Transcript
Marla: So today we have a great guest, Larry, so great to have you on our show.
Larry: Thank you. I'm glad to be here.
Marla: And you are the founder of Confluent.
Larry: That's right.
Marla: As well as a former CEO, as well as the industry physical therapist.com specialist. So I know you have a podcast and you have a website and do a lot of different pieces on physical therapy, telling us all about what's coming out, what's happening now, and just really guiding the whole industry.So it's a pleasure to have you here today.
Larry: Thanks, it’s great to be here. Love what you guys are doing with the podcast and Prompt and everybody who's just such a contributor to the industry. It's just always a great feeling to be associated with that, so thanks for allowing me to be here.
Marla: Great. And I know today we're really gonna dive into a lot about clinician shortage and what we could potentially do. We’ll be talking about burnout, talking about enterprise organizations and what they can do to help foster the passion of clinicians and making sure they really love what they're doing and they're thriving in this field.
So just start a little bit of a background about you. Give us a background and then we'll go into that.
Larry: Sure. You want background on me? So as she mentioned, I'm a former CEO. I was CEO for about 38 years. Really have been involved in private practice for a long time. But my career started out in the military.
I'm an Army physical therapist. I was a captain in the army. Went to the Army Baylor program. And the Army was a great place if you're an entrepreneur because you could do the more you do, the more they ask you to do. And so I started all kinds of programs when I was in the army. Loved it. When I got to about the five year point, I started doing a little bit of moonlighting.
I always had a bent for startups and ventures. And so before I got out of the military, I had already started moonlighting a bit, started a private practice in Kentucky, in the southern part of Kentucky and our name was Southern Kentucky Physical Therapy.
And so we eventually changed the name to court and developed over a period of a decent number of years, really up to about 20 years, developed outpatient clinics.
We had some hospital agreements. And we really rode that quite good in the call it the late eighties, throughout the nineties, even in the early two thousands. And along the way we partnered with select Capital or Select Medical, which was a private company at the time, sold the majority to them.
And then in about 2008, I had a different vision for what I saw going on in the industry, and so chose to exit that company and started the next company, which was Confluent Health.
In Confluent was started by a bunch of private practice physical therapists. I think Confluent Health probably has a neighborhood of 150 physical therapists that own parts of Confluent Health.
It is the largest private practice in the United States by a long shot in terms of number of therapists that own it. And it started by really just partnering with entrepreneurial PTs who are building great businesses around the clinical model. We had a company called Evidence in Motion, which really was designed to put in hybrid residencies.
We were the first hybrid residencies across the us. We then started partnering with higher education to do two year DPT programs instead of three, all in a hybrid environment. Graduated about now about 1200 students per year and we started a company called Fit for Work, which does onsite, call it early intervention.
It's really prevention oriented 1900 points of service. Primarily PTs, occupational therapists, and the like. And then all told about 800 outpatient physical therapy centers under multiple brand names. All these brand names represent founders and entrepreneurs. That started them under a really highly clinical model ranging from California to Rhode Island and several places in between.
Along the way we were all self-funded and then took in some minority private equity. And then in 2019, we partnered with a Swiss private equity firm called Partners Group who bought the majority of the company. Then I'm still the largest individual shareholder by a long shot. I have lots of partners in it, involved with the business, but not in a day-to-day operating role.
Along the way, I've done a lot of other things in the physical therapy world that have been fun and innovative and served in a variety of volunteer capacities. I have a real passion for the industry. So everything from the advisory panel on practice, I was an officer in the clinical electrophysiology section on board certified in both orthopedics and clinical Electro.
And was on the foundation for physical therapy for a number of years, which is one of my passions, which is funding research and evidence-based stuff for PT. So that's a long-winded thing to say, but I've been pretty busy over a long period of time.
Marla: You have been very impressive. And you've really seen it all.
