The ‘Business’ of Physiotherapy – *Long Post*

TheKettleBellPhysioUncategorized0 Comments

This started out as a random thought in the car, that became a spontaneous Facebook live video, that later morphed into a Facebook post, then quickly into this ‘blog’.

Opening a new Physiotherapy practice and building something from the ground up has been quite a rollercoaster ride.

I liken it to pain. On one hand, it seems easy; you know:

GPs send their patients our way, people leaving hospital will need our help, sprains, strains, aches and pains – before we know it, we will have to employ more Physios and bring forward our plans to open a second and third practice. On the other hand, it’s complex beyond my comprehension. There are so many variables going into the mix that I’m unsure what the right ingredients are supposed to be to get the result I’m looking for.

What if that doesn’t happen; what if you built it and they *don’t* come. What then?!

Helping someone with pain should be easy, right? What if everything you’ve tried hasn’t helped. What then? What if you don’t have anyone else to refer to and the buck stops with you? You’ve got two options, (1) give up on that person with pain, wish them luck and shut up shop or (2)  keep going until you find a solution.

Six months into this journey it was painfully clear that the referrals and walk-ins we had anticipated weren’t materialising.

We did plan! We spent a *lot* of time planning. We were supposed to be sitting pretty by now, I have the forecast of patient numbers and P&L to prove it – our landlord had us run it by an accountant too. Clearly there were some fundamental errors in judgement. Six months ago people started asking me “how do you stay so positive?” We have a 3-year lease – that’s why I stay positive because quitting isn’t an option. Now almost 18 months in, we’re still facing a similar dilemma and to be frank, it’s painful. Not physically of course, the kettlebells do that, but emotionally. I still will not quit because I am 100% certain that we can help people. I have zero doubts about that.

So what now?

Next week I’m buying time to meet with a 8/9 GPs in a local practice; I feel like one of the three kings meeting the baby Jesus, only I’ll be taking the saviour(s) lunch instead of frankincense. Anyhow, I’ve made a commercial decision to bulk bill physiotherapy visits on GP referrals for the next 6 months. That simply means that the patient won’t be out of pocket. It means we lose $28 per visit not charging the gap between the Medicare rebate and our standard service fee, but it means that we may be seeing more people, and that alone will create more opportunities for us. It is possible that we may get no referrals of course. Last year I offered 2 months of FREE Physiotherapy to 54 locals GPs for patients in 4 distinct clinical groups and received just one referral which was a young women diagnosed with anxiety and depression. It wasn’t what I had expected. A further six hip and knee surgeons also failed to take advantage of the same offer of FREE medical care for their patients. Nothing surprises me anymore, but we will be keeping our fingers crossed.

So moving on to walk-in business.

Gary Vaynerchuck is the most insightful businessman and entrepreneur I know. He’s said on many occasions that right now is the biggest shift in communication in the human race since the printing press. Our lives now revolve around our mobile devices and the things that have our attention ‘win’. Simple. That’s marketing. Marketing precedes sales, and sales keep businesses open.

One challenge I have is this – the epidemic of low value healthcare and consumer services throughout the profession. Physiotherapy isn’t supposed to be a low-value consumer service; it’s supposed to be a medical service. Even the Australian Physiotherapy Association got behind the Wise choices call of ‘Making physiotherapy care more valuable’ by publishing the paper by Traeger et al, unfortunately the APA doesn’t exist to enforce ethical and best-practice, and the Physiotherapy Board of Australia well, I’m not exactly sure what they might be doing to hold us all accountable to high standards of ethical and medical practice

We don’t see local GPs promoting the latest flu vaccine or health check on Facebook, or on Instagram using a local influencer to promote the latest antibiotic, or dissolvable sutures. Cosmetic surgeons do self-promote, but that’s generally an appeal to vanity and a consumer service. Nobody ‘needs’ breast implants; that’s a consumer service, not a medical necessity.

How do we even define what’s medically necessary in Physiotherapy?

Most of what we do in private practice simply isn’t medically necessary. I shared this recently (on social media of course) showing that even after major joint replacements, patients may not be any better off seeing a Physiotherapist. Funnily enough it was on the back of a Twitter conversation with Gene Shirokobrod about branding and our core competency, which triggered this post from Roger Kerry in which Roger makes reference to my Facebook live video about the Therapy Insiders Podcast.

