The PT Future Is Full Stack: What That Means for You

0:00 you're listening to the pt pinecat where smart people in healthcare come to make noise here's your host jimmy mckay voice guy big thanks to empower emr if your clinic is stuck on an emr that slows you down Well, that's a choice that you are making. It's a bad choice. Empower EMR gives you speed, clean workflows, and features PTs actually asked for. Better notes, faster documentation, smoother operations. All wrapped up in customer support that doesn't ghost you. Upgrade your clinic's brain. I mean, that's kind of what it is, right? Your EMR. Upgrade your clinic's brain with Empower EMR. You're waiting for the website so you can go kick the tires?

0:41 Good. EmpowerEMR.com. That is EmpowerEMR.com. Guests today have stood on both sides of a stethoscope. First as PTs, then architects of the digital health revolution. Intrigued, are you? One race cross country on skis. The other crushes anime marathons. Same thing, right? Together, they're making sense of CMS innovation pilots, RTM codes, and the hybrid care wave. reshaping rehab whether you like it or not their newsletter is where clinicians go to learn how tech policy and business are reshaping healthcare delivery you don't want to be surprised by these things be ahead of the curve at least a little uh get ready to meet the co-creators of full stack healthcare ryan and jonathan jumping in the studio there they are gentlemen welcome to the show Love it.

1:33 Yeah. Let's start with the why. Write a newsletter, creating a podcast, doing anything. It's effort, man. It's work. So let's start with the why behind this. Why did you guys feel the need to create this? You saw something that wasn't there and you were like, I want it to become. So I don't care which one goes first, but there needs to be a why. And they could be two different whys for both of you. I mean, I'll start where, honestly, Sharky and I have worked together for, God, it was like five years. And we had all these conversations on the side about all this stuff. We were kind of like, hey, what's going on? How is this working? I had no idea how all these business models worked forever. And I was just like, hey, I have to talk this out. We had all these side conversations.

2:15 We're like, okay, this is awesome. I have a better understanding. And at some point I was like, okay, when I started to talk to other people, they had the exact same questions. And I'm like, why am I not taking this stuff and just sharing it? Why are we not putting all these thoughts on paper? So there was like two false starts. To be honest, I tried my own personal thing. Didn't work. Tried a different one. Didn't work. I just kind of kept falling off. And Sharky and I, I think what was really helpful, we had coffee up here in Seattle, and it just came down to like, hey, dude, let's do this together. And what's been really helpful is just having a partner to hold each other accountable. He's like, hey, Shaki, like, okay, I'm going to do this because I want to get this out and I'm not going to overthink it.

2:55 And that's been the thing that's actually like made it stick this time around. So you're like a verbal processor like me, which is like, you could give me the exact instruction manual. And I'm like, great. I need to talk. Like, can you read that and then explain it to me? It's just how my brain brains. Ryan, same for you. Different. Similar. Yeah, definitely similar. I think this is probably the most exciting thing that's happening to health care right now, in my opinion. And so a lot of the digital transformation that's happened really the last, I'm going to say, ten years, pretty much since the Affordable Care Act kind of kicked a lot of this off, has been increasingly more exciting.

3:40 And so, yeah, I think John and I both kind of share this, you know, both curiosity towards like what what is it that's really going on underneath the hood here? But but also, you know, we see this as sort of a future that we're, you know, we're kind of hoping that health care runs runs toward that. It's going to have sort of this this inner interwoven, you know, human and digital aspect to it that just, you know, allows things to be so much more seamless for everybody. You're going to be naive if you say this isn't a thing, right? So first, we'll get it out of the way. Where can someone go? I'll put it in the show notes, but where can someone go if they're like, all right, got it. How can I get this delivered to me? Where do they find Fullstack Healthcare?

4:21 Yeah, well, they can find us on Substack at Fullstack Healthcare is our primary newsletter. Also, feel free to follow John and I on LinkedIn. We're going to be out there continuing to spread the word. All right. So let's dig into this. You talk about new care models. That's what John just sort of led off with. Not just RTM or telehealth alone, but a full stack of delivery formats. I see what you did there. What does that actually look like in real clinics? Because I'll go through the whole, I think it's the Schopenhauer quote. said all truth passes through three stages first it's ridiculed second it's violently opposed yeah third it's then accepted and then people just go oh of course this is going to be a way so i don't know where we are i think we're still in ridicule like we're sniffing it around maybe we're violent i mean i think we all go through these phases but those are the three phases of grief or whatever whenever something new showed up I've got this thing in my pocket.

