PRIDE Physiotherapy & Nutrition has been a labour of love for more than three and a half years. The dream of running my own business and helping people through exercise has been more than a quarter-century! We officially opened our doors on my late father’s birthday (no coincidence) November 30, 2015.
This post explains why we are closing our doors and I will be happily turning my back on clinical practice.
What follows is a lot of my own experience and opinion, which I recognise counts for nowt.
10 years ago, I was frustrated. I’d been happily teaching a manual therapy Diploma based on the principles and practices of Osteopathy. I loved everything about my role as a therapist and my job teaching others to do the same. I felt confident in what I knew to be true and fixing people with techniques which seemed to work like magic.
I was frustrated because I felt I had no real recognition in the eyes of the public. With a ‘massage’ label I felt stuck with the image of candles, day spas and whatever else people think Massage Therapists do. The course I was involved in was excellent. Muscle energy, positional and myofascial release, neuromuscular techniques (for trigger points), joint mobilisations, dry needling, taping, scraping, cupping – I had skills god dammit! I even taught my own Kahuna course for several years. I showed people how to ground with mother earth and we thanked father sky together. I never actually believed that spiritual fluff but I went through the rituals with people nonetheless because that’s what was expected and I was good at the bodywork.
I’d also been a gym-junkie for over 20 years and taught a Personal Training course prior to career shift toward manual therapy, so I was comfortable with ‘exercise’ too and that has always been my real passion. In one way or another, exercise has defined my life since I was a child I used to be exercise with dad in our living room to tapes of Michael Jackson before going to school.
I didn’t know what pseudoscience was 10 years ago even though I was in the thick of it. I had no reason to believe that what I thought was happening and the effects I was having on people’s pain and function may have been due to something else; what I now know can in part be attributed to the therapeutic alliance and contextual effects. One wonderful student in my early days teaching manual therapy had a successful business as an Auro-Soma practitioner. I didn’t understand it, I didn’t believe in it, but equally I wasn’t in a position to critically appraise it either. To be honest, I didn’t really know enough to care that much what other people were doing either. It was none of my business and I was far too engrossed in my own importance.
As a Personal Trainer and Massage Therapist, Physiotherapists were always on another level; *they* were the real experts, not us. They knew more, they had more skills (or at least that’s what we all thought!) and they weren’t to be challenged.
I recall driving past a sign advertising the new Doctor of Physiotherapy program at Bond University and thinking “that’s it!”. I’ll be able to call myself a ‘Dr’ like the Chiropractors and Osteopaths and *then* people will take me seriously. That was my one and only motivation for Physiotherapy – credibility. I started studying at Bond in September 2007 and graduated in 2012, 13 semesters later with Degrees in Exercise Science and Physiotherapy. I was a mature student fast approaching 40 and graduated top of my class with a grade point average less than 1% ahead of young-gun Jared. I was set! I’d reached the pinnacle of clinical practice.
While studying I’d learnt that in academic circles, if you want to be taken seriously, you need to be a ‘real’ Dr with a PhD. [sigh] I had zero aspirations to do that. After finishing my first Degree in 1996 I’d sworn never to go through University again.
My academic success at Bond wasn’t due to any natural aptitude or academic talent, I just worked my arse off. I was emotionally invested in being there and had nothing better to do with my time. I’d also find something I was really motivated by – learning. In 2006 through the Clifton Strengths-Finder profile, I’d discovered my no.1 natural strength – ‘Leaner’. I was like a pig in poo.
I never had any interest in Hospital Physiotherapy; it was Private Practice or not at all. I had a position lined up for the four years through Bond and was involved with regular clinical observations at the practice. A few weeks after starting in my first Private Practice role I went overseas to complete a Graduate Diploma of Manipulative Therapy because I felt I needed those skills to fill my tool bag of techniques. I certainly hit the ground with enough knowledge and skills not to fall flat on my face. I hadn’t anticipated what was coming.
With no interest in working in a hospital setting, my entire BSc felt like a frustrating wait to reach the real meat in the sandwich which was the Doctor program. What I hadn’t appreciated at that point was that 80% of my Physiotherapy training would be in a hospital setting. So, much of those six semesters also felt like I was waiting to reach what I thought was going to be the holy grail – Private Practice! I did spend my weekends working in a local hospital as a Physio-assistant though. As a side note, nearly every weekend Physio was a med-student, which is interesting. Jack Chew just recently discussed the brain drain here.
