreciate it.
Thanks for having me. I’m excited to share our story and how we've grown this.
I know your story and I’ve had the opportunity to watch you from a distance. If people have checked the previous episodes where I interviewed the Co-owner of your company, Teton Therapy, Jeff McMenamy. He's got a great story starting from working in a racket ball court and starting his physical therapy clinic way back in the day, but he's grown, expanded and brought you on as co-owner in Teton Therapy in Cheyenne but you've done a lot. I want to highlight you and your story and your successful actions. Let's go back a little bit. Do you mind sharing with us a little bit about your professional path?
I went to PT school just like everybody else. I went to a school in North Dakota, the University of Mary. Jeff McMenamy who's my business partner, is an occupational therapist. He's from North Dakota. He was there at a career fair. We talked and it's a funny story. He tells it better than I do. I show up in a full suit and tie and he says, "What do you want to accomplish as being a physical therapist?" I was naive when I looked at him and said, "I want to own my own practice." This is the first time we've talked. At that point, he mentioned how impressed he was with my drive and my determination to expand as a professional. I signed up with him to go ahead and work for him.
I move my way up within two years as a clinical director and then as vice president of operations. In the meantime, I did a lot of training on business techniques and different management techniques through measurable solutions. I got trained in how to run the company from a vice president of operations standpoint. I'd been doing that for several years and he approached me. We had an option to move the clinic down to Cheyenne. He asked me what I thought about doing that and moving my family to a new area. I took my wife and kids down here and decided that this would be a good move for us. We moved down here and opened up the clinic with not knowing anyone in Cheyenne at all.
I put up a sign out by the door that says, “Please call for information and consultations,” a couple of months before we opened. We did a little basic type of stuff to tell people we are coming in town. We opened the door with zero patients on the books. When it hit the pavement hard, it all started with a Parkinson's support group. I met my first patient there. She brought her in. We did a couple of treatments with her. She told her doctor. The doctor was having some issues. She came in for me to treat her because we're getting such good results with her patient. She told her friend, who was another doctor who was having some elbow pain. She came in and I treated her. It expanded from there of initially first treating physicians and then getting the word of mouth out and then expanding the practice.
You've got a nice connection there.
Over the past several years, every year, we've had substantial growth, but 2019 has been a big growth for us. Like most practice owners, when you first start out, you make a lot of stupid decisions and you're trying to fill spots. Your hiring is okay as you're first learning it and then it gets better and better. We've had a complete staff turnover at least once. Within a couple of years, we've brought on some real key players that as we started transitioning people. We've seen significant improvement within the quality of care we're giving first off and then second off in our business growth because of that quality of care. That's been our biggest thing.If your goal is to be completely autonomous, you got to be able to handle everything. You can't just handle the basic things. Click To Tweet
Finding the right people, hiring the right people, and then helping them to expand in their position in and what they want to accomplish as well. As I sat down with you, we looked and it was more than doubled. We almost tripled based upon having the right staff members in place, expanding the right way, following the right systems, and implementing things that have helped. The basis of my story is starting from about nothing, to where we're getting ready to hopefully get into a new space. It’s finalizing some things on that, to where we'll be able to double our space and hopefully continue to expand our practice and provide good quality care for the city of Cheyenne.
I don't want to go gloss over it too quickly. I do want to get to what some of the specific steps that you've taken that tripled your number of total visits per week. Can you share with us a couple of your bad decisions that when you look back on, you’re like, “That was bad, I should not have done that,” or “I would have done things differently?”
When I started out, I had done all this management training. When I first did the management training, it was more like, "I'm doing this for the company." Most people are going to have executives out there who they bring them on, they do the training, and those people are doing the training because they want to expand the business for that particular owner. When you become your own owner, you get this mindset of, "I’ve done that training. How do I want to do this?" You start thinking about how you'd want to do things and trying things that haven't necessarily been tried or tested.
Are you doing things differently than what you're trained to do?
Yes, because you're trying to make your own way. For me particularly, I’ve had this owner that has developed me into who he thought to be that good physical therapy owner. I had some ideas, some preconceived notions that there were some things I wanted to do differently than what we were doing at the other clinic. I stopped implementing some things that are successful in other clinics that bit me hard. I needed to get back to the basics. That was the one thing that if I could go back, I would stick with the basics of the training and implementing the statistics. The things that we use in our business to make sure we're producing and doing what we need to do. That would be the one thing that I go back on that I would stick with the training that I had and move forward with that. The second thing is sometimes we hire out of desperation instead of hiring out of what we need. Everyone's had it where they want a position filled with someone that can fog up a mirror. They walk in and they've got the proper license and you hire them, but they're not necessarily the right person for your company. There's a couple of times where I wish I would have taken the time and done better with the hiring process like we do now and found that key quality person that fits with our group, team, dream, and purpose, all those things. Those two things are the biggest things. One is sticking with the basic technology of managing the clinic. The second one is to hire based upon what we need not just to fill a position.
You looked back on some of those decisions in terms of hiring out of need and I wonder how much time did I lose by finding a person instead of waiting for the right person. We've had instances where it would have been better for us if we had simply let go of the entire team in a poisonous clinic and started from scratch all over again. It would have saved us a year of headaches if we started from scratch. Sometimes it's that distinct in my head that sometimes you have to wait for the right people. I also want to congratulate you. You said you're going to expand. You're looking at a new 6,000 square foot facility that you're going into. I misspoke. You're not only doubled, but you tripled in productivity. Of course, things didn't happen all of a sudden and I know it wasn't like one new provider started sending to you. You didn't necessarily niche out and do anything in particular. As you look back along the timeline, what started this process of growth if you look back a year and a half ago to lead you to the point where you had such dramatic changes?
Looking back, there is a key event that happened that sucked. It was the worst experience of my life. I had an employee that totally went ballistic on me. He was upset about things. It wasn't a good situation. He reported me to the board saying we were doing an insurance fraud, claims that made me decide what type of a team do I want to have and how do I want to foster this team to do what's best for patient care. It changed the way that I hired after that point because, initially, our HR person would contact them. This is particularly with physical therapists. I would say, "Once we get down to the top five, give me their names and I’ll set up some time to interview them."
This time I said, "Who's your top ten? I want to make personal phone calls to each one of them before I even bring them in and talk to them." I laid out everything on the line. I was very open within these interviews and talk to these individuals to try to find the right people for our team. We looked at is this person the right person for what we need? I got down to one particular candidate where there were two that I liked. I sat down and thought this process out. I didn't make a quick decision. I thought about it and what we needed. There was one thing in particular with the one that made me think, "This one is the one we need. She's going to take our clinic to where it needs to go based upon our conversations and what I saw."
With this particular one, I had some hard times with it because the HR person, our VPA, she was leaning towards another candidate. She's great and I totally trust her completely, but I didn't feel right about that other candidate. We were about ready to pull the cord on the other candidate when I said, "No, I feel there's something with this other candidate." I talked to my business partner. I told him what I thought and he called both of them. He felt the same way with this other candidate that we hired. We pulled the trigger on this. She's been one of our best producers because we followed that gut feeling of what's best for the business and for the clinic. That's been the biggest thing for me, looking at things in terms of what's best for the clinic. Sometimes it's not necessarily what's best for me personally, but it's what's best to expand the business and make things work for the team as a whole. When I started doing this and adding additional therapists, I was very upfront with my expectations.
It's a funny story. I have this PTA. We were sitting down at lunch and we were super busy and I said, "I need somebody but I don't know if this is going to be a full-time position. Would you be interested in coming on part-time or coming on as a temp position and then it could go into a full-time position depending on how you do?" During the conversation, I don't remember saying this but she said, "If there is someone who doesn't fit in with this team, I'm going to straight-up fire them." She tells me that. It struck a chord with there that I'm serious about this team needs to be working hard together to get to our purpose, which is taking care of patients.
That's what we need. The biggest key to our success is finding the right team. You've probably seen this as well that when you find that right team, the patients seem to come. When you have that right flow, the patients show up because there's something about it. That's what we've got. In times when we're going to slow down, all of a sudden, we get these boom of patients coming in. It's from word of mouth and it's from people seeing what we're doing. They're happy with the results and sharing it with everybody else. It all starts from that team having that same purpose, working together and working for what is best for the clinic.
It sounds like what you did and unknowingly is try to find people who were in alignment with you. You had the best interest of the company in mind and that goes to show how important it is to have that filter. The company comes first. The owner comes second and then the employees come third. It seems like from your story that you focused on finding people who were in alignment with you. It was cool that you could call Jeff, the co-owner and have him also phone interview these people because you and Jeff are aligned. You two can find the right person who was in alignment with you and that starts creating a culture of like-minded people who share the same purpose, vision and goals. It starts to accelerate the growth process. I've seen it hundreds of times and it happens all the time with people I have on the show.
As you start finding those right people, you start developing a culture. Culture is simply the way you do things at Teton Therapy in your case. People do things the same way. They're saying the right thing, they show the same values, and they treat patients the same way. Not to say that they're the same, but the culture is similar and there's a feeling there that starts to gravitate like-minded individuals to the practice to work with you. That's a sense that patients can get when they come to your clinic. They'll start coming. They'll start returning, they'll start referring friends and telling their doctors. It's almost like you can't stop that as long as you continue to hire the right people.
On top of that is I got to a point where we were doing well in the last part of 2019. We were getting things in but then the next step is that network out. That's when I approached you about coaching because I needed the next step, which was to help somebody get me to the next step. I'm talking about phase one versus phase two. Being an owner is phase one, you're that clinician, you're in there. You’re handling all the day-to-day stuff. Phase two, you're transitioning out and you're handling the business side of it. It comes down to as a therapist, you have to decide. With my two hands, I can only do much to help people.
I can only see many patients, but if I take my skills and my two hands and teach others how to do the same thing I'm doing, the amount of people I can help is unlimited based upon the amount of people I can train. Those people can then expand their hands to help more people. The whole goal of a therapy clinic is to help as many people as you can possibly. You can't do that if you're doing treatment all the time and you have to make that decision of, "It's time for me to transition to do a greater good." Therapist is a great good, but there's a greater good of training others to do it that you can help more individuals. You can help more people.
To go back into your story a little bit, and I don't want to gloss over this because it's important. When we talked, I was excited to work with you because you said, "I've learned all this stuff. I've learned the management technique. I've read the books. I’ve got the training. I know what I'm supposed to be doing but I need someone to hold me accountable." I remember that sticks out in our conversation that we had back then. As we started training, you recognize that you need to do less treatment on patients and get out of the full-time treating.
I hope you don't mind if I share but then you got Bell's palsy. Physically, you were not capable of seeing patients anymore. Correct me if I'm wrong, that was a turning point where you were able to step back and see what would happen if you physically weren't present and recognizing that, "Now that I’ve got my head out of treating patients because I'm forced to at this point, I can see the things that I can do." Whereas, when you were treating patients, maybe you didn't have a clear vision. It seems like you had to go through that experience to see that.If the game's easy, it's not worth playing. You've got to have a harder game. Click To Tweet
That was a big part too because at that point, we’re almost 100 less visits than what we're doing just within that last time part of starting this process of the coaching and me stepping out. There's part of you that thinks as a therapist that if I step out, this clinic is not going to do as well. You figure you're going to lose visits. You'll never be going to hit an all-time high unless you're sitting out there treating patients. What I found out was my mindset changed of we're not going to hit an all-time high unless I don't see patients. I can't see patients or we're not going to hit it an all-time high. I have to be doing other stuff. I can't be out there on the floor.
If I am, then my time is not being used for more of that working on the business as not working in the business. That's been a big change. That's been something that's been working with you, working with Jeff. Because we all have that sense when we stop treating patients, it's that timeframe of what do I do now? How do I make this productive? How do I continue to grow the business when I'm not the one who's doing everything? It's a big mindset change and you do need somebody to hold you accountable because if you don't have somebody to hold you accountable, you do find yourself very scattered. What do I do? You find yourself gravitating towards getting back on the treatment floor again, which is not where you need to be.
That's the easiest path and that's what you know. You spent the last 30 years studying to become a physical therapist. Naturally, if you have some free time, you're going to go with what you know and treat patients, but you've got to pull yourself back. It takes a mindset shift. I see this with my coaching clients. There has to be a change in the mind and it doesn't happen immediately. It usually happens over time to the point where they recognize that, “I can do more for the business and for my team, my other providers, my front desk members by not treating patients and focusing on the business to give myself freedom, the bandwidth, the mental freedom and the energy to work on it and make it a better place for my team. Make it a better place for the patients that come in the door and be a greater influence in the community.” It's that mindset shift.
I look at this with my kids. I don't want them to be as good as me. I want them to be better. I want them to do things better. I want them to not have to deal with all the mistakes I have and had to deal with. I don't want it to stay the same. Within the physical therapy profession, I don't think we understand what physical therapy is going to be like in 10 to 15 years. It's going to be different in the way we approach things, the way we do things because we are constantly growing and improving this profession. As business owners and private practice owners, we've got to be at the forefront of training our therapists to be better than we were as therapists. Giving them our basic knowledge and then letting them expand that so that we can continue to expand this field. If our goal is to be completely autonomous, we got to be able to handle everything.
We can't just handle the basic things. We've got to be able to handle everything within the musculoskeletal system and the realm of physical therapy but always pushing those boundaries. That's why, you and I, both involved within hands-on diagnostics because that's what they're doing in Measurable Solutions and another company I'm part of because that's what they're doing. You network with those peoples who are pushing those boundaries because that's what we have to do in this profession if we want to see it succeed. That's what you have to do within your business is pushing the boundaries, not stick in that cookie-cutter box that we have been in the past. The past isn't going to get us to the future. It's the present of working and improving our goals, improving ourselves, improving what we do as professionals.
Did you find it was hard to make that mindset shift? I mentioned that it usually doesn't happen overnight but take some time. What made that switch for you? When did you recognize that, I can't keep seeing patients? I want to go back and reiterate what you said since you stepped out of treating full-time your business has increased 100 visits per week since you stepped out. It did it without you. What was the shift that helped you change your mindset?
It's deciding where do you get the most gratification. For me initially, it was treating patients but then as I'm treating patients and as most of us know, when you've been treating patients for a long time, it becomes second nature that you're not thinking about. You're doing a good job treating the patient but you can tell that it's not challenging you. You get to a point where treating patients becomes this easy thing. Some people reading this may say, "I don't think it will ever get that way." It gets to a point where it's not the easiest. It's the easier thing to treat. The more gratifying thing for me was bringing on new therapists and watching them succeed. That's where I get my joy from. When I see my therapist totally handle a difficult case and they come out like, "I’ve got this guy better." That's what excites me.
Watching them do that and giving them tools to do that. We brought on an OT and she's got her caseload up to where she's seeing exactly what she needs to do. She's built this amazing caseload and seeing that was huge for me. That was a happy moment for me of seeing somebody push it and work hard to obtain something that a goal she had. That's where it comes from. You step out to work on a higher purpose of helping others, helping your staff see success, seeing them help people. You're in the background going, "This is amazing what these people are doing and these clinicians." Even your front desk staff and other things and other positions you have. Seeing them expand their positions and helping people, that's what's brings you greater joy for me, particularly. Anytime I’ve had treating a patient, that's a huge success.
You came to a point where simply treating patients didn't meet your purpose. My coaching clients who experienced this are people who are like, "I’ve got other things on my mind." They're stressed and torn. They're like, "I need to see patients full-time but I know there's the stuff that I'm learning from Nathan in which I need to implement in the clinic that I'm not getting to. I'm thinking about the business while I'm treating my patients." It's an internal struggle. For me, looking at it from the outside perspective, it's that internal struggle. The purpose that you had up into that point in treating patients had changed. Even without you’re knowing or you recognize, “I have a different purpose in mind now.” It's that transition from one purpose that got you to where you were to a different purpose that's going to get you further. You have to figure out what that greater purpose is like you mentioned.
For you, it's to create an environment in which other people can flourish and grow either as providers and hopefully in the future leaders within your own company. Be a greater influence not only in their lives but in their family's lives and in the community that you serve. I see that. We talk about a mindset shift, that's part of it. It's also a change in purpose that you have to come to grips with that as you grow, your purpose isn't being met by treating patients but your purpose is different. For you, it was to grow people. For other people, that greater purpose is meant by having more clinics and growing that way. It can be individual. That shift has to happen and you have to find that greater purpose to go to in order to do let yourself stop treating patients.
It's finding your greater purpose, playing a different game. That's another concept that is part of it as well. The game gets to a point where it’s easy and you need a harder game. If the game is easy, it's not worth playing. You've got to have a harder game. You've got to challenge yourself or you don't want to get up in the morning and do what you need to do. It's constantly keeping yourself up to playing a bigger game. Maybe you add more clinics and that maybe our next step is we're adding more clinics. I've got some big goals and we've talked about some of those things. Some of them I look and go, "I don't know how I'm going to accomplish this but we're going to try other things." It seems goals that I’ve had in the past that are coming to pass and seeing greater good throughout the community. We all do this profession because we want to help people. It's not a money thing. It's a helping thing.
That's why we put all this time and energy into this. I learned this from Jeff, my business partner that I can only do so much with my two hands but when I train others, I can do so much more. I can see more good done through my company because of that. Because of me not being the one who has to touch everything, I can now step out. The nice thing too is it's a different game because you can step in whenever you want. You can help out your employees. You can help them with handling difficult situations in the clinic, but you can also step out. You're not the main guy anymore but you're that teacher. You're that leader that helps them to develop how they need to develop to be the high-quality clinicians and the high-quality people they're capable of being.
Looking back on your timeline, much of it is similar to what we see in the other physical therapy owners. The successful ones. You started hiring the right people, people who were in alignment with you. I know your timeline as well. Go over it and you can correct me if I'm wrong. You also brought on a marketing person to help you out and take that off your shoulders. You also had some consulting and training. You've also done some networking. You already did two of the three steps that I always promote in that is you already reached out and got some training because that was part of your leadership development. You were also part of networks. You reached out and network. When I started working with you, we started focusing on that third piece, the stepping out process and getting out of treating full-time.
We started working together. You brought on another front desk person and based on my experience, and you can share yours as well. Around 120 to 150 visits per week, you need a second front desk person. They can only handle so much. You're bringing on other providers. You've gone from visits that were in the hundreds per week to over 300 visits per week. You've got great goals to get even busier. It's important to note that timeline that you started hiring other people. A marketing person was beneficial and other front desk person was beneficial. You might say that I helped out a little bit as well, but you made that you made those important decisions after hiring the right people and then you exploded after that.
The biggest thing is we're constantly looking at what's the next hire we need to do because it is growing so fast. This might make some therapists, especially owners on this show a little like, “This guy's nuts, how was he able to do this?” We saw a need. I got to travel to try my caseload by having that intention, having those feelers out within recruiting, traveling agencies, to get somebody on immediately to handle those needs. We're in the process of filling that position with somebody more permanent and then adding more part-time help to offset our schedule. Our biggest issue is space. We don't have space until we get into the new building to expand what we want to. We're expanding hours and looking at other options. That takes into account of, we need to add some part-time help to help with this. It's constantly keeping that mindset of what's the next hire? What's the next step? What do we need to do before we get into this new building? How do we handle that? That's where a lot of my time is spent, being that vision of where we are taking this thing.
The time that you spend is much more intentional looking forward. Instead of fixing what was wrong in the past, you can look forward and look, "At this current growth rate, we need to hire another person. We need to find this person." Looking ahead, you can do that simply because you're not treating much if not at all. You're able to intentionally find those right people and take the time it takes to find the right people. There's so much value in that. As you were treating patients full-time, did you foresee that you could fill up your schedule with all of this administrative/executive work? Were you at the point where you're like, “I don't know what I would do with my time if I wasn't seeing patients?”
Initially, you think that the concept of “What am I going to do with my time if I'm not seeing patients?” Once you step out and you start filling it in with executive functions, you think, “How did I even run this company by treating patients because I’ve got some stuff to do?” What it comes down to is once you stop treating patients and you see all the balls that you're trying to juggle that you weren't juggling. You claimed you were juggling but you're not. You can't because you're so focused on patients or you look in your like, "That visit was okay with that particular patient but I don't feel that my quality is up to par where it needs to be." When you focus on those things, you realize that I can't do things halfway for one thing and be okay doing it halfway for another thing. I've got to be fully focused on one thing. I can't have two things that I'm trying to focus on or I'm not going to be focusing on anything.Help patients start the process, change the things they need to change and stop the things that are preventing them from getting better. Click To Tweet
If you're focused on two, it's going to go all over the place. With that being said, since I have the time to handle the executive stuff, when there's an issue on the floor and I do need to see a patient, I'm focused on that patient. I know I have the time to handle the other stuff later. This is a part-time thing of me helping out as needed. It helps me focus more because I know I'm going to have the time on the back end to handle the business stuff, to handle the administrative stuff. I'm okay to focus on this patient. I can focus on the administrative stuff because I have that time. When you're treating full-time, you don't have that administrative time. It's always in your head, "I'm not handling this." You're swimming trying to make it and you don't. Eventually, you start drowning and you're like, "I got to handle this." It's a big mindset change but once you make it, it's so freeing. You free yourself up a lot.
