“Good is the enemy of great. And that is one of the key reasons why we have so little that becomes great. We don’t have great schools, principally because we have good schools. We don’t have great government, principally because we have good government. Few people attain great lives, in large part because it is just so easy to settle for a good life.”

– Jim Collins

Good to Great: Why Some Companies Make the Leap... And Other Don't

Jobs Applied: Impute

physical therapy browdering

Have you ever noticed that the packaging for Apple products is simply beautiful?  I hate to throw these things away – its obvious great attention and time goes into each one.  Steve Jobs personally spent time on the design of the packaging for the iPhone, believing that it set the tone for the experience.  He put his own stamp onto every facet of the product so that there was intention behind every aspect of it.

“They ‘do’ judge a book by its cover.”  -Steve Jobs


Everybody utilizes first impressions to make judgements.  Patients ascribe (or ‘impute’) characteristics to their therapist based on the packaging.  Can we intentionally design the patient’s first impression to create confidence that we can solve their problem?  I suggest that how we appear and how we dress plays a role in patient confidence, and thus in our ultimate outcome with that patient.

How do we want to be perceived?  I think patient’s for the most part don’t really know where to put us in the hierarchy of healthcare professionals.  What style of dress gives the best impression?  Is it different for different people?  There has been a little bit of research in this area, but nothing all that definitive and it seems obvious to me that setting makes a difference.  Interestingly, this research did not include the style I would choose for men in outpatient settings (dress shirt no tie).

‘Scrubs’    – I loved that show. Have you washed those recently?









‘The Coach’   – Are physical therapists like really smart personal trainers? Hey – P.T. – the initials are the same!










‘The Golfer’  – Are physical therapists like athletic trainers? I had one of those in high school.

Physical-Therapist polo


‘Business Casual’     – Nice shirt! Is that stain from massage lotion?



‘The Coat and Tie’    – Did you just come from the bank?  Is that tie uncomfortable?







’The White Coat’    –  Are physical therapists like physicians?











What kind of ‘packaging’ sends the best message in your opinion?  I’d love to discuss it with you below and we’ll be #browdering on twitter as well.


“A company should limit its growth based on its ability to attract enough of the right people.”

– Jim Collins

Good to Great: Why Some Companies Make the Leap... And Other Don't

Jobs Applied: Put Products Before Profits


Steve Jobs, when creating the first Macintosh computer, famously ignored cost trade-offs and profitability in favor of making the computer ‘insanely great’ and with a mantra ‘don’t compromise’. This actually led to his ouster in the early ’80s as the Macintosh ended up both amazing and too expensive to compete with the cheaper PCs of the day. In response, Apple hired a less product-oriented CEO recruited from Pepsi, John Sculley, who focused on profits. Focusing on profits led to a decline in quality and Apple nearly died before Jobs’ return in the early ’90s. The return to a focus on innovative, ‘amazing’ products led to Apple’s emergence as a market leader.  Even in the face of challenges, such as we are facing in healthcare today, Steve Jobs kept the focus on providing the best product, rather than on profits.

A few weeks ago I  posted ‘Jobs Applied: When Behind, Leapfrog‘-  a discussion of Harvard strategy guru Michael Porter and Thomas Lee’s timely HBR article “The Strategy That Will Fix Health Care”. One of the key principles Dr. Porter brings up is the definition of value in healthcare.

“Value is defined as the health outcomes achieved that matter to patients relative to the cost of achieving those outcomes. Improving value requires either improving one or more outcomes without raising costs or lowering costs without compromising outcomes or both.” (Porter and Lee, HBR Oct 2013)

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In health care and other service industries the ‘product’ is a patient’s experience and a health outcome… so the lesson here would be ‘Put the patient’s experience and health outcome before profits’. As the payments for providing health care services decline this is a reminder to continue to put the patient’s needs first.