5:17 I don't know if you guys have one of these. This is a smartphone. When I saw this in two thousand and eight, I was running multiple radio stations. I immediately started looking for the door because I was like, people were ridiculing it. Then they were violently opposing it. And I was like, that's when I know this is a thing. So, so I guess my question is like, what is, what does that actually look like in real clinics in terms of a full stack delivery format? Paint us the future or, you know, current picture. Sharky, you want to go? Yeah, I'll take that one. You know, you're, You're looking right now at a system that asks for, continue to bring patients into the door.

6:00 And that's how every clinic is paid. They're paid simply by the number of bodies that come in the door. And that's where you get some of the terms of some of the mills and some of these clinics that are just going on volume. And what you're going to see moving forward is, That's fine. You're solving an access issue, but solve an outcomes issue. You're really going to start to see a shift towards what are the outcomes that you're producing. It doesn't matter how it's produced. It can be produced by having someone come into your clinic ten times.

6:40 It can be produced by having them come in once and you're just sending them whatever it is, the exercise plan plus just checking in with them plus You know, whatever else you need to do to make sure that that outcome is achieved. You know, that's really what, you know, what the future of health care is looking for. Yeah. Yeah. What would you add to that, John? Yes. I mean, like we looked at this in the very first, I think, two or three articles that we wrote were all about this idea of, OK, what we see right now are these like pockets. So we see a large health system. They'll have a virtual telehealth team. They'll have some people doing RTM on the side. They may have a partnership with some digital health vendor that provides messaging only services.

7:22 It's all kind of like broken out. Piecemealed. Super piecemeal. It's super fragmented. And then even health plans are doing this, right? It's like I've had Primera and I have Regions. You look at their thing and they have these things, but they're all like different solutions, right? So you can see they're trying to stitch it together, but it's just, it's super fragmented. So as a patient, you're going through, you're like, okay, cool. Like I interacted with Jimmy on the telephone. I acted with this messaging service. They're not talking to each other. So we're seeing this, like, they're all trying to figure it out as an organization, but nobody has really brought it together. So the entire thing is together. So that's kind of what we're, that's kind of how shark, you know what I'm saying? It's like, it's the parts are there.

8:04 They just have to figure out how to stitch it all together. So we still like in the, you know, the baby deer Bambi side of, you know, situation where, you know, it's amazing deer come out being able to walk, but they're just not great at it, but they keep working and you got a lot of knees and elbows slapping around, but there's a reason for it. So if we look at a North star, I've only been in healthcare for ten years. Usually the government is the one to lead the way. If the government says it, they move slowly, but when they move, they are telegraphing what's coming. So you don't have to even read tea leaves. You just sort of read the slow comet trail. CMS is throwing up major signals. What do physical therapists specifically need to understand about the access model and RTM codes that I, I think forward thinking PTs jumped on this again, a lot of baby deer we're figuring out, but if you're not leaning into this, I think you're already behind still catch up, but let's start moving.

8:58 So what do PTs need to understand about these things? Yeah, I mean, this all started in July of last year, really, where CMS got a big congregation of different tech leaders, and they started to hint at the idea that things were going to change, and they were going to throw out some some new innovation pilots, and really looking to create, and John, I think you've used the words of portfolio of different bets that they're taking to move things forward over the next ten years. One of those is the access pilot, and what the access pilot does quite simply is it just says, you know, we're paying you for outcomes.

9:41 And so, you know, we're, we're going to pay about, you know, half upfront and then half, you know, once we actually see the data. And so they're, they're starting to put their monies where, you know, a lot of, a lot of, a lot of times their mouth has been, you know, about trying to really actually change the way that, you know, healthcare models work. So I think that's, that's sort of the, The T's are into the access model, but John, I'll let you jump into. So Jimmy, I'm literally pulling this up because there was two quotes that literally, so if you go to CMS's website, you Google access, you can see it's all, it's literally right there on the website. They spell it out. As much as we're like conspiracy theory, they're pretty open when they start moving in a direction.

10:23 They move slow, but they keep going typically. Like there's two quotes that sit out to me. One, and there's a little trailer video, highly recommend watching it. It's pretty funny. It's pretty gnarly, but it's like, it's right on the page. So here's a quote, new ways for primary care doctors to partner with technology supported care providers so they can continue supporting patients with chronic conditions, even when they step outside the doctor's office. That's pretty, it's like so obvious. Here's the second part. We value this because we understand that doing this will save us money. And we are in the, love them or not, the government is in the separating money from its constituents game. And second is spending as little money as we can. And they recognize this.