One thing that the audience doesn't know also is that Ben is good about having weekly team meetings with his providers and the whole team, not just the providers of his clinic every week. One thing that sticks out to me from our past conversations that is a conversation that you had with them about control. You could see that the numbers were slipping a little bit, whether it was arrival rates, the number of billing units they were billing per visit or the efficiency of care and noticing that people were dropping off. I don't know what triggered that but as you're watching the statistics, they had dropped a little bit. You felt like the need to address the providers about control. Tell me a little bit about that story simply because it's important to give owners and leaders some of the verbiage or ideas to talk to their teams about being in control of their positions.
We get very complacent with things and we try to make ourselves okay with issues in the clinic being okay. For example, so-and-so didn't come in because they're sick or we had a downturn of visits because it was snowing. We can always find excuses for why things aren't happening. Not necessarily, my teams are good about taking control and handling things. They do a great job of taking ownership of when things happen and trying to solve issues. We all tend to do this when things start slipping, we start making excuses and we start figuring out, we can't control this and that. It came up to discuss what the term of control meant. We’re discussing with the team saying, "Let's define control as the ability to start change or stop something. Let's stick with that as our definition of control." I said, "What can we start? What can we stop? What can we change within our patients?" Define that and saying, "What we have to do is control the things we can control and then we'll deal with the other things as they come up." When you look at illness, weather, and all those things, those are minimalistic on the ability of a patient to come into treatment. Most of the time, why a patient won't come in is because there's some other internal reason they're not telling you.
They're claiming it's an illness, weather conditions, a work issue, or all these other things, but most of the time, there is something else going on. A patient is not committed to the treatment plan. The therapist doesn't have control over the treatment plan. Pushing that on the therapists of saying, "You need to control these patients. They're coming to you to be able to handle this situation. You need to be able to help them start this process, change the things they need to change and stop the things that are preventing them from getting better." That's what our focus is. If you're not able to do that, sometimes you have to have hard discussions with the patient. Maybe therapy is not the right answer for them at that time. Maybe tweak a couple of things, get them recommitted and then you've got a patient who's making progress with therapy. That was the biggest thing I talk about with them is making sure we're handling the patients. Making sure that we're getting those things done that the patients need so that they can handle their condition. My therapists do a good job. Our percent arrival rates stay above the 90%.
They do a fantastic job of getting their patients in and committing them to their treatment plans to a point where we have them sign a document and that first part of their treatment is saying, "This is what our plan is. We want you to complete this plan. Please sign this if you're in agreement." Most of them are signing, they're excited, and they’re ready to make these changes. That's the biggest thing when those stats come down. It’s looking at what we can control and focus on that and not focus on the things you can't control. You can't control the weather. We'd like to. You can control how you're treating the patient and helping that patient to see the value of physical therapy. You can work with that patient to make sure that physical therapy becomes a top priority. You can also have those discussions when a patient is not doing what they need to do of it's time to have those tough discussions and physical therapy is not right for them at this point. Maybe you need to part ways. There are definitely some difficult conversations you have to have, but you also have to be willing to do that to control your situation.
As you're talking about it, I love how you defined control and you put the patient's plan of care in the provider's hand. They need to follow up but they also have to be bought into what the provider is selling. Would you go so far as to say that if those numbers are coming down, if the arrival rate is poor, the patients are dropping off and not completing their full plans of care, if they're only coming in one time a week, hit and miss that maybe the provider isn't fully in control of the patient care and they're leaving it up to chance?
That's a big thing and that's an issue that we have within our profession. We tend to get complacent and feel that way of, "I can't control this patient, so move on to the next one." That's where we have to stop and say, "What could I do to better sell this patient on treatment? What do we need to do differently? Do we need to do some more testing? Do I need to have a second therapist look at this person and see if there's something I'm missing?" It brings in that whole team approach of what could we do to make this experience good and to help that patient get better. It's funny because we've done surveys.
Most patients say the reason they liked coming here or they like coming to physical therapy, getting better is low on the list. The first ones are experience with the therapist and how much the therapists cared about me. All these things are more important to them than getting better. When you foster those two where you're focusing on the patient experience, that ultimately gets them better than any physical therapy skill you can put on them, it doesn't matter as long as you're giving them that high-quality experience. You're making the time. You're showing them your vested in this and getting them to be vested in their health, that's what gets them better.
I totally believe that's true. Many patients don't know what quality therapy looks like or feels like. They're coming into it as a blank slate. The experience you provide them is going to color so much of what they know about physical therapy and not necessarily the techniques you can provide. There are many different techniques that can get people to the same place. Your skills only add to the experience. The better they are, the faster they're going to get. Fundamentally, it comes down to developing a solid relationship with the patients. Getting that buy-in to the plan of care and providing a positive experience for them, which I would assume is focused on improving their functional capabilities.
As long as you've bought in and in control and not saying, "So and so didn't show up, he's not going to get better. Leave it at that.” A therapist that's in control is going to get on the phone and say, "What happened? We agreed to a plan of care that will get you better. I can't guarantee that you're going to get it better if you don't follow it." Instead of the therapist that forgets that so-and-so fell off and two weeks later says, "What happened to that guy?" Being in control shows up in your statistics as you're measuring them. If the therapists are in more control, then you're going to see a better arrival rate. You're going to see you more completed plans of care, etc.
It's great when a patient gives you cookies and all that stuff. That's great and you know that they liked you. One of my patient was on the final day and this particular patient turned to the front desk and said, "I feel like I'm leaving a family." That's the mentality you want in your clinic. You want them to feel like this is a place that helps them get better. This is family, this is a place they can come to if they have issues. That particular patient would have happily come back if they needed it or they're telling all their friends about it. That's what you want. You want to create that family atmosphere that's light and fun, the patient's getting results, everyone's high toned and well personally. That's what you're trying to foster in your clinic. When you can do that, the success comes.
It was cool that you recognize that based on some of the statistics that you had been tracking and recognize that this is what my providers need to hear. I know that your statistics turned around within the week or two after that in huge uptick because they started to take control. You couldn't have done that if you hadn't been tracking your statistics regularly. Ben, I know we can go on forever but I want to thank you for taking the time, especially as busy as you are. You have more free time to do an interview like this, which is cool. Thanks for sharing your insight. As I said on our coaching call, "I’ve got to have you on." I forgot you tripled your visit totals per week. I was like, "I’ve got to have more people like you on." That's why I interview people like you. It's because there are plenty of successful actions that other owners could gain from. Thanks for coming on. I appreciate it.
You're welcome, it’s a plug for you. Nathan, as a coach, has been extremely helpful for me, giving me that accountability. It's taken my mindset from where it was before is, I got be in training to catching the vision of why I need to be out of treatment. Sometimes you need that outside person looking in versus those people who are involved in the day-to-day. That outside perspective helps. A big part of the reason why we're doing this well is because of the coaching. We talked about the consultations stuff that I’ve had with other companies as well, particularly working one-on-one with you to look at the statistics and decide how do we improve this. We've seen my goals have been met. The first day we talked about getting me out of treatment and doing that over a six-month timeframe and we're already there. It's verbalizing those goals and then having someone to keep you accountable for is important. Someone outside of the business who's not caught up in the day-to-day side of things, that's key. I'll plug you every day because of that because you've helped turn around this business for sure.
I love to hear that and I appreciate it. I get so excited after all of our calls and share it with my wife like, "Ben is killing it. It's exciting to work with him." Thanks for the plug. I appreciate it. If people wanted to reach out to you for whatever reason, are you open to sharing your contact information?
The best way is email because I'm not the best in answering the cell phone. My email is BLarsen@TetonTherapyPC.com.
Thanks for your time, Ben. I appreciate it.
Ben has been a member of Teton Therapy since May of 2010. He graduated with a Doctorate of Physical Therapy from the University of Mary in Bismarck, ND and conducted his field work primarily in out-patient settings while in school. During his time at Teton Therapy, Ben has taken many continuing education courses on topics such as Dry Needling, Kinesiotaping, neuromuscular re-education, running analysis, and injury prevention—a topic which he immediately found a passion for and has since conducted classes to the community. Ben quickly applied this vast amount of knowledge to the practice and sharpened his therapy craft. His general interests include water sports, running, outdoor activities such as camping, competing in triathlons, and most importantly spending quality time with his wife and children.
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Reaching out for help from coaches helps us gain the needed insights for the development of our practice. In this episode, we are following up on the owner of Druid Hills Physical Therapy in Atlanta, Georgia, Dr. Avi Zinn, PT, DPT, OCS, about how he has developed his business. Although he has been successful in the development of his practice to this point, Avi reaches out because he recognizes that he needs to gain more business knowledge as the CEO of the business. He shares the importance of the stuff they did not teach in PT schools, such as tracking KPIs, leadership development, culture creation, and more. Learn how he is managing as a PT business owner and get a real-life look into what a business coach can do for you and your practice.
This is the first episode that I have with an individual PT owner in which I'm going to follow along with him as he receives coaching and implement some of the coaching programs into his independent PT practice. Avi Zinn is a Physical Therapist out of Atlanta. He reached out to me to get some coaching and see if maybe we could work together to help him achieve his goals. Full disclosure, he didn't end up going with me as we talked a little bit about what I could provide and if that might fit for him. I actually offered him a couple of friends that he could call and talk to about getting coaching and consulting services with them and he decided to go with a friend of mine, which I'm excited about. Avi’s ready to grow and he needs to take the next step. I wanted to bring Avi in order to not only follow his path but also because Avi is pretty unique. He hasn't followed the typical entrepreneurial path. He didn't go through the burnout, the crash and burn stages that many of us may have gone through before. He did something different. I want to share his story with you.
I've got Avi Zinn, Owner of Druid Hills PT in Atlanta. I'm excited to bring on Avi because he reached out to me in regards to getting some coaching and we've talked a number of times about his needs and how I could help him out, but things changed a little bit. He is looking for some coaching and consulting help and I want to follow his progress essentially and see what the coach or consultant has done for him to forward his clinic and to achieve his goals. This is the first introduction of that series of interviews because I imagine that down the road I'm going to do some follow-up interviews with Avi. I'm going to show you what it's like and what you can expect out of coaches and consultants and how they can help you as an owner. Let's get to know Avi a little bit and some of his influences and what got him to the point where he was reaching out. First off, thanks for coming on, Avi. I appreciate it.
Thanks a lot, Nathan. I’m happy to be here.
Tell us a little bit about you. Tell us a little bit about your professional path. How long have you been a physical therapist? How long you've been an owner? All that stuff so we can bring everybody up to speed on.
I went to PT school in New York. I finished in 2009. Shortly after finishing school, my wife and I moved to California and we went to the Bay Area. We were in Berkeley. I started my PT journey there. I’m looking for places to work, trying to see what was there. I found a cool PT practice based off their website. They’re more independent. The pictures of the clinic looked personal. They had a good vibe. I reached out to them and they hired me on, which was cool. Starting there was a good experience for me in a lot of ways, which ultimately led me opening up my own clinic.
Did you always have aspirations of having your own clinic?
No, not really at all. When I first started there, they had just done some coaching and consulting. They were in the process of transitioning their whole business model. I soon found out that when I started on, there was a huge turnover right before I came. I didn't realize that at first, but after being there for a few months, the remaining people that were still there were starting to talk about the old days or how things were different and not necessarily bad, but I think the change of the business structure led to other people just didn't agree with what they wanted. From following your show and all the people you've had on, it seems like that's a pretty common thing. You guys talk about your culture and your team. If you're changing your business structure and you're changing your team, then you’ve got to make sure that people are in line with that. I would assume if they're not, then they're going to leave or they're going to get told to leave. That led me to start my own clinic because it was an independent clinic. It wasn't a chain and it was two owners and they had a few locations at the time. I started seeing what it was like from the owner's side of things because they were at the clinic all the time.You have to take risks in order to have something you desire to create. Click To Tweet
Whereas later on when I started working for chains or hospital systems, you don't see the owners at those clinics. You just see clinic directors or whatever. Being there, I saw that the community and the PT practice had a great reputation. People knew about it but at the same time, the employees, the staff, the PTs weren't saying the same things that the people in the community were saying about the PT practice. It was interesting to see how there could be a different perception that the patients are loving it, but the PTs aren't. That probably happened because of the change in the business structure and however that played out. I started realizing that there could be different ways of going about this business. Clearly, we're providing good service because people were talking about it and people knew about it but the staff wasn't happy. That was interesting to see. That's what really started me thinking about like, "Maybe I could do this." Everyone thinks, "I could do this." I thought, "If I am going to do this, maybe I'd make it so people are happy at their job."
There are a couple of different reasons why people open up their own PT clinics. Either they have an entrepreneurial spirit and they want to own the job and that's something that they have a burning desire to do. I'm sure there are many other reasons, but the two that come to mind are the second one being, "Maybe I can do this better or maybe I can create something that I can fill a need or I can create some value that I don't see in my current position. I can treat the way I want to and expand on that.” There are a number of different reasons in your situation, in particular, you're thinking, "The owners are doing great. They've got a great connection with the community, but the internal structure and culture could be improved. Maybe I could do that myself and create my own thing." Is that about right?
Yes, that's right, Nathan. You have to remember, I was in the Bay Area, that's a hotbed for startups and entrepreneurs. I do think that was a part of it. I remember a good friend at one point. I was talking about a startup and entrepreneurs. He even said something to me that I could be an entrepreneur if I started my own PT clinic. At that time, I didn't know what that meant to be an entrepreneur. I didn't realize that starting a PT clinic would be the same thing. Getting that entrepreneur bug, that's what I'm sure we'll end up talking about pretty soon in The E-Myth what Michael Gerber talks about. I think doing it better though and realizing that maybe I can do this in a way that would provide that service and also have the people that work there happy as well. What I was seeing at that clinic that combined with getting that entrepreneur bug, those two started the process of me thinking about at one point starting my own clinic.
You eventually went to Atlanta and decided to do that?
My wife is from Georgia. She grew up in Savannah and I'm from St. Louis. We were in California and we didn't know totally, but we started thinking that we would want to be closer to family. Atlanta seemed like a pretty good city. My wife did an internship in Atlanta and that was when I stopped that job. We went to for the summer to Atlanta to do the internship, but also see if Atlanta would be a city we'd want to move to. We liked it and when we went back to the Bay Area, we knew we were going to move there. I knew I wanted to open up my own thing or start my own clinic, but also knew we were going to move at some point. I never really wanted to do it in California. At that point, I started doing other jobs and experiencing different types of PT. I did work comp for two years. I started doing home health, which was interesting. I did that for a bunch of years.
Eventually, we did move to Atlanta and started doing home health when we got here to learn the city also. It was a good opportunity that I learned the city, but I was driving around for home health. I was trying to get a sense of where I would want to start a practice. It all happened at a time where I was ready to do it. This location opened up right in my neighborhood. Literally, a four-minute walk from my house. It's on the main street. It's across the street from this big shopping center on this road where they say 50,000 people drive by every day. It was perfect. Everything worked out. That's when I started to get things going because we found this place and I had been thinking about this all these years. It was time when this place opened up.
How long ago was that?
That was the end of 2017.
During this time, had you been reading any books about business ownership or accessing any resources?
When I was doing home health, I was driving all the time and I stumbled upon Paul Gough's podcast. That was really the first one that I started listening to. That was talking about owning a business and how to run it. I don't know if this is exactly what he said, but this stuck. He said, "You don't have to have the best PTs, you just have to have good PTs. You can hire the good PTs and you have to be the one who's working on the business.” The truth is I could be combining that with some of the other, like Michael Gerber, your show, but I believe he did say that stuff and it started making me think about how I was going to set up a practice and what that meant.
The cool thing is that it set up a mindset for you, knowing where you are. You don't have to be the best physical therapist. Soft skills are more important than hard skills. You already had an idea that you were going to bring on some other physical therapists anyways. It wasn't going to be the obvious in a physical therapy clinic and a one-man show. You had aspirations for more right off the bat. You've opened up your clinic and how did you start working in it? How did you start developing it, so that it wasn't obvious in physical therapy clinic?
When I was trying to figure out what to call it, I was really against calling it my last name, Zinn. A little back story. My father-in-law has his professional experience. He opens a lot of businesses. He was able to guide me through a lot of this in the beginning. Helped me set up the LLC. When I was looking at this place to rent and lease it out, he guided me through with creating a pro forma and talking to the landlords about having my financials in order, even though we didn't have the financials in order. Getting that set up and he was set on calling it Zinn PT. He wanted me to do that and I was like, "I don't want to call it Zinn PT. I don't want it to be about me." Maybe because of listening to the podcast and knowing Paul Gough’s podcasts, knowing that I wanted to bring people on and I didn't want it to be about me because maybe had a little foresight knowing that I would have to do the business stuff at some point and not always having people wanting to go to Zinn but to the PT practice.
What did you start doing initially to make it so that it was not Zinn? You ended up developing Druid Hills Physical Therapy, you were the initial physical therapist. How did you start the progress? This is an important part of the introduction of you. You did things a little bit differently and I'll highlight that as we go through the story.
First of all, I was still doing home health, which was a huge help because home health is super flexible and I was able to bring in some income while setting up the practice as a group. There was no other way to do it. I took out a loan. I could've taken out a loan three times the size and lived off of that for a while. That would have been a little overwhelming. Setting it up, I started getting things in order. I don't know if it was from the podcasts or not. I wanted to experience every part of the business at first to know what it was like so that I could start putting people in those places. When I started, I did everything. I was a PT but I was also running back and forth to the front desk to answer phones and schedule. Instead of a front desk person, I had an answering service, which was helpful and they would email and text anytime someone called. I had a doorbell. That was my front desk person. If someone came into the office, I knew someone was there and I could run back and forth to the front to greet them. I started getting things in place. Aside from the business things, I had to start getting patients.
I tried doing all that I thought would have been the normal way to do it, which was called doctors but that didn't work. It started with that. I was lucky that a third-party work comp insurance called me and they were like, "We want to give you a contract and send some people to you.” I was like, "I need people to send patients," which was also cool because work comp authorizes a certain amount of visits, they pay the rate, whatever it's going to be. You don't have to fight with the insurances. They're not going to like deny certain code, which was a great way to start. Because I got those patients, I knew those visitors were coming in and I knew they were going to pay whatever they paid. That was also a little bit of a hard part, to begin with, was the money part. How you charge people. All of it was hard. I didn't know how to do anything.
How long did you go like that before you took on your first hire and eventually before you got your next physical therapist?
I started at the end of 2017. We had our third kid in March of 2018. It was a great idea to start a business and have a kid the same year. Right after that is when I hired on the first PT. The business was growing slowly. Knowing that we were going to do this, I started looking back at the schedule and tracking what was happening. The schedule was pretty light. Looking back, I don't know how I was confident enough to even hire someone on.
That's the question I have for you. How many visits were you at per week before you hired that physical therapist because you went against the grain?
I don't know. At that point, I was doing three days a week at the office and still doing two days a week home health.
You brought on your PT at that point. This is why I wanted to bring you on is that you hired a physical therapist, what most people would consider is too soon. Based on my training experience and if you were to ask me, "When do I bring on my next physical therapist?" I'm going to tell you, you bring on the next physical therapist when you're meeting at least 90% of your slots that are scheduled out in a given week on average. That's the time when you know, I'm working hard or my other PTs are working hard. It's time to bring on someone else where these people are going to get overwhelmed. Maybe you even have a waitlist, but you went against the grain and you don't necessarily know why. You brought on a physical therapist because this is the thing, the typical entrepreneur story is we don't do anything until we get overwhelmed. Sometimes there's a crash and burn element to it. If you read to some of my previous shows and the successful entrepreneurs but you didn't get to that point, so you brought on the next physical therapist. You must've had some faith that things were going to go in the proper direction or maybe you had some real intent out there in the universe that things were going to grow?
It was a little bit of both, Nathan. I was thinking about starting a business, in general, is a huge risk and I've maybe realized that you have to take risks in order to have a business. That was the same move. I saw the trajectory and patients, it was growing slow but it was steady growth. It looked like things were going in that direction. It was time to hire someone on and keep it going.