As you said, you've seen the military background. You've been a private practice owner of a small group all the way to a larger group that had hospital based contracts as well. And now for Confluent, probably one of the largest practice out there currently, as you said, outpatient practices and you've seen the ebbs and flows of clinicians.
So I would love to hear your thoughts and a little bit more about the clinician shortage and what's happening in the industry.
Larry: Sure. This great industry as we talk about what's happening and maybe limiting our growth by the clinician shortage.
So to put it in perspective, I became a physical therapist in the mid eighties, 1985, roughly. And I will tell you that for my entire career, there's always been a shortage of physical therapists, with perhaps one bump.
There was a time through the balanced budget amendment where tons of physical therapists were laid off from the long-term acute care environment when they changed from salary equivalency. And that caused a temporary time period where we, I wouldn't say we had a glut, but we actually had therapists competing in interviews and those kind of things.
But really we've had a shortage. And what you really have to do is tie the shortage currently to a number of other factors happening at the same time. I think one, we have huge turnover in the industry right now. The migration of PTs are constantly entering the transfer portal. That's a factor.
A second factor is we have an artificial cap on what a physical therapist can make. And what I mean by that is Medicare has reduced our reimbursement in real dollar terms by about 14% since 2021, through direct cuts and the impact of inflation.
A third factor has been inflation itself. We've all now lived through the highest rate of inflation on supplies, labor, and everything else in an industry where we can't raise prices to actually help us deal with the effects of inflation.
And then I think the fourth factor really is the whole idea behind the limitations that payers place on us. So they limit our ability to see a number of patients through things like, rule of eights, other superimposed rules that Medicare has, which effectively puts a regulatory impact that limits our productivity.
Some recent data has shown that our average therapist used to see about 12 patients a day, and that's more like 10, almost closer to 11. So think of an industry that in any industry where you've seen a decreased productivity in the last 20, 30 years. So that's our industry right now. All of those, coupled with the factor of COVID has caused a shortage.
Now let's really examine the shortage for what it is. The real shortage of PT started in 2001 or the effect of 9/11 because prior to that time, we had about 5,000 new graduates a year. And we'd have 5,000 foreign trained therapists enter the US. Technically about 10,000 would come into the US, half would pass the exam, but we were going with 10,000 therapists a year for many years. After 2001, we'd really put a huge limit on foreign trained therapists.
It's trying to make a little bit of comeback today. Then we went back to 5,000 new graduates. Now we produce about 12,000 graduates, but that's been between 2001 and 2025. The other thing that changes there would be about three people competing for every spot in a physical therapy program.
Now, 86% of the people who apply to a PT program get accepted, and there's about 300 PT programs. We're not even filling up all the seats in many PT programs right now, which is hard to believe. The effect of COVID, the effect of wage inflation and stagnation, the high cost of education not keeping in lockstep with a salary.
So all that is now we have this kind of a mess. We have a shortage of PTs. The flip side of it is we've been incredibly resilient and we've proven out our model. We're a victim of our own success. So the demand for PT has never been as high as it is today. Every month, more new patients want to come to PT than the month before.
We don't have a marketing problem. We don't have an identification problem in PT. We have a shortage problem, but all of those things interact to really create the shortage problem. And it's a big problem right now. I virtually know of no employers that aren't hiring PTs.
You have a turnover rate of 25, 30%. So if you need 10 new therapists, you really have to recruit 15. And this never ending cycle is is real problematic for our industry.
Marla: I really want to focus on that turnover rate. So that turnover rate of 25 to 30%. Prompt did a study that talked to all the PTs who actually left the field and went elsewhere. Customer success, technology, all these different areas, and said why did you leave the field? You spend so much education, you spend so much dollars time for something that you loved and then you ended up leaving the field.
And so that problem of them leaving, it's like you can't close the back door, so you have to keep hiring and there's not enough to hire. So would love to hear your perspective on the ones leaving the field and why.
Larry: Yeah. There's a lot of factors at play here. Let's talk about leaving the profession in general.