To get to the point, my Private Practice career came to an abrupt end after just four short months because my income depended upon me filling my weekly caseload and making myself busy with bookings. Those were the metrics by which I was measured. I quickly lost 6kg with the stress of having to sell services I didn’t think people needed and following a scripted cookie cutter approach to clinical care. Our retention rates after the initial visit were only about 15% but that was pretty average for the group and not because we were telling people they didn’t need us; there were a couple of people I’d sent away with a “she’ll be right mate” which the boss didn’t appreciate. My hopes and dreams of finding clinical excellence and becoming the medical provider I’d hoped to become, lay shattered. Nothing was what I had expected or wanted it to be. The majority of clinical skills among my peers were no different to those I’d been using as a Personal Trainer and entry-level Massage Therapist. This was supposed to be a step forward! To add insult to injury, I knew nothing about ‘pain science’ (and neither did anyone else) and looking back my nocebo narrative was the norm and clinical reasoning akin to swiss cheese.
Jamie Lowy wrote about The Bus to Mediocre-ville stating that “we’ve traded the aspects of providing meaningful treatments to our patients” because productivity metrics (which determine our personal income and the business’ profit) Is it really about the patient? Or is it now about having a job that pays the bills, the student loans, the vacations, the new car?” Jamie asks.
Whilst my initial experience wasn’t the horrendous high-volume factory mills we occasionally hear about, that was Scott Iardella experience and the reason why he chose to walk away from it. It’s a sad story, but Scott’s doing great things via his podcast and I presume he’s much happier.
One Friday while taking part in a CPR course my former employer told me the door would always be open if I wanted to return to teaching. It was all the encouragement I needed. Looking back now, I felt stuck. Imagine signing up for an idyllic island holiday in a luxury 5-star hotel, saving hard for five years to afford the holiday, then arriving to find that you’re staying in a caravan with no scheduled flight home. My old job felt like a life raft and I jumped. I resigned on the Monday and was gone within a week. It was an ‘out’ but not a solution – I was a Physio with career goals which didn’t include moving backwards.
I’d *loved* my previous job but returning wasn’t without its challenges. One individual on the team had Narcissistic Personality Disorder and her bullying made my life in and out of work utterly miserable. That became the catalyst to chase my dreams in opening PRIDE Physiotherapy & Nutrition Pty Ltd.
My best friend Jenny and I spent a full year preparing our business plan, tweaking our model and defining the systems while we found the right premise. I still feel proud of the plan we put together. It *should* have worked. It could have worked. Only it didn’t. Doing much the same thing worked out pretty well for each of these people, so why not us?
The market we were hoping to appeal to never materialised. That was a realisation very early on and back then we had plenty of scope to change in response, so that’s what we did only that didn’t work either. PRIDE is the first business I’ve owned but I’m been around long enough and been through enough business courses not to be naïve. When I landed in Australia in 2004, I was a qualified Project Manager and member of Australian Institute of Management. I was a Business Analyst for goodness sake!
In hindsight, why it has failed is crystal clear. We’d started from scratch. It was a new business with no existing client base and a different approach to helping people; our by-lines are ‘Changing the Face of Physiotherapy’ and ‘Doing it Differently’. We had a 120sqm shell with a purpose-built fit-out with three consulting rooms and almost 80sqm of open-plan gym floor space. We offer Physiotherapy, Personal Training (under the guise of Physiotherapy), Nutrition Coaching, Massage and Group Fitness. I don’t think it’s too far removed from the norm, but people weren’t coming through the doors.
Here are a handful of the signage and branding strategies we’ve used.
I’m not sure which came first – PRIDE or The Kettlebell Physio. Clearly one’s the business and the other is me. The latter and the logo which goes with it are simply more memorable and representative and what I do, that’s all. There are several other examples of Physios, Chiros and Osteos with similar styles of pseudonyms which are working well for them.
Initially we started with just the main blue lightbox above the front door – that certainly shouldn’t have created any challenges. I wanted to avoid like the plague being known as just another Physio that does massage, the massage banner didn’t go up until much later in our first year when we accepted that we were getting more clients for manual therapy than Physiotherapy, so I swallowed my pride to capitalise on what was our main source of revenue. In other practices, it would typically be the Physio providing the manual therapy. We chose to employ manual therapists for manual therapy.
When we started, we had Jeff on board who was the only Titleist-Certified Level 2 Medical Professional on the Gold Coast, not to mention a Personal Trainer, Myotherapist and S&C Coach too! We offered a golf-specific package for players. It didn’t take off and we had to can it.
From the outset, we wanted to appeal to the ‘fitness’ crowd and make that clear. We thought that with me being an Exercise Scientist, Physio, Kettlebell instructor and Personal Trainer it would make me a more exciting and appealing prospect to the punters. Apparently not. Being next door to a 24hr gym too, we expected that we would be able to work with the PTs and help their clients with anything related to pain. We’ve had all the PTs in for training, took them through the FMS as a tool for them to use and they had all received massages on us so they would know where to refer if their clients ever needed it. I can count on one hand the number of gym members we’ve seen.