During this time, were there some resources that you fell back on that might have stoke that faith or inspired you to bring on someone else so that it wasn't on you? Did you also maybe see that there were some aspects of the business that you needed to work on so the PT would take the treatment side of things off of you so you can focus on those things? Was there a combination of some of those?
Because of how busy things got, I realized that I had to do more of the business stuff. That was what it was. It was the beginning of 2019 or it must have been earlier when I started following your show. I remember in January of 2019 is when I started reading The E-Myth. I don't remember exactly when I found your show or how that happened exactly. Even before that, I realized that I had to be able to step away to do from treating, there were only so many hours in the day. I didn't want to be working all day long and then going home and working all night long. I realize that the only way to do it was to step back a little bit. It wasn't a lot, but it was by hiring another PT that I was able to step away and do a little bit more of the business side of things.You have to take risks in order to have a business. Click To Tweet
The common fear when someone makes that first step is to bring on another PT. The biggest fear is, how am I going to justify that salary? I'm going to be paying somebody $70,000, $80,000. What if they don't work out and they don't produce? Somehow you overcame that fear. How did you do that?
After that first job in California and when we came to Atlanta, I did a traveling PT job. When we went back to California, I started doing PRN. When I learned about what PRN meant, that is ultimately when I hired my first PT, I didn't hire her on full-time. I hired her on PRN and it just happened that I found someone who wanted to do it. She was in a different job and she wanted to switch it up a little bit. She started doing two days a week with me. That is why I was able to not be so overwhelmed because essentially instead of making it five days a week for me, since I was only doing three days a week in the office, I made it a five-day PT but split between two people. I was able to have the patients coming in on all day, every day and then still have two days a week where I wasn't treating and doing some of the business stuff.
You were still running the front desk and taking all the calls and some of that stuff?
I was still doing that stuff and the billing, the front desk. Shortly after that, I got someone two days a week at the front desk. Gradually we started getting more patients, so that part-time PT ultimately wanted to switch all for hours over to this place. It worked out well because I didn't need to look for another person. She was already there. We were organically growing and filling those hours on the schedule without having to hire on a new PT and then have to be scared that you're not filling up their schedule for three months because we did it gradually anyways when she first started by two days and then added on more days.
She started taking on more hours. You started treating less it sounds like and you're working on the business during this time.
I don't think I really started treating less because for the most part, I was still treating the same amount, but it had blocked off certain times from the beginning to do billing, networking, calling people and driving around.
That's a huge part right there and I don't want to overlook that. You blocked off time on your schedule. As I'm talking to PT owners that are treating full-time, that's probably one of the biggest hurdles is to get them to commit to blocking off chunks of time, whether it's four days or 4, 5-hour blocks to work on the business. That is to look over your financials. That is to put together a pro forma like you're talking about. Consider what the future might look like. Do some networking. Even start developing some policy and procedures and hiring the right people to fill the spots that you either have open or are going to have open in the very near future. What you started doing maybe someone told you to or maybe you inherently knew you needed to do was to keep that time sacred for admin work.
Around the beginning of 2019 is when I read The E-Myth. That was transformative. I've heard people say it on your show a million times, working on the business and not working in the business. I think he came up with that. It made so much sense and you can't do it any other way. There's only so much growth you can have if you're working in the business. When I read the part about what a lot of people do is they create a job for themselves. That part was like, “I’m not trying to create a job. I'm sure I didn't try to create a business." I did somehow realized that I needed to keep that time separate to work on the business. Once I read that, it was when I started realizing I need to do more of this and if I want to grow, I need to not just hire more people. It would actually start taking more time to work on the business because once you start getting busier with more and more things going on, you need to have more time to figure out all the things that you had mentioned, which I still have not done yet.
We have to give it proper credit. The book that we're alluding to and referencing is The E- Myth Revisited by Michael Gerber. He does layout a lot of this stuff. When we say you working on the business, what are some of those things that you're doing? I have even some owners say, "If I'm not treating and I'm not catching up on my notes and I'm not paying bills, what am I doing?" What do you do in those admin times?
First of all, I still do the billing. That's part of it.
That's going to change soon. What are you going to do when the billings off your plate?
We'll find out soon. You did mention about policies and procedures. That's what I started doing was creating systems, which is what The E-Myth is all about. I created an organizational chart, which is another thing that they talk about in the book. Even though every single job in the organizational chart was me, I still was breaking up what created the business, all the different parts and all the different jobs that make up the business. I started writing out what happens under those positions, what one does for that job. Basically, I use Google Drive and Google Docs and I have a nice organized folders system of docs for every one of those job positions. Every time something happened that day that I had to troubleshoot or figure it out, I would put it in that doc and then I would try to create a system to make sure it didn't happen again or t try to delegate some tasks to the front desk person or the PT so that they can do it so that we wouldn't have to keep on going through the same mistake every time. We would know what to do every time.
You wouldn't have to learn the same lesson twice.
Yes, we don't have to learn the same lesson twice. Also, we wouldn't have to be where someone had to knock on my door and asked me what to do for it.
This is why I love having you on. You're at a place in your ownership that I would say a majority of PT owners are not. I'm including the guys that have been out there for 10 to 20 years. They haven't taken the time to write up their policies and procedures. I can say I was in that boat 10, 12 years after opening up my first clinic. Didn't take the time to write down policy and procedures. I didn't have an organizational chart. It doesn't matter if you are in each position. At least know what the structure of your company is and what it should be and what it will look like when other people start filling those positions is huge. That comes as naturally to some people more so than others, but you're organized enough with your Google Docs to have everything written up underneath each job with a job description, the responsibilities and the tasks that are given to each position. That's huge and that is the reason why you are where you are is because you've done some of those things. How many therapists do you have?
We have three therapists besides me. They're all about 30 hours or so. Part-time but full schedules. One is actually reducing hours the same original one who wanted to take on more but also step out of her first position and try something different. She's going to try something different and reduce her hours, which is fine. Everyone wants to do different things. There's nothing wrong with it. We're about to hire another person and she's going to be my first full-time. We'll have one full-time, two pretty full-times, one part-time and then me.
Being less than a few years into your ownership. That would be unfathomable for some people. I'm talking to some owners who are one-man shows and they're overwhelmed and they're three years into it and they don't see a way out because they're treating 50 hours a week and not working on their business. Whereas you've set yourself up such that you have multiple providers and you're already experiencing some freedom that most PT owners don't have.
Nathan, you probably would agree with this, but for the people that are working crazy hours, I made sure I did this in the beginning, I worked at the office. I did some stuff at night, but for the most part, I was in the office 9:00 to 5:00, and that was it. I made it a point to stop at the end of the day. Of course, you do some stuff at night, you answer emails or you work on the website.
You had some intention behind putting an end to the day.
I think that's what it is. That has allowed me to keep going. It prevented me from burning out and I didn't get so overwhelmed because I was like, “This is the end of the day. We're going to stop, we'll pick it up the next day.” If I work an extra five hours, it's not going to be any different. You need to put a brake on it every once in a while.
There's some power to that. Number one, the time that you do have is limited. There's going to be an urgency to get things done. If you don't have that end stop, you're like, "I can work until 7:00 and I'll take my time getting things done.” Inevitably there’s something called Parkinson's Law that, "The amount of things to do will end up taking up the time that has allotted to do them." If you're available to work until 7:00, you'll have plenty of tasks to keep you busy. If you put that hard stop at 5:00, you've done two things. Number one, you've set a deadline, but also, you were concentrating your efforts on doing the admin work. You can get more done for the benefit of your company by focusing that time on your business than trying to get tasks done. Instead of trying to get payroll down or pay bills. I'm sure you were focusing on what some people call the MIT, the Most Important Thing of the day and that is developed policy and procedures. Get my organizational structure in place. You're doing the billing, but that's a separate chunk of time. The fact that you spent that time on the policy and procedures and the organization of the structure of the company means you've developed solid integrity around that and you've accelerated your growth as an owner and as a business to the point where you are.There's only so much you know how to do. You need to reach out and ask people for help. Click To Tweet
To be clear, I still have a lot more work to do on the policy procedures and all that stuff. That's ultimately what we're getting at with coaching and consulting. In March of 2019, I hired on the second PT and then that's when I drastically reduced treating time down to twenty hours a week of treating.
Was that a scary transition or something that you're, "I need to do this?"
It wasn't scary at all. It was, "I need to do this." Partially because at that point I had read enough of your blogs and also had probably read to The E-Myth again for the second time or maybe even third time that I realized that it doesn't even matter if it's scary. That's what you have to do. There's no other way around it.
You recognize the need of the company was to go in that direction, right?
Yes and it was my business. If I'm treating, who else is going to work on the business? I have to be working on the business. There's no other way.
You talked to me about doing some coaching and consulting. What led you to that point?
Where I've gotten myself have been a lot of working on the systems and policies, but at the same time, there's only so much I know. As the business grows and when we're getting more patients in one of the main things that I've noticed is there are cancellations and why are we having 30 new patients in a month. We had eighteen new patients in one week and that was awesome. That was the most we had. The following week the schedule was half empty and it was like, "How is that happening?" I started running analytics, WebPT. I called them up asking, "How do I find out how many times each patient is coming in?" I’m trying to see what their plan of care and how many visits per week? I find that a lot of patients are only coming once a week or they schedule two visits and then they're gone and no one was tracking that. I run this lost patient report from WebPT and then all of a sudden, I look and there are 50 to 100 people on this report of people that came in and we never got them back on the schedule. That was a huge thing.
You recognize that you need to start monitoring your metrics and if you haven't taken the time to do that, then the metrics will control you and sink you.
On the analytics and WebPT, they have their main KPIs. There are six KPIs on there and that was cool. I realized I don't know. I feel like I've done a lot to get myself here, but there are people who know a lot more to take those numbers to who've already gone through this, who can tell you how to use those KPIs, those metrics and what to do with them. How to affect them and also, one of the biggest things through all this realizing that I am not just the owner, but a CEO of the company. I need to learn how to do that. I need to know how to manage my employees, train them and set up different structures and have certain people responsible for different parts of the business. I realized that there's only so much I know how to do. That's when I was time to reach out and ask people to help me along that.
You realize that you are the final word. People are going to come to you because you need to have the answers for the company. I don't think a lot of physical therapy owners who are relatively new don't put on that hat per se. They think that the ownership somehow is not as separate from them. They know that they're the owner, but they don't act like the owner and that they should be monitoring all the metrics and the financials. They should have some idea of what to do when a statistic goes bad and how to look and investigate issues in the clinic. It sounds like you had that realization that you need to take on that hat.
Nathan, that part is hard. I went to PT school, I learned how to become a PT. I didn't go to business school. I don't even know if you learn how to do that in business school either. I don't know how to run a company.
We're all in the same boat.
To answer your question, that's what it was. I realized that I needed to be the CEO essentially and I needed to learn what that means and how to do it.
You reached out to me and we had a conversation. I actually gave Avi some recommendations of other coaches to also consider outside of me and he has decided on another consulting company and I'm excited because he's going to do amazingly well. You can see that he's already set up the foundation. I want to follow you along this journey. How will you know if you've been successful with a coach or consultant? How will you know that they've met your goals? Is there a statistic that you want to see? Maybe gross revenues and net profits or is it more freedom for you? Is it growth?
I'm starting to understand financials and understanding gross revenue. I'm at the point where I can look at a P&L and understand it and gross revenue, of course. Let's get that up.
You need a return on your investment to the coach. You expect a multiple of your investment on the coach.
Having the patient drop-off, go away or at least get better. Maximize the utilization, which is something you were saying. If there's so many hours that the PT is treating, they should be treating patients that whole time or at least let's say 85% of it and figuring out how we can make sure that happens. Training the front desk also is the best way to take part in the patient's experience. Also, making sure that they're following through with their plan of care when the PT comes and brings them up to schedule. Making sure that they schedule it and making sure that they understand what it means and the cancellations are detrimental not to their progress but to the whole business. Probably a million other things at the front desk can do but hopefully, they'll help me out with all of that.
Are there some particular goals that you have then over the course of the next year or two? I'm sure the coaches will help you along with this, but what are some of your goals that you have?
As far as freedom goes, I don't need to be not in the office 200 days a year, which is great. Maybe one day. I like being in the office. I like working, but I don't want to work all day, every day. First, producing the treatment hours, that was key. I've done that myself, which is talking to you and talking to other coaches. That's what ultimately is going to set me up for success quickly with these coaches is because I've already done what a lot of people have to do initially once they start with the coaches is to back out of the treating.
You're a step ahead already.
That ultimately is going to allow me to focus on some of the goals a lot quicker. In 2020 who knows? Maybe this will happen in two months. If we have twelve hours of the day in the office, 7:00 to 7:00 and we have five PTs, I want to be able to fill up that schedule, which is ultimately going to bring in more revenue.
You're going to have to expand.
Yes, hopefully. These could be long-term goals. I remember early on Paul Gough that he’s talking about how he owns some of his own real estate and some of the practices. That could be a cool goal. I don't know so much about that on the numbers side. I imagine at some point it's beneficial, but maybe it's not always. That could be five years from now. I want to grow this space location that I have to maximize it. If I have to work twenty hours a week still treating patients, that's fine. I like treating, but I also recognize that I have to do other things. If I need to not and I can get someone else to do it, great. Maybe later on, in a few years, I can start treating again. Wherever the business needs, that's what I'm going to do.
That your decision matrix has to be exactly that. Whatever the business needs. If you're not wanting to set aside time to work on the business and want to treat full-time, then go work for somebody and work full-time. Don't spend the stress and energy to own the business on top of it. If you're going to commit to owning a business, you need to put the business first. That comes first. What a lot of PT owners don't recognize is the clinic needs them to treat less, needs them out of treatment because it's a distraction to treat patients as an owner. You need to set aside times to work on the business and eventually what happens is they work themselves out of treatment because the needs of the business become greater because they were expanding and growing. I'm excited for you and what you're looking. From my perspective, looking at where you're at, you're looking to gain more knowledge so you can confidently and securely wear that CEO hat and become more efficient. You're recognizing that there is a lack of efficiency maybe in your company and you don't necessarily know how to affect it.
That's what I think when I pulled up that last patient report that one time and I realized, that's why our schedule is not full, even though we're getting all these new patients. We need to figure out how to make sure that doesn't happen.Work on the business and not work in the business. Click To Tweet
That's a dagger to the heart when you find stuff like that.
That was hard.
It goes through a couple of things. That is a whole few pages, maybe one or two pages full of lost revenue. More than that, if you're looking at from a higher level, these are patients that didn't get the full complement of care. These are the types of patients that go back and say, "Physical therapy didn't work for me. I've been to Druid Hills Physical Therapy and it didn't help." You don't want that. That can happen unless you're focused on getting them to complete their plan of care. I said this in an interview that I did. I found out about it a couple of years ago when I interviewed Heidi Jannenga of WebPT, and they did their annual survey that most small businesses lose on average $150,000 a year because patients like those on that lost patient report don't complete their full plans of care. That's a detriment to you as a business owner. It's a detriment to them as patients because they're not getting better and the chance of recidivism or the chance that they didn't even get better is significantly higher.
It is a detriment to the profession as well.
We'd become a commodity. They say, “Physical therapy didn't work for me.” They don't say, "I'm going to try a different physical therapist." Like anybody would maybe with a dentist, they say, "Physical therapy didn't work, so I'm going to try something else." It's unfortunate. I'm excited for you and I want to follow along with you and see what you learn along the way and so we can share with the audience essentially the benefits of coaching. I wanted to share your story number one, because it's amazing that you haven't gone through the typical cycle of an entrepreneur that's even spelled out in The E-Myth Revisited. It's not in the physical therapy space, but I think she was a baker of pies and she had that burn out and she's like, "I can't do this anymore. I'm not seeing my family and I hate my job." You never experienced that because you looked ahead and started planning and started acting forward in faith that things were going to continue to grow and it's worked out well for you. You're going to continue to grow that you develop that foundation.
I want to say one funny thing that happened. We're in the process of moving houses. We're going through a bunch of things and I find a box of all my notes from PT school and I open up a folder from my business admin class, the one day that we spent on and pull out the handouts. There was right on the top was The E-Myth Revisited. I don't remember the professor ever talking about that back in the day. If anything, they were doing a good job teaching about business because they talked about The E-Myth. I'm sure there are other ways to look at it, but following that way of setting up systems and organizing the business and working on the business. That is what has allowed me to get to where I am.
What's different about you Avi compared to a lot of entrepreneurs, whether it's physical therapy owners or not, you've had it on the one book and I'm sure you've read other books, but this one's been influential for you. There are people out there that have read the book and I've read hundreds of others and aren't in the position where you are. The differences that you've actually taken action on what you learned. I read The E-Myth Revisited 6, 7, 8 years ago, but I didn't implement it to the level that you did it either. I would submit that people who are reading the business books, if they read The E-Myth Revisited, don't read it as a nice, good story, but to actually implement what he recommends.
The only way to implement it is if you take time away from treating and work on the business.
You've actually put those principles into practice and that's what I separated you from somebody who is simply read the book. I'm excited to see your growth here as you get some greater insight and knowledge on how to improve your stats and become more efficient. We'll follow up with you and do another interview and see what you've learned and what's been influential for you. Maybe there are some pitfalls, maybe there are some things that happened along the way, who knows? You might experience for yourself what your initial outpatient company did in San Francisco. Maybe not everybody's aligned. That or everything is going to go in a great direction because you have your ducks in a row already. I'm excited to see what happens. Is there anything else that you want to share, Avi?
For anyone, if they are reading for the first time, reading your blog has been helpful also. I talked a lot about The E-Myth, especially because I've set aside some time to work on things. I'll read your blog whatever interview person you have on and then try to implement those things that day or that week. It's been also helpful to know other people's stories.
That makes me feel good. Not only a resource but an inspiration to you. Thank you for that. We will stay in touch and we'll come back around to the story that is Avi’s in Druid Hills PT.
I'm looking forward to it.
Dr. Avi Zinn, PT, DPT, OCS is the owner of Druid Hills Physical Therapy in Atlanta, Georgia. He opened his practice at the end of 2017 and has slowly built it up—transitioning from a staff of one (himself) to a team of administrative staff and treating therapists. He continues to grow the practice gradually. Avi’s main mission for Druid Hills PT is to provide high-quality, personalized care to each and every one of his patients.
Avi has his doctorate in physical therapy from Touro College, and is a Certified Orthopedic Clinical Specialist. He lives with his wife and three children in Atlanta.
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In this episode, host Nathan Shield talks about the people within your company with the CEO of Pure Physical Therapy and Founder of Next Level Physical Therapy, Frank Garza, PT. Frank started seeing growth in his PT clinic once he started weeding out the "bad apples" in his organization and focused on hiring and firing those people who weren't in alignment. How did he do it? He, along with his wife, established the purpose and values of the company and hired and fired accordingly. Now, the people on his team are rowing in the same direction and growth has accelerated. Plus, the energy in his clinic is fresh and exciting, and the culture is drastically changed. Want to establish a culture like Frank? Set the standards, establish purpose and values, and get your team on the same page. Your growth and an exciting culture will immediately follow!
I have Frank Garza out of Texas, a successful physical therapy owner who recognized that once he had established his purpose and values, he was able to weed out those employees that weren't on the team and we're limiting him. By removing those people, he has been able to achieve significant growth. Based on the book, Tribal Leadership, Frank recognized that there were certain stages of people and certain stages of a team that contribute to your success. As you weed out those people that are in stages one and two, and as you move your team into stages four and five, that's when you make significant growth. That's when you make significant progress and start to achieve the purpose that you set out to achieve. This is great that we can have a personal experience establishing the purpose and vision, hiring accordingly, getting the right people on the team, and then seeing the success that comes from it.
I've got Frank Garza, a physical therapist out of McAllen, Texas. He is the CEO of Pure Physical Therapy and Pilates and also a Founder of Next Level Physical Therapy mastermind and consulting group. I've interviewed a number of original founders and members of Next Level Physical Therapy. Frank is on to talk about an important topic. Thanks for being with us, Frank. I appreciate it.
Thank you for having me, Nathan. I appreciate it as an NLPT being able to come aboard and talk about all the stuff that us private practice owners wish we knew when we were starting.
Tell us a little bit about you. Where did you start? Tell us about your physical therapy path and especially your ownership and entrepreneurship path and what's led to where you are.
