Graham Sessions Unplugged: Reimbursement, Students & the Future of PT

0:00 You're listening to the P.T. Pinecast, where smart people in healthcare come to make noise. Here's your host, Jimmy McKay. Here's your host, Jimmy McKay, still pushing buttons as we go live. And we're live. There we are. Sky Donovan, Mike Ring, welcome to your live stream from Graham Sessions. Thanks, Jimmy. This is your first Graham Sessions? It is, yeah. This is your first? My first. Look at this. Very odd to me. That's weird. Because you're very elbow-rubby in APTA. But I don't own a private practice. Oh, that's a good point. Yeah, but you're a big thinker. I like to think I think. I think you're right. We're going very Dr. Seuss here. All right.

0:40 Yeah. So that is a good point. I just see I know you're in academics, but to me, you're sort of everywhere in PT. But Mike, background, back of the baseball card. How long you own your practice? Sixteen years. Yeah. Sixteen years. Good for you. Our second location, actually, December four. Can you see it from here? You can't quite close. It's not close enough to see. Close enough. All right, so why'd you come? How was this framed for you as a practice owner? I was thinking about this. A lot of practice owners in there. Leaving a practice for a day is hard. Your business is going on. So how was this framed for you to come to something like this? What did you expect, and then what has been delivered?

1:22 To be honest, this was the first time I knew this existed. I literally had no idea that Graham Sessions was a thing. I got an email from private practice section. And so I don't know if it was because I was at the past couple of PPS meetings or how I got on the list, but I did. I looked at the content. I was like, actually, you know what? That's kind of cool. And it actually worked out great because I don't see patients on Friday anyway. Jackpot. And then Sky, APJ vice president, you get brought to lots of different things in the corner of PT. Being in PT for a long time, right, in the profession. Are you calling me old? No. Walked right into that one. Good.

2:02 But no, you've been in PT for how long? Been around a long time. Uh, not as long as you think. Orthopedics, academics? Yeah, I mean, I've been a PT since two thousand three. Okay. So twenty three years. So, uh, what were you expecting and what are you seeing from, I mean, you're like, you're sort of like the down the middle person this is designed for and you're not, which means you're both going to look at what is going on here differently. So what did you expect was going to happen? What did I expect was going to happen has happened, was that I was going to hear totally different perspectives than I usually hear. So I love conferences like this because I'm not exposed to this kind of lens and thought about their everyday lives.

2:45 And also the meta, like how can we change things so they're better for the future? So that has been really good for me. And I got to meet a ton of people that I've never met before. So I always love that. This isn't the area you're normally in. Yeah, so I get to listen a lot, which is so cool. When you looked at the agenda, as a practice owner, what made you say, ooh, yeah, let's drill down on this. That's exciting. Yeah, so there were a couple things. One was the opportunity to hear a little bit more about the APTA's decisions specifically with DEI stuff, right? So that was very interesting to me. And then a couple of other pieces were, you know, talking about where we are with reimbursement, honestly, where we are with reimbursement, how we're going about changing things, what our plan is, what are some of the options.

3:33 One of the things that I'd like to hear a little more, quite honestly. That's my next question. Keep going, keep going. We've talked a lot about the what's wrong. and I'd like to hear a little bit more about here's some options. Here's some solutions. So we know it's wrong. We know reimbursement's declining. We know we're having a harder and harder time. We're getting squeezed. We're one of the very few industries that is not tied to inflation. I can raise my prices all I want. I'm not going to get paid a dime more just because inflation went up. So how do we combat that? So I'd like to hear a little bit more of that kind of conversation, and maybe we will today or tomorrow. In what format? Like people who've done stuff and then they walk you backwards and reverse engineer that for you?

4:15 Correct. Exactly. Exactly. So we know there's a couple options out there and we've heard a lot of those options that they exist and maybe we didn't know they existed. But I'd like to hear some more about how do you get there? How do you get from point A to point B? Right. that's why like a show like bar rescue is kind of cool i mean i know it's you know it's sort of set up right but it's like we go in there and there's the glaring problem john taffrey yells and screams but they do a pressure test everything explodes the owner loses their mind but then they go all right now here's how we're going to fix it and i really like when they do an episode that they go hey remember that episode from three years ago well they're still in business or they've tripled their whatever you're like oh yeah this stuff works over time Which is good. What's something that you thought should have been on the menu?