11:03 So this is good. Yes. Here's the second quote. Care may be provided in person, virtually, asynchronously, or through other technology enabled methods as clinically appropriate. That is not a hint. That is not subtle, right? That's like, and that's kind of when we saw that and we're like, we, thank God I can actually say we have, we have the receipts. We, we put up our blog, our sub stack before this came out, but I looked at like, that's false. That is exactly what we're trying to describe. We're saying as a patient, you should have access to in-person virtual asynchronous and technology enabled methods. That's, that's the way it should go and clinically appropriate. That's, That's essentially what we are trying to say. Like, okay, this is where it's going.

11:44 CMS is putting a big, this is not a small bet. There's a big bet. Yeah. Government typically makes big bets, right? Cause it's got to do it for everybody. It's also not novel because the employer health space has been doing this for years now where they've allowed these digital health companies to come in through their benefit system and say, okay, you're going to help to reduce some of the spend in our company. Great. All right. We'll let you kind of figure out how to do that. One of the big levers has been just the fact that it's free. If you have an employer and your employer has one of these digital health vendors, most of the time you are going to get that vendor for free as a part of your employee benefits.

12:30 Access is taking that page right out of the book. They're saying, okay, great, we're going to waive co-pays for Medicare members if they're a part of this model. I think that's something that's going to be really enticing for a senior that's on a budget or a clinic that sees a senior on a budget and says, hey, how do I get them in the door? How do I actually allow them to come in? One, I can help them, but also we can have them in for for generating revenue. So yeah, I think that's another really interesting piece that CMS is taking right out of the employer book. You've said before, total caseload is the new metric.

13:11 Explain that idea to PTs who've only really ever been judged on billable units. How do you reframe that? That's such a hard one. Yeah, I think it's, it goes back to, I think what Sharky said about outcomes and, you know, it's, it's hinting at, you know, we can stop beating around the bush. Ultimately, this is always goes back towards the concept of value-based care. That's kind of where this is trying to get to. Right. And it's saying essentially, it's like, As you said, as Sharkey said, you can see a patient for one visit, you can see him for ten visits, you can see him for half a visit and then remotely monitor them without worrying about billing. Let's take the billing part out of RTM, like remote monitoring and messaging by itself as a concept.

13:53 You could do that. And so you have, let's say, let's say a traditional PT could see maybe one eval day, two evals a day. And then if you had a higher volume, you're going to be certainly higher than that. But in the end, if you have a population of thousands of people that you have to manage their health, how do you actually do that effectively? And if you were to say you're going to get X number of dollars to do that, Eventually then you say, okay, do whatever you have to do to manage that population's health. How would you actually do this? What I've seen in time, and I've seen this time and time again, ultimately what ends up spinning up is something like there's some virtual care, there's some asynchronous care, there's high touch care for people that need it, there's low touch care for people who don't.

14:35 That's what happens. And so ultimately, it's that idea of rather than how many units, Jimmy, did you bill for that patient for that forty five minutes? It's with that hour of time. How many people did you touch and did you actually impact their health? Right. Those two completely different metric. Right. And that's that was the thing. Again, second career PT here. I think I figured this out or started to get like clued in on my first clinical rotation. I was like, oh, I'm incentivized if I'm bad at this. That sucks. Like if I could have done it in three, but I did it in ten, I'm financially better. But the patient did, you know, we wasted the patient's time and effort and we wasted money.

15:19 And that just seems like a crappy system. I remember like, you know, because I came, I've seen doctors, I saw PTs. And then once I was on the other side, I was like, oh, this game sucks. Yeah. I think it, this, you know, it changes a little bit as a PT of also what you're going to do with your downtime. You know, if, if you have a new show, what does that mean? It completely changes, you know, how you're going to view that time because now you're, you're, you know, most likely going to be looking at your panel and saying, you know, Hey, who's, who's dropping off. You know, most likely you're going to see, you know, tools come out that are going to let you just assess everybody, you know, and start to reach out to them individually.

16:01 Hey, you know, I got whatever it is, you know, ten percent of my caseload hasn't done any exercises this week because I can see it, you know, on this dashboard. So I'm going to reach out to them and I say, hey, you know, what's going on? Is there anything that I can do? You know, I think that changes things. This sort of just came to me. Burnout is sort of caused by doing a lot of work that doesn't have results. I never have had or have problem doing a lot of work that I felt was impactful, right? Might be overwhelmed. I'm not saying you're not tired. I'm not saying it's not difficult. I'm saying it doesn't feel burnout-y. I mean, for my example was staying in a radio station until one o'clock in the morning because we had something really big coming out.