I graduated and I played sports. I think like most physical therapists, they get into it because they got hurt and got exposed to the field and connected with their physical therapy team at the time. That's how I got intrigued about it. I ended up graduating and I coached and taught for a little bit. I liked that, but I knew that I wanted to be my own boss. I knew that I wanted to do something that I could control and that I could lead. In football, that's the position that I held. I liked it and embraced it. Going into physical therapy, I knew that I could have my own business. That's why I got into it too. I went through it and got out. I worked for a private practice clinic for a year. Right after that, I felt I knew enough to go out on my own and do things on my own and get my feet wet. I say sometimes that I rushed it and I say that might have been a mistake, but at the same time it probably could have been the best thing I did because people were there trying to help.
There was a time when there was a lot of work. Private home health companies were picking up PT companies to do their home health visits on the side and paying them a good rate. That's how we got started. We said, “This is an opportunity to go on our own and do something that we can fill our schedules and get other people to work under us.” We did that model for two to three years and then it went south bad. Luckily, we had already planned to do our outpatient clinic and that's how our outpatient clinic got started.
You started doing home health first before you went into it.
We started doing home health first. The reason for that was the people that we were working for said, "There's enough work out there. We'll help you get started.” You build your company name, you get a contract, you start bidding home health agencies for work. There was so much work that you could fill your schedule fairly quickly. It's also something easy to manage. You didn't have all the red tape about credentialing and audits and all that stuff with paperwork because they controlled everything. You were just a contract payer. It was a good way to get that taste of freedom, flexibility and ownership of your own business. At the same time, it was one of those models that you were chasing the profits all the time. You weren't making that much money and you were seeing a lot of patients, you had people that were underneath you seeing a lot of patients and you have to pay them. If they didn't pay you on time, then you couldn't pay them on time. We started learning that it wasn't a great model to grow, to scale and to make the money that we wanted to make. We started saying, "Our ultimate dream was to have an outpatient clinic." We had enough capital to invest in that.
It’s a good thing we did because the home health went south shortly after that. There were a lot of people getting busted for fraud. That model went to hell. We've entered into outpatient and we did what we did and we got started with what we knew. The experience of running the home health, but it was a totally different monster. There were so much things that we had to do before we even saw our first client, our billing and all this other stuff. It was an adventure, to say the least. We knew right away that we needed to hire people to help us. We hired staff. We chugged along for a year, two and three. Have you ever been on a roller coaster ride and sometimes the whole cart shakes on one of the stable tracks? That's how the first three years felt like.You almost have to fail at everything HR before you understand it. Click To Tweet
Not everybody was a good fit for your team, I'm sure.
That's exactly what I was going to get to. We started realizing quickly that who we hired was like, "It's not going to work out. Who are we going to hire? We don't have anybody to hire." I think our mentality at the time was, “We need people to work for us. Let's pick up whoever is available.”
“If they're breathing and can follow some instructions, then bring them on.”
If it was somebody that somebody referred, that helped. That's even better. There were people that we knew in the home health field and they were like, "I have a cousin, a friend that was looking for a job." We quickly assemble the staff. We also quickly found out that we were in for some trouble if we didn't fix it because it wasn't the ideal staff. We didn't know what the ideal staff was. We learned a lot.
In my situation, I was like, "I don't necessarily have any job descriptions written out, but I'm going to put you in this position. I expect you to do what you're supposed to do." I was so naive to think that I could put him in a position and expect immediate productivity, an immediate buy-in. I found out later on that it was probably good to hire people who have bought into your vision, who share the same values. They're aligned. Maybe it's even better if I actually develop a job description and tell them what productivity looks like and how I'm going to measure them. It all comes over time, but you wish you would learn that sooner rather than later because things change when you start hiring based on that model.
I learned a ton. I learned that if we had concentrated on that department itself early on, on the human resource department for sure, that maybe we have not struggled as much as we did because it was a struggle. I look at my position and I'm learning that it's still a continuous work in progress. There's never HR and building your culture and your team like that. That doesn't stop because it's always evolving, things happen within your team and you’ve got to replace them. There are some things you can't control, but it's a work in progress. I also learned that you almost have to fail at everything HR before you understand it. We're not taught any of this in school. We don't know where to grab all these concepts, stuff and resources early on. It sometimes takes you telling the story of failure to another friend and they're like, "You had to do this and you’ve got to read this. You should go take this class." You learn a lot from failure, but who doesn't? One of the other things that I learned is that you cannot swipe someone else's HR material and expect for you to understand it and then much less for your staff to understand it. It doesn’t happen.
You think that there's a one-size-fits-all HR employee handbook. That's not true. Much of your culture and so much of you is simply how you do things. That's what I consider culture to be. This is the way we do things around blankety-blank physical therapy. That eventually develops your culture and it goes even back to your HR material. This is how we treat patients. This is how we expect you to show up to work. This is how we handle disciplinary actions. All that stuff needs to be broken down and individualized for your own clinic.
The number one thing that I learned early on is that we did not have that company culture that we wanted for the first three years and we have to fix it quick. It started with us, which is exactly what you were saying. We have to make a transformation mentally of what we wanted to instill in our company, what the vision was, what the mission was, how were we going to do it and make sure that everybody understood that, everybody was clear on that message. That was the number one thing that I think if people are out there wondering, "How do I do that? How do I avoid making the same mistakes?" Travis already did a show about this. It starts with us and our vision and our mission. It’s making sure that our staff clearly understands that and making sure that everything they do is working towards that common team goal that you're trying to accomplish. It's something that we realize we didn't have early and we started to change it quick.
It's probably you and your wife that came up with the vision and the mission. Maybe you created values between yourselves and your team. When you finally implemented that after three years, was that rough to implement it and get everybody's buy-in? Did you end up getting rid of a lot of people after establishing and planting the flag like “This is who we are?” Was it an easy transition for you or was that something that got smoothly brought into your company?
The transition is never easy when you're trying to get rid of bad culture and create a totally new culture. For us, we identified that we had people already in our organization that we're not going to work out based on the meeting that we had about our mission and vision, all that stuff about what kind of individuals we wanted, what kind of characteristics they needed to have per each individual position? That's key too because you want them in the right position. All of that starts with us. We need to identify the vision and mission and how you are going to do it? It’s on your core values. If you know that you're hiring for the front desk, you're going to go look for certain characteristics for that front desk. That's your expectation. You got to give them an expectation for every position. I looked back and I said, "What did I do in some of my coaching career with my team to get buy-in and culture? What did other coaches do with me when I was playing?” There was one coach that brought out a binder like it’s the beginning of the football season and everything that we were going to live by that season was in that binder.
Our hyped-up a chant before the game is spelled out, everything is written. That was his way of instilling that culture. It was a new coach coming in. He was changing everything. Even before school started, we were reading stuff through that binder and getting to know what his philosophy was, how we were going to do things, and how he expected us to do things. If we didn't abide by-in or if we're doing something different, then there was a consequence to it. The same thing applies to your business. You got to set that standard as a CEO and as a leader. You make sure that they follow it.
That's the important thing to note. A lot of times when you set the mission, vision and values in midstream that you've been practicing for a few years, you decide, "Let's establish a foundation and get down to some fundamentals and talk about vision, mission, and values." Inevitably there are going to be some people who don't like the implementation of that structure and that don't have buy-in. You're more than likely going to lose some people. You have to understand that up front and you've got to be okay with that because the people that you lose are the people that haven't bought into your clinic. Once you shed yourself from those people and you can attest to this, Frank, you will then experience some accelerated growth. Especially as you start replacing those people with people who actually do buy-in to your mission, vision and values. As long as you're establishing that over and over again, you don't stop talking about the mission, vision and values after the initial introduction. Once you plug it in and then start hiring according to those, then you start getting some people who buy-in and the growth then accelerates.
It’s happened to us on two different occasions. One of the things to educate our audience on is how do I identify the bad ones and the good ones? What are some characteristics of some bad culture in your company? I was brought onto this book called Tribal Leadership. It goes through five different cultural stages. After reading that, I started evaluating my staff and listening and observing their body language. You'll find out right away who's on board and who's not. I'll go through those cultural stages to help people identify them for those that are wondering what are they and how do I identify them. Stage one is characteristics and qualities. This is the type of mindset that creates street gangs. We don't want any of this in our company. Their thing is that life sucks. They're despairingly hostile, they band together to get ahead in a violent world. The great example is The Shawshank Redemption. We don't want to hire stage ones, but sometimes you'll get people in your meetings that have that bad body language and in everything you say they’re like, "No, yeah, whatever." There's always something negative to everything you say. There's always a problem to every solution.
Stage two is a little bit different. Instead of, “Life sucks,” they're a little bit more personal, “My life sucks.” They're a little bit more passively antagonistic. They may not say something verbally, but in a meeting, they'll go cross their hands in judgment and not be totally bought in but not be totally against you either. They never get interested enough to spark any passion. These are the ones that sometimes you come in from a mastermind or conference, you've got all these ideas to share with the group and they're like, "I’m not interested." They're not too excited. By the same token, if you say a funny joke to them, the laughter is a sarcastic resigned thing. They’re the whatever type. The talk is that they've seen it all before and watched it all fail.
A person at this stage two will often try to protect his or her people from the intrusion of management. The mood here is that their life sucks. It’s a cluster of apathetic victims is how they characterize that. Stage one and twos are exactly what you don't want to have. If you're looking and coming into meetings and you're seeing these types of behaviors, you want to know that they're not the ones that you want and then they start changing a little bit. They start getting a little bit more positive. Stage three, the theme is, "I am great and you're not.” Knowledge is power so people hoard it. They're the people at this stage they have to win and winning is personal. They're your big competitor people. They will outwork and outthink their competition on an individual basis. The results from this as a collection of lone warriors. These are your hardworking individuals, but not so much team players. They're often seeking help and support, continually disappointed that others don't have their ambition or skills.
If somebody is not trying as hard as they are, they’ll be disappointed. Their complaint is that they do not have enough time or competent support. They’re like, “I’ve got to do this by myself.” It's a bunch of self-described star players. You can't have too many star players. They can't play together as a team. That's basically the theme there. You’ve got your stage four and five. These are the ones that you want all the time. Instead of going from, "I'm great," the stage four theme is "We're great." This is where I think most of your positive company culture is, your great, thriving, growing companies. When they have great culture, they have a great team. They have a lot of stage four characteristics and qualities because it's all about team. Everyone is excited about seeing each other at work. They take the tribe away from the person's sense of self. These are the people that if they take the team away, they feel like, "Where am I?" They feel lost because they feel the team is their second family. At this stage, the culture is effortless. Nobody's trying too hard. Everybody's doing what they’ve got to do and working for each other as opposed to for themselves.
The only one that has influence is the tribal leader. Here in stage four, whoever's at the very top is the only one that actually has influence over this culture because other than that, there are no lone warriors. Everybody's working together as a team. You have your last one, which is, "Life is great." The language revolves around infinite potential and how the group is going to make history. They want to make a global impact. This is where they make an example of Apple where they say that the innovators from Apple and Steve Jobs were at stage five because they did things that made a global impact and they wanted to make life great. The mood is an innocent wonderment. A very small percentage of companies have this type of characteristic. Most have stage four, but you definitely don't want the ones and twos. That's important to understand, to identify what you have.
That's great because you can put this assessment up against each individual within your team very easily. I think it's easy by what you laid out to say, "Who are my stage one players? Who are my stage two players? Who are my stage threes?" What have you learned? Can any of these people change from two to three or three to four? Do you simply hire slowly or fire fast? Do you simply get rid of them?The transition is never easy when you're trying to get rid of bad culture and create a totally new culture. Click To Tweet
The ones and twos, there's no change there. The threes can get into fours and that's definitely what you want.
Just cut your losses.
Especially if you have a big organization and you have this person in a position where they have a lot of people under them. If they're a stage one and two, imagine what they're telling all those people under them. Imagine the mindset and the stuff that they're feeding them. That's what those people think of everybody else on top. That's not necessarily true.
When you have those people in your company, they can be a real poison. It's almost like if they're allowed to linger long enough, everyone that they touch in their immediate circle becomes poisonous as well. We've had that experience before in one of our clinics where one person in particular was poisoned and unfortunately, they were the leader. After that person left, it took at least a year before we got everybody out who they had an influence on before that clinic started turning around. Looking back on it, my partner and I both believe that we should have closed down the clinic, fired everybody that had a connection to that poisonous leader and started from scratch and got some new people. It can be that devastating and that pervasive when that one person has that much influence.
I'll tell you a personal story of my own too. Sometimes you think it was so bad and then you’ve got a new staff and it got better. You're meeting some goals that you'd never met before and you're like, "This is great." It plateaued for me. I was like, "What's going on?" We've got a new hire. This new hire, it was the first time we have put them through a rigorous hiring process and had this funnel built out and had all these triggers that they had to do before they even came into an interview. I was like, "This guy has got it." We hired him and sure enough, he came in and in six months outworked everybody in the front desk so much that we redid all our internal processes at the front desk. That's when I knew, I was like, "We may have another problem." That wasn't his job. He was going to come in and do reception. He ended up coming in with all these things and changes and made things better. The problem was those other two people that were there before him didn't I go through that interview process that you went through. We didn't weed out as much as we thought early on.
Since then, we've hired another one and we ended up tweaking his process more to make it more specific and refined to make sure that we got another person just like him. The other two people are not there anymore and the other two that we hired are now all cross-trained the way he did everything at the front desk. When we brought them on board, we made the onboarding process and the interview process very detailed to everything that he had created and changed up there with my direction. Even when you think you've got it, you probably have to do another thing. That's what happened to me. We went through and we hit some numbers that we had never hit the first time around. We plateaued and we weren't hitting our goals that had after that. He came on and totally changed it. We brought these two other girls on.
As soon as the new staff came on board without the old staff here, because there was a little bit of overlap, they have put in their two weeks. There were several part-timers in training. The very first week when all the old staff was gone and it was just a new staff with the person that we trained up there, we hit our 200 visits a week goal that we haven't hit in a while. It always happens for the better, but I feel it only happens for the better if you put in that work, your blood, your sweat and your tears into making it better. We refined our process, we identified the leaks, we identify leaks again. We tweaked and refined the process and we got a better product out of it. You got to keep tweaking and refine. That's the main thing.
That's the perfect example of the theorem that the people that got you here are not the same people that will get you there. Some people will be good at getting you to a certain point. What's cool about this also is it exemplifies how you were so intentional about the person that you want to hire. In your own words, it was a rigorous process. For someone at the front desk, if you can breathe and say hello, usually that's good enough for us to sit at the front desk, but you took it a step further. What do we exactly want out of this person? How are they going to be the most productive and how are they going to be the face of my clinic? Immediately, as soon as you did that and got rid of the other people, your numbers grew again. That’s a great example.
Our main focus was we want to create overwhelm for these candidates. That's what I told the guy, Bruce, he helps some of my marketing and all my funnels and stuff. I said, "I want to create overwhelm." He goes, "What do you mean by that?" I said, "I want you to give them everything and all descriptions and tasks that they will be having to handle." Even if they only have to do it once, even if it's not their main task. I said, "I want them to feel overwhelmed." I was like, "Why?" It's because if somebody can come in knowing that they're a little overwhelmed and stick the interview, then they're going to be good because there's a lot of overwhelm at the front desk. Wouldn't you agree? He’s like, “Yes.” That’s what our mentality was when we did that.
Congratulations that you experienced that because that front desk is such an important part. Correct me if I'm wrong, are you paying these newer guys a little bit more than you were previously?
They're still in the probationary period. It’s equal to what it was for the others but going forward, they're both doing verifications. I already prepped them and have their one-month meeting and say, "This is where I want to be able to get you at, but I want to make sure that you're completely independent with all of these things." They're not quite there yet, but they're helping so much more than the other two were as far as what they're going above and beyond doing.
That's awesome because you're incentivizing them and you're telling them, "If you're going to make more, this is how you're going to do it." That's always awesome that you can incentivize them. There was also a change in the quality of the candidate once we decided to increase our per hour rate that we were willing to pay that front desk person. If we were stuck in the $8 to $10 an hour range, we’ve got $8 to $10 an hour type of people. Once we bumped that up to closer to $12 or $15, then we got $12 to $15 an hour people. I'm not saying that you need to share your numbers, but I'm leaving that as an example that sometimes you should be paying a little bit more for someone who is super productive at the front desk because that person drives so much of the success of your clinic.
I had a conversation with my wife about this. We were going to try to increase base pay across the board for techs and front office going forward, but with these expectations, our next tech coming in is not going to start there. He's going, "You're going to start here and you could get to here once you get to a year-and-a-half experience and you're doing this." Our techs had been with us for about a year and a half, two years. They’re in a little bit more responsibility. One of them is responsible for the cleanliness of all the gym and the other one is responsible for all the equipment. We have to order stuff. He knows my online account where we go order. He just gets it approved. They're a big part of what we do here and they're making more, but if somebody that comes in and starts to do tech work, they’re not going to start there. They're going to have the expectation of, "If you can do this like Alex is doing at some point, this is where you could be.” I do bonus them. Everybody got a bonus. We do a little a profit share at the end of the quarter. Even though their base rate is a little lower, when they get incentivized and bonus, it turns out to good hourly grade. I do feel you on that trying to get those candidates.
We're talking about front desk and tax, but this is correlated with physical therapists and PTAs as well, even the clinic directors. They can have such an influence on your team if they're in stage one and stage twos. You want to have more of the stage fours, people that are bought into the culture. We're talking about your hiring process. Are there other things that you do to cultivate that culture and move those people into stage four types of employees where they're bought into the team and it's all about effortless culture or the things you do to maintain that?
I've been working on that a lot. That's something that we've been changing around here because before, we were tied up with life. We're trying to get their business to where it needed to be. Get the kids in the home life to where it needed to be. It wasn't at the top of my focus at the time, nor did I know it needed to be. I started seeing all the positive effects of that. I read a line by Peter Drucker somewhere in his book, he said, "Culture eats strategy for breakfast. It never stops. It's a 24/7 thing." I said that to my wife and I said, "I'm going to take on this hat and know that I'm going to be coming up with some ideas to hang out as a team. We're going to be celebrating any and all little wins, things that nobody else is looking at." We’re trying to create our identity. That's what I told her. As a team, we’ve been hanging out a lot.
Every quarter, we set some goals and when we hit them, we celebrate them. When we celebrate, we go out. I rented a house on the beach and everybody came out and I barbecued all day. They went to the beach and we're in the pool and hung out and had a place to stay and drink. We’re hanging out with each other. We try to create an atmosphere of family and trust just like you do at home. It's hard because it’s like, “They're not your real kids, Frank.” I was like, "I know they're not my real kids, but if we take care of them, it's going to turn around two folds, ten folds for you as a company.” It takes a lot of work.
You're talking about regarding culture, we've talked it about a number of times on the show. When your team members treat their work team as if they were family, that's next-level stuff. You get so excited when they'd not only bought into the company culture, they've bought into each other and they wanted to see each other succeed. They're trying to help and they're trying to promote each other and help each other out. That's the stuff that you hope for as a business owner. In order to cultivate that, it takes celebrating wins, creating goals together. I think quarterly meetings are a huge success. You can push a lot of great cultural values and unity in those cultural events if you're intentional about it and if you plan those out properly. It can gain a lot of traction. It's nice to not only implement the mission, vision and values, but then follow that up with intentional culture-building activities that show the mission, vision and values. We talk about it during those times. That's when you start seeing a culture change.
We try to do that, even when we get together casually, we'll play little games, “Who can recite all our core values the fastest?” We throw stuff out there and always relate stuff to the clinic, even joke about some things that happened in the clinic and create that atmosphere. At the end of the day, we're CEOs and that means we have to lead. We want to lead them to do great things. I used to be a coach too. We can lead them to be good, but when they overachieve and we lead them to overachieve, that makes us feel great. They want to make you feel great. They want you to be proud of them. They don't want you to pat them on the shoulder and say, "Great job." In some cases, you may not know this or they may not tell everybody, but they may have a hard life at home and work is their happy place. It says a lot about how you do that. You can lead by a lot of ways. You can lead by service. You can lead by love. I like to motivate my team. Every Monday, we do a Monday update and we do a little motivational Monday video clip. I'm big into motivating.Knowledge is power so people hoard it. Click To Tweet
The other thing I've learned that I think helps them respect you and learn a little bit about you as a boss is to not be afraid to feel embarrassed in front of them for something you did. Being in a business where I own it with my wife, I have some experiences sometimes since we work together and we live together. Sometimes you're at work and I may say something that maybe I don't realize that other people are in front and it's rude. When I realize that, I immediately will stop, apologize and make it public like, "I messed up." The faces and the looks that I get from them sometimes it's cool because they're like, "He's normal." They're not afraid of me because they know I'm just human as they are and we all make mistakes. The example is man up about your mistake and make it right or make sure that you expect them to do the same when they messed up. You're going to move on. It's okay.