4:56 Oh, that's not what I thought you were going to ask me. I thought you were going to ask me the question you asked him. No, you're on a practice. But how would you have answered that one? I am really looking forward to tomorrow because I have the good fortune of being on a panel. And I get caught in a vacuum of listening of how to solve the problems from academics. And I really want to hear what a business person has to say about how we can solve this problem. I watch that a lot. I get caught in that a lot, right? Because I do live streams with business owners and we're like, you know, academic this, this, this. And then I know somebody who's in academics and you're like, okay, I see what you're saying. But actually, that's not how, not even just how it works.

5:36 It's like, we've tried that or you can't do that because of A, B, X, Y, Z. So it's good to know that. Why don't you just do this? And you're like, oh, hey, thank you for pointing out that thing that's so obvious in my line of work that I can't do because of these seventeen reasons. You're like, oh, I didn't know that. Sorry. So to answer your question, not be a bad guest, the question that you did ask me, what did I want to see? Or what did you look at and say, oh, I thought that would have been an edgy top, like something Graham Session worthy that wasn't? knowing that they can't put everything. Right, they can't put everything because it's a pretty small conference. But I don't know. I would have liked to see something. And we touched on this a little bit, but like...

6:18 How to maintain your optimism. Okay. Or how to continue to think big in a world that seems to be more restrictive. Squeezing. Yeah. Going into the diamonds caused under pressure. Yeah. So how do we keep diamonding? Yeah. I would say Rihanna, but there's no way. We can do that. We'll do that later. And I was just talking with Patrick Graham. You guys are following Patrick Graham, the guy... this thing's named after. And he and I both concluded, I was like, these are great discussions. I'm like, Patrick, but where's the real, where's the real conversation? He's like the bar. And I'm like, right. We know that the answer, which is why this podcast, how this podcast originated. If you were to be on the planning committee for next year, what would you be like this?

7:02 Either I'm going to give this talk or I need, this needs to be here next year. What would you do if you had sixteen years? What do they say? Ninety percent of the biggest person, three years. And if you make it past three years, it's like, dude. Yeah, exactly. So what I would probably say is one of the topics and Sky just sort of touched on it. You know, how do you maintain the optimism? How do you how can we sort of combat all the challenges that we're facing as a profession right now? without changing the quality of what we do, right? So I would sort of focus on that piece. I'd say, all right, well, what's successful? What works? How does it work? And how do you make sure that we value our people, that we value the care we give, and put that above all else?

7:44 We stop competing with each other, right? We stop competing with other PT practices, and we focus on competing to get paid what we deserve, right? And what's the key to that piece, I think? You are in academics. You take people to work for you who have just graduated from academics. What's something that you think is important? Right now, the discussion going on right now is about generations. And we're like, what's important to you? And how do I figure that out instead of these kids today? These kids today... It's usually followed by a negative. Some of these kids today are so innovative. It's usually negative. But how do you or how have you over sixteen years been able to say like, all right, here here is a generational divide and I need to figure out how to incentivize or work with this person when they value something drastically than I did?

8:36 Yeah. So I think I think that answer is it's probably pretty simple, but maybe not easy. uh the great things are yeah right and so um it's just doing what we as physical therapists do the best right from we talked earlier today about the diagnostic tools that are now potentially available in a bunch of different states but I still think the thing we do the best is listen. And if we listen to the new graduates, to the prospective hires, and figure out what motivates them, figure out what they want to do. Do they wanna own a practice someday? Do they wanna manage a practice someday? What do they wanna see? They wanna see a bunch of athletes that like geriatric populations? Talk to people, listen to them, figure out what they want, then figure out a way we can provide that build that right build that so that because listen if you came to work for me jimmy and and you said mike i really only want to see soccer players and basketball players i said okay you know what i will do everything i can to get you that population you got to work with me a little bit as often as possible i need to fill up your schedule but as much as we can i will get you relationships with the people who are going to send you that population and i'll support you because this is what you love right honestly if you do what you love It's great.