The Exercise Medicine and Performance Coaching went up to make it clear that we also helped people with pain, injury, rehab and medical conditions – it isn’t and never was meant to be another Personal Training studio – we do *Physical Therapy*. In over 18 months plus we seen about as many post-surgical patients and medical cases as people from the gym. This has baffled me. Where have these people been going!?
When we accepted that the brand of lying on a table and getting fixed with manual therapy was likely the road block, we thought we’d spell out PERSONAL TRAINING in massive letters outside the front door – that and a kettlebell couldn’t be any clearer could it!? Even the lure of being able to receive a health fund rebate didn’t attract people. Meanwhile, the PTs in the 24hr gym next door remain busy enough. It seems that people wanting a Personal Trainer don’t go looking for a Physio, even if they’re also a PT. Perhaps being over-qualified is off-putting.
‘FREE Initial Assessment’ is an effective attention-grabbing slogan for one of the largest franchise groups in the country. In addition to their Money back Guarantee, both combine to overcome the issue of someone parting with the $$’s they would rather be spending elsewhere – “it’s FREE and I can get my money back if it doesn’t work” they must be thinking. We tried both strategies and neither have been effective. Offering all of our Remedial Massage clients a complimentary 15-min consultation with the Physiotherapist did prove to be valuable for them and us.
We replaced the Free initial assessment in the A-Frame with the free Metabolic Age body scan (a fancy bioelectrical impedance device) which had proved to be extremely popular at an outdoor event we attended. We use it a lot to track people’s progress and it certainly gets noticed, but hasn’t been effective at getting people in the door who stay.
As our clinical tool of choice is the kettlebell, we set up a grading system of sorts (think martial arts), as well as the Pride Kettlebell Certification (PKC) which we’ve promoted to Personal Trainers. Internally they’ve been well received and they’ve been good for branding, but none have attracted any significant influx of people wanting to join in. Videos shared on FB of clients doing amazing things in class has by far created the most interest.
A local skin cancer specialist suggested that we should go into business together as there was a “tsunami of women” who were going to have lymphoema due to a massive increase in the number of surgical lymph node removals. We established a new Company – Lymphoedema Clinics Australia – and were on the verge of officially launching it when the Dr received a better offer of his own and pulled out. We shut it down before we’d seen one person.
I’m a nerd and I love teaching so last year I set up a Journal Club for the 200 local Physiotherapy students. University students giving up an hour of their lunchtime on a Saturday….on the Gold Coast in summer – who was I kidding!? 3 students came. That stuff was gold too!
These are just a few examples. Yes, I had hand delivered flyers to almost 3000 homes in the local area. Yes, we tried print-media. 6000 DL flyers with various ‘special offers’ went into the shopping bags of people right on our doorstep, and on and on and on…. The outcome has been consistent, and yes, I’d been in contact with various hospitals too.
Quite early on, I made contact with 46 local GPs (PCPs in America) and 6 Orthopaedic Surgeons. We offered two months of FREE Physiotherapy for their patients if they fitted into one of four distinct clinical groups or had just had a knee or hip replacements. One GP referred one young female with depression. That was it. We’ve never promoted ourselves as the traditional physiotherapy practice and that’s been our downfall. We started at scale with overheads and anticipated something that never existed. This podcast with Tim Ferris released yesterday covers some of that.
I can understand why the Remedial Massage, Personal Training, Kettlebells, and Group Exercise hasn’t worked. Why we haven’t attracted anyone with medical and post-surgical issues has continued to baffle me.
If someone had told me there might be a possibility that I could be sitting in the practice 12 or 18 months after opening with zero bookings for the day, I would have bet my children that wasn’t feasible. That was so far from the worst-case scenario, we didn’t plan for it. As it turned out, that *is* possible and it did happen. The net result is that we started with a 50k start-up loan (which very quickly shrunk with the fit-out) and we would have fixed monthly outgoings to pay. Thank f*ck we didn’t take the 300sqm premise!
In August last year we sold our home to pay off the debts and make sure we had enough cash in the bank to last three years if things continued as they had in the first nine months. It wasn’t a forever home, but we’d built it from the ground up and only moved in on Christmas Eve of 2014. We specifically took out a $20k term deposit to avoid risking our home if things went tits-up….and we still lost the house! That was a very bitter pill to swallow.