Our physical therapy practice has been a leader embracing a care model that allows for improved efficiency, but keeps the physical therapist (PTs) firmly engaged with each patient. Texas allows physical therapists to utilize technicians (unlicensed assistants)to assist with some treatments under the direct supervision of the physical therapist. While when we first started in this model we were challenged by PTs providing ‘1 patient for 1 therapist for 1 hour’, these practices are increasingly failing in states with the greatest payment challenges and have either evolved or are hanging on by a thread. While in part due to other issues, the 2013 chapter 11 filing of the largest physical therapy provider in the US accentuates the idea that this lesson might be better termed ‘put products before survival’.

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Many states have strict requirements requiring care be provided by only licensed personnel (PTs and PT assistants – or PTAs) and federal payers (i.e. Medicare and Medicaid) will only pay for services provided directly by one of these licensed personnel. These regulations in our ‘over-licensed society’ (Litan, R. HBR Apr 2012) have created a perverse incentive where a model that may decrease value to the patient actually becomes the most easily sustainable model of provide PT services.

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For the first 10 years of my career I was a physical therapist in the US Air Force. I am proud to say that the US Military employs perhaps the finest orthopedic and sports oriented PTs in the US. Direct access to PT services and an advanced level of musculoskeletal screening and cross-collaboration with other specialties is integrated in a manner that the public sector should look to when reforming our health care system. There is mounting evidence that early referral to PT, which is sometimes available in the military system and now available in some states improves outcomes and reduces downstream costs.

One of the challenges, particularly in military medical centers, is that many of the actual treatments are not provided by PTs. A typical patient encounter would include an evaluation with a PT, then multiple treatment sessions with personnel roughly equivalent to a physical therapy assistant (PTA) with a follow-up visit with the physical therapist at somewhere between 2 weeks and 1 month after treatment.

PTAs have associates degrees and are licensed to provide PT treatments under supervision. Manual therapy is a key challenge to providing care that is centered around the utilization of PTAs in an outpatient orthopedic setting. The APTA has issued guidance discouraging PTs from allowing their assistants to provide manual therapy interventions. One of the reasons I eventually left the military medical system was to be able to provide these evidence based interventions without requiring a lesser-trained intermediary.

The regulations imposed primarily by the federal government in conjunction with steadily declining payment for services have created a concerning incentive. The care model long utilized by the US military looks as if it may become one of the few viable business models for private practice. Driven by a high median income ($52,160 in 2012)there is a flood of interest in becoming a PTA. With the median salary for physical therapists (doctoral degree) at $79,860 this is no surprise. There are now 21 PTA programs in Texas (compared to 12 PT programs) with more on the way.  In my opinion, the relatively high cost of PTAs (and their wages) will likely dramatically decrease as demand is met and then exceeded over the next few years. At that time the incentives provided by declining payment for services  and regulatory requirements align very well with a business model where a single physical therapist provides minimal oversight to multiple PTAs.

1194984910785474358stop sign miguel s nchez svg medI have encountered this model recently, when interviewing PTs for director’s positions within our practice. One PT I encountered reported evaluating over 100 new patients while supervising 2 PTAs providing over 900 visits in a single month. By his report he was able to follow up with his patients for a short time approximately every 4-5 visits.

Utilization of PTAs, in itself, is not what I would argue is the problem with this business model. I believe there are models where PTAs can be leveraged as part of a tightly knit team to improve efficiency and to maintain or improve quality. However, as the ratio of PTAs supervised by each PT increases, the level of involvement of the PT in the patient’s care invariably diminishes. In the Air Force we would see this in the variability in the quality of care provided at medical centers versus in the smaller outpatient facilities or the deployed setting. My wife, Alexis, has experienced this in the home health setting, where she was asked as the PT to provide an initial evaluation and a follow-up visit at 30 days. I believe it is hard to make the argument that the patient’s progression is meaningfully guided by the physical therapist in that scenario.

A counter-argument would be to compare this scenario to the increase in utilization of care extenders to decrease the cost for primary care providers to care for patients or even the explosion of ‘minute clinics’ and the like. While the situation is similar on the surface, it is perhaps more extreme when looked at more closely. To compare these arguments would put the doctorally trained physical therapist in the provider role (not inappropriate from my perspective), but would put the PTA in the same category as a physician assistant or nurse practitioner. While I have worked with excellent PTAs, the training received at an associates degree level is not comparable to the masters degree level that physician’s assistants and nurse practitioners receive.