Show a little bit of humility. Show them that it's okay, that we can make mistakes and we can overcome them and next time I'm going to do better.
At the end of the day, I tell my kids, “As long as you give it 110%, that's all that matters. Give it your all.”
Is there anything else you want to share, Frank?
This is one thing that I read and I thought I want to share with my staff. I read this and I'm going to share it with them at the next meeting. It says, "If your presence doesn't make an impact, your absence won't make a difference." That goes for all of us. As a CEO, you want to make an impact on your business. You have to come in here full of positive energy, leading your team, motivating your team, loving your team, setting the mission, the vision. Make sure everybody's clear on it so that everybody can focus and go forward. As an employee, you need to do your job and make an impact in your post. When you're not there, it's not going to make a difference.
How do you want to make an impact?
When you're not there, they're going to be like, "Where's Frank?” because you made an impact.
As a leader, you want to be able to say, “I made this impact.” As a leader, especially in a physical therapy clinic, personally I didn't want my impact to be that I saw 60 patients that week. That's not the impact you want as a leader. The impact that you want as leaders is, “I've affected these people's lives whether it's patients and or employees. This is how I lead and this is how I've created a culture that inspires people.” That provides much more power than it does simply treating patients all day.
It's who you are, what are you there to do and how you're going to do it?
Frank, thanks for taking the time. I appreciate you sharing your wisdom. If people wanted to reach out to you and ask you questions, what's your contact information?
I'm going to give you two ways that you can opt in for any information. It's a text message. You can text MM to 844-444-1481. If people want to get onto our app and get some of the free stuff that we have on there for mastermind stuff, they can text app APP to the same number.
That's for the Next Level PT mastermind and coaching that you are doing?
It's always awesome talking about culture. I get excited about what we can do to filter out people who aren't bought in and find those people who are bought in because the sailing is so much smoother when you got those people in the right seats in the bus.
We're still tweaking and refining because that's the process we have for the front desk, but we still got to create one for the clinic and for PT and everything else. It's a work in progress.
Thanks for your time, Frank. I appreciate it.
No problem, Nathan. Thank you.
Dr. Frank Garza has been a physical therapist since 2006. After working as an employee for one year in private practice, he decided to venture into an independent private practice setting, with his wife, where he is now the CEO.
In doing so they began to see patients in their own home for about 2 to 3 years before expanding into their current outpatient physical therapy facility, Pure PT & Pilates (PPTP), which he owns and operates along with his wife, Dr. Amy Garza.
Together, they have been managing and running the practice for seven years, soon to be eight. Frank is also a founder of Next Level Physical Therapy (NLPT), a consulting group that helps other physical therapy CEOs create the time, choice and financial freedom they deserve.
In the last 2-3 years, he has been really focused on developing and refining his practice’s Human Resources Department. Frank is currently a resident of Mcallen, Texas, a small city located in South Texas, with his twins, Frankie and Tessa, as well as his beautiful wife Amy!
Transitioning from one profession to another takes a lot of courage, preparation, and experience. Kevin Kostka, DPT, PES is a great example of someone who has excelled in the different aspects of professional growth and successfully transitioning to the next phase - from a high-achieving student (four college degrees) to specialized physical therapist (co-wrote a book) to successful PT owner (five clinics and counting). Each transition requires learning new skills, but becoming a successful business owner can be especially difficult for PTs since they typically have no prior business training. Therefore, as Kevin shows, it's imperative to invest time, money, and energy into developing a business owner's mindset, learning what tools are necessary to be successful, and what actions are most. Like many of us, Kevin also learned a little bit through the school of hard knocks, but hopefully you won't have to if you intentionally transition into your ownership role.
I'm excited to bring on Kevin Kostka out of Chattanooga, Tennessee. Kevin is the owner of multiple clinics out in Tennessee, but I'm excited to bring him on because he's an example of someone who maximizes his potential in the different arenas of his professional career. What I mean by that is here's a guy who's gone to college and attained four university degrees, maximized his initial foray into physical therapy’s clinician to the point where he co-wrote a book and did a few studies. When it came to starting his own practice, here's something that was new to him. Like the rest of us, he spent years studying and then went to physical therapy school and spent all his time and money on physical therapy and becoming a clinician. Now he's up against something where he didn't have any education, nor any background as a business owner.
Unbeknownst to him, he used the formula that is he reached out, he stepped out and he networked. He got some coach in consulting. He got out of practicing every day so he could work on his business and he networked with other physical therapists and business owners. His story, although not unique, is impressive because he spent a lot of effort and energy to teach himself while also following the formula. It's our responsibility as business owners to teach ourselves, to invest in ourselves. To spend the time, money and energy that it takes to actually become the leaders of our companies. I'm excited to bring Kevin to you as a great example of what to do in order to become effective executives. Let's get into the interview.
I’ve got Dr. Kevin Kostka out of Chattanooga, Tennessee. He is the owner of Summit Physical Therapy and the VPO of Next Level Physical Therapy. I'm excited to bring him on. He's a partner with Travis Robbins who I had on in Next Level Physical Therapy. I'm excited to bring him on because I think we got an important topic. First of all, thanks for coming on, Kevin. I appreciate it.
Thank you for taking the time to talk to me. Hopefully, we can help some other private practice owners out there.
I know it's going to be great. I'm sure you've got a ton of great information to share. Knowing your story and knowing how successful you are at this time, do you mind backtracking and sharing a little bit about where you started, where you came from on a professional path?
It was probably back in high school when I decided that I wanted to be a physical therapist. I always thought I wanted to own my own physical therapy company. As I was going through my high school career, I was going to different orthopedic clinics. I was going to hospital-based clinics, neuro clinics, these clinics trying to find if that was actually something that I wanted to do. Of course in high school, you got a lot of people out there that try to tell you that it's too hard to get into physical therapy school and that's something that you can’t do.When you have read leadership books and the mindset, everything snowballs to success. Click To Tweet
That pushed me even more to want to pursue physical therapy. I honed in and along my journey in college, I was able to get four degrees along that way. I was able to get a lot of my college credits in high school. I was good enough that my high school allowed me to get quite a few credits. I did one year on a scholarship and then the very next year I got to apply for PT school and they let twenty of us in out of 400 or 500 people. I began that particular journey going through PT school. We moved to Knoxville, Tennessee, which is northeastern Tennessee. My wife had a harder time finding a job than I did. That's where her family's from. We moved up there and I had a great learning opportunity. I worked with an orthopedic clinic up there. I got to work alongside fellowship trained MDs.
One of them actually took me under his wing and he was a shoulder and elbow specialist. That was something that I was interested in because nobody was interested in the shoulder at that point in the game. I was like, “I'll take those patients.” He took me in and I'd wait after work for them and we'd work out together, we'd chat and then developed a relationship from there. Since I was inside that type of environment, he would ask me to come over and he'd show me what particular X-rays looked like. He taught me to read radiographs, showed me some MRs and taught me to read MRs. We started getting closer and closer.
We wrote a book together and then started writing a couple of papers together. I was a new grad, but still one of the highest producers there. I went to the director at that time. I was like, “I'm killing it here.” This was back in the early 2000s. I made peanuts as an undergrad. I was like, “I feel like I'm producing the most here. I’ve got a lot of value. I feel like I'm doing some good things with the doctors here.” I’m looking for a raise and trying to present it. Of course you're young, you're naive and you think you know it all. He was like, “It's like you're going to have to start your own practice to make money like you're talking about.” I'm like, “I’m going to turn him a four-week notice.” I turned in my four-week notice then came back to Chattanooga.
Can I go back a little bit simply because I think there might be a little bit of a question there? One of the things I tell people to do is to network. You took advantage of a relationship there with a physician and that was beyond your typical marketing approach. Was there something specific that you did to create that relationship with a doctor that he would take you under his wing like that? What feedback or what insight could you give us maybe recommendations for physical therapists to develop those types of relationships with their local physicians?
I was eager to learn. I wanted to learn more than anything. When I would try to write notes to him on my progress notes or my evals, of course because he’s right across the hallway there. I'd walk the patients there and that was the benefit of working in a physician-owned clinic at the time. I tried to coach patients on what to say when they would go back to the doctor as well. I would always ask the doctor after work or if I did see him, I'd always ask him, “What did you think about Mrs. Jones? What'd you think about Sally? Is there anything else I can do differently?” That's how it came about. I was getting results with his patients, so I'd ask him about particular techniques and ask him about particular tests and how to do some special tests. From a professional standpoint, that's how it started. It was more about a personal relationship that I would build with them talking about his kids or ask him what it was that he liked and that he was interested in. That’s the direction that I would go with my conversations.
I think there's some carryover there, a couple of those aspects. Not everyone works in a physician-owned physical therapy clinic where they can have that easy access to a physician. However you hear about some physical therapists who take the time to go with their patients to the follow-up appointment or maybe take the time to ask the physician about a patient if it's not at the appointment or some other time. I shadowed physicians. I loved shadowing my orthopedic physicians especially to see how they do things. Their evals are so quick and easy because they have to be. I’m like, “I wish my evals were like that.” Take advantage of the opportunity to be curious. Simply ask questions, be a part of it. What can I do better? What can I do differently? What do you like? Make it not all about, “This is what we provide,” rather, “What can I do to help? What can I do to improve? What would you like to see?” Coming at it from a different perspective is something that we can learn from your experience.
You show that humility and you're selfless in that aspect. When you know that your purpose is to help people and you have a genuine interest in that and doing what you can to be able to improve yourself every day, then you'll take any approach. It came naturally to me. If I had an hour that somebody didn't show up, then I was walking next door and doing what you did, trying to shadow. I would block off the schedule for two or three hours if I could, “Do you mind if I come and shadow you during the clinic?” As crazy as it sounds, but a lot of orthopedic surgeons, they don't like the clinic. They like surgery. That's where I wanted to be too. They're in a good mood because they're in surgery. When I was there in surgery with him, he was like, “You need to go see this guy.” He would communicate back to, “This tissue wasn't that great. We need to go slow with them external rotation. Let's only take them 30 degrees,” or “Can you see on screen when I'm arranging this shoulder right here? It was only going to flexion to 90 degrees. Now you can see the stress that's going right here.” It was a great communication tool.
When I was in the clinic, he would pick up the phone, call me and say, “You're going to see Sally on Tuesday and this is what I want for the first two weeks until she sees me for that ten to fourteen-day follow up.” Having that open line of communication and that's what I brought back to Chattanooga. I found those orthopods that had similar interests that I did and try to develop those relationships based on those interests and getting into surgery with them, giving them my contact information and telling them what I had experienced in the past. Those are hopefully some takeaways.
You eventually opened up your own clinic and it was smooth sailing from then on out.
The silly thing that we did is in 2007 is when I quit. In 2007 when the housing bubble had burst, that's when I decided to open up my own practice. I didn't know. We have this perfect opportunity inside a fitness club. It's not like a gym or anything like that. It's a fitness club, a high-end facility and we're like, “We want to do this on the side of the space right here.” We went to the owner. At that point, the money that they wanted, it was well out of reach for us. I'm going to go to a bank in 2007 and ask for some money. They're like, “I'm not going to loan you any money.” Me and my business partner, we had to come up with a creative idea to start stacking some cash so that we could open a brick and mortar.
Our creative idea was to do house calls. I utilized the mindset when I was in Knoxville of getting to know the doctors and buddying up with them. I was lucky enough to come in contact with an orthopedic surgeon that had done a fellowship and a rotation and knew the doctor that I had worked with specifically. We became buddies and talked to each other since he worked with him in his clinic a little bit, shadowing them and I got to see a lot of his patients. It was like a concierge for other business owners or people that own other franchises. Those were the people that I got that didn't necessarily have time to go into a clinic. I actually would go to them.
I started from there. My business partner was in the home health line and so we started getting into assisted living facilities and offering our services there. We were delivering a good product, a better product and that was being delivered to those facilities at the time and getting good results and staying in constant communication with the MDs and the directors of nursing inside those facilities. Within a year, we had an LLC and we filed all the legal paperwork. We started in 2007, but legally it was 2008 under the Summit name and we got it protected somehow.
Now you're up to five clinics in the area.Talking about life and interests to physicians is a great way to build personal and professional relationships. Click To Tweet
As of September 2019, we have five orthopedic clinics. We're working on one more clinic that should be open on December 2019. We still have that home health product line that we're able to offer. We still offer house calls for certain people that can't make it into the clinic.
You've made the transition. You were well-regarded as a physical therapist. I'm sure you were awesome. You transitioned over into becoming a real business owner. I'm sure it was a gradual transition. You take on patients full-time, you're running the business on the weekends and at nights and that kind of stuff. What helped you make that switch? We'll go into a little bit more about what it takes to become effective as a leader, but what did you do to make that transition from a full-time physical therapist to the owner, leader and manager a smoother transition?
As we started to grow in 2007, 2008, we're starting to hire more people. Our head is down and we're treating patients, we're trying to figure out payroll. We're trying to figure out getting people's time off covered. We're trying to figure out all kinds of things. All the arrows are coming right at us. As all those arrows are pointing at us, you're getting overwhelmed. You're out here working seven days a week. You're working from 6:00 in the morning until 8:00 or 9:00 at night and it becomes very overwhelming. It was hard to cope with that.
We decided to hire a practice manager. We're like, “That's our answer.” We can go in, we can treat all these people, we'll have somebody else doing it. Of course, we didn't know what we were doing. We thought this person knew what they were doing. We kept our head down. “How are things going?” “Things are going great. We're doing awesome.” We didn't keep statistics at the time. We didn't know. They don't teach you that stuff in PT. You treat one person an hour and you do this and it’s going to be great. You're going to change healthcare. It didn't work that way. The only thing that we could figure out is we had to start keeping numbers. We had to start keeping metrics to figure out exactly what was going on. That practice manager didn't necessarily work out. We figured out that we had to start pulling out of practice to be able to start working on the business instead of inside the business.
I think a lot of people in your situation, you think you bring on a practice manager and you're thinking that you're delegating, but what you're doing is abdicating any responsibility. There's the fallacy that, “I'll give it to this person and they'll manage it as I would.” What needs to happen is they need to come underneath you to run the practice. You need to manage them now even more closely because they don't care about it as much as you do, honestly. It's tough because we have to go through hard times like that. I’ve talked to other practice owners that go through one, two, or three practice managers before they finally figured out, “My job is to oversee the practice manager, actually, not for them to run the clinic. I'm still the owner.” You never get rid of that responsibility.
Dan and myself, we figured that out very slowly as money was leaking left and right and we weren't collecting and so that was that person's responsibility, but we didn't have any systems in place. We started pulling out slowly and our responsibilities were to get better organized, to create systems, to create policies and to create procedures as we started to grow because we were delivering a product and a lot of people liked the product. They were getting better and they were happy. They wanted to refer to friends and family and they wanted to come back and see us again. As our visit started to climb, we were hiring more people, but we didn't have those processes in place. We were leaking money and leaking things everywhere. We created those policies and those systems. We created those procedures and then we started to better organize our business. As we started to organize it into different divisions and different departments, the arrows started to go away from us as opposed to all the arrows coming at us.
Were there certain tools or resources that you used, whether it was certain books that you followed or consultants or coaches that you used to help you along the way?
We definitely hired consultants. We read a lot. For about a year and a half we studied and had coaches and consultants try to help us from a business standpoint. The next year and a half, we started studying marketing because that's something else you don't learn in school, in the physical therapy world at least. To me, I think those are two key aspects that you have to have a good grip on before you start your own practice.
Were there any books that stood out to you that started changing your mindset or giving you some direction?
I probably read 50 books and I try to read as much as I can. Can I say that there's one? No. You start with a Dale Carnegie or something like that and you start reading How to Win Friends & Influence People. That one will snowball into another book and then that one will snowball into something else. You go from this personal development world and then you go into this next little stage of, “There are some business books out there. Now there are these mindset books. Now that you've got all this mindset, you've got these leadership books.” It all continues to snowball. I would hate to leave one book out and not be able to tell the context behind why I started that. When somebody starts reading that book from there and they're like, “What? That doesn't make any sense. How does that apply to me?”
It's obvious what you did. You're a smart guy and not unlike other physical therapists who are a high achiever. We haven't spent the time and money on our business education. We spent plenty of time and money on becoming a great physical therapist, but comparatively we have no business knowledge whatsoever. It's imperative that we take the time and spend the money and invest in our business education. That's what my business partner and I considered. Some of the learning that we had ended up costing us tens of thousands, maybe hundreds of thousands of dollars if you look at it over the years. Because we lost money, those were hard lessons to learn and that's not the way you should get an education about business.
When you invest in a coach, when you spend the time to study the books, when you get consultants, you name it, that's part of my mantra. Reach out, step out, network, step out of treating full-time, invest in your business education. Reach out to someone to get some help and guide you along the way because you need that education to become a business owner. I'm excited to talk to you a little bit about this because not only you become a business owner, but you have to become an executive. You have to know what you're doing. Correct me if I'm wrong, but I'm getting a sense that maybe it's hard for physical therapists to transition over to becoming an executive into that administrative role because maybe they don't know what that even looks like. We've been physical therapists for so many years. What am I going to do with my day? How am I going to be “productive” if I'm not seeing patients all day?
That was a mindset shift that I had to go through because I felt like I had to be inside the clinic to be able to help people. What I realized and what other people helped me realize is that I can only see so many people in a day. If I'm able to implement, get better organized and start to implement these procedures, then I can actually help more people. Because now I can have therapist A and therapist B inside the clinic. I can only see ten, fifteen people a day, whatever it may be. If I'm able to set up good systems and be able to deliver good products, now I can have two therapists in there that can see ten to fifteen people a day. Now I’ve helped more and then I can open up another, duplicate that same facility here and duplicate it over on another side of town and then duplicate it on another side of town. You have to have those systems in place to be able to do that. That's the mind shift that you have to go through. It's a team. You had to start to develop that culture and you have to have that leadership to be able to do that.You have to start to develop the culture and have the leadership to be able to have a system that works. Click To Tweet
What are the first couple of steps you recommend for someone who is pulling out of treating full-time? Honestly, they say, “I finally have a full day, or maybe I have two half days. I’ve got two five-hour segments where I can do some executive work, some admin work.” What would you recommend to them to be most effective at that time?
This is something I helped Travis Robbins do. As you start to gradiently work yourself out, start with two hours, work to get to four hours. As you start to do that, a lot of the owners at that time are like, “Now what do I do?” They start twiddling their thumbs. It's about becoming better organized. Start trying to create these different divisions within your organization. What happens when that patient first walks in the door? Create a system based on that so you can take that system and do it at clinic B and do that at clinic C. What we tried to do is hone in on that. My business partner, as we started to create these divisions, he actually took the first three divisions, the next three divisions that we came up with. I started handling the operations, quality control, continuing education and external marketing. He took over the finance, the personnel and the statistics piece of it. He handled that. I handled the other piece and then we started honing in on the different pieces of that particular division.
It reminds me, I had Jerry Durham on. I like what you said about starting with where the patient comes in the door. Maybe going through the patient life cycle, it would be easy to start if someone's considering, “What do I do?” It's funny because if you were like me when I first had those initial hours, I would start catching up on my notes or paying bills. I could pay bills and track down new contracts for different vendors all day long. It's a waste of time and it's not getting you where you need to go. What Jerry Durham explained so well is going through the patient life cycle. What are they seeing, what are they doing, what are they hearing as soon as they walk in the door, or even before that? I should back up, what did the initial phone call sound like? Write it all out.
Now you're starting to develop a culture and the culture is how we do things at the clinic. As you start, you want your patients to be treated a certain way. You want them to see certain things. You want them to hear certain things. Starting from the first phone call when they're saying, “Do you take my insurance?” Is your front desk person saying, “We’re not sure,” and they hang up the phone? You don't want that. Let's start developing a script and how that looks through the plan of care. After the fact, what does the billing and collections look like? How are you going to reengage them three or six months after discharge? That goes into marketing.
I think the benefit behind looking at the different divisions like you're talking about is the patient goes through those different divisions. They're going to come across the personnel. For lack of a better term, they're going to become a statistic, but they're going to get care. They're going to be marketed to after the fact and it becomes a full circle. There's a benefit to sitting down to break down the different divisions that are responsible for different parts of the company running well and see what does the patient get to see at each point? How are we going to put them through that cycle to make it a successful encounter with each patient?