Every business needs customers; we call them ‘patients’ or ‘clients’. People don’t *want* to spend time and money on physiotherapy though, not like they may want to spend money on their favourite coffee, buy a new shirt, or go to the cinema. We can use tried and tested sales techniques to highlight the ‘pleasure’ of being able to return to normal activities, or the ‘pain’ of not being able to do X, Y or Z. If we’re having to ‘sell’ an outcome though, I’d suggest that it’s probably not medically necessary – if people don’t *need* Physio after a joint replacement, they sure as heck don’t need it for back pain, which Erik Meira and JW Matheson discuss here as not being a medical condition. I won’t mention Adam Meakins and the #GetPT1st campaign. A surgeon doesn’t have to ‘sell’ the removal of an angry appendix, the repair of a nasty fracture or removal of a gangrenous toe, because those things are ‘medically necessary’.

 

The unfortunate reality, from my perspective as a practice owner at least, is that as much as I/we may want to see ourselves as ‘medically necessary’, unless we’re receiving sufficient GP and medical referrals to pay the bills, we *have* to sell ourselves otherwise we go broke. There will be nobody through the door. Once again, this comes back to the issue of core competency; what is it? How are we different from Osteopaths, Chiropractors, Personal Trainers, Athletic Trainers, Sports Trainers, Strength & Conditioning Coaches? From the outside, some Physiotherapists appear to be pseudo Massage Therapists and Acupuncturists.

As Erik said in ‘The Ethics of Healthcare Advertising’ “we are “getting our assess kicked” by the targeted and effective advertising strategies of alternative medicine providers. People are either going home without our services or going elsewhere for the services that we believe should be provided by a physical therapist. We need to take things into our own hands! We need to promote what we do! We need to define our brand to the community and let them know that we are a great option for them! We need to quit losing market share to alternative medicine providers like chiropractors and acupuncturists! We need to promote our profession and convince the public that a physical therapist can help them!”

And so we come full circle back to ethics. Our patients are vulnerable. Fear-mongering and disease mongering is easy and rife. We can sell sickness because it’s good for business. It gets people in the door and it keeps them coming back for more. Only yesterday I met a guy with an acute onset of low back pain. He said the Physiotherapist he’d seen had put three needles in his back and left him for 10 minutes, and then after mentioning “Work Cover” the recommended treatment frequency instantly doubled. The patient didn’t go back. Here’s his STarT Back Screening result: “Low risk. Recommend action – support self-management. I’m not expecting to see him again. The attending physician at the hospital (don’t ask) gave him a clinical diagnosis of it being his sacroiliac joint based on the local area of pain (thankfully he didn’t have the MRI which had been ordered) and he thought his back was “out”. The GP had signed him off work (although he *wanted* to be back at work) and just needed someone to tell him it was ok. It was.

Back to Erik for a moment:

Well, shit.

For 18 months I’ve been busting my balls trying to promote PRIDE Physiotherapy & Nutrition to my medical and surgical colleagues and direct to the public. As a business, we offer (1) Physiotherapy, under which we appeal to different demographics e.g. post-surgical care, persistent pain, second opinion service etc., (2) Remedial Massage (the RMTs provide that because Physio’s providing massage service is quite frankly a joke – see ‘medically necessary’), and (3) Nutrition Coaching because what you eat is important too (our Nutritionist does that).

Back to Gary Vee. A ‘business’ regardless of whether it’s selling a product or service needs to be visible and in order to be visible today, it needs to be producing content. Quality content of value. Frequently. If you look at Gary’s various channels, you’ll appreciate just how much ‘stuff’ he’s pumping out, and this is his “side hussle”; he’s worth hundreds of millions.

I’ll give you an example which follows on directly from the brief Facebook Live chat about branding.

On April 27, Episode 7 of the Pain Reframed podcast with Sandy Hilton was released. Sandy has already established herself as a thought-leader in our field. Sandy co-hosts the Pain Science and Sensibility Podcast with Cory Blickenstaff and co-owns Entropy Physiotherapy in Chicago, which last weekend was host to Erika Meira and Adam Meakins’ Hip and Shoulder courses. Erik and Adam are both ‘Key People of Influence’ (KPI) in their own right (see below). Sandy has a niche in helping people with pelvic pain and appears regularly in the places that matter – San Diego Pain Summit, CSM, PainCloud, podcasts (she’s been on many) etc. Pretty much all of our Top 10 are in the same or similar circles of influence.