We have the largest number of PTs that have left the profession the last couple years, and the simple reason why is not enough money. Like I said, there's a cost cap in Medicare that effectively limits the wages of what a practicing PT has.
We have about 230,000 PTs in the US, but if you really run the numbers, we only have on a full-time equivalency basis, only about 20% of our PTs are active clinicians.
What's with the other 80% on an FTE basis? Many in academia, many in roles that are not traditional PT roles. Many of them go to regional managers or management roles. We have a real hierarchy problem in PT. The clinicians who used to produce, let's say, on average about $300,000 in net revenue per year.
That $300,000, minus their pay and benefits, that profitability or margin, if you will, went to pay for regional managers, went to pay for infrastructure, for all the things on overhead that you need. That margin has been reduced severely because therapist salaries have gone up.
So now we're still trying to pay for regional managers, more management, more kinds of other things, investments to be able to make in a practice, but the margins aren't there. What has caused what then happens is employers have then started really monitoring employees like they know every second of every day how many units per visit, how many visits they're doing, how many new patients they're doing.
We monitor our PTs more than our PTs do remotely monitor our patients. It's very ironic. What does that cause? Loss of control, depersonalization, exhaustion, compassion fatigue, and turnover. And then you throw in all the compliance rules and regulations.
We do everything in the profession and make somebody a strong clinician. Then once they get in the profession, we do everything we can to take them out of the profession, all the rules and regulations, all the locks and controls on their productivity, all the monitoring that they do.
And then we say, oh, and you've got a good customer service and you gotta be compassionate. You gotta be empathetic. And oh, you gotta talk to that referring physician. And then you have patients that come in and, and, and. And so you have all these things going on.
I think the education world is a lot like this. Teachers don't complain about the teaching. They complain about the monitors and the report cards and all the other stuff they do. PTs, we don't complain about the clinical care. We love that. We just can't get enough of it because of all the externalities that really cause us to do. So what ends up happening is this turnover effect is very real.
We've never had as high a turnover when we've had as this much of shortage. Isn't it interesting the correlation there?.
You would think that employers would be doing everything they can to hold onto their employees, but instead these external behaviors that they do are pushing people out of the profession or to another employer.
And that we have to change. We have to go all in as a profession, treat our therapist as autonomous professionals. Allow them to eat what they kill model. They don't need to be handhold and have all these management, and have all these regional directors and have all these other kind of things they need to be treated like professionals.
Allow them to control their schedule, their own destiny a little bit, provide a community and contacts for them, have real conversations about their feelings, psychological, safe spots, and all kinds of other things that they do. And just acknowledge that you need to be more proactive in retaining employees.
That's not going on in at least what I'm seeing in the environment.
Marla: Yeah, and you made a couple really good points. One of them, you said all of this autonomous, they have to be able to have a little bit more control. I know from you I learned about a book, Daniel Pink’s Drive.
Larry: Yeah.
Marla: And you had said with that book, and I'd love to hear a little bit more from your perspective, that there are three key principles that employers should be doing to help retain their PTs to help create the culture they want. Because it's a lot more expensive losing them than it is retaining them.
Larry: No doubt.
Marla: So tell me a little bit about that book and the principles in there.
Larry: Yeah. Daniel Pink's book, he's written a number of them, but that one in particular looked at the psychological factors. He culled together the various research. He's very good at doing that. He didn't do any of the research himself, but he culled together various research and he found that what really employees want is autonomy, mastery, and purpose.
Totally makes sense when we're talking about PTs. We go in to make a difference, to do meaningful work that impacts lives. We want to have some control over the element of our schedule, whatever that means. It could mean different things to different folks. And we want to become masters. We want to become master clinicians.
And so if you're an employer, you should take heed to that and manifest it in different ways. I'll give you a couple examples.