9:41 Right. What's the old saying? You never work a day in your life. Right. Right. Yeah. I believe that's very true. I heard a great interview question that you can find something like this out, tease it out, which is, uh, the guy taught me to ask, uh, in the initial interview, when you're hiring a clinician, um, if you were to quit in two years, why, why, why would that be? And if they're, if they say something like, well, if you didn't pay me enough or if it was like, there's no growth or I wasn't seeing that there, instead of saying like, What do you need? It's saying, why would you leave? It turns it into a story. That's why people don't leave his clinic. I mean, really, he listens to them and he helps them see what's valuable to them and then he tries to make it happen.

10:22 I feel like you pointed out that the job of a business owner is to create a good environment. and listen but the job of clinician is to create a great environment and listen differently right but doing both of those things for different audiences can lead to success absolutely you see and interact with students long before they graduate and join the workforce um what can academics teach business about these things or how to predict what's coming like i feel like you should just be like writing messages in a bottle to mike and be like okay in six years these students are gonna be like this and you should do this I really think we need to be better in academics about having it be bi-directional because we get a lot of these kids today, we get it from the clinics and they're like, you guys aren't doing a good enough job in academics to prepare them for what real life clinic is like now.

11:15 So I think that we should be working together more to sort of develop a curriculum and a more, you know, in context learning experience so they can understand what the current challenges but then how do they turn those into opportunities i'm always thinking about too like we need to give them more for what they're paying for and what they're doing like students you mean yeah i mean like i just think about can we give them a skill set where it's like how do we get them to be more entrepreneurial and how do we do design thinking because we can't just prepare them for the way that how I practice physical therapy, you know, it's like, we have to prepare them to be like, what's the next thing.

11:58 And if we want the profession to move forward, we should also spend some time developing almost like what you'd see in a business curriculum, not how to open a business, but how do you have that mindset to think bigger than what we are now? Cause I'm always also thinking about the profession and it's like, we keep having the same discussion over and over again. Like, why don't people know what we do? Like, Why don't people see the value? We know that we give great care and it's more economical and we do prevention, but it's like, no, still, we're not moving the needle as far as we can. So I'm sort of like, well, do we create armies of people who, you know what I mean? Like, I am not the first person to say this, but why do we teach goniometry?

12:40 goniometry over sixteen weeks. I don't know. It's the same device. Just pick a different joint. Maybe we just do, here's one ball and socket, here's one hinge joint. Do it on the upper and lower extremity. We'll teach you the spine. I get it. There's academic bloat. What do you take out? What do you put in? But I think we have to rethink it. Love it. Yeah. Same question, but different point in life. How do you know when someone walks in who's just graduated, who's going to be a great clinician? And how can you tell when someone walks in, they're going to be a great student? So what are you looking for?

13:21 What are the things that you're like, yeah. great clinicians, probably, mostly for me, when I sit down with somebody for an interview, the kind of things I want to hear from them are not about all the different things they've seen in other clinics or as a student or anything like that. It's It's probably hard to quantify. It's, it's a motivation. It's a, it's a desire to see. And it's a passion. If they've got a passion about something, if they, if they can explain to me something they love, and it's one of the questions I always ask is, tell me what you love. What do you love about physical therapy? Like, why do you love physical therapy? And quite honestly, I've had some interviews where they, well, I'm not sure I do. You're like, got it. And you're just drawing a right line.

14:02 Well, so maybe, but, but the first question I asked after that is, why? I love what I do. I love what I do every day since I've been doing it. I've been doing it for twenty five years. So like I don't know how you couldn't love this. Tell me about where you work now. Tell me about your last experience. What was not to love? What would you not like about that? Right. Because then I'll get a sense of because if they describe my office and they don't love that and they don't love that, they're not going to love me. Right. And they're not going to come work for me. But if they describe an office where they're asked to see thirty patients a day and they're not given the time and not given the support and they're not given Con Ed and they're not given any sort of professional development or encouragement to pursue their passion. I was like, well, I can fix that.