So, you get the idea – you start with a financial hole and a plan to fill it in and eventually build yourself a castle on top of it. What if you built it and they don’t come? You have two choices – 1) keep digging and continue working hard with an expectation that things will turn around or, 2) stop digging and climb out of the hole, assuming you haven’t dug yourself in too deep. Gary Vee often says, the market doesn’t give a shit how good *you* think your product or service is; the market decides. Everyone has a line of debt beyond which they’re not prepared or able to continue. Where would you stop? – $50k, $100k, $250k, $500k, more!? We reached our line and decided to climb out.
There’s one simple solution to any struggling business – sell more stuff. I didn’t study my arse off to become a medical professional to end up having to be a salesman though. At one point, which also didn’t last very long, I used to sell gym membership. I was paid on commission and had to sell *50* new memberships a month just to make commission, and there were six of us all doing the same thing. You do the maths. Todd was a sales-gun! He would consistently sell over 100 memberships every month and was making a lot of commission. I would scrape past 50. Todd was a hustler. He did so well because he was extremely skilled at employing the tried and tested sales tactics and preying on the emotional insecurities of the people who found themselves in a gym. Sales is a game of numbers and successful sales people are often driven by financial reward.
Most of the people I’ve spoken to about our predicament have a very similar response; “have you tried [insert solution]?”. I’ve been working really hard for 18 months and have exhausted most things, which was one of the reason for deciding to quit – I felt like we’d simply run out of options. Quite literally every week since we opened I’ve been marketing my arse off trying to get people through the door. Short of deliberately tripping people over, we’ve given most things a go. I even wrote more than 60,000 words of a book last year because the KPI program told me that being a published author is the first step to getting noticed. That worked out extremely well for Brad Beer, as has the Physical Performance Show Podcast he started, and the hourly content being shared via their multiple social media channels. He’s a marketing machine and metaphorically speaking he and POGO Physio is spanking most of the big names around the world, many of whom are highly regarded academically and clinically – here’s one Top 50 list they feature in.
It’s easy to work backwards from outgoings. I wasn’t interested in starting out of my garage; it was do it properly or not at all. That was a mistake. Let’s say fixed outgoing are 10k a month, at $80 a visit that’s 31 people just to break even. If the goal is to earn 100k before tax, that means you’ve got to be seeing consistently 56 full-fee-paying people every week if you’re not taking a holiday.
The sales structure I used to follow back in 2004 was to talk to 30 new people every day with the goal of making 10 appointments for people to come in to the club. We expected 5 would turn up, 1 would walk away, and we’d hope to get 3 people saying “yes”. 10% was a reasonable conversion rate. If we followed the system we would give each of those people a branded backpack and goodies (apparently) worth $30 in return for the names and telephone numbers of 30 friends and family, and so the cycle continued Ad Infinitum.
Systems and techniques evolve but principles remain the same. Where we previously asked for phone numbers, now checking-in and ‘liking’ stuff on Facebook, hosting podcasts, tagging people and places and endorsing products on Instagram, Snapchat and whatever else has people’s attention at the time in the norm – here’s Matt doing it.
We now have to do whatever it takes to get noticed. There’s nothing wrong with it, I’ve been doing it – that’s one of the reasons we’ve been running a Top 10 every month this year. It’s still just a numbers game. But what the heck does this have to do with being medical practitioner!? If you’re a business owner, it’s unfortunately everything! ‘Physiotherapy’ comes second. Unless we’re getting enough people through the door to pay the bills and make sufficient profit to pay ourselves, we’re just digging a deeper hole and that isn’t sustainable.
I’ve talked a lot about Gary Vee. I appreciated that his delivery isn’t to everyone’s liking, but that doesn’t mean he’s wrong, and you certainly should believe me! But, if you’re a Physiotherapy practice owner and doubt whether any of this holds weight or has any ROI, listen to this on the Entre Leadership podcast from 40min instead. “The barrier for growth of a business is really about when you get systematic”.
If you’re not sure what that means, I would urge you to following all of POGO Physio and Brad Beer’s content for a week – everything! The website, Instagram, YouTube, Twitter, LinkedIn, SnapChat, Facebook, and compare it to what you’re doing. I think you’ll be surprised. The result speaks for itself.
Here’s an example from American Physical Therapist Jarod Hall and how we need to self-promote using social media. Jarod shared a post on his Facebook page tagging multi-billionaire and founder of Tesla Elon Musk. He opened with some public praise (most people respond well to that) in sharing an article about how Elon’s a top bloke and awesome CEO. He finished the post with an offer of his own services as a PT to Elon and his company. He could have contacted Elon directly of course, but that wouldn’t get him noticed by everyone following Elon. Jarod’s rapid rise was predictable and it will continue. Yesterday he followed in the footsteps of several other bigwigs in giving a live webcast on the Trust me I’m Physiotherapist page. None of this is a bad thing at all; it’s called hustle. It’s what you have to do now just to get noticed. Long gone are the days of hanging out a shingle. But that’s my point, we *have* to hustle. It’s everywhere. As Gary Vee says, every business is now a media company first. It’s no wonder that Jarod’s currently putting together a course: “Simplifying Physio Practice: Trimming the Fat and Cutting the Crap”. Here’s Marketing-101 with ‘Dr Mike’ and here’s how to build a following with Dr Jen Esquer on Therapy Insiders.