What I see really good employers do is they preemptively understand that it's a relationship between the employer and the employee. They sign a prenuptial agreement, a katuba of sorts, that basically says, “I am gonna commit to you a lifelong learning example.You have to commit to learning. You have to commit to doing this and I will provide that.”
And so you have that kind of relationship to start out with. You're going to start out, you're going to go to a certification program or a residency. You're going to become a master clinician. You're going to become board certified.
So that gets to all the mastery part. It gets to all the clinical brain. The scientific side of, we're going to remind you of the great work you do. We used a technique when I was a CEO called remind, and I would do it every month. I would write an article or have videos that reminded people about the great, wonderful work they do and how they're recreating people's lives and getting people back to doing things.
But we become acclimatized to it. We become habituated to it, and we forget that the work we just did was a miracle. And so our Remind is a technique where you're reminding folks about the miracles. They do keep those thank you notes you get from your patients. Keep those kinds of things. Reflect on that. We have to bring back the connection and the meaningful work to reality of what you do.
And the third component of it is we have to create a real connection for them. You come aboard as a new employee, you're enthusiastic after 60, 90 days, but then you become a little bit disillusioned.
I can't take off every other Friday. Oh, I gotta do notes. Oh man, I gotta see pay. And so you have this re-recruiting event at 90 days. I call it the time when you have to re-level set everything. You have to re-recruit them, or they're gonna enter the transfer portal.
Celebrate the milestone of being there 60, 90 days. Give them feedback on how they're doing. But the most important thing is have them give you feedback on how they onboarded. What did we do right in our onboarding? What did we do wrong? How could we help the next therapist have a better onboarding experience?
And then re-level set? Never delay gratitude. Show them your appreciation, celebrate that event, and remind them of the meaningful, purposeful work that they've done along the way to get there. And so you create a culture and a language around that.
And it isn't the objective things. How much do they make? What are your benefits? Those are all important, but those are table stakes. Those are things that everybody can do. Equally, it's what are you doing that another employer isn't doing and it's going to be connecting with them, collaborating, really getting them in a moment and time where they could be autonomous providers.
Marla: Wow. Wow. So one of the things I heard, which I loved, is you said that you almost sign an agreement with each other. You sign an agreement of this is what we expect from you. But this is what you should expect from us and we're going to give to you this culture of lifelong learning, this process of continuing to reinvest in you.
And I love setting that stage right from the beginning. And then on that onboarding plan that's when a lot of people leave. As you said, that 90 day mark is saying, what are you doing in your onboarding so that you are making sure. You're re-recruiting them to make sure they love what they're doing.
I love that for any big company or small company. Sometimes it's hard to set that up and it's also hard to set up the educational pathways or career ladder pathways. Can you give some guidance or tell us more about that?
Larry: Yeah, first of all, I don't think it's that hard to set up. We call that entry a commitment letter. It's a bilateral. You’re poking holes, getting blood, and you're mixing the blood together. Like I said, it's a commitment.
It's a pre-commitment. Pre-commitment is very sound in psychology where if I've pre-committed to something, I'm gonna do it. If I pre-commit to a good exercise program, I know I'm gonna get up and run. So that's using psychology to help you. I think residency and certification programs have been very normalized in the us The cost is not, the cost is actually cheap.
I don't know how any company, including my own evidence, and I don't know how they make any money off residencies and certification programs because they practically give them away. And companies, if they're big enough, they can do it internal, so I don't think those are very difficult to come by.
I think at the end of the day, it takes intentionality and it really takes a commitment to the culture of the organization. If you look at employment and employee engagement and the great work that Gallup has done it's not that complicated. We've made it more difficult than it is.
Do I know what's expected of me at work? Do I have the tools and resources to do my job? Am I getting feedback? Has somebody recognized or rewarded me in the past week?
I would have our managers just think of those 4 things. Have motivational sort cards. Do I know how every one of my employees likes to be rewarded or recognized?