16:45 I felt like I was being pulled. It feels like when... When RTM or AI Scribes first came out, everybody's first panic was, what do we say? First, they ridicule it. Then they V it, let me impose it. Like, well, then they're just going to give you more patience. Yes. And I sort of feel like, well, if it's better work, the stuff that I showed up for, I feel like it doesn't completely remove, but it starts to improve that feeling of burnout. Like, this is what I'm here for. Give me more of the thing that I thought I was going to be doing that was on the brochure when I signed up for school, right? Yeah. Totally. Yeah. Yeah. I was talking to this one clinician owner and he, he had this strong, really strong perspective, like about RCM particularly. He's like, I was like, why are you, why are you guys doing RCM?

17:27 Get to the bottom of it. Yeah. And he's like full stop patient experience. He's like, we want to deliver the best patient experience. Why would I not give them access to me between visits? Why would I not say I want to be the provider of choice? And I was like, that's a completely different view. on why you would do RTM and it said she's like I want my therapist to have a caseload of a bunch of people where their patients love them and trust them that's why we're doing RTM and I was like You're probably in the one percent right now. That is the concept. That is kind of the idea is like, how do you build stronger relationships with patients? But also, how do you do it in a scalable way? Because in the end, if you do hour long appointments, you know, five or six a day, you just you can't scale that.

18:12 It's not possible. So is there a way to do it in a way that's not so intensive in the in-person side? Yeah, absolutely. That's somebody who understands what game they're playing, which is step one. Understand what game you're playing. Then you can understand which things to lean on. It also shows that people should understand. I heard this in the nonprofit world and it landed, which was no margin, no mission. I know that you're like, icky, I want to touch money. But if you're the American Cancer Society, the Leukemia Lymphoma Society, no margin, no money, no mission. You don't have money to pay the people or keep the lights on or do the things that you're set off to do. You don't have a better relationship with money.

18:53 I put a post on LinkedIn the other day. We will argue with insurance companies and then poo-poo the idea of a patient giving us money for a thing that we just said was valuable. I don't know. The call's coming from the inside of the house. It's us. We are the people who have a bad relationship with money. Let me get a good relationship with money. Want to thank U.S. Physical Therapy for sponsoring the show. You've built something special, but scaling your clinic and planning for what's next can feel overwhelming. At U.S. Physical Therapy, they partner with clinic owners who want to grow without giving up their identity. You stay in control. U.S. Physical Therapy brings the support. Learn more now at USPHPartnership.com.

19:35 That's USPHPartnership.com. Why do you think there's still resistance to RTM or hybrid care, even with reimbursement outcomes and access benefits? You just talked about that example right there. I have a thought. You want me to throw my thought out first? It's always fear. We're big, dumb animals. It's fear. It's I don't like this. This is new. This is scary. If I do this and fail, what happens? So to me, it's fear. It's not technology. It's not policy. it's fear that's my assumption i think that's i mean i think that's that's probably spot on for a lot of people right it's fear fear of change fear of doing something different right um yo i'll say i i do always wonder about this because i you know i talk to a lot of different therapists and like owners all over and so one thing i hear a lot of is it's almost like this mis perception of what rtm is about right and so i think you know what i've heard is There's this, this perception is not skilled and I'm just like, okay, okay.

20:39 Let's have that conversation. Yeah. Right. Let's have that combo. And it's like, they don't view. Like looking at someone's messages and responding to someone's messages, like in concerns between business is skilled care. And I'm like, I'm not really sure I have a strong opinion against I'm like, this is skilled care. Yeah. If you, if you fundamentally disagree with that, it's going to be hard to get you on board with RTM. The right message at the right time for the right person, the right situation. I mean, I'm not a policy guy, but that feels like skill. Yes. Like if you could handle it in a minute sending, hey, Jimmy, I'm going to change your exercises because you told me X. That's skilled care. And that's better care, in my opinion, than waiting for the patient to come back in six days from now.

21:23 And lower costs. Yeah, exactly. So that's like a fundamental kind of thing that I want to dig more into and understand, like, okay, how do we just kind of continue that conversation and be like, okay, how can we help you understand this is skill? because the research is pretty darn good on whether it's like RPM or RTM. It's there. It could be better. Like there could be more of it, but it's pretty consistent. That's why being a researcher is a great job because at the end of every, you could just boilerplate this, at the end of every paper, like more research is needed. And that's just one researcher elbowing the next going, I got you, bro. I got you, right? You're never going to get there. You're never going to get perfection. So I think it's fear, fear, all those things.