There are two things that I want to dovetail off of that. When you said you would do your finances or you'd catch up on notes, it dovetails back to one of the books that I read a long time ago, The One Thing. You get them back to the one thing and what's the one thing that I can do right now that's going to make the rest of my day that much easier? It brings you back to that mindset. You create your checklist and you go through that checklist. “I got that one thing done. I needed to create this system for when I need to create the verbiage for what we do when we answer the telephone. I want to create this whole cycle that starts here.” It goes to this point and this is the algorithm that it goes through. If she answers yes, if she answers no, this is how it goes. My ultimate goal is to get them on the schedule. You’ve got to take it to get those arrows pointing away from you and part of the executive or part of the director, part of the VP, whatever level you're at. It's all about implementing that particular system. It’s making sure that person then becomes accountable and responsible.
They know what that end product, it's to get that patient on the schedule. You're exactly right, that's where the metric comes from. The metrics don't necessarily have to come from patient care. It can come from my office coordinator at the front desk, how many phone calls she's handled that day and how many people actually converted to patients based off of that. It’s making sure that they're accountable and responsible for that and they have a statistic to measure their final product there.
How long do you think it took you guys to do your initial setup, systems and processes? It takes some time. I want to say it was Paul Keller that wrote that or something like that. Anyways, it’s a great book. If you can knock out that one thing, the first part of your day, it doesn't matter what you do for the rest of the day. You've already been successful. Knock out the one thing as soon as possible. How long did it take you to feel like you had a decent system in place?
It took us two and a half, three years to go through all of this. For our organizing board, it probably took us about a year, a year and a half to create it, get it up on the wall, people look at it and be like, “What in the world are these guys doing?” I would even look at it during lunchtime and be like, “How in the world were you going to get this accomplished?” You take it day by day. You take it one day at a time, hour by hour, as we would do with patient care. I would never look at the end of the day. I would just look at it hour by hour and roll with the punches. I was going to be there until 5:00 or 6:00 anyway. When I look at the organizing board, I knew that as I would take it day by day and try to break it down as slow as I could and gradiently implement things so that people didn't think I was crazy. I do it as slow and as possible as I could so that people could get a good handle on what exactly it was.
It wasn't until we started having meetings where we separate everybody out. We had different meetings for the marketing team, for the rehab team, for our office coordinators and we had people above them so we can finally debug some of these systems that we created. Once you start debugging and then you start changing them, that's whenever the magic starts happening. People take ownership over them because they are their ideas, they're no longer my ideas. Our ideas don't fly too well. They have to be somebody else's ideas. It's all about the executive or the owner or whatever role you're playing within your organization. It's all about your ability to be able to communicate that to your juniors in a sense where they want to do it. You've promoted it enough to so that it makes sense to them and they can see the greater good of it. It's a win-win for everybody.
The thing I like about your story is you recognized the issue you had with the initial manager that you brought on, the practice manager. The first thing that came to mind is, “I need to know my statistics.” One part of what you need to do on a regular basis as an effective executive is to look at your statistics. Nothing should come as a surprise eventually as you start nailing this down. Start figuring out systems, processes, and procedures and writing them down. That's a lot of grind for me, especially creating content. I hate it, but that's where the rubber meets the road. The benefit can come when if by chance you have any rock star talent on your team, is to have them write down their processes and procedures.
That might be hard for them, but it’s telling them, “Just take fifteen minutes and give me an idea of how you answer the phone,” If they're good at converting patients onto the schedule book or, “You're good at getting behind the doctor's front desk and talking to the physicians. Can you write down what you do?” The onus isn't so much on you all the time, but you can take what they've got, massage it, manage it, and then once it's written down, then you can implement it into the next person. Because there's going to be staff turnover, you can implement that and train on the next person. You essentially start working your way out of a job.
I had a wife of a very busy PT call me and she's like, “I don't see my husband anymore. He's a great physical therapist, but he is busy all the time and we can't get on top of our business.” A lot of us as physical therapists take it for granted that we treat patients well. I think there's a lot of responsibility for us to write down what we do to be successful physical therapists and get patients to come back and get high retention, completed plan cares, lower cancellation rates and that stuff. A big onus is on us to write down what we're successful at as physical therapists so that we can turn that over to someone else and put the time into the executive stuff.Always try to improve yourself on a personal and professional level, reading and applying them to the situations you're in. Click To Tweet
I love hearing you duplicate all this stuff because that's exactly what we did. We would ask our office coordinator, “You do that well. Can you write down how you answered that phone and how you handle that objection? Can you write this down for our PTs?” We would do the same thing. It's constantly living and breathing your organization. It's constantly changing. As you know and a lot of the readers probably know as well, change is inevitable. You have to embrace it and make sure that you're okay with change. If something isn't working, then change it. That's where those statistics come in. All we're doing with those statistics is making sure that what we are doing is working or if it isn't working and we're going downtrend, then we need to make sure we change something up. It's all about communication and having that conversation about what everything looks like from the metrics because those are your answers.
I’ve got a ton of stuff going through my head, but I want to ask, did you have a lot of fallout as you started implementing the structure? Did you have a lot of kickback from the employees?
Of course, because we didn't know how to lead. We didn't know how to do any of that stuff initially. We started reading about culture and we started trying to develop a culture within our organization based off of values that we felt were important. Of course, we didn't come up with the values. We had the other people within our organization come up with the values. You can check out our website and check out our values. We have all the different definitions and different quotes behind what we feel like from a communication standpoint to a willingness standpoint, integrity, all that type of stuff. That's how you start to develop that culture. When you're in your grassroots company and you're homegrown within your city, then those values can start to seep out into the community and you can start doing community projects. That's when the team starts pulling together. When you close all five clinics down and you have 30 people show up to the soup kitchen and we’re all dispersed into different teams and are helping to make lunches for the homeless or trying to go in and fix up one of the rooms that they stay in. That's when the team starts coming together and it's all about letting the other people come up with it.
What I think you're a great example of as you started figuring out, “We need to become executives.” It’s statistics, systems and values. I'm sure a lot is going on behind the scenes. You're hiring the right people, you're running through some people who are resistant to structure and they’re like, “Don't tell me what to do.” You start gaining some traction to a point where now there's still some stuff that comes up, but I don't have to spend as much time pushing all the buttons anymore. Now I'm developing a leadership team that is bought into the culture and I can trust to do the work. You're still managing by statistics. You're still watching the stats on a weekly basis and people that have to be held accountable to them, but now you're pulling yourself up the organization board to the point where your growth is almost dependent upon the team. You guys have some leadership and you're going to have a vision. I didn't say anything about it, but everyone should have a vision. You have an ideal scene. Now, the team is pushing towards that. You're all rowing in the right direction. It's not surprising now to hear that you had your fifth clinic open. You've got another one open. Growth is inevitable at that point.
It's a matter of me and Dan getting out of the way. I think that the more we get in there and start tinkering and messing with stuff, the more things will start to slow down. Now that we have our executive team in place, we have our executive meetings every month, then those meetings trickle down and we have that culture. We have the executive team making a lot of those decisions on policy and changing the policy. We don't have to necessarily do a lot except for look for new opportunities that are out there through the networking, which you mentioned, through the network that you are doing at this point in the game. That's what happened to us.
Our Chamber of Commerce here voted us the small business of the year for a medium-sized business. That's when things started exploding, “Will you put a clinic beside me?” You get phone calls all the time. From an executive standpoint, we got to put systems in place to, “What does that new clinic look like?” We've got a checklist for that. What are we doing with the contractor? What are we doing with the PT equipment? We have checklists for all that. Where do we want to put it? When is a good time to do this? You’ve got to learn the hard way sometimes too and not grow too fast because then you get in trouble with available capital.
Now you're developing processes and procedures on a higher level. I'm sure you're looking at demographics. When you're looking to open up a clinic, you have a general idea how much cash and on hand to not only open the clinic but sustain you for a period of time and then it all becomes systematized. At that point, you really can't hold back the growth. It's impressive.
The only thing that's going to slow you down is money.
What has been your most successful action in developing leaders underneath you? I want to get your two cents. You didn't jump from all of a sudden starting to run your clinic a couple of days a week to all of a sudden not seeing patients five days a week. What were some specific tips that you provide people to grow their leadership team?
To me, it's a mindset. It's always trying to improve yourself on a personal level as well as on a professional level. Always trying to read and trying to apply what you are reading to the situations and the scenarios that you're in. Once you start getting these ideas, it's all about executing on these ideas. In order to be able to do that, it's about communication. You’ve got to figure out a good communication method to persuade and presuade the way that you word these ideas so that becomes their idea, more so than it is your idea. There are certain questions that we go through to try to figure and try to lead those people in that direction, facing the facts. If we don't do this now, then what will happen or what could happen? There's a whole process that we actually teach in our mastermind on how to do that from an executive standpoint to implement a new program or to implement a new policy.
I had Travis on and you guys are starting another mastermind group with Next Level Physical Therapy. I'm sure people can go to that website if they want to learn more about the mastermind like you're talking about and some of the principles that we discussed. Thanks for sharing. I appreciate it, Kevin. It was great to talk to you and hear about your story. Are there any words of advice, anything you want to share?
I'm a personal growth guy, so I'm always looking to try to do better than I did the day before. As physical therapists and as private practice owners, the best way that we can help other people is actually making other people in our organizations responsible and accountable for their particular position and working together as that team. Another quote from another great book, “If you can get everybody going in the right direction, then you're unstoppable.” Being great leaders and learning how to do that is something that I love to see our profession continue to evolve with.
You're a great example of someone who has taken the time and effort to develop as an executive. Maybe that wasn't your idea when you wanted to open up your own clinic back in the day, but you got to understand if you're going to own a clinic, you've got to put in the time, the education, and spend the money in your education to become a successful owner. When you do so, then you can become a greater influence in your community than as a solo practitioner.
You can't be a know-it-all. There are people that have been out there. Before we got on here, I was asking you questions and you're giving me ideas. It's all about helping one another so that you can continue to grow as a person and grow as a professional.
You're doing great work. I appreciate your time with me, Kevin. Thank you for coming on.
Kevin has an extensive educational background receiving four degrees from The University of Tennessee at Chattanooga. Foremost, he received a Bachelor’s Degree in Psychology in 2000 and Exercise Rehabilitative Science in 2001. He went on to assume his Master’s Degree in Physical Therapy in 2003 and achieved his Doctorate of Physical Therapy in 2004.
Kevin began his professional career working with the Knoxville Orthopaedic clinic, where he had the privilege to work beside fellowshipped trained medical doctors for whom he acquired valuable experience with differential diagnosis and diagnostic testing in a one on one environment with the fellowship-trained specialist.
Kevin achieved his Performance Enhancement Specialist (PES) Certification from the National Academy of Sports Medicine in 2006. He researched and assisted in the writing of a journal article with a fellowshipped trained shoulder and elbow specialist as well as a hand specialist for distal bicep tendon repairs from 2007-2008, while also working on his first publication with Edwin Spencer, MD, Post Operative Rehabilitation of Shoulder Pathologies. Kevin was a Member of the American Society of Shoulder and Elbow Therapists. He was on the board for the University of Tennessee Chattanooga Physical Therapy Department along with adjunct, associate professor and special guest lectures in the physical therapy department.
Kevin has been in private practice since the inception of Summit Physical Therapy in 2008 with his business partner Dan Dotson. They have grown their business in their hometown of Chattanooga and now partner with other local businesses to help promote local healing. Summit Physical Therapy was awarded the Small Business of the Year Award in 2015 for the category of 21-49 employees and voted on through the Chamber of Commerce Board Members. And has been voted into the Best of the Best for physical therapy in 2017 and 2018. Summit Physical Therapy currently has 5 outpatient clinics and home health product line.
Kevin is also a founding member of Next Level Physical Therapy where he helps other practice owners to improve their practices so they can help more people in their communities.
Developing a winning team is crucial for an organization or company to reach its goals. Craig Phifer, PT, the CEO of Rehabilitation and Performance Institute of Evansville, IN has put systems, rubrics, and filters in place to REALLY hone in on the successful characteristics and traits of the top performers in his company. Plus, his company's focus has been on providing his team the autonomy and support to pursue their individual dreams. Putting these two focuses together has allowed RPI to create a culture of aligned individuals looking to significantly affect their community - and they've done that! They've grown to five clinics in three years and will continue to grow, considering the incredible team members they are developing to take more responsibilities. Plenty of insight in this episode! Get your pen and paper handy.
I've got Craig Phifer out of Evansville, Indiana, CEO of Rehabilitation & Performance Institute. I was going to talk to Craig about an article that he wrote in Impact Magazine entitled Assembling Your Winning Team. My initial thoughts, and I was mistaken, that he was developing a leadership team, but he was talking about assembling a winning team and a culture throughout the company. The reason why I'm excited to bring him onto the show is because the things that they've done to filter, hire and train have developed and refined their culture to create one autonomy for their providers, of stability and purpose for every hire that's in their practice. They've grown to five clinics over the last few years. I’m excited to bring in some of his successful actions and share those things with you. Craig does an awesome job in explaining things. There's a lot of stuff that was like, “That would have been great if we did that. I hope everyone's reading to this.” There are plenty of things that you can do within your own clinics to take advantage of what Craig shares with us.
I've got Craig Phifer, Owner and CEO of Rehabilitation & Performance Institute out of Evansville, Indiana. Thanks for coming on, Craig. I appreciate it.
Thanks for having me, Nathan. I appreciate it.
I recognize Craig's article in Impact Magazine about assessing a winning team and I think that's such a vital part of the growth of any clinic, especially if you're looking into multiple clinics, if you're looking to free yourself from some of the day-to-day tasks as an owner, so you can become that leader. It helps to start creating a culture and an environment that's not solely dependent upon you. First of all, I want to get into your story, Craig. Why don't you tell us a little bit about your professional path and what got you to where you are?
Years ago, we started RPI. Prior to that, I had been running an office for a large orthopedic practice, transitioned into doing it on our own and started with the idea of things weren't heading down a great path for PTs and clinicians. We were starting to sense a lot of those classmates you would talk to who’s the smartest people in the room. They're great and you think, “That person’s going to go out and they're going to be awesome. They're going to crush it.” You talk to them about two years in and they're starting to talk about like, “I'm not sure I want to be a PT anymore. I want to get out of this. I'm trying to find something else. I'm trying to do something different or something nonclinical.” It’s like, “You're so much smarter than I am. You are the person at PT school who I thought was going to be out there doing amazing things. I'd be reading all about you now. Here we are and the profession is beating you down two years in.”
When we started RPI, the idea was how do we put clinicians in the best possible position to succeed? How do we strip away all the things that don't matter, that we spend time and money and attention on? Can we take those away and focus on the stuff that matters, that puts clinicians in a great position to deliver great results for their patients? We're still searching for that every day. We're still trying to make changes and tweaks. I think we've done a lot right. We've also found out we've done a lot wrong, but a few years in and we have five offices in the region and it's going well.
Congratulations, that’s awesome. It sounds like you've developed a model where you're the owner and CEO, but you also have some partners in some of the other practices.It's hard to change a community in a meaningful way when you're not living in it and when you're not involved. Click To Tweet
Our company has nine owners in total. What we've done is you have all these people who made a personal investment in the company without making a financial investment in it. We got to a point where we thought you can't expect as an owner for somebody to put the same amount of blood, sweat and tears into it as you have. When you have these people who do, you need to reward them with something like that. I don't think it necessarily has to be ownership, but we thought that was the right choice in our company was to say, “You can buy into ownership. You're doing such amazing things. This company is successful because of you. We're better when you're a part of the decision-making process.”
Do these people tend to then be the clinic directors at the individual clinics or have some management responsibilities on top of their physical therapy work?
Almost everybody in our company has some management responsibility outside of physical therapy work. Some of those owners do manage an office. Some of them don't. Some of them help refine our clinical processes and they play a role in that. We say we need 30 hours of clinical care to make the company go. That's what pays our salaries and the bills. What we want to do is condense that 30 hours to where you have some other chunks of time you can use to do what it is that want to do, what you've told us you love outside of just treating patients. We have somebody, she’s wonderful and she gets our company mission well. She gets our vision and we got big enough to where it's like, “I can't manage the HR stuff on my own. We need somebody who's doing that.” She took that role and has done awesome in it, much better than I was doing.
After you get to where you're excelling and succeeding in your relationships and the care you're providing patients, we think that takes about two years for most. We've had people who got to that point. One of them was less than a year and we were able to say, “You're doing great. You're doing phenomenally well. When you're ready to take on something else, we've got things that we think you'd be great at. We need you to think about what you'd want to do outside of treating patients. We can start to make some of that happen.”
How do you assess when they've come to connect with patients, they've been able to develop relationships and see great results personally between them and the patients and professionally with their results that they're providing?
We have two main things that we measure for every clinician in the company. We measure for every office and for the company as a whole. Definitively, I can tell you our most successful offices on every measure, and this includes financially, boil down to these two pieces. The first one is therapeutic alliance with patients because that's such a great predictor of people dropping off or not. People dropping off in physical therapy is such a massive problem that doesn't get nearly the attention it deserves.
When you say dropping off, are you talking about the 10% that complete their plan of care in our industry?
Yes, that is a pretty big number. That's our primary measurement. Our second one is we have offices that are about 80% direct access. How many of your patients said, “I don't just want to get physical therapy. I want Eric to be my physical therapist. That's the person who's going to help me. I trust them before they come in.” When you have created relationships to a point where your patients trust you before they ever come in the door, that’s powerful for being able to help them completing care. It helps us from a cycle of we don't need that many new patients because they're not dropping off as much. We don't have to spend very much on marketing. We don’t have to spend very much in a lot of areas because our patients are staying. If somebody is successful and a lot of their patients, request them not just coming in for physical therapy, but request you and then our measurements of therapeutic alliance, if you're succeeding in those two areas, I can tell you everything else was going to be good.
This isn't the topic, but I love how you guys are doing things. I want to learn a little bit more. The situation in which maybe they ask for Eric before even coming into therapy, is this because a prior patient of Eric's has referred a friend or family member to Eric?
Yes, that's one of the big ones. The other one is community involvement on an individual level. We want to put people in a position where they're living, working, playing in the community they're in or from. If somebody has to commute an hour to work, it's hard for them to be actively involved in that community. Not that they can't do a great job, but it's hard to change that community in a meaningful way when you're also not living in it and when you're not involved. I would say about half of that comes from community involvement. It's got to be something you genuinely enjoy being involved in. We don't want anybody to go out and say, “I'm going to join this running group even though I hate running because I know a lot of runners get hurt and need PT.” That's the wrong reason to be there and it doesn't work. It needs to be something you love doing anyway. A lot of people are being part of their church. For some people, it’s being active in running groups. For some people, it's helping coach youth sports.
Your therapists seemingly from the get-go, as soon as they come on, there’s an expectation that they're going to do some outside involvement or promotion. I wouldn't call it marketing, but they're going to be involved in the community such that they can find ways in which they can help.
Part of our hiring process is that we are looking for people who have already shown and have already demonstrated that they like being active in the community and they like doing things like that. It doesn't feel like work to them. It's something they would do no matter what they were doing for our profession. We think that those are the people who change the health of communities, people who are out there working in it and interacting in that community.
That's part of your interview process. It’s like, “What kind of community activity are you in? What kind of groups are you involved with?” That's one of your main criteria for joining you.
When we talk about defining who is successful in your organization, the people who are the most successful for us, to a person or all people who enjoy being out there in the community. They don't even have to be extroverts necessarily. We have a lot of introverted people who have things they like to do in the community or in their particular group. There's no right or wrong way to do it. It’s like, “We don't have anybody involved in soccer in this community. I need you to like soccer and go out there and get involved.” It only works if it's something people want to do anyway.We're all pretty overstimulated and it's created this need for flexibility. Click To Tweet
Those introverted people, they're not necessarily introverted when they're in a comfortable environment. When they're part of that group, maybe they're introverted but they like CrossFit. There's their tie to a community. There's a group that they can be a part of and benefit from. I had an interview with Sturdy McKee out of San Francisco. One of their criteria for bringing people on was they would ask people if they participated in team sports anytime during their lifetime. If you said no to that, they wouldn't hire you on. I bring that up because there are some things that are outside of the box and you alluded to this in your article in Impact Magazine about assembling a winning team. There are some things that you're looking for. There are traits, characteristics, even personality types that you want to bring on and create a winning team and sustain the proper culture in your company. You get down to, “We're hiring for this person, a physical therapist. They're going to be actively involved in their community. If they're not actively involved in their community, that might be a red flag. We might not necessarily hire them.” Would you go that far?
Yes. Some of the mistakes we've made through the process is one, initially, we asked people about their desire be involved. Everybody can give you a good answer in an interview. PTs are smart people who are great test-takers. They've exhibited that throughout the doctoral training they have. People can give you a good answer to a question. We've had to start to look at less about the answers to the questions that we ask but more, “What have you done? What are you currently doing? What are the questions you're asking us?” That tells us more about what you're interested in and what you're trying to achieve, then your answers to the questions we ask you.