Some people like public recognition. Some most people hate it, but there are other ways to recognize people. People like to be recognized the way they like to be recognized. If you're a good supervisor, you'll know what motivates those that you supervise if you do all of those things.
Virtually none of those things I talked about are cost you anything except the element of time, attention. And they create a culture that really, then feeds on itself. And then those therapists attract other therapists in your organization.
And I think development is a filter. Do you really wanna hire a therapist that doesn't wanna develop into a master clinician? You just trying to fill a spot.
I wrote an article and, 'cause I had a lot of therapists call me and say, I'm interviewing for my first job, what should I ask? So I wrote an article about that, and the biggest thing is this a replacement position or is it a growth position? If it's a replacement position, why did the person leave?
What is your retention in therapists that have been here for more than for a year? Now we're in an industry where the average therapist changes his job once during their first year. The average therapist, it's really tough on an industry. And the reasons have changed over the years.
It used to be they would go for more money. Now they're leaving lousy organizations. They're leaving organizations where they don't feel a connection and a sense of community. And you know what? This transfer portal is big and their positions, any and everywhere across the United States in every setting for them.
And so they've got optionality. And so as an employer you can't course people into staying. You have to really invite them to, and be part of that, as well.
Marla: Yeah. Take care of your individuals before somebody else does.
Larry: Exactly. That's exactly right. Absolutely.
Marla: I definitely see that. It's nice to see the focus on how important that is. And I think that we all know that, but sometimes they get lost in the shuffle. What else can company owners, whether they’re large enterprise organizations or small mom and pops, what else can they do to make sure they are proactively taking care of their employees?
Larry: Yeah, I think what it boils down to in many cases is understanding what the employee wants out of their job. We make assumptions. We make an assumptions that a clinician then wants to become a manager, or that they want to become, a manual therapist or something, but we have to ask them, what development pathway are you on?
I call them playbooks. So playbook is a combination of their job description, but it's not a measly job description. Here's what the expectations are, marketing wise, documentation wise, compliance wise, and everything else. Then on top of that, we're gonna have a performance development plan. Okay?
We use sort of a meritocracy system at our company where so many points would get you additional additional things. The idea being the better you develop, the better we develop as a company, the more we can reward you both financially and otherwise. Sometimes that's vacation time increases and other kinds of things, not just financial.
And then really seeing in that performance development pathway, what path do you really want to be on? Most do want to become a master clinician. You become a master clinician, become a board certified. Then you get opportunities to teach in the residency, you get opportunities to take students, you get opportunities to get more advanced skills, whether that be in dry needling, whether that be in manual therapy, other kinds of things.
And then if you want, you can do a fellowship in manual therapy. So it really is a function of what that person wants to do. You have some that do want to become owner operators, they do want to become managers. I think that's a very guarded area right now.
I think it's one, you have to be really careful. There's just not enough margin in the business to have many middle managers. When you look at large scale primary care or dental offices, how many dentists or docs or regional managers, or even onsite managers. PTs are professional. They're DPT graduates.
They don't need their handheld as much as we've, I think, in my mind, have coddled them over the years.
Marla: I'm really happy you brought that up because I do continue to see all of those extra positions being created. Now I have an a CD then an RVP, then a than a senior RVP, then A VPO, right? Yeah. So you've got all these extra positions.
And you're saying no, maybe take away some of those and allow your clinicians to grow in patient care because you sometimes you're just pushing them towards management because that's the only other avenue of growth. And now you're taking away what they love to do, which was treat patients.
So you're allowing them to grow in clinician care. How can you do that but also pay them more money? Tell us about that.
Larry: Yeah, so therein lies the whole dilemma of our profession right now. If you look at most medical and dental practitioners, you don't have this layering effect. We pushed them to management, because there was a belief and reality that you got paid more money.
Now you think about all we do is to generate revenue as clinical care. There used to be enough margin where it would support somebody overseeing two or three clinics or X number of therapists. We can't afford that anymore.