22:04 Ryan, what do you think? You know, I think that there's a lot of clinics that have figured out a great operating model, and the operating model is everything to do with fee-for-service. Again, whether you call it fear or resistance to change, going into something that's totally new and saying, well, okay, how does the model that we have today fit into this model of tomorrow? That's valid. I think that's a tough one. But yeah, fear is probably the primary. Any sort of resistance is going to come off of that. Yeah. I mean, Shrek and I have talked about that with Access in particular, too. We're like, we're looking at it.

22:44 And so you can see where a company that's tech first, they could probably be pretty successful in this model. And then we're talking about, okay, how would a brick and mortar health system or a brick and mortar clinic get involved here? And I think they can. I mean, I think CMS wants them to. But we talked about like, hey, you might need to break off a pilot team. You might need to do this a little bit differently. Give them some freedom to try and figure this out on the side. If you try and cram it into your existing operations, it's going to be really, really, really, really hard. I mean, it's the inception concept, right? Make it their idea.

23:26 you can only do that so much, but like when I was working with a tech organization, I would say we would do pilots of six for a piece of tech. And then I would say, and I love doing this, especially with an owner who was pretty hands-on, give me three people who are pretty forward thinking, like three people who were like, yeah, they'll enjoy this. And then I say, give me three crusty laggards. And they're like, what? And I'm like, here's the thing, man, I'm gonna, I'm selling you this. And I was upfront about it. I think this is great. You know the three people who are forward thinking are going to love this. If the three crusty laggards love it, I don't have to sell this at all. Now you know that your people will do it. You being on the phone with me tells me you understand that this is a problem and that I'm in the running to be a solution.

24:12 I'm okay with that. It's a jump ball. I'll take the jump ball all day. But if I can convince the crusty ones, my man, I ain't got to do no pitch. At the end, you just said the people who would want to resist this the most are cool with it. That's a risk, but I try to get to the no as quick as possible. Yeah, I think that's smart. Yeah, it's smart. Rather than kind of dragging the feet and then like seeing it kind of trail off, you're saying like, let's do this and let's actually see. Let's get the people on board, right? Yeah, because I think that's... This is the format of every episode of Bar Rescue. First, they see the ugly... Then they come in and they poke and then the owner yells and John Taffer yells back and then they do a pressure test. They bring in, if the bar can hold a hundred people, they bring in two hundred and they watch where it fails.

24:57 And that's good. I think we're resistant to that. Yeah. I'm like, dude, I need to know where the leak is. Like a good plumber is going to go turn the pressure up. Well, there's going to water squirt. I go, this is dripping already. Like let's squirt it for ten minutes and let's figure it out. What are we doing here? Are we just giving the leaky pipe vibes? That doesn't do anything. Let's get to the point. I'm here to solve problems. You're here to solve problems. Let's solve problems. Avoiding it. Although I recently found out ostriches don't actually put their head in the sand. That's a fallacy. I know. Welcome, internet. But that's, you know, using that cliche, that's you just burying your head in the sand and pretending that it's not going to be a problem or it's not going to slowly kill you. I don't know. I heard the line once, there's always going to be a leading cause of death.

25:39 There's always going to be a leading problem in your business. Why solve the smaller ones? Because they feel easy. Because I feel like I get to check something off. And the bigger ones are hairier and scarier, except they're the reason you're going to close, not the small ones. What's one question every PT should ask their clinic owner? or director, this is what I'm talking about. You have the forward thinking PTs at your clinic, you got the laggards, but what's a question they should ask if they want to explore innovation where they work? We hear from owners saying, oh, we want our clinicians to be intrapreneurs and bring up, you want to make more money? Let's make more money and you get a cut. So what's the question a clinician could be or should be asking an owner or a director, no matter what situation you're in?