KPI comes from this program, which I think is excellent. It was the driving force behind Brad Beer’s book, his podcast which now features highly in the iTunes charts and the introduction of POGO Physio’s Finish Line programs which Brad was talking about at the #ESSABF17 conference over the weekend – “stop selling time & start selling outcomes”. Less than 12 months old, POGO is now looking to partner with other Physiotherapy practices to licence their Finish Line programs. I’ve known Brad for more than a decade. He’s a lovely guy and incredibly passionate and driven as a businessman. He’s put in extraordinary amount of work into his businesses over 10 years and what he’s doing now is textbook in terms of the KPI and what Gary Vee promotes. His profile has increased exponentially as a result. It’s not what you know, it’s who you know – check out the people Brad’s interviewed. That’s a lot of connections and phenomenal exposure for Brad and POGO.

If you want to see the power of content, check out Brad’s various social media channels. It’s the reason why POGO is currently sitting at #16 in the Top Physical Therapy blogs (a US-based page too nonetheless!), ahead of Jarod Hall (#29), PT Think Tank (#39), Jesse Physio (#44), and Physio Edge (#54) – the latter being the very first Physiotherapy podcast with David Pope. In the last 24 hrs on Instagram, his page has averaged one every hour. There’s also Twitter, Facebook, LinkedIn and likely others, and they’re not all duplicates either. The ‘branding’ is consistent and the content is appealing to the typical Physiotherapy consumer. I can only presume that there’s someone at POGO employed to do all this marketing, and this isn’t mentioning resources spent on Google Ad words and YouTube.

The ‘5 Ps’ of the KPI program are:

1.   The Perfect Pitch

2.   Publish Content

3.   Product Ecosystems

4.   Raise Your Profile

5.   Partner with Performers

The goal of the program, as you can probably imagine, is to become a Key Person of Influence. That then enables you to develop partnerships, and it’s from those partnerships that ‘business’ grows exponentially with exposure to new networks. Ben Cormack, Greg Lehman and Bronnie Thompsom who have all been in our Top 10 have been interviewed via Facebook Live on the ‘Trust me I’m a Physiotherapist’ page which has over 220k followers, with Adam Meakins, Jason Silvernail and Kieran O’Sullivan already lined up in the wings. I’ve lost count of how many podcasts I’ve head Greg Lehman on!

This is the reason why podcasts are sponsored and commonly have ‘special offers’ to listeners partnerships. That’s business. Physiotherapy may be (or trying to be) medical care, but it’s also ‘business’ whether we like it or not. We’re in sales too – Dustin Jones talked about that on the Senior Rehab Podcast in this episode ‘Yes!! YOU are in Sales’.

Become a KPI and everyone wants a piece of you, just ask Greg Lehman! Lars Avemarie is also an example of having created an profile as a human encyclopedia of ‘evidence’ – when you’re up to date and sharing ‘science’ in multiple groups of people all interested in what you’ve got to share, you get noticed pretty quickly.

Many of our Top 10 are now travelling the world as invited speakers at conferences or running courses; Ben Cormack at Cor-Kinetic is a great illustration of that happening. You’ll notice his FREE Pain Flashcard download – publishing valuable content. He’s also prolific on Facebook created a big profile their too. Greg Lehman just released his updated and phenomenal Pain Guidebook here over the weekend, which also coincided with his second interview on the Physio Matters Podcast here with Jack Chew. Greg already had a well-known profile, but you see the same themes of publishing content and partnerships. More people will want to buy his books, attends his courses, recommend him as a clinician etc. on the basis of the content he produces.

Gary Vee says he would gladly give milk free in order to sell cows. If we don’t produce and give away ‘content’, the other guy (or girl) *will* and he or will win every time because they’ve got the attention.

Jarod Hall has earnt his place among the influencers because he’s been regularly producing useful content like this:

It’s valuable to the DPT students (smart move – becoming the influencer of the next generation PTs in the Doctor of Physical Therapy Students group) and clinicians interested in keeping current. You can see the profile he’s created for himself based on the number of KPIs tagged (nearly 50 people) in the recent share of Greg Lehman’s book; it’s a who’s who list, and Jarod’s on it. A few days ago, Dr Bronnie Thompson (PhD) posted this. As a KPI herself the post was quickly picked up and shared widely. What Jarod did was this. He didn’t just share Bronnie’s post, he wrote a review of it on his own page and shared that instead. That’s smart. He ‘added value’ and used another influencer to increase his profile. Promoting Bronnie, the Pain Reframed podcast and in so doing, himself too. That’s how it’s done. Having established himself as a credible influencer, Jarod is now ‘partnering’ with OPTIM Manual Therapy. Before too long, it’ll be him presenting at conferences and running courses.