14:42 I can take care of that. So you're at you're teasing out as an environmental or internal. Yep. And if it's internal, I can't fix that. I can't fix that. There's nothing. But if you were in a crappy situation, let's get you in a better situation. Yeah, exactly. Yeah. Okay. Great answer. So how do you want to answer this? Do you want to answer what makes, what do you see that you know that this person is going to be a good student? Or what do you see while they're a student that you're like, Oh, this person's going to have, this person's going to do great things. I think the answer is the same. Okay, good. And I think it is people who are successful, who have enough self-awareness to be open to change. I think PT school is very challenging and the people who are sort of like this is not going to be forever.

15:26 I may need help in this. I'm excelling at this and I'm going to go like show my skills to somebody else. And I'm going to feel proud of myself for that two weeks that I actually had my stuff together out of a hundred and twelve weeks. I had two. But I think it's the person who is adaptable and they are willing to like know who they are, what their shortcomings are, what their strengths are, and be able to kind of like be okay with all of that because that kind of a person is going to be like our patients come in like that too. Right. So that kind of a person is like someone who's like, the job's going to be different every day. I'm going to be working with different people every day. I'm willing to learn about them.

16:07 I'm open to growing as an individual myself and not being kind of like stuck in the like, every day is going to be horrible and I'm not doing great. And it's like, can we just sort of rise above and like the students that really see this as a opportunity to live in the moment and do all the things in the moment, but this is just for now. And they have the capacity to be something different at the end. Do you remember when I had a clinical in an underground mall? I remember that. What was the name of that mall? It was like an underground bomb shelter. It doesn't even exist anymore. It was in Crystal City. It was across from Panagon. It was in Crystal City.

16:48 It's right here. So I was in the food court of an underground mall. It was a national chain. I'm not going to throw them under the bus. And I literally remember messaging you and being like, is this it? And you were like, no. And I was like, well, this feels like this... I like to think I'm pretty resilient, like at least like a B plus. But I was like, what are we doing? And my CI was rubbing butts through jeans. He was like, dude, I remember just being like, I don't know what I'm doing here. Yeah. Underground mall where I was looking at a subway restaurant because I was in the food court. Yeah. And that was fun. But I think I said something to the effect because I say it all the time.

17:30 Well, I think I said something like you can learn as much about what you don't want. Right. And that's a valuable experience. It is. Yeah, that's right. Look at it more like sculpture. Like, what are we chipping away? We're not going to have that. Got it. You need windows. All right. Check. Because literally it was like winter. It was like now. So I would go to work at like in dark, zero dark thirty. I would leave at zero dark thirty. Never saw the sun. Never saw the sun. And I was just like, this is great. This is this. I used to play rock music loud and give away beer and concert tickets. But now we're rubbing butts through jeans. And this is my job. I'm like, cool. In the dungeon. And I'm like, well, at least there's this on the bright side. There's a subway right there. Got as many subway punch things. And I got a free footlong.

18:11 um uh is there anything i didn't ask you didn't ask me what session i want to see oh yeah sorry i forgot what would you put on the docket how to have a nerd lunch What's a nerd lunch? Oh, I have them all the time. What is a nerd lunch? So you know what a nerd lunch is. Do I? Yeah, because you've been to one. I have. You're going to be invited to the next one. I eat lunch with myself. Yeah, no. So where you have a lunch and or it doesn't have to be lunch. You have a moment and it's on a repetitive schedule and you have a group of people that do things that are completely opposite to you. So it's like your accountability group. It's like, how do you form that? Like if our group chat was just like, we're going to meet Fridays at one, twelve to one.

18:53 Right. We all do in our group chat is like a bunch of PTs. But I don't think do any of us do the same thing now? Yeah. And why is that good? because I've said this before, it's like, we gotta get out of the silo. So I think having people that are comfortable enough to challenge you, and I think it's even better when they're outside of the profession, because they just look at things so differently. Yeah. So I'm just going to come back. I'm doing a cohort. I'm a teacher now. I'm teaching people how to podcast. So I've been asked before. I was like, I'll do it, but only if a couple of you are going to do it at once because it doesn't make any sense. So I've got three or four people going through this at the same time. And week one or two, I was like, this is your homework.