26:25 Such a good question. I'll go first. I think every clinician should be asking their owner, manager, give me three pain points that you have that is just sort of eaten away at you throughout the day. Because what these types of models are all of a sudden doing is they're opening the floodgates for forward-thinking clinicians to be able to see that pain point and say, oh, we got a no-show issue? Okay, great. I think I have somewhat of a solution. In fact, John and I just... put out an article that we, we built a startup, you know, quote unquote, where we, you know, said, Hey, there's, there's a, you know, nationwide issue with no shows, you know, about, you know, clinics that, you know, have, you know, are, are dealing with, you know, what, I think it's so great let's use access to you know create all of a sudden a a network where you know if you have a space of time great get on a virtual visit with the senior because they're just right there um you know you'll have a company do the marketing or your company will do the marketing and then all of a sudden you you have a whole new you know influx of patients starting with solutions is a bad idea start with the problem then test out solutions Start with the problem and then, yes, just don't go right to your first solution and then stop there.

27:50 Take it, you know, five, six, seven, ten, you know, different ideas and then see what sticks. Yeah. Yeah. Okay. I got two on this. One's a question, one's not a question. One is, or actually neither are questions. Tell me how the business works. From a money perspective, if they're willing to share with you, tell me how the money flows. Cause I think that's one thing, honestly, I, I did not ask the question of early in my career. And I realize now like how important that really is because whether it's like private practice, health system contracts, all that stuff, it's like, you, you really can't understand what the actual pain point of that director of the business owner is until you have a better understanding of how the money flows. You're like, oh, I get reimbursements going down.

28:33 How do we solve that? Oh, I get it. No shows are a problem and that's driving revenue down. How do we solve that problem? that's like if you don't have that understanding of how this works it's going to make it really hard to actually understand the financial drivers that are kind of moving it the second is almost just ask for ask for forgiveness so just start doing something i'm that guy yeah go to your owner yeah and they'll be like hey i tried something and it works uh-oh That's almost like, in a way, an easier way. It's just like, I forgot what the podcast was, but basically it was just like, just do things. Just start doing stuff.

29:13 You probably can figure it out. You may need to spend a little time outside work doing it, but just do it. And you'll be surprised. And that's initiative. That's like showing innovation. It's just doing something. And you don't want to break the rules or anything, but that's not what I'm telling you. Just do something, try it out, prove it out, then bring the value back to them. I mean, I was in a profession as a broadcaster, right? Working at a radio station where I was in a studio alone for four or five hours. It was my show. I couldn't run and ask my boss every time I was going to turn the microphone on. Hey, I was going to say this. What do you think? What do you think? He was like, dude, you have the chair and the microphone. If you can't fit, your job is literally figure out what's in bounds and what's good and what's bad.

29:54 I'm paying you for taste. I'm not paying for you to read a liner card. We used to call those liner card jocks. That was somebody who was on the air, who they just sort of read what was in front of them in radio voice, which is not a skill. It's not. And I was always taught when I got a little higher and became program director of the station, it was like... And I was always nervous about screwing up, partly because I got like a woo personality and I wanted my bosses to like me. but I wanted to be seen as clever. And literally my boss just sat me down. He goes, Jimmy, just run this through your head. Like you're going to have to explain whatever you're doing. If you're okay saying this happened, I did this to me in my office, then do it. Like we're all make, we're monkeys on a rock in space, dude.

30:36 We're all, this is all made up. Everything's made up, right? So it's like, if you're okay with saying, I saw this, I did this, that's the filter. And if the answer is yes, hell yes. Then don't do it. I also had kids that were younger than me who were my broadcasters. I'm thinking about doing that, and I go, if you're asking me, the answer is no. We're not going to win or lose based on this ridiculous Hail Mary. We're not. We're not going to win on that, but we sure might be able to lose on that. So I like that. Ask the questions. Just do stuff, kids. Are you guys ready to play a quick game? We're going to do a quick game. You guys cool with that? Let's do it.

31:18 The game is brought to you by Sarah Health. Big thanks to Sarah Health. Good timing. The remote care platform helping clinics boost revenue without adding staff. It's almost like we timed it. Sarah automates daily patient check-ins via text. You just did the math. No app, no logins. All you have to tell me is I don't have to log in or I can log in with my face and I'll show up. Just better outcomes. It's a simple way to meet RTM requirements, improve follow-through, and actually get reimbursed for care between visits. Sarah Health. It's Sarah without the H. There's always that girl in your class who's like, no H. S-A-R-A health.com. That's S-A-R-A health.com. This game is called Full Stack Fire.

31:59 So I'm going to throw out a line or a question. And then you guys have to respond. We'll go John, Ryan, John, Ryan. Those will be the lines. So first question on full stack fire round. RTM or telehealth, you have to keep one. You have to ditch the other. You can only have RTM or telehealth. Which one is it? Keep RTM. Got it. Why? Real quick, just a second. Yeah, yeah, for sure. You know, in the end, telehealth is always going to have a point. By the way, telehealth is part of RTM. It's lodged in there, if y'all want to. No, but I think in the end, I think that's the one that scales better. And it's actually the one I think patients will like and adopt in the future.