So the cure for that, the antidote is really simple. We need to go to more of the medical and dental model, which is you eat what you kill. You come on board your first six months, you're gonna get a guarantee. We're gonna align and show you how, what you're producing, how that aligns with what your salary and benefits are.
And then after that you're on a model where what you get a portion of what you produce plus good benefits plus development, plus other kind of things that a good employer would have to do.
But the byproduct of that is you don't have to worry about then your only next wave to become more money is to become a manager. Because in fact, managers in most medical and dental are non-clinician and they're paid far less than the clinicians. Show me anybody in orthopedic surgeon's office that makes more than the doc, right? And so if we want to go all in as a profession, we really have to go all in. We can't afford not to anymore. We have a business right now that where most patients want access PTs and they can't because only 19% of our. Our therapists are clinicians on an FTE basis out 230,000 PTs.
We don't have enough PTs. We don't, we just don't. We're not graduating enough. We don't have enough interest in it. Our new graduates aren't making enough money to pay for their educational debt. By the way, that's another good benefit that employers are doing right now is pre-tax on educational debt.
We were one of the first companies to do that. I'm glad to hear other companies do it, but really at the end of the day, it's your business model. I think it has to really. Be professionalize clinical care and make that the destination, not management.
Marla: Yeah. And that's why sometimes I get a little bit worried when you say the eat what you kill, because it could be about more patients, more productivity. And we don't necessarily want that to be the model. So explain more of the eat what you kill and how you can add the quality care aspect to it as well.
Larry: Yeah. There's a great company, I think it's part of your company now, called Onus One that's been on this track for a number of years now, and I've partnered or bought companies that used them and they did so very successfully.
But the real idea is that, if you start seeing patients that what you are producing revenue wise, so in most markets, an average PT can produce about $300,000 in net revenue per year; could be a little less in New York, in Buffalo, it could be a lot higher in Seattle, Washington. It's just a function of what your reimbursement is at.
It's also a function of your payer mix. And so Medicare has a cap on earnings effectively because of all their rules and regulations and 14% less reimbursement since 2021, factoring in inflation. And so what you would see happen in this model isn't that you'd have to be overly productive. You would get a bigger cut of what you're actually producing.
The company needs less of that cut because it doesn't need the management. And it also gives you the option of what kind of practice do I want? Do I want a pelvic health plan where there's no Medicare patients or it's private pay? Do I want a combination? And so it allows you to have some choice.
Think of the dental profession. If I wanna specialize in orthodontics or in teeth fillings or in bridges and crown work, you have that option as a dentist. As a PT, we have the option to really identify the patient population that we have the most passion for, and we really ought to receive part of that.
Eating what you kill isn't a high pressure situation. Let's say you, you see your average of 10 to 11 patients a day, you're gonna get a bigger cut of what you produced than you do now. But the company will do better as well because think of the monitoring costs that they're doing constantly telling you're not seeing enough patients, constantly telling you don't have enough units.
All those kinds of things goes away.
Because it puts more pressure on the professional to be autonomous and so that you can do the higher order, what I call neck upskills. The examination, the treatment planning, manual therapy, the clinical hands-on skills that are higher order skills.
And be able to then use technical assistance or PTAs for other components of the value chain and do it in the right way. But right now it's the only antidote that I'm aware of that is disruptive, where it allows therapists to be more in control of their schedule and the amount of money they make.
It takes cost off of an employer, right? And it kinda rightsizes things a bit. Now we gotta get better reimbursement, we gotta get less regulation. We gotta get more people graduating from PT school. We gotta do a lot of other things. But at least that gets us on a better path of less burnout.
And less turnover and get a reduction of this 19%. Let's get back to 30% of our clinicians actually seeing patients again.
Marla: Yes. I love that. And it's also a performance model, right? So they have that base of their salary and then they've got that performance piece. And if you treat in a certain way where you're billing really well and you're billing for your time, you're actually gonna do a lot better. Even if you saw less patients, then the person who saw a ton of patients and really couldn't build the units.