As someone more comfortable on the medical side of the fence it’s not about the validity of the content either. This is a case in point from the fitness industry – we cannot compete with this crap. Pumping out garbage isn’t limited to the fitness industry either – plenty of Physios are guilty of it too. As nationally registered health professionals, you would think we would be held to the high standards expected of us. We’re not, and there’s plenty of snake oil being peddled. The public has no interest in RCTs and the latest meta-analyses.
It may sound like I’m anti-business, anti-profit and against people being financially rewarded for the value they provide, which isn’t the case at all. I listen to almost as many podcasts about business as Physiotherapy. Someone once criticised Walk Disney in a letter – ‘you just want to make money’. His response; ‘we don’t make films to make money, we make money to make more films’. For some people in business, it’s about the material stuff and accumulating wealth, and that’s ok. For others, it’s more about the ‘thing’, which in our case is Physiotherapy.
Money is a means, not a master – not working for it, but using it as an opportunity to do more of the work. I’m not suggesting that Physiotherapy practice owners think like Scrooge McDuck, but I do feel that we (me included) in the world as it exists now, have to in some part think like Mr McDuck because we have a responsibility to make money. I’m no longer going to be able to help *anyone* because we haven’t been able to make enough money to stay open. That’s a hard smack of reality to face and the Catch-22 I’ve been faced with. I wasn’t prepared to compromise on my moral, ethical and professional values and that’s ultimately been my/our downfall. I’ve turned someone away today in fact, because providing the service she wanted would have been insurance fraud. I expect a practice up the road will do it though.
If I wanted to be in sales and marketing and if I was primarily motivated by running a business and making a profit, I wouldn’t have chosen to become a medical practitioner. I recognise that making a profit is essential. If you’re focusing on the finances, you’re missing the point though. Show me a successful Physiotherapy practice which isn’t following current marketing trends and I’m pretty sure I would be able to show you a practice which fits Erik Meira’s definition of a consumer service and one which fits the bills in terms of low value healthcare.
Now this is where things head off in a direction which I really dislike. For arguments sake, let’s say that we get the 56 full-fee-paying people through the door each week; what happens next week and the week after that? Some people *will* be coming back, but a lot won’t or don’t need to, and so the empty appointments need to be filled. How and where from? If every person was a single visit (which isn’t going to be the case) that would be 2,912 people each year, or 728 people each having four appointments. If we can get each of those 728 people to come 5 times instead of 4, that’s 146 fewer people we need to attract to retain the same revenue from appointments. It’s far easier to have an existing client return for one more visit than find a new one. Or we increase our fees. It’s just numbers. Show me a financially successful Physiotherapy practice and I reckon I’d be able to show you an astute businessperson running it.
How about this – every new person comes 3x/ week for the first 4 weeks, then 2x/wk for the next 8 weeks, then 1x/week thereafter. Perfect! That way we don’t need to spend nearly as much time finding new people. I bet nobody’s thought of that yet. Or how about we sign people up to weeks of care and have them pay in advance, that’ll keep us busy too and as they’ve paid up front, it doesn’t matter if they don’t actually turn up – that solves the challenges of last minute cancellations and no-shows. I bet nobody’s thought of that either. These aren’t the only clever marketing strategies being used to fill Physiotherapist’s schedules. Scare mongering and over-servicing is rife.
I once worked in a Chiropractor’s clinic which was open 25hr/week. At that point, one chiropractor would provide 400 “treatments” in the week. The last time I met with the owner, that peaked at 700. The average fee of an adjustment was over $40.
“Increase your prices” I hear you say. That may work for Baroona Physiotherapy or the team down the road at POGO but that only works once you’ve already got a client base and can afford to lose those who cannot afford or are unable to pay higher prices. High prices don’t necessarily attract new people either, and we’re in a location where a lot of people can afford higher than average prices. I’m happy that our fee schedule is reasonable as it is. We’re not the cheapest and we’re not the most expensive by a long shot.