Say the community involvement, do you take that down to even some of your administrative personnel whether the front desk person or an aid? Do you take it that far?
Everybody, yes. It's an important part for every role. There are certain things that we look at are traits where somebody might be successful as a PT, versus what they'd be successful as a clinic director or clinic manager are different. The same thing for somebody who is working in a front-office role. Some of those traits are different, but there's a lot of overlap and community involvement is some of the overlap.
I can see where community involvement in your situation has bred a culture and an environment within your companies from what it seems. When you get down to job descriptions, then there are different traits that you're looking for. In your article, you talked about rubric development. There are certain things are looking for, but there are also certain things that might come up as red flags. You mentioned yellow flag as well that you want to make sure you steer away from. Is that something that you've developed over time or did you sit down ahead of time and say, “These are the people that are super successful. What do they have that makes them successful?” How did you develop a rubric like that for the different positions in the company?
One of my favorite books that I stole this from is Work Rules! by Laszlo Bock. He used to be the head of people development at Google. It’s a fantastic book where he says, “You've got to put your top people under a microscope.” Your culture is almost like a living, breathing thing and it's changing as the people in your organization grow and develop. If your culture stays stagnant, that's probably not great. Your culture is changing, developing a little bit. Who was succeeding a year ago are the same people still succeeding now. Study those people. What we did is we put people through five whys, “Why is Eric so successful? Eric's patients seem to like him, but why do Eric's patients seem to like him?” You keep going down the road until you find the traits of that person and compare that to three, four or five other people who are doing a phenomenal job for you. You've got a pretty good handle on those. These are the things that make somebody successful in our culture and also change with us as we grow and develop. They're the ones who have kept up through the process.
Are these typically people that have been with you a long time or are you seeing some of these most predictive people even in your recent hires?
We had some in very recent hires that have come on and picked it up better than I ever could have imagined.
Do you attribute that to your interview process? Do you attribute it to looking for those certain traits?
I think it helps. I'd be lying if I didn't say that we nail it every time and that luck wasn't a part of it too. We've built a culture where in our area we've become well-known of if you can get a job there, that's where you want to be. It's going to work outpatient or orthopedics. We put ourselves in a good position of having a lot of people to choose from. That's been incredibly helpful.
I'm sure the people you've brought on that have been successful and enjoy being there will attract people. They've got friends either from PT school or in the area and they're like, “I can get you on.” These are like people and they're going to have similar traits. There's a huge advantage to that.
Some of our best hires have come from somebody saying like, “I know we don't have an opening right now and we're not exactly trying to hire somebody. I've got somebody who I think is going to be phenomenal.” Everybody at our team is cognizant of what we're looking for and what somebody needs to be successful through us. There are people that said, “That's a good friend of mine. However, I don't think they're a great fit here.” Somebody who said, “We weren't that close in PT school, but I know them and I think they're going to do awesome here. They're going to be great. I think we're going to be great friends even though I don't know them that well now.”
Having your employees be part of that filtered process is amazing and powerful.
It made the recruiting so much better. From the first time we were trying to hire somebody, we had to go through five, six, seven different channels to get one or two applicants. It was hard. We got to thinking like, “If it's going to be this hard to hire a PT every time, what are we doing here?” As we started to get our name out a little bit more and our own people started to feel like, “We’re onto something here. This is going great.” I don't want my friends to work here. You should leave where you're at and move here and come work. That's been phenomenal for us.20% of your time should be spent on something that you love. Click To Tweet
That's a great position to be in. Are you doing any recruiting work in some of those surrounding PT schools as well?
We have people who are quite involved in local PT schools, a lot of lectures and a lot of students. We value the clinical learning process. Anytime some of the local PT schools want to send us somebody, the answer is yes. We just got to figure out where to best put them so that everybody is successful.
Have you ever hired a PT without necessarily having an opening because you knew they were the right fit?
I've got a few people who crushed it for us. We knew them beforehand. They did great in the interview. We knew they were somebody who are going to be able to drive some of their own patient care volume. That came from us saying, “We know that fewer than 10% of people who need PT get it.” There’s a market out there that if we're able to reach the people that we can help, our PTs have the ability to drive their own schedule. When we find somebody who we think can do that, we'll hire them no matter what.
A lot of people will consider that a leap of faith. You talk about this in your article about giving them some autonomy. I like how you used the word autonomy and not necessarily responsibility. You haven't said that they have a responsibility to generate their own patients. You more talked about how they're in control of their own schedule. I'm sure you have some expectations, but it doesn't seem like it's coming from top-down. It seems like somehow you developed the culture that allows them to be internally driven.
That was the exact thought process when we started. The big things that make something go are autonomy, mastery and purpose. If we can drive those things and put people in a system where we have autonomy, I think part of autonomy is flexibility. Can we give people some flexibility and schedules and how we get things done? If we just tell them, “This is what we're going for, this is what we need,” PTs are hardworking people. It's hard to get into PT school in the first place. It's hard to finish PT school. Once you've finished PT school, it's hard to pass your board exam. We're picking from a group of people who are smart, driven and motivated. We need to give them the platform to let all those qualities shine. That's what we're attempting to do.
From an owner's perspective, from my past experience, when you talk about a scenario like you're in where a lot of your PTs drive their own patients and patient load, a lot of PTs that I come across almost seems like that's the company's responsibility to market the doctors, talk to the people and get out in the community. If you want me to treat patients, I'll do that all day long. What I'm finding out is that you've filtered those types of people out.
That type of person no doubt exists. We've hired that person before and it's not that they haven't been okay. They haven't excelled in our system. I understand anybody who wants their career to go like that. Not everybody wants to work in our system where you're probably only going to be successful unless you want to do some of those things. Filtering some of those people out through the interview process, but also as we bring somebody on, we want to help them find the reason they got into this in the first place. PT is a profession. We're incredibly autonomous people probably to a fault. Most people want to help others when you show them that this is your best route. If you want to help people, this is absolutely the best way to do it. You can’t only have them in your life for 45 minutes twice a week or whatever it may be, depending on where you work and never see them again or never see anybody around them that you're going to make a change. You might be the best clinician ever, but you're still not going to make a change on bigger level.
You're promoting your physical therapists to make a difference outside of the clinic. It extends beyond the clinic, extends out into the community. I love that you brought up the fact that we only address 10% of the people that actually need us that have musculoskeletal injuries because a lot of times we think there's so much competition, but when we're talking about competition, it's for the 10%, it’s 90% out there. We could be such smaller fish in a bigger pond if we could reach that other 90%. That's a huge difference. You talked about getting rid of some of the things that lead to the two-year-old PT to be frustrated and looking for something else. Maybe I'm putting words in your mouth but it leads to burnout essentially. What are some of those things that you've pulled away from your therapist to help them be more engaged, involved and minimize possible burnout?
The first thing we wanted to address with our therapist is to put them in a situation where they were only having to treat with one person at a time. PT is realized when you're seeing two, three, four people at once, no one is getting the best of you. We're such a caring, altruistic profession people by nature that I don't think anybody can internally deal with that very well. They either need to shut their own professional life off from everything else if they're doing that because they have this internal feeling of like, “I know I could be doing better for them. My system doesn't allow me to.” Our first part was if we don't spend money on stuff that doesn't matter. We spend money on your relationship with that person and the things that allow you to develop a relationship with that person. We want to get people to where they feel like they're making a difference because they are. We give them that element of purpose.
The second thing is I think we're all pretty overstimulated and it's created this need for flexibility where there are times where we want to work, there are times where we want to get away from work. I will always say that if we have a job at our company that a working mother can't do, then we don't have a job that's two jobs. My wife's a PT. She's a professor in the local PT school. If she can't do a job within our company, I haven't provided the flexibility of somebody who's going to be great. That was our next focus of saying we need this many visits a week. We need 30 hours of patient care. You tell us how that works for your schedule. You tell us how to make that happen and you have a couple of patients in the morning cancel. That's okay. Your schedule is your schedule. I'm not treating those people. You are. If they can't make it in and you're going to come in an hour-and-a-half late because your first two patients scheduled and now you've got something else you needed to get an oil change, that's perfectly fine. We'll see you when you come in.
As a past owner, I can think about some of the issues with that because there has to be an expectation as far as productivity. You talked about that in your article about how you create measurements or statistics with your employees. Tell me a little bit about that and how you maintain productivity in your situation.
For us, we tell everybody before they ever start. It's the best question somebody who's interviewing for a job in PT should ask an employer is, “How do you measure if I’m successful?” Because oftentimes the answer just ends up being more when you don't know if you go into a place, “Am I doing well? Just see a few more patients, build a few more units and you'll be good.” We tell everybody before they come on, this is exactly what we're looking for from a productivity standpoint. We put that piece aside, “Here's how we find it best to get those things without running yourself into the ground because nobody needs that. That's not good for you, for us, for your patients. Here's how you get it that without reaching those burnout levels.” Once people figure out, “Here’s how I get those things. Here's how I do a good job. I find out I've got a lot more energy. I've got something else I want to take on.” Let's talk about your other goals. We have a professional development period, our pyramid for people where they're able to say, “Here's the ultimate goal that I want and here's a couple that are leading up to that.” We'll talk with everybody monthly about, “What are you doing to get toward that? What can we help you with? What kind of obstacles can we help you remove to make that happen?”
What are some of the statistics that you measure your providers by? Is it visits per week or some other statistic? You don't have to share numbers, but what are the KPIs you use?
We talked about the big two and if those are going, then I know pretty well everything else is probably going to be good. From a pure productivity measurement, it’s visits per month. It is the timeframe we look at. From that, we have a unit per visit. We have a range. It's going to be slightly different depending on your particular office. Those are the two things that are pure productivity. I think it's good for everybody to understand before they're going in that if you were working on a line and you needed to put out ten widgets in your shift to make ends meet, then you know, “I need to make ten widgets to make the ends meet.” For us, that's how we make money. That's how we continue this. That's how we help people, “Here's what we need financially to make it everything else go so we continue to help people.”
Where did you come up with the 30 hours per week of treating? Did you work backwards from what you need as far as revenues? How did you come up with that number?Everybody tends to gravitate toward the person teaching them and leading them. Click To Tweet
We pulled it out of the 80/20 rule. We want 20% of your time to be spent on something that you love. We started saying, “Can we make that happen? What do we do to it to drive that?” Then we worked backwards, “If that's what we need, here's about how much we're going to make per visit in our area.” We knew that. “If we can generate that much revenue, here's the bucket we have to spend on.” Anything that goes outside of that, then we've got to start saying, “Here's what we don't need. Let's pull that out.” We're more of a destination place. We don't need to spend astronomical amounts on storefront and being the most visible location. Most of our patients drive past somewhere else that offers physical therapy to get to us. We’re very comfortable with that because it means we don't spend a lot of money on square footage. We spend a lot of money on the relationship with our patients.
I love how you guys have set up. This is something that you've probably developed over time is your interview process. You seem to have nailed down. It's pretty close to a solid, finished product. I've talked about this with other guests and consultants. Bringing up the productivity expectations at the very forefront is huge. Leaving that as something that's part of their training is wrong. They need to know exactly what they're getting into and you need to be upfront about what the expectations are. I think that goes a long way. I love how you talk about what is their professional path. Some of them might want to be lifelong clinicians and that's okay. You might have a position for that. There are some people who are like, “If I'm doing these ten years from now, I'm going to shoot myself.” You've offered an opportunity to show them that there is a path for development. I think that's huge as well because you then are aligning what they want with what you can provide and show them a path to do that. That gets a lot of buy-in into the culture.
We've developed a couple of people right out of our organization. Somebody might say like, “That stung you. They developed as an individual faster than you are as a company that they got this great opportunity somewhere else that you can provide them.” It's like, “I think that's awesome.” We're able to provide the kind of place where people can grow and develop. If you're developing yourself so fast, because we as a company, we have everybody. We're growing as a company. We're doing lots of new things and lots of exciting ventures coming up. If you're even outpacing us to where we can't provide you the opportunity, good for you. That's phenomenal. I'm glad that happened and I'd be happy to help you do whatever you want to do.
I loved reading your article about assessing a winning team. You developed a team, not just the leadership team. That's how I went into this, helping people recognize what it takes to develop a leadership team. You’re talking about a team from the bottom up. You're talking about developing a team and growing than you're leaders from the get-go, and you've provided a professional track for them to do that. There's some development in place. There are certain levels that you address on a month-to-month basis, which is very cool as well. You're having one-on-one meetings with them to do that. That's all amazing. When it gets to leadership, what are some of the things that you might have them do? Are there some tests that you take them through? What do they need to do in order to become a leader in your company?
We have been developing that path to different leadership. The qualities that we found internally people who become most successful in that role, one of the big ones is vulnerability. That person is able to share, “This is where I've failed doing that or this is something that I have trouble with.” It puts everybody at ease when you realize that this person I look up to and that I'm following are not perfect either. As far as qualities go, that's the quality that we've tried to develop culturally within our organization. We see our leaders have high levels of that.
You're that from an observational point of view, I'm assuming.
We’ve noticed that those are the people that almost attract others. They might be a staff physical therapist in their role and we might have three other staff physical therapist there. Everybody tends to gravitate toward that person teaching them and leading them. A lot of times it's the person who will sit there and they're talking after work about a patient they're struggling with and the person's like, “That's tough. I don't even know what's going on. There are so many directions you can go in. I'm stumped.” That person is the one we're finding that other people naturally start to follow.
If they’re interested in leadership, do you tell them, “There are books that you should read,” or do you give them small tasks to see how well they handle management?
Both of those things. We have almost a progressive reading list of things. The first part of it is leading yourself. If you don't know you, you could argue that very few people actually know what they want, why they want it, how those things developed in their own life. If you can know you, that's where we want you to start. The book I love for that, that we recommend is The Subtle Art of Not Giving a F*ck by Mark Manson. I think it's a phenomenal book. The title scares people off because you're like, “I do want to care. I don't want to learn how not to care.” It's more about teaching you how not to care about things that don't matter and finding out what does. That’s our initial reading list book. We find that once people understand themselves well, it becomes so much easier to lead others.
You said a lot of people in your organization have some responsibility. Are you talking even down to the physical therapy aids if you have them or even the newest physical therapist? Did they have some responsibility?
For the most part, we don't put other things onto people for the first six months to a year. We have had people who jump into things right away and show a natural proclivity too like, “I enjoy doing that. I want to do it.” We're like, “You do your thing.” We want people their first couple of years to be about honing in clinical skills and working with their mentor through that process. Developing a system and developing their own pieces of it where they know when they're successful with a patient, when they're not successful with the patient, where they went wrong, what went right and focus on that element of expertise. As you get that, we want you to start taking on some other things.
It sounds like that you've systematized things that there's not a lot of subjective recognition of how well these people are progressing. You've got a system in place for the training and also for their assessment.
We've got it up about as objective as it can be. There are certain things that I don't feel can be fully objective measurements. It’s about as much though as it can be.
You can only go so far, but if you can define those traits of the successful people, what they're doing and how they're acting and list those things out, then it gives you a blueprint for how the next person's going to be. It can change. There can be some modifications here and there and not everybody's the same, but you have a general idea of what makes them successful and people can follow that. That makes things a lot easier, especially on the owners when it comes to training up the next person.Once people understand themselves well, it becomes so much easier to lead others. Click To Tweet
We can say we've got a system around you that you don't have to think about all these little energy-draining elements throughout the day. Our job is to make sure that all that's done for you and that you can focus your attention on the task at hand, which for a lot of people is going to be that patient in front of you. If we can do that, we built a good system.
What's your meeting schedule like? Whether it's in the individual clinics, with your leadership team and with you and the owners. What is your meeting rhythm like?
We have quarterly ownership meetings and monthly leadership team meetings. Every clinic director meets with every person on his or her team once a month as well. We find that when it's too much more frequently than that, people get by meeting. If it goes too much longer than that, we have a lot of people who feel like they're being left out of the loop on what's going on because we have so many things that we're trying to develop and move forward.
The clinics themselves outside of the director and their team members, do they have typical staff meetings once a month as well?
Yes, we try to provide opportunities where we can get together as a group. Our clinics, their farthest apart are about two hours. We try to provide something at least quarterly, we’re doing something fun getting together, nothing to do with work where we can do something fun as a group and everybody can bring their kids. We found that's a helpful element for us too.
We found that same thing. They call them quarterly town halls. They got it out of Verne Harnish's book, Scaling Up. When they can get together, they'll talk a little bit about values or maybe focus on one value, have some activities and get-to-know-you games. It’s huge for the culture and maintaining that and even creating it. People get a lot of buy-in from situations like that.
It has been big. It's probably the thing that I would say we need to continue to get even better at is creating more of those opportunities, more different things that everybody wants to be a part of involved with. We don't want anybody to feel like, “Here's this Saturday morning where I have to go hang out with these people.” That's something that we provide for everybody generally who wants to be involved with.
You want to invest in that because I'm sure you're seeing the impact of it, the ROI on that, culturally speaking is huge. Craig, thanks for your time. I appreciate you expanding a little bit on the article that you wrote in Impact Magazine, Assembling Your Winning Team. You are doing a lot of things great and it shows in your growth. It's impressive. Thanks for coming on.
Thank you for having me.
If people wanted to reach out to you, are you available on email or social media?
Thanks for coming on. I appreciate it.
Craig Phifer, PT, MHA is the owner/CEO of Rehabilitation & Performance Institute.
He is on the Editorial Board for Impact Magazine, and helps PTs start their own practice through craigphifer.com.
He can be reached at firstname.lastname@example.org and on Twitter @craigphifer.
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I’ve got Matt Booth, a physical therapist out of Boise, Idaho on the show. I don’t typically talk a lot about treatment protocols and programs on the show. I've had Tom Dalonzo-Baker and Michele Kehrer. They are experts in what they do but we didn’t really focus on the treatment they provided and that’s the same thing with Matt. He is doing a specific treatment in Idaho and he teaches it across the world called the Fascial Distortion Model, FDM. The interesting thing about his story and how he uses FDM is from a relationship that he has created with his local physicians. The mentality that he uses now as he markets physicians or has marketed with them for the past few years and that is on the peer-to-peer relationship. I typically find for myself as a young owner and many therapists who I talk with that their approach to physician interactions is this is what we do. This is what sets us apart. This is how we treat your patients. We care more. We provide more hands-on therapy. While all of us have been known to share that same message without really standing alone and standing apart.
What Matt brings to the table is a different mentality in what are some of your problem patients or who are some of your most frequent patients and how can we help you treat them? Over time, Matt has become not only a therapist who can collaborate with these physicians but also a teacher of some of the methods that he uses. He has become more popular and gained a lot of notoriety and he became very busy in the Boise area. It’s that mentality that I like in our discussion. We also talked about how he has become free to treat as much or as little as he wants and allows him to instruct in this methodology. Let’s get into the episode. I think you will learn a lot simply from the mentality that he uses in his marketing and how he duplicates himself in the clinic to set himself free.
On this episode, I have Matt Booth, out of Southeast Boise. He’s the Clinic Director at Therapeutic Associates Physical Therapy and also the Cofounder of the Fascial Distortion Model Academy, the FDM Academy. He's been an instructor across the world. He's doing some great things within his clinic, both treatment-wise and for the physical therapy profession. First of all, thanks for coming on, Matt. I appreciate it.
Thank you, Nathan.
Let's get into your story. You've got some interesting stuff. When you first reached out to me, you said you were doing some intriguing things in the physical therapy space. I'm intrigued by not only the treatments that you're providing but more so how that's correlated to the success of your practice and the growth of your practice. Do you mind sharing your story about how you got into things and where you're at?
A number of years ago, a physician, an osteopath talked to me about this new treatment and got me into this course. Little did I know, he was pulling strings. I was the third PT in the US to be taking this class called the Fascial Distortion Model. I took the class and I loved it. I saw greater results fast and things took off from there.
This was many years ago. Was this a local doctor that you were working with?
He was local to Boise. He got me into it. I started doing it more. The patients were raving about it and it helped boost the clinics. We outgrew our previous space and we had to move the clinic for the second time.
That’s simply based on not only your relationship with this physician but the therapy that you're providing. Go ahead and get into that a little bit.