19:35 Who are you talking to? Make up a fake person. As dumb as it sounds, exercise actually helps. And they're going through it and they're doing their thing. And then week two is like, now I want you to like, now it's what's one episode for this? What's one problem? And the funny part is the person who their podcast is launching is like really hard to articulate what they're trying to do. The other two people are like, oh, no, no, no, this is it. And they're able to rattle it off so damn easy. And then like, how are you doing that? I'm like, watch, you're going to be able to do it for him. He's going to be able to do it. You're going to be able to do it for the other people. You have the curse of knowledge. Like you've exhausted all the probable solutions because you know this space.

20:16 And then you get another person that comes in and they're like, I've been tried this thing that you've never heard of. And you're like, no, what is that? Three M the company three M did this. they couldn't figure out how to do some engineering thing. And they were like, some entrepreneurial Scotsman came up with this idea. Essentially he created open source problem solutions. So they were like, all right, we're gonna put this on a website and we'll put a bounty on it. So some like, the famous story that I heard on a podcast was some shepherd was like, well, have you tried this? And these engineers were like, what the hell is that? And like, oh, well, we've, this, this, this, and it solved it. you needed a shepherd to solve an engineering problem why because engineers are taught engineering things they don't know how to get the flock out of here um all right uh is there anything i didn't ask about uh graham sessions or you know uh yeah all right we'll wrap up uh last thing we do on the uh episodes we call it the parting shot This is the parting shot.

21:17 One last mic drop moment. No pressure. Just your legacy on the line. I will point out, I've been doing the parting shot for a decade. And just twenty eight minutes ago in Graham Sessions, someone on stage, I won't say who, but a pretty prominent person was like, do we have any other parting shots? And I was like, that's my turn. That's when you know you've been saying something over here. All right. Parting shot. Just last chance for whatever. Mic drop moment. Soapbox statement. Something. What do you got? I think the main take home for me from this whole Graham session has been, if you find people who love what they do, you'll be successful running a private practice. But you got to find people who love what they do and support them.

21:58 You know, one of the other, I feel like I've been saying a whole bunch of sayings today, but I apologize. um is hire people smarter than you yeah right and let them do what they're good at yeah that second part's not easy like that's why steve jobs that's why that's so there's a cliche right but have you been in that situation have you been the person hired and then told what and how to do oh yeah sure and that's terribly frustrating and then the boss is like why isn't this working well yeah i think i said the other day which was uh In the context, it was the CEO kept messing with marketing. And I think my response was something like, well, if you keep putting your fingers in the soup, don't be pissed. It tastes like fingers.

22:40 Stop touching the marketing and then it won't taste like fingers. But it's simple, but not easy. Parting shot. Clears before beers. I think that was my first party. That was her party shot like ten years ago. Yeah, I'm saying that to my kids. I'm like, just please, clues before beers. So I heard this yesterday. So it wasn't at Graham Sessions, but I heard it yesterday. So we were sort of like in the lead up to Graham Sessions and it was find the extraordinary in the ordinary. Oh, what does that mean? What do you think that what is that? What do you? I think you can mean whatever you want it to mean. I think it's like about reinvesting in wonderment because I think right now we don't have a lot of wonder in our lives. Good. So I've been trying to spend some time.

23:21 I wonder what we should do. Did you find this at dinner last night? With the dinner that you were at. At dinner last night, I pointed out to people, you know, I was a typical twenty five year old rock radio DJ. We would make fun of things and people. That was our job, like to sort of be a dick. And now I'm like, like if I find out someone likes, I don't know, Pokemon or Disney or whatever. I used to be like, this is lame. Now I'm like just excited that they're excited, like finding extraordinary. I'm like, I don't care about Disney or whatever, but I'm like, that's cool. Why do you like that? i'm never gonna like that thing that's okay but it's like i'm actually excited you you're super into hula hooping tell me more about the hula hoop uh uh you know community and how i can be a part of it um so this is fun uh i appreciate you guys doing this now uh we should dip out of graham sessions early and go to dinner sounds like a plan That's it for this one, but we're just getting warmed up.

24:17 Smash follow, send it to a friend, or crank up the next episode. Want to go deeper? Hit us at pgpinecast.com or find us on YouTube and socials at pgpinecast. And legally, none of this was advice. It's for entertainment purposes only. Bulls**t! See, Keith? We read the script. Happy now?