So that almost allows you to have more quality time with the patient yet. Make more revenue.
Larry: That's correct.
Marla: And as the clinician, get more of it for yourself.
Larry: That's right. Because all the solutions we're looking for in private practice right now are all win-lose solutions. I'll give you an example, and I know it's, this is debatable. I'm a big believer in AI. I've written quite a bit about AI.
I'm a big fan of it, particularly in the back office and other kind of things where we can get scalability. But the one area that I predict is when we have better AI for documentation. We've got a lot of good trials going on. There are a lot of good products out there, and I really mean it. I've seen a, and there's not enough of 'em.
Everybody says that's, it's a crowded space. It isn't crowded enough, in my opinion, and I do firmly believe that we'll get significant burden of time reduced by therapists by spending too much time on their notes. It's one of the causes of burnout. Is that they're spending too many hours in the doing nonclinical tasks.
Marla: Absolutely.
Larry: That will get better. It is getting better. So what are employers gonna do now? You could be more productive now. You could produce more units per visits. Now you can see more new patients and they're never gonna get out of this rat race of what really is cause the fundamental causes of burnout.
And organizations that deal with this proactively will see that it, will not use AI as their cure for burnout because it could actually make it worse.
Marla: Oh gosh. I hope not, because as you said, that note writing documentation after hours, what we call the drama time, documenting, that's causes burnout. It's the less meaningful work. And you're doing it outside of your work, right? We've all been working hard to get those features to make sure that the clinician isn't just spending their time documenting.
Larry: No doubt. No doubt. And doing all the admin work.
One other factor that I forgot to mention, I'm not letting PTs off the hook either, or students, I should say. The data kind of tells us that about 50% of the PTs on their first day of work are already burned out. Now we know from the medical literature that is actually absolutely true.
So physicians from the time they're in medical school, their empathy goes from here. By the time they leave, they're down to here. Their burnout actually starts to happen while they're just in their educational phase of it. So they fall on our desks. Now we have new PTs that are already burned out.
At least half of them before they've even started their career. And because of all the externalities of life and all the things that go on, and all of a sudden they're being an employer coming in who's now paying 'em now you're gonna see. So all these things kind of work together and that’s why it's really difficult as an employer to know I have to deal with not only recruiting a therapist and getting them to, for retention and re-recruiting and doing development and all these other kind of things.
I've gotta deal with the fact that they're burned out, 50% of 'em the first day. And so you have to identify that after intervene. It's not an easy problem to solve. If we take the assumption that new PTs coming in and they're already healthy, behaviorally sound, all those kind of things, not burned out, and we start doing all these things to 'em, we're only gonna add insult to injury.
So you can diagnose it and you can assess it through a variety of means, validated instruments and such. But you really need to know when you're onboarding a therapist. Where they're at in their fatigue level, where they're at with depersonalization and zest and meaningful work, because by the time they've already done clinicals, they may already be in a mode where, gosh, I everything I do, nothing makes a difference.
And that's a telltale sign.
Marla: So when do you recommend ;ooking at these different measures of burnout and what measures of burnout do you recommend to look at?
Larry: Yeah, so I recommend when you onboard right from the beginning. So you've now found, you've signed, you've tried the whole thing in blood.
You've done your commitment letter. You've found somebody that's interested in developing and becoming a master clinician. They've signed, they've agreed to a long-term development program with you. You're onboarding them in a way based on feedback from the people who you onboard and probably screwed up on.
They've given you good feedback. So you're doing all those kind of things well, and in your assessment tools, which could include everything from their personality typing, strength finders, whatever you want to use on those levels. You really ought to use either the Maslo burnout inventory or there's shortened versions of that.
Big believer in it. Big believer in it. I'm a big believer in screening patients for depression as well.Especially if you work in a in kind of an orthopedic setting. But yeah, you really need to, you really need to have a it's tough.