The lesson of putting the patient’s experience and outcome before profits may come into play if we allow over-utilization of PTAs or any other extender to disconnect the PT from the patient’s intervention. In the face of ever-increasing costs of doing business, it is my hope that we can continue to ‘put products before profits’ and create innovative care models that meet Dr. Porter’s charge of improving patient experience and outcomes while doing so at a decreased cost. Removing well-meant but misguided regulatory hurdles would improve our ability to meet the charge to provide high quality care by PTs in a model that can accept lower payments for services while maintaining the patient’s experience and outcomes.

I suspect that this post might touch a few nerves – even in some of my good friends and fellow private practice owners – and I am looking forward to engaging in respectful debate on the topic. Please add your perspective!  I don’t pretend to know the answers and freely admit I might be wrong.  Maybe we can come up with some ideas together to move our profession forward in these challenging times.

Find your Flow


Proposed by a Hungarian positive psychologist named Mihály Csíkszentmihályi, flow is the mental state of operation in which a person performing an activity is ‘fully immersed in a feeling of energized focus, full involvement, and enjoyment in the process of the activity’.

I am almost certain that if I couldn’t get into a state of flow while performing patient care, I wouldn’t be a physical therapist.  Its also one of the reasons why I enjoy being engaged in a busy clinical setting, with just enough patients to where I can flow from one to the next with just enough time to get mandatory documentation and such accomplished.


This is so much more enjoyable than a slow day that drags on and on, or a day that is so hectic that I can never catch up.  When I get just the right amount of patients scheduled and making great progress on their goals, time seems to disappear.  I’m in control and the day feels like a dance put together by a master choreographer.  That is flow.

You have to be involved in an activity with a clear set of goals and visible progress.  This adds direction and structure to the task.There are three conditions that flow theory postulates have to be met in order to achieve flow:

  1. The task must have clear and immediate feedback.  This allows you to adjust performance to maintain the flow state.
  2. There must be a balance between opportunity and capacity.  In other words, there is opportunity inherent in the task and you have the capacity to meet the challenge of the task.

Clinical practice can often meet all of these requirements when we are fully present and engaged.  One of the ways I get into flow during a busy clinic day is by avoiding email, facebook and other distractions.  I put my electronic medical record system in full screen mode and avoid the temptation to ‘check in’.  This by itself doesn’t create flow state, but one thing is certain – you can’t flow while you are distracted.

Patient care lends itself to meeting the requirements for flow.  We often see changes and make improvements immediately when working with patients.  This gives us not only goals and visible progress, but immediate feedback.

We have the opportunity to make large improvements in patient’s lives, and we definitely have the capacity to make those changes.  Few clinicians have the same opportunity to make immediate improvements and gain the reward of instant positive feedback.  This is part of what makes physical therapy a highly sought after profession.



Jobs Applied: When Behind, Leapfrog

When Apple found itself behind, Steve Jobs would innovate his way out of the problem.  The best known example of this is finding that the original iMac, great for creatives and photo handling, wasn’t any good at music… it didn’t even have a CD burner!  Apple was getting trounced by PCs in this area.  Apple not only gained ground, but leaped ahead by creating iTunes and the iPod.  These products literally restructured the entire music industry for everyone but Garth Brooks and a few other holdouts.

Got a job girlLast week as I was pondering this week’s post I thought to myself … ‘Self, how are you going to turn this obviously tech related, innovative ‘leadership lesson’ into something that has utility in the private practice physical therapy world?  I was stumped.

Then I read a fascinating article in HBR by business strategy icon Michael Porter and Thomas Lee titled ‘The Strategy That Will Fix Health Care –  Providers must lead the way in making value the overarching goal.’  You can find the abstract here and I recommend buying the article.  Everybody in the the US healthcare chain should be forced to read it.

” At its core is maximizing value for patients: that is, achieving the best outcomes at the lowest cost”

Here’s the gist: Providers (OK so he really means hospital systems and physicians) need to do 6 things all at once to fix America’s ailing healthcare system.