32:39 You don't need to talk to one on the video. You can just text with somebody. You can message them. It's monitoring. I think that's the way it's going to go. Ryan, RTM or telehealth? It's a Highlander. There can only be one. Yeah, I'm going to go RTM as well. Okay. Yeah, as John mentioned, I don't think it's just the scale, but anything that's a little bit more asynchronous is going to play better. So forcing patients to get on a screen every time is going to be really cumbersome for them, and it's just not a great patient experience. Okay. Here's the second one. Clinical pilot or product prototype? What gets you more excited personally?

33:21 Do you want to see a clinical pilot or a product prototype? This is personal, so there's no right answer here. John? I'll go clinical pilot because I want to see how it actually works and what happens. Pressure test. Yeah. It's cute. It looks great on the shelf, but how's this thing swim in the deep end? Yeah, exactly. And people do the craziest things and you're like, oh, I had no idea you could work around like that. That's pretty wild. Like you learn a ton. So, yeah. Ryan? I'm going to go product prototype. Okay, awesome. Because they're more fun. I mean, yeah, you get to kind of take what's in your head and then all of a sudden it's just there and then you can kind of play around from there. You got to pick a side here. Clinician led or VC backed?

34:04 Which one do you choose? This is like the Civil War. Clinician led or VC backed? Who's going first on this one, Jimmy? You're going to go first. I like that there's a pause. It means you're thinking. I like it. Okay. I will say clinician-like because that's what Shark United are doing with our thing here. It's like, hey, we think there's a lot of room. There's a lot of room. And they're completely different games. I think that Shark United have had that conversation. They're not the same game. I understand what game you're playing. There's a ton of space for... smaller more nimble companies people to do things just just go do it and start it up and see what happens like that's good that's literally what shark and i're trying to do is right we think we can actually do something and have an impact at a very small level like we have no desire to be a vc backed sub stack um you said it on february it's recorded it's recorded well i feel all right ryan you answer then i'll actually chime in for this one so there's no wrong answer Well, since John said that, I'm going to go beat BC back.

35:10 Got it. Yeah. And this is not in any way a dig at anything that's clinician-led. Having having voices that are outside of the industry come in and question what's going on in the industry is is something that I think is very healthy. And so there's there's that VC backed portion that gets too far away from what good care is. And that's why you need clinicians in VC backed companies to be able to help to kind of make sure that the ship is continuing to steer in the right direction. But yeah, I think it's healthcare. It's, it's funky.

35:51 And people ask, you know, like really great questions about things that have happened in healthcare for, you know, twenty, thirty plus years. I was like, why do you all do this? And we all kind of sit around. We don't know. So, yeah, I think it's good to ask those questions. So clinician-led, VC-backed, plus the money's not too bad when you get VC involved. But then, hey, man, you're giving up some control. But hey, listen, listen, this is why it's not necessarily one or the other. It's like clinician-led, who are the clinicians? I need to know more information. VC-backed, who's the VC? What are their goals? What's their experience? What's their motivation? What do they bring to the table? It's a simple question. It's just not an easy one. Last one. Substack post you wish every PT would read.

36:33 What's one thing you've taken time and effort to put out there that you're like, listen, if I could have one, this is the one I'd want you to read. I'll say the very first one that we put out, that was kind of that whole idea of what the heck is full-stack healthcare. And I think that was the one that was just kind of, that was burning in my mind for years. And I was like, I just, we got to start thinking about it. And it's just like, care is not just in-person care. I think that's like fundamental belief number one, that if you can get over that, it opens up a ton of doors. And that's kind of literally the first one we put out. I was just trying to describe like you can do care a lot of different ways.

37:15 Patients kind of don't care how they get it as long as they get their problem solved. Like they don't care the delivery method. It's just, just get it to them. And I think that's, yeah, that's like number one. So you had your whole life to write your first post. And then the second one, that's the struggle with artists. You had your whole life to release your first album. And then the company's like, great, here's a bag of money. Do that again. Ryan, Substack posts you wish every PT would read. uh i'm i'm gonna i agree with john i think that first post is probably um the the most impactful for for any clinician though i'm gonna go with we we did a post on different models of care uh and i i feel like this is one of those that uh a lot of clinicians when they read it they their brain starts to kind of open up and say oh there's there's other models other than fee-for-service like yes there's there's a number of those and let's learn about them and i think that kind of like gets the the curiosity going for clinicians on, you know, learning a little bit more about, you know, the broader scope of healthcare.