The treatment, Fascial Distortion Model, it's actually assessment and treatment. One of the main differences with it is the physician that came up with it recognizes patients. They tell the story of their symptoms with their hands or their gestures. If they draw a line, it's different than if they point the finger. It's different if they point with multiple fingers or a thumb into a soft tissue spot. It’s different than if they're moving across the joint line. It’s different if they are moving their hand around that can't quite put their finger on it. He identified six different sets of gestures. Those correlated with treatments he had done in the past or new treatments that can be made up on the spot that was likely to get quick results. He developed this model. It was among the osteopathic physicians and then started to get spread more. I got into it like, “This is great in a physical therapist's hands.” We do hands-on work. We can do something fast. The patient loves it because if they'd had any previous treatment, they usually notice, “This is a lot faster than this stuff I had before.” They're getting results quicker and they're out telling their friends about it.
It's all based on the hand motions and their description of their pain and how they're reacting or telling their story.
Telling their story in words, but mostly with their hands. When we teach this, we tell people, “You need to get out of your laptop. You need to be looking at your patient because they're telling me something with their hands. That can tell you which treatment you want to use.” It overlaps well with orthopedics. You might think of it as a soft tissue mobilization, a trans prescription to joint mobilization and joint manipulation. Any variety of different techniques with ASTYM, Gua Sha, Graston and ART. A lot of these things fit into this puzzle, but which techniques are we going to use? There are a lot of different things out there.When we talk to physicians we ask, 'Who are your most difficult (musculoskeletal) patients?' This allows us to talk with them about how we can help and what they can do in the meantime. Click To Tweet
You said it's both an assessment and a treatment model. It sounds like you can assess using this model but treat with any number of different things.
You could call it anything. One of the things I remember doing very early was like, “This is one of the things I learned as an intern.” Many years ago, this was a treatment we were thinking that we were releasing the muscle and there's a different theory for it with the Fascial Distortion Model. The treatment was exactly the same, but the reason I went to do that treatment was that the patient had shown me with their fingertips. They're digging into their upper trap and we're suspecting that there's a certain issue there and there's a set of treatments that we can use for it.
In the DO world, is this fairly common? Do most DOs know about it?
There are more and more DOs that are learning about it. It's been around for many years, so it's relatively new. It's one of those funny things where it's been around, but it hasn't been mainstream enough to be everywhere. It's being taught at more DO schools. I've been helping to teach it at some new medical school here in the Boise area. I went up in Washington, but it's going to more and more of them.
I don't typically have therapists who come on and discuss treatments they're providing and whatnot because we're focused more on business-related topics. The intrigue that I had with you as we talked on the phone prior to this is you've taken that and you've used this model in your relationship with local physicians, especially those who don't know the FDM. I think that's important to highlight and share that even if you're not using the FDM of treatment per se. What you've done is become someone who's talking on a peer-to-peer level with the local physicians. Tell me how do you promote this? How do you talk about this with the local physicians that you might not have done prior to?
It was helping a lot of the family practice physicians. We'd tell them, “There's a class coming to town.” I can't go and say, “There's this physical therapy class.” They're not going to want to go to that. If I say, “There's this class taught by osteopathic physicians, mainly taught to osteopathic physicians,” that spoke to them. I’d say, “It can help you assess and treat your patients faster. Even if you don't do the treatments, at least your differential diagnosis may go faster. Maybe you're not going to need to use as much image in your labs. Maybe those challenging patients that you're not sure like, ‘Is this personable anger? Are they symptom magnifier?’ You may be able to figure that out a lot faster.” I was going to them as a problem solver like, “This could help you with your tough patients. This could help you get through things faster.” Those that are concerned about the cost of care like, “This could reduce some of those costs.” You can use this first line that doesn't work, then you can back up to the medical model. A lot of the musculoskeletal conditions stuff fits into this. You learn this, use it first and then if you want to do some hands-on, great. If not, refer to us and we'd be happy to do it.
Do you recognize that this translates better or that the DOs gravitate to this more than MDs or some of the mid-level practitioners?
It depends. It's a personality. It's like they're Rorschach Test. Some DOs love it and some DOs lost their hands-on skills and they don't care to do that. They might still be interested in the assessment part of it. I have some MD friends that love it and they do it as well, even better than some of the DOs do. Nurse practitioners are doing it. PAs are doing it. It's open to chiropractors and athletic trainers.
As you're inviting them to these courses, did you have a tough time going to the courses initially or did you have an open door because the DO invited you?
I had an open door because a DO invited me. It was almost like the door opened for me and then closed behind me. For a lot of reasons, they had to have more DOs doing it, partly for their certification to get the continuing medical education credits for it. It took a few years before it was opened to other physical therapists. I had to keep beating on the door saying, “This would be great to let PTs in for a number of reasons,” and eventually that happened.
Have you had experience with PTs going to physician-focused courses in the past or what's your experience with that?
I've never heard of PTs and physicians going to the same courses before. There's a little bit in the North American Institute of Orthopedic Manual Therapy. I saw a couple of physicians go to classes there. They’re very cool doctors that they were doing some of this learning about manual therapy, but it’s extremely rare to see that.
Tell me a little bit about your relationship or how do you approach doctors with this technique or maybe even do have a relationship with them. Could someone who's maybe not FDM trained or certified go with the particular techniques that they follow or trust? Maybe learn from you on how to approach physicians regarding that technique. How do they weed out those patients that would do well with the treatment that they focus on and provide?
Do you mean without the FDM?
Yeah, maybe the way you approach it translates well to other techniques that they might be using.
I would say from the assessment part of it, it makes it easier with the FDM of like it's something that can learn. What's nice is having this relationship of being able to talk about, “We can assess and treat things at a higher level.” Maybe it has even given me more confidence of going and talking to the physicians about what we can do as PTs regardless of FDM like, “We're experts in musculoskeletal care. This is our wheelhouse. Tell me about your problem patients. What do you have? Who are your difficult patients to treat in your clinic?” We start talking about, “Those are plantar fasciitis people. Those are sacroiliac joint dysfunction people.” I can talk to you like, “Here are the things that I would look for. Here are the types of things that I like to do. I like those problem patients.” It's still going into them and being a problem solver of like, “Let's figure out what difficulties are in your practice and how can I help.” Instead of going in and asking for, “Can you send me some more patients? I need to see more patients.” Turn it around of like, “What are your problems? Can I help you solve them? I'll make your life easier because I love to treat these types of people.”
I love that message more than the, “We care more,” or “We have a hands-on approach.” All of us have used that in the past, but the issue is we all say the same thing because we all care more than the other guy down the street. We all use our hands more than the other guy down the street. That leads to the commoditization of our services. I love how you go and talk to them, specifically about their patients. Are there certain practices that gravitate more towards this, whether it's a family practitioner versus podiatrists versus a chiropractor versus an orthopedic physician or a neurosurgeon?
I've had referrals from all of those people that like the level of interest or their time attention span. You get up to the orthopedic surgeons and the neurosurgeons, they don't have the time to concentrate on you as a PT so much. I have one ortho-surgeon and he knows that we do something different. I told him about Fascial Distortion Model and he will write on the prescription pad, “Do that thing that you do,” like until we had it on the prescription pad, they don’t even remember what it was. “If it was something different, do that thing that you do.”
Among those other practitioners, the family practice doctors, anyone in family practice, urgent care places, they tend to like this. We can say, “For your work comp patients, if you've got somebody with a sprain or strain, this stuff works best. If you want them back on the job quickly like this week, let's use this.” I had a patient sent from Urgent Care with Achilles tendon issues and he was like, “I'm not sure if I'll be able to get back to this baseball game. It's two days from now.” We saw him for the second time and he's definitely playing. The Urgent Care loves those ankle sprains and knee sprains. The thing they don't like is that often we're so fast that the crutches and boots that they might issue to them, it’s not likely they’ll need them for very long. They're getting out of it often at the first visit.
I would assume that you'd have a lot of success with nurse practitioners and physician assistants. Simply knowing the lack of depth of their schooling, that something like this would be beneficial for them.
My number one referral source is a nurse practitioner and she will bring a lot of force with her hands-on techniques. She does a ton of it. If it works, then she sends the patients over to us. If it doesn't work, then she tells them, “You need more expertise,” and then she still sends them over to us. She doesn't have the time to do the follow-ups, but she loves to use it as part of that assessment.
Do you also teach that to local physical therapists in town?
Since it opened to PTs about a few years ago, it’s slowly catching on. Business-wise for myself, I'm interested in teaching other referral sources about it. I've been out to the physician community, PAs and nurse practitioners. We've had in the past maybe eight classes in the Boise area. There are 60 to 80 practitioners in the area that are doing this. That's for referrals. On top of that, we also work with the family medicine residency program. Every two weeks, we go over to their clinic and we treat their patients at their clinic with one of the residents and a faculty member who's been FDM trained. We're teaching the residents quickly like, “Let's get this going.” The patients are screened. This is a musculoskeletal case that’s likely to succeed with FDM, but then they're learning, “We can do things fast. Maybe we don't need to do injections. Maybe we don't need to do medication. Beyond that, we can also teach them about the other things in physical therapy we do outside of FDM.
The value I want to bring to the audience is finding something, whatever it might be, whatever your techniques are to bring that information to the physician's office and not keeping it to yourself. Training them and teaching them exactly on what you're doing so that they can recognize who is going to be a great candidate for physical therapy and who might not be. Maybe even help them do some treatments on their own. That ends up being maybe beneficial to them in cutting down their episode of care. It can also strengthen that relationship with physicians. You’re many years into FDM, but initially, as you got started, was it hard to get in with those doctors and have those talks about what you're providing and what you're doing or was it pretty smooth getting into it?Your leadership comes from how you're able to provide a platform for other people to provide solutions. Click To Tweet
It depends on the relationship and some of their interest level. Some physicians are wide open and ready to learn new things and others are set of how PTs are. Some of them were easy to talk to and they loved it. Others, it was a learning process. For me, I still need to go in as a problem solver to that conversation of what is it they want to figure out. Even though I'm excited and I think it would help them, that isn't necessarily where they're at that moment. I have to figure out how do I help them figure out that this would be beneficial for them. I have to find their problem first and then show them how they could solve it. If the FDM is helpful for them, that's great. Probably only 5% or 10% of the people I've talked to about it goes to a class, but they know there's something different about that.
I like your mindset because anyone can take the mindset that you talked about, “How can I help them?” Not everyone's going to be open to it. Maybe for another guy out in Kentucky who's looking to grow his practice, not every physician out there is going to be looking for the next physical therapy to send his patients to. What makes you different is you can go to that physician and say, “How can I help you? What kind of patients are you seeing? This is what I would do with them and this is how I can help you.” Coming from that mindset and from that perspective instead of, “How am I going to soak in more patients out of this guy,” it puts you in a different position and helps you show that you care and that you are a peer. You can show that you have some knowledge. I think doctors would appreciate that.
That has carried over and helped us in some of our other programs like men's health and women's health. They don't know what some of the things we can do. They never knew there was an option besides the medication or surgery for incontinence, pain problems in the pelvic area. It carries over for sure.
What do you see in the future? What are you going to be working on in the next few years?
Things are going a few different ways. We're starting to teach into physical therapy schools. We’ve gone down to Rocky Mountain University in Provo, Utah. We get a lot of interns from there. We’re looking at getting into more PT schools. We’re definitely working with more medical schools and those classes where we have combined. Sometimes we've had seven or eight different types of professionals in a class like MD, DO, PT, PTA, chiropractor or athletic trainer. It's cool seeing like, “We're all going to work with this one model, but we all have a different way of looking at the patient.” The class has become a networking opportunity so that people there are like, “I need to get your number. I didn't know where you're at. We might be even 100 to 500 miles away. I didn't know where you are, so I can send patients.”
You're the Cofounder of the FDM Academy. For someone who might have a treatment idea or interested in getting into continuing education as a presenter or speaker, maybe they’ve got some good treatments that they're providing and they want to spread the knowledge. What would you recommend to them to break into that field and get known?
This fell into my lap so easily. I don't know if I'm the best person to answer that one.
Did you have some hurdles along the way? Even at the very beginning to spread the message, whether it's the doctors or physical therapists that you could say, “If I were to do it again, I might recommend someone to do it this way.”
I'd love it if we had more research. That would be great, but it is interesting how long it takes to get research going. There is some research out about FDM. We took it to the Cleveland Clinic and PT there, they're big on it. After the first day, he's like, “This is great.” He had ideas for seven different studies. It's been a couple of years and he hasn't finished the first one yet. It takes on to get these going and then publish. A time machine could go back 40 years, dropped us off of somebody and then catch up with them now.
We’ll be ahead of the curve at that point. You find that if you can get published, then that's a huge boom to whatever you're proposing.
Getting research out there, that's wonderful. It's not my cup of tea. I'm not great at it. Being an instructor for this, I have a conflict of interest. It’s not my baby. If I was on the title for a research thing, I have a conflict of interest. That's going to taint the article. I'll throw up my hands and say, “I'm not the guy, but there are smart researchers out there that are starting to work on this.”
You're the Cofounder of FDM Academy, you're the Clinic Director at your own clinic and then you're traveling across the world presenting and doing these seminars. Are you treating full-time? I'm wondering about your schedule and how you manage your time.
I'm wondering about my schedule too. I wonder how I manage my time. My wife says that when retirement comes, I won't know what to do with myself and not reinventing something else. I like to stay busy. On top of all that, I'm usually training for a Half-Ironman Triathlon or a Full-Ironman Triathlon like every six months, Half-Ironman, a few years ago it was a Full-Ironman. I like to stay busy.
How often are you treating? How much time are you treating per week?
I would see probably 50 patients in a week. I'm there the whole week. That's returning visits, 30 minutes and clinical evaluation, 60 minutes.
You're a super busy guy. My recommendation is always that PTs, especially owners or directors of their clinics have two days a week where they were focusing on admin stuff. It's impressive that you're able to keep that schedule and that patient load.
I have a good team around me at my clinic. They help out and people have stepped up and do other leadership roles. Part of my lead as being the director has been helping others to lead. As among the aides, staff PTs and my front office, they all get their own thing to do and they get incentivized in different ways. That makes my life easier and then allows me to go on these teaching trips.
There you go because it seems like you've obtained that capability of having the freedom that you want in your practice. It's simply because of that. I want to highlight that to the audiences is that you've developed a leadership team to do the things that you need them to do to keep the clinic running and successful. You have admin, systems and procedures in place because Therapeutic Associates has been around for decades. You've got a lot of policies and procedures already out there that provides you with the freedom then to treat as much as you want. I'm sure you could treat less than 50 patients a week if you wanted to, but also train for Ironman and cofound an academy. That's impressive.
It is fulfilling to be able to do all this. It keeps you from getting bored and doing one thing too much. This balance keeps the juices flowing. When I go out and teach, it's a lot of stress to go out and do those things. Sometimes I'm presenting mostly to physicians or one time it was to the only physician. I was at the A.T. Still University, the first osteopathic medical school in the world. The stage fright there was like, “I'm at the Mecca of where osteopathic medicine developed and I'm lecturing them as a PT.” I have to think this is osteopathic techniques. It's an assessment and I have tons of quotes from A.T. Still in my lecture. It's okay. It's good.
That’s impressive because it's important as we get older into the physical therapy profession that if you were treating simply full-time all day every day, that could be difficult. It's important to grow, whether that's in terms of leadership and doing other things to keep the energy level up.
I have to credit my team. There are multiple people in my clinic that have helped me get to where I am. Even in the growth phase of when we started doing more FDM and we're getting busier, it was my clinic staff that came to me and said, “Here's all the data on why we can no longer stay in this clinic and we need to expand. We need to move.” They told that to me. The more I learned about leadership, the simplified way I tell them at the staff meeting is, “If I get out of the way, you guys do a great job.”
Out of entry, are there certain leadership books that you read, follow, techniques or whatnot?
Therapeutic Associates has a leadership training program called Hot House. We do a ton of stuff with that. We do a Myers-Briggs type of personality thing. You take that information and then that is put into this training program. The leaders of our program are improv actors. I've got us out of our comfort zone of doing some improv type of acting in some of our work with different tools. Trying to get us out of our comfort zone but let us help the other people in our team lead. The leadership was so much about us leading in a more top-down approach. It was a bottom-up of like, everyone's in this and we listen to them. Our aides have wonderful ideas. We have to give them an outlet for it and make them feel that they're heard, it's worth it and we need that.
That's impressive because no matter where you're at across the country, but if you're the owner and director, your leadership comes from what you're able to provide a platform and outlet for other people to provide solutions and help them understand that you're not the answer man for everything. They can provide solutions and create an environment that they want to work in. That's impressive that you'd done that. You've also seemed to probably duplicate yourself because you've trained these people in FDM and what you expect out of your treatments and protocols and how things should be done. You've been able to essentially duplicate Matt Booth a few times over within the clinic.There are plenty of people that can do a lot of things better than you can. Click To Tweet
We take as much as it's helpful the duplication process. We don't want complete duplicates of me, but that's what's great about when people are coming to me. The clinic has been around for seventeen years. I have a lot of people asking for me, but I can say, “Go to my other PT. They'd been trained in this and they can do these other things too.” I can offload in my schedule. I don't need to be there for everybody, but I can train to be there for everybody.
That's where you've probably started gaining your freedom is you've been able to, I say duplicate yourself, but where you're not carbon copies. Duplicate what you do in the treatments that you provide so that you have not only faith in the practitioners, but you can then express that faith to the patients who are asking for you and move them along to the practitioners. Also, seeing that things get done the way you want them to get done with your admin staff, your techs, support staff and whatnot. That's where you've found a lot of freedom is what I can tell.
Patients that come to me that think that I can do everything, it's great than to say sometimes like they want me to schedule them or do something else. I'm like, “No, we have policies and procedures here and one of those is we make it director-proof. If I can't do it, it's director-proof. That means I can't screw it up. Someone else is going to do that task for you because they can do it much better than I can.”
An important lesson to learn is that there are plenty of people that can do a lot of things better than you can and give them the ability to do so. Is there anything else you want to share with us, Matt?
You ask where FDM is going, one of the things that we're doing, we’re doing some global outreach. They took FDM down to Belize and we taught six Belizean doctors how to do FDM. We had a great experience there. They're considered third-world country bordering on into the second-world country, but there are not a lot of resources there. I heard of this before I’ve gone to Africa for a teaching trip as well. In that situation, it is so cool to see something that has no cost to it. There are no real tools involved. You use your eyes, your brains and your hands and you can help people quickly. To see it put in action, we did a couple of clinic days. We had about 100 patients that we treated in two days after we did the training, and 95 out of 100 were better.
The doctors were blown away like, “If we had known how to do this before, we would have given them NSAIDs. We would have told them to go to the hospital and maybe surgery. We couldn't have worked on all these people and gotten them better so quickly. We're going to go back there year after year and do more training with the doctors. It was even cool for our American friends going down to help with the training. They were getting so much experience on these people that need your help. Think of first-world problems like some of my patients back home are like, “This was pretty minor for you.” This person in Belize, this is the difference between their food getting on the table or not. The pressure is on when we go out and treat. It’s like you need to get this person better right now. All the people were going and said it helped enhance their hands-on skills. They have the thinking cap on of, “I have to do my best to get this person as good as possible now before they leave.” That was a great experience.
Do you have other service projects plan like that in the future?
We have another one to Belize in February. We're probably going to go there for a few years. One of the physicians looks like she is interested in becoming an instructor. She needs to be able to help out with Central America and then they go on to other countries that are needy. Everyone I've talked to loves this thing because it's cheap. It doesn't cost anything. You just learn it and then you go do it.
Thank you for your work. That's a great story. It's impressive. If people wanted to reach out to you or find out more about FDM or Therapeutic Associates, how would they get in touch with you?
Email works well for me. Email at email@example.com, that stands for Therapeutic Associates Incorporated PT. Email is the best.
Thanks again for your time. I appreciate it.
Thank you, Nathan.
Dr. Matt Booth is a graduate of the University of Southern California, earning both a Bachelor’s in Exercise Science and his Doctor of Physical Therapy degree. He has been the director of Therapeutic Associates Physical Therapy – Southeast Boise since 2002.
In 2010 he was introduced to Fascial Distortion Model (FDM), finding better results for his patients, and an opportunity for the entire physical therapy profession to provide better care. Since that time he has immersed himself in FDM, as well as paving the way for physical therapists to also be trained in FDM.
In addition to being an Instructor of FDM through the American FDM Association, he also teaches FDM to physician Residents in the Family Medicine Residency of Idaho. Dr. Booth has taught and presented on FDM nationally and internationally, including classes at the Cleveland Clinic, the Mayo Clinic, in Burkina Faso, Africa, Canada, a global service trip to Belize, and at the FDM World Congress in Cologne, Germany.
He is Clinical Faculty for the University of Washington Medical School – Family Medicine, and the Idaho College of Osteopathic Medicine. When not in the clinic or teaching, he can be found with his family training for his next Ironman Triathlon.