I’m frustrated by three things;
- The simple fact that our business has failed
- That my profession (and the Physiotherapy brand) is defined by low value healthcare and clinical reasoning built on this house of cards
- The non-stop stream of professional pissing contests
I often catch myself standing in our practice admiring what we’ve created…. simultaneously pulling at my rapidly receding hair line that it’s not full of people being helped. I’m immensely proud of the facility we have and the evidence-informed systems we’ve put in place and have continued to fine-tune as we’ve learnt along the way. But that’s irrelevant if nobody’s using them.
As an ignorant know-it-all Personal Trainer and then Massage Therapist, I didn’t have my ear to the ground nearly as much as I do now, but I wasn’t aware of much in-fighting back then. Jason Silvernail would call me a lurker; someone quietly watching and listening. The name-calling and in-fighting within Physiotherapy and between professional is on another level! A quick look on Twitter or in a few closed Facebook groups is evidence of that.
It’s not just minor squabbling over big important things either. It’s disagreements on *everything* to do with clinical practice. Here’s a perfect example from Greg Lehman after a video was recently shared by the North American Institute of Orthopaedic Manual Therapy. “This is fully unsupported and has been utterly discounted for almost 20 years. All of this just seems to be taught to perpetuate a false sense of knowledge to keep cranking out non-evidenced based continuing “education” courses. Adam Meakins predictably wasn’t quite as polite in pointing out that “This profession is nowhere near advancing or progressing… nowhere near.” He’s right. Peter O’Sullivan echoed that sentiment too here on a recent episode of the Pelvic Health podcast. In terms of pain science Paul Lagerman shared this asking “WTF have we been doing for the last 30 years?” In Explain Pain Supercharged, Lorimer Mosely says “If you hold up the mirror and can say honestly, that this is not you [believing that tissue damage = nociception = pain], then you are well and truly ahead of the pack. You are completely consistent with the massive amount of research on this, and sadly but understandably you are still in the minority – it sure can be a lonely place!”
It is. Very lonely.
On Sunday night I spent two hours chatting via Skype with Karen Litzy (name drop) and Swedish Physiotherapist Adrian Valkeaoja about pain. It was such a buzz to talk to people with people on the same page!! I mentioned that I don’t know any local Physios who I could have the same conversation with. That’s crazy.
Pick any topic and you’ll find people fighting over it, waving their various forms of evidence and biases. Here is one recent example among *many* – “MMT (Manual Muscle Testing) just poisons the well by enabling us to justify substandard care.” Add the inter-disciplinary Physio Vs Osteo Vs Chiro squabbling, and that just magnifies the situation.
Two of the podcasts I’ve listened to recently were this one on the BJSM about swimmer’s shoulder and this one on Health Wealthy & Smart about taping and bracing. If you’ve had your finger on the clinical pulse, you’ll understand the challenges of giving a diagnosis of shoulder impingement and the validity of scapular dyskinesis. You’d have to have been hiding under a clinical rock if you thought everyone was on the same page with the clinical use of kinesiotape!
For 18 months I’ve channelled much of my frustration in to creating solutions and focusing on our tribe as Seth Godin calls them (this is an excellent video about having a successful business philosophy), but the low value healthcare which defines us I have found utterly soul-destroying. One of my career goals was to overcome the low-value nonsense and make a significant difference in changing the brand – Changing the Face of Physiotherapy is says above our door; apparently much easier said than done! In part, I think perhaps it’s been a vicious cycle of business owners responding to the reality that there simply aren’t enough people who *need* Physiotherapy. Perhaps in response we’ve created a need in people which also self-validates our role as the healthcare provider. Academia plays a significant part in this too of course – looking at you ‘core stability’ and your dodgy postural-structural-biomechanical mates! – and we know that it takes well over a decade for research to find its way into the classroom. The science of pain hasn’t got there yet.
We look at people’s anatomy and tell people what’s ‘wrong’ with them, even in the absence of symptoms, and offer them a solution. We continue to peddle outdated theories and practices despite overwhelming evidence which does not support them. We treat like pseudo-massage therapists and have in our elevated professional capacity, abandoned much of the ‘exercise’ interventions because that’s what the Personal Trainers do and apparently, we’re above that.
Explain Pain Supercharged explains how Patrick Wall often lamented the disconnect between what the biology of pain was saying and what the clinical community was doing. I still consider myself a newcomer to the ‘pain science’ movement but it’s mind-blowing that the profession isn’t catching on faster. Really, it’s mental. It hasn’t been published yet but Associate Prof David Nicholls at AUT University has just written a book (here) titled ‘The End of Physiotherapy’. It’ll no doubt be an interesting read
As far as treating with exercise goes, I think we’ve cut off our noses to spite our face and done ourselves out of a lot of business where we could be making an extremely valuable contribution. If someone decides they need to start exercising, they don’t turn to a Physio (because our brand is not exercise), they go to a Personal Trainer. If a GP decides that one of their patients’ needs to be exercising, they refer them to an Accredited Exercise Physiologist (because Physios don’t do exercise). At PRIDE, we’ve been offering Remedial Massage and Nutrition Coaching too, but people seeking massage typically look for a massage therapists, not a Physio, and the same principle applies to Nutrition. When we started, several people told us the brand was confusing – exercise and Physiotherapy, and WTF are those kettlebells and the RKC all about!?