Rehabilitation following a knee replacement isn’t sexy and doesn’t sell. What’s sexy and sells is the stuff that isn’t medically necessary. Physical Therapist Kelly Starrett of Mobility WOD and Supple Leopard fame (plus Ready to Run and Deskbound – (2) Publish content) is a great example of effective marketing and branding. Kelly’s not the only one either, there are *lots* who are more visible on the fitness side of the fence. Chiropractor and CrossFit enthusiast Ryan DeBell of The Movement Fix is another. Popular on Instagram, there’s @moveu_official who are highly entertaining! with 163k followers and the DPT students @prehabguys with 139k followers. The list goes on, and on, and on. Everyone is vying for our attention.

The squeaky wheel gets the oils so to speak. Those producing the most or most interesting / entertaining / valuable content win. It’s that simple.

What’s interesting is that there’s a divide, in my opinion, between those getting lots of consumer attention because they do stuff which is interesting, entertaining and fun (on the fitness side of the fence), and those who receive a lot of clinical attention because they do ‘science’ on the medical side of the fence. As there’s the rub. Selling science, selling ‘medical care’ isn’t sexy, and it’s incredibly difficult being a new business owner *needing* to attract patients but wanting to provide a service based on best practice.

I posted this in the Explaining Pain Science page this morning because I’m genuinely interested in understanding pain. I’ve been doing Facebook Live videos almost daily since the start of the year. I’ve been writing regular blog posts, sharing videos and producing a lot of content on Facebook, Instagram and Twitter, appropriate to the audiences on those channels. From a ‘business’ and marketing perspective, it’s a fascinating exercise.

 

Sex sells, right? Most people seeking the help of a Physiotherapist have pain or some other unwanted symptom and they’re looking for a solution. It’s nothing more than supply and demand. The patient is demanding a solution, and if we can supply them with a solution that meets their need, that makes them feel special, important and worthwhile, then we’re on to a winner. With a dash of fear mongering, a sprinkle or sickness-selling, a hefty dollop of sofology and a fancy looking ‘tool’, we’re guaranteed to be maximising the non-specific effects beyond what’s ethical. Rob Tyer from the Physio Matters team shared this video today. Check out Dr Beau’s profile – he’s certainly making the most of a lot of tools at his disposal to maximise his profile – 50k and counting.

 

There’s been a lot of chatter on the interweb recently about placebo and this article doing the rounds: “Lying to patients is almost always unethical. But, in order for placebos to work, we have to believe they are “real” treatments, which means the doctor would have to lie to us and say that the placebo was actually a real treatment.” Non-specific effects (placebo) are a good thing and we’re supposed to make the most of them in treating our patients, because they work. It’s the same with surgery. Where we draw that line in the sand is passionately debated across disciplines.

This morning I was randomly listening to this episode of the Ask Mike Reinold Show. Mike founded Champion Physical Therapy and Performance in Boston and he’s *really* well known. Regarded as a shoulder specialist, his approach appears to be quite the contrast to Adam Meakins’ course for example, who is also considered to be a shoulder specialist. Who’s correct? If you listen to the podcast, you’ll hear that Mike and Champion has an extensive range of products and services to sell.

The latest episode (#272 – Defining your Physical Therapy career – Part 1 ) of the Healthy Wealthy & Smart podcast with Dr Karen Litzy (DPT) and Dr Brett Kestenbaum, is a 2-parter with Part 2 due to be released tomorrow – May 11. They discuss some of these topics, in particular, how to build a profile using the internet and social media.

Several years ago, I was happily treating patients as a ‘structuralist’ because I didn’t know any better. I blamed pain on posture, movements, muscles, tissues, weakness, ‘syndromes’ and trigger points. I used ultrasound, various tapes and had patients doing clinical Pilates to improve their ‘core stability. I know better now and my moral and ethical compass simply won’t let me ‘sell’ that low value physiotherapy any more. I have become a slave to the Lehman Effect ; professionally fantastic; commercially disastrous.

If you care to look, the two groups of Physiotherapists – those on the ‘science’ side of the fence and those on the other side – don’t play well together. At all. We exist to serve our patients and we have a valuable contribution to make in healthcare.  The ‘business’ in what we do is important though, vital in fact. We deserve to be remunerated for the value we provide and at a level which reflects our degree of training (‘Doctor’ anyone?). Cash flow is our life blood. We need to make a profit otherwise we won’t be able to help anyone. However, we cannot have our head in the sand ignoring the science and clinical practice guidelines while we continue to provide low value healthcare. Choosing to make a few bucks now from Sandra who has non-specific low back pain does the profession and Sandra more harm than good in the long-run.

Next week I may post a video of a sweaty workout in some tight short-shorts. That stuff seems to get noticed. If I call it an experiment, that makes it ‘science’ though, right?

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