  1. Organize into Integrated Practice Units (IPUs).
  2. Measure outcomes and costs for every patient.
  3. Move to bundled payments for care cycles.
  4. Integrate care delivery across separate facilities.
  5. Expand excellent services across Geography.
  6. Build and enabling information technology platform.

What struck me when reading this is that we are already behind!  Dr. Porter did bring us up a few times as excellent examples of how we can save costs and how utilization of ancillary providers (like PTs and nurse practicioners) creates efficiency and cost savings.  For example, we are < 1/4 the cost of a physician visit and there is plenty of evidence to show we can save downstream costs.  As a profession, this single article may do more for us in terms of positioning us as a part of the solution than anything else I’ve seen to date.  However – it was always in the context of the PT in the medical center.


This model would create Integrated practice units, which PTs are certainly a part of and have a role in. IPUs are like a next generation Center of Excellence focused on being the best at one diagnosis or patient type.  These already exist – the example Dr. Porter uses is Virginia Mason Medical Center in Seattle – which focuses on treating low back pain.  After calling a single number, patients are scheduled to visit a PT and later that day a PM&R physician (just in case?).  If the patient needs anything other than PT then they can receive it right there in the same hospital.   In the IPU strategy the expected outcome is that IPUs become bright spots in care delivery for particular diagnoses.  Employers and health systems are then to be encouraged to send exclusively to them to handle the entire course of care… including rehabilitation.  So how then do they take care of the outpatient PT piece? Answer:  they ‘expand excellent services across geography’.  Ouch.

“Organizations that progress rapidly in adopting the value agenda will reap huge benefits, even if regulatory change is slow.”  (Porter and Lee)

So how do we leapfrog ahead of this (admittedly brilliant and needed) strategy to ensure that private practice physical therapists have a place in this New HealthCare World Order.  More to the point – how to we do that in whatever less well thought-out version we end up with?  Do we all have to go work for the hospital?  I think there are two ways we lead our organizations to get there:


First – measure outcomes.  Our company uses FOTO to measure functional outcomes on every patient.  This is the first step in participating in the new healthcare world.  We have to be able to achieve and demonstrate a high level of value for our patients and ‘what gets measured gets managed’ (Peter Drucker).  If we don’t measure it – how do we know how much value we are adding?  How can we improve?

Second, we have to be ahead of the need for efficiency.   We need to figure out the innovative care models that stretches the PT’s capacity to see more patients effectively in a day.  The days of 1 PT caring for 1 Patient for 1 hour are gone… to the same place that the family practice physician visiting your home went.

Where we will continue to have demand for our services is in our ability to be where our patients live, play and work.   People will go across town to see a specialist.  If they work for Wal-Mart and a few other enterprising companies they will travel, expenses paid, across the country to get a new hip.  However – what they can’t or won’t do is travel any real distance to attend physical therapy sessions.  IPUs will have to figure out how to provide high quality rehabilitation to remote patients.  That isn’t the clinics owned by physicians (POPTS) or hospitals (HOPTS) – that’s us.


IPUs face the challenge of trying to be good at all aspects of care delivery for a given condition. High quality physical therapy providers who measure outcomes and have some geographic spread away from the IPUs can leapfrog ahead by being ready to participate in these IPUs.  Perhaps we can participate as partners through hospital contracts or at minimum by being a provider of choice for the IPUs, who by definition care about outcomes enough to care about the value we provide.

What that means is that your practice will probably be judged in part on your therapist’s ability to communicate back to a coordinating physical therapist at the IPU.  Think this isn’t already happening?  We regularly see patients from the Andrews Institute in Florida (our practice is in Texas).  Why?  Because this high quality orthopedic practice, which receives patients mostly from domestic medical tourism, knows that we use their protocols and are open to discussing cases with the therapist that sees the patients on follow up.  Some good outcomes on initial cases have earned us preferred provider status and they typically call us about patients even before the patients call to schedule.

Steve Jobs was a master at innovation and leapfrogging over Apple’s competition.  We can do the same thing by focusing on what will be important in the New HealthCare World Order.  That is likely to be the best outcomes with the lowest cost.