Where I saw an excellent clinical tool (a reformer is just a tool too) and a unique point of difference, everyone else was looking back at me like this. I ignored it and carried on regardless, convinced that people would see the light as I had.
Last year Jack Chew shared this predicting that “Well-informed personal trainers will outsmart ill-informed professionals unless the MSK industry reforms… soon.” He’s on the money. Here’s another example and there are lots more. It’s feels ironic that as a Physiotherapist wanting to focus on exercise, I’m now losing out to the Personal Trainers I trained 12 years.
Physiotherapy has a brand crisis and my “Facebook Livey thingy” got a mention in Roger Kerry’s popular blog Physio Will Eat Itself. Roger’s post got a reference in Laura Opstedal’s post about Letting go of traditions which was also well received in the Twitter-sphere. Laura asks “Who are we and what is it we do? Impossible to define, because we all “do” different things… and bicker about it endlessly!” Laura isn’t the only one who’s pointed out that in making ourselves needed, we’re ignoring the art and appropriateness of doing nothing. Over to you Erik:
- A medical provider “doing nothing” is actually doing quite a lot
- Sometimes it is enough to simply be an expert telling a patient, “It will be fine eventually if you just leave it alone.”
I think our brand should be rehabilitation. Here in Australia, there is no one profession known as the rehab experts. A Physiotherapist may be the first person people think of, but that’s different from branding; branding is what we’re known for and it sure as shit isn’t that! From where I sit, Jo Public’s experience of us revolves around massage oil, manual therapies and Pilates. That’s not rehab.
I’m 42 and far too old to think that I know it all. In this impersonal digital environment, I’ve experienced what it feels like to have a group of Physiotherapists knock me down as a human being rather than my clinical ideas. It wasn’t pleasant at all. Adam Meakins must have incredibly tough skin, but even he’s started to crack under the pressure!
Those who do really know me, know that I have more self-doubt as a clinician than most and they are frequently infuriated with my usual response of “it depends” to their questions. As a business owner, being at the low-confidence end of the Dunning-Kruger graph is a massive disadvantage (I discussed it here) when the people we serve and those we work with don’t care for vague, they want to see and hear absolutes and confidence; the first rule of the Dunning-Kruger Club is:
You do not know you’re in the Dunning-Kruger Club. Absolutes and facts don’t exist in Physiotherapy because it’s both an art and a science. If it was all art and no science that would be a different story, but those of us on the science side of the fence are there for good reason and typically have a low tolerance for fluff.
As a student Physio, I had one business subject, but it didn’t cover any of this. There was no mention of the ‘business’ of making a profit from being a medical practitioner and healthcare provider. It certainly doesn’t get a mention anywhere in the description of Physiotherapy here. It’s almost like it’s a dirty little secret that nobody wants to talk about unless you’re a part of a business group somewhere, where the talk is about making money, not medical practice. I’ve just left one such group for that very reason.
This interview with Andrew Read on the Leo Training podcast is an excellent illustration of how things are. Andrew’s a well-known guy in the fitness industry with a no-nonsense blunt as a brick approach to what he does. The things people actually NEED – more sleep, less stress and more regular exercise – aren’t sexy. In the fitness industry, you simply can’t sell what people *need* and Physiotherapy is no different. Half the time the best things is to do nothing; the other half is to just load it and nearly always almost without fail the simplest solution is usually the correct one. The fitness industry is a salesman’s pond, hence why people like John Rusin and Perry Nichelston fish in it with great results – chuck in some sofolgy horseshit and people lap it up faster than a hairy dog on a hot day e.g. “the muscles don’t work individually, we have to coordinate something I like to call the synergistic spiral effect of the entire kinetic chain working as one”. Dr John Rusin.
Credit where credit is due and a hat tip to John for this, “I figured out that I didn’t have to be a traditional Physical Therapist, I could go and I could make my own path, really preaching the principles of strength and conditioning and meshing them together with the best most advanced techniques in manual and physical therapy and also corrective exercise programming and just ultimate human performance.” Once again, it worked for him, so why not me!? If you listen to the podcast and watch what John’s being doing, it’s very obvious what he’s needed to do to get there, and he’s received a lot of criticism for it.