38:16 Yep. And I mentioned that Schopenhauer quote, right? First, it's ridiculed. Then it's violently opposed. Then it's accepted as being obvious. And of course, I believed in this thing the whole time. I remember I got ridiculed launching a podcast as a PT student. Classmates were like, are you still doing that? That's cute. I had a professor tell me it was a giant waste of time. And I was like, all right. So there's the violent opposition. I think she just wanted to like... exert force and was like that's silly you should just study more and i'm like i gotta be honest i am studying when i'm asking these questions and getting great answers i'm a verbal processor as we started the episode off uh last thing we do on the show guys is called the parting shot this is the parting shot one last mic drop moment no pressure just your legacy on the line Whenever you want to be your last, yeah, just your entire legacy on the line.

39:08 Not really, though. Whatever you want to leave with the audience as your parting shot. What do you got, John? All right. So I think my, I really challenge anyone listening. So whether you're a PT, you're a leader in the field, really take a step back and think about what will change the trajectory of the profession. I guarantee it's not going to be, it's the new best exercise. It's the new investment. It's not in the new best manual therapy technique. It's not going to be that it is going to be how technology changes care. It's going to be payment models. Like those are the two things that will literally change. They will, they will change how you practice without you even knowing it. And I think that that took me for, I did the whole fellowship route.

39:49 I did all that stuff. I tried to go there and I was like, that's just incremental. And it's fine. We need that. I'm not saying we don't need that. But if you're really going to take the PT as a profession, technology and payment, you got to look there. You just got to start to understand that stuff better. Ryan? If you are a PT and you hang your hat on diagnosing the perfect injury type and creating the best exercise plan for that, you will readily be made obsolete in the next five years. What's going to what's going to separate really great clinicians from someone who's average is going to be the way that you communicate, you know, and it's going to be your communication style.

40:35 There's a ton of research that's starting to come out on communication, a lot like how we were starting to understand habits about fifteen years ago. We're starting to understand that there's just different ways of communicating and there's different conversations that are happening in the exact same way. In the exact same conversation, are you having a logical conversation? Are you having an emotional conversation? And being diagnosed that is going to massively improve how you're able to connect with people. my parents are so excited that i got a journalism and communications degree then came to healthcare and it didn't make any sense but now i'm like guys guys this is my jam look at this this intersection i live here this is my house come on in let's solve this thing yeah it's a communication thing you mentioned uh emotion or logic if i'm having an emotional conversation if i'm sorry not a conversation i'm having if i'm giving emotional statements and you're having a logical you're sending me logical statements back that's when we're just starting we're just two dubbermans yet barking at each other through a fence understand what game you're playing understand what kind of conversation you're having or it will not progress it's just not going to do it the book i would suggest would be uh chris voss never split the difference, communicate like your life depends on it.

41:52 Former FBI hostage negotiator. He deeply understood how to do this with little to no scientific like formal background but he was like i'm in a high-stakes situation i gotta figure this out that's why i love the title of the book too it's like never split the difference he couldn't roll up to a bank robbery like all right what do you got you got a million dollars and ten hostages all right why don't you keep five i'll take five take you half a million dollars we'll take the half a minute we'll call it a day that's not how it works it's sort of a zero-sum game and that's how it is in your business That's every and the line I love there is every conversation is a negotiation for information, whether you're trying to get someone to understand or you're trying to get information out, treat it as such.

42:33 And I don't think it's a silver bullet, but it's pretty dang good. It's pretty dang close and starts to make things better. Say it again where people can go read these full stack health. Hit the website one more time. Yeah, so fullstackhealthcare.substack. Fullstackhealthcare.substack. I'll put it in the show notes. That's why I like the show notes after. It makes me look like I took notes in class, but it's all at the end. Gentlemen, thanks so much for doing this. We'll have you back on when we've got something that pops, right? Something that's the great thing. The only constant is change. Something will change and it'll shift and then you guys will be there to explain it to me. Appreciate your time, guys. Thanks, Jimmy.

43:15 That's it for this one, but we're just getting warmed up. Smash follow, send it to a friend, or crank up the next episode. Want to go deeper? Hit us at pgpiecast.com or find us on YouTube and socials at pgpiecast. And legally, none of this was advice. It's for entertainment purposes only. See you. Bulls**t. See, Keith? We read the script. Happy now?