Instead of giving people what they actually need, we prey on peoples fear and ignorance, we adopt the role of an operator instead of interactor falling foul of the a Post hoc fallacy and our own anecdotes as evidence of efficacy and effectiveness. In private practice, nobody needs daily Physiotherapy and more is not better. If more “patients” [cringe] had more patience and received better advice from the outset, they’d be much better off. We wouldn’t be giving people the chocolate cake which simply makes them ‘feel’ better and we wouldn’t be selling our souls as the used car salesman of the medical profession. We spend far too much time amusing the patient while nature cures the disease and flinging shit in the hope that something will stick.
If we were recognised as the healthcare professionals I think we should be, people would be far more receptive and inclined to listen to our advice
Physiotherapy is the science of uncertainty and art of probability. We know that selling exercise (especially with our current brand image) doesn’t work, but we can chose to spend more time on the things which matter, recognising that people aren’t problems to solve, spending more time educating and empowering people who have pain, building therapeutic alliance and agency, and maximising the non-specific effects without taking the piss. In the ideal world inside my head, we’re treated differently and not being ‘trumped’. More people would be better educated and far fewer would be fooled by what they see and hear on the internet because they’re better educated about their own body and we would be celebrating more successes that failures.
So much of what we’ve done hasn’t lasted the test of time and our collective cognitive dissonance prevents us from leaving behind the outdated practices which currently defines us.
Advertising is everywhere!
Pick a topic and someone somewhere is selling a product or service to make a buck, evidence or not.
The clever marketing boffins at companies like Chattanooga are selling Radial Pressure Wave Machines as if they’re ‘Shockwave’ with the label of Radial Shockwave and we’re too daft to perform any sort of due diligence and identify it’s just a con. Then we have to recover the $12k we spent on a machine… and so the client pays for it with treatments no more useful that a warm bath. Nick Tuminello says here “Listen to everyone, but believe no one. It’s by far more dangerous to assume people know what they’re talking about, than it is to assume they don’t and let them prove you wrong”.
Chatting with trustworthy Trent about this over the weekend, I likened it to picking up a car after its service when it’s been cleaned and the wheels waxed. Mechanics call it smiles in a can because they know that the thing the client *isn’t* paying for (making the car look nice) matters more to them in the transaction than what’s being doing to the engine which may have no tangible benefit whatsoever. A successful service transaction between two human beings is an emotional one. We know that someone can be very satisfied with the care they receive with little or no improvement in the clinical outcome although “In the health care industry, many will argue that patient satisfaction is directly associated with better outcomes and health status.” We also know the importance of building a relationship of trust and respect with someone and making the most of the therapeutic alliance. Arguably that will be the most important variable in gaining the desired outcome. That’s the ‘art’ in Physiotherapy. And so it comes back to it being far less about anything specific and more about the soft interpersonal skills and providing more of what they want and less what they need – the Physiotherapy equivalent of a smile in a can – making people happy with massage oil?
As Physiotherapists, we’re sold too just as much as we then on-sell the same garbage to the people who come to us – just like the Personal Trainers Andrew Read discussed.
From the team at Evidence in Motion, we’re told to ‘Give Your Patients What They Really Want’. This is not new – focusing on the value we provide to get buy-in. It’s simply appealing to someone’s emotional decision-making processes. “the more elements provided, the greater perceived value and the higher the company’s revenues”. The author of the article of course now shares his knowledge and experience through teaching and mentoring therapists who want to have their own practices and achieve professional and financial freedom i.e. the business of running a health practice. There are many many examples of business mentors just like Paul!
Alain de Botton explains here why we often display great hope through feelings of anger. I’m not angry, but I am incredibly frustrated. Adam Meakins though, he often appears angry. I‘ve often felt a form of kinship with Adam, perhaps it’s because we both have so much misguided hope for our profession.
“Chase your passion” we’re told…. “Don’t follow your dreams, chase them!” but remember, you can’t take the risk out of the rent. I’ve put my heart and soul into PRIDE for three years. I would like to have been able to pay myself a salary for the past 18 months, but that hasn’t been possible. I’ve chased my passion and the money didn’t come; it ‘went’. The fact that I’ve very happily been in the practice 60hrs week for 20 months and sacrificed an inordinate amount of time with my wife and kids and in return *paid* for the privilege of working speaks volumes. But, all good things come to an end, and that’s where we find ourselves now.
It’s been an invaluable, albeit costly, life and learning experience. Now it’s time to take that experience and move on.
“You can’t solve a problem on the same level that it was created. You have to rise above it to the next level.”
— Albert Einstein
Changing the face of Physiotherapy….. the dream lives on 😉
Falling down is part of life. Getting back up is living.