It's what good employers have to do though.
Marla: Yeah. So then you do the screen and you recognize the ones who are burned out. Now what?
Larry: I'm gonna tell you, take it a little bit slower, I'm gonna be more intentional about reminding 'em of meaningful, purposeful work. I'm probably gonna have a mentor who's understands empathy and makes authentic connections with them, who could really sit down with them in a safe space and say, how you feeling?
How are you doing? It's not just objective. It's like when we get patients, we tend to objectify everything, right? How'd you get hurt? Where'd you get hurt? How long have you been hurt? How old are you? Boom boom. What we have to do with patients is get their understanding of how they're feeling about their injury and what they're hoping to overcome from it.
So you have to make this sort of emotional connection and they need a mentor or somebody who can do that as well.
Marla: So you're saying exactly what we do with our patients, creating the therapeutic alliance and seeing some require more attention than others. Some require more reminders and a little more care to get them through their plan of care.
Larry: Yeah.
Marla: We as employers have to do to our clinicians
Larry: A hundred percent
Marla: Especially our new ones coming on board and personalize that a little bit for the ones that we recognize are already burnt out when they get to.
Larry: No, that's exactly right. So I'm a military guy. I was in the military as a PT. I didn't need a mentor, I needed a clinical mentor.
I needed somebody who helped me to learn manual therapy skills and helped me become a master clinician. But I didn't want anybody sitting down and tell me, asking me how I feel, right? And it's just not who I was. I wasn't burned out. Yeah. So you have to, what do we tend to do though?
An all in solution of we're gonna give everybody a mentor. Now we have our clinicians, again, taking 'em out of clinical work to do all this kind of mentoring, right? They don't all need mentors. Some of 'em need mentors, and you have to define what that needs.
And so you better believe though that if you have a coordinator or a mentor for somebody who's got probably again, statistically, 50% of the people you're hiring are burned out, so you better deal with it or else they're gonna be gone in six months.
Marla: Yeah. Now, how often do you recommend redoing that burnout survey? Because maybe they weren't put out then, and then six months or eight months later, there's other things going on in their life. So how often do you recommend?
Larry: Yeah. Traditionally, it's interesting, we would do employee satisfaction studies or employee engagement surveys annually.
I think now the employee engagement survey of the future is a combination survey instrument that assesses behavioral health issues, including Brown.
Marla: Great. Great.
Larry: Because see the difference is burnout actually has a behavioral component because any work that I do incrementally, I'm not getting it in return.
I have no zest. I've got compassion fatigue and all those kind of things. That's different than depersonalization. So you take a therapist, you're seeing 10 patients a day. I guarantee a patient number eight, you're probably gonna depersonalize a little bit. Teaching you the awareness of that, then that really means you're not looking at 'em as a whole dimension person.
You're looking 'em as a, two dimensional paper doll. Take a break, take a pause, break, go outside, mentally do what you need to do. For some, it's meditation, for somebody else, it’s checking their Instagram or whatever the case may be. But do something to reset you back into, I'm looking at you as a three dimensional person.
That's not burnout, that's depersonalization. That happens to everybody every day. The big problem is if we conflate depersonalization with burnout, everybody then is burned out, right? And so let's use burnout to really mean burnout, okay? And not to mean depersonalization, because what's happened now is we use the word burnout a little too.
We give it, we let it off the hook, but it really does have meaning to it.
Marla: Okay. Yeah, that's a great point. So being able to recognize it and know the difference. Yeah. And then being able to consistently build it into your, perform your annual surveys or, I don't know, every six months or annually.
Larry: It's somewhat individualistic, but I would think at a minimum of a yearly. Yeah.
Marla: Okay. Great.
Larry: it's not a big screening tool. This is not a, a big ask here.
Marla: It's a quick tool.
Larry: Yeah.
Marla: And then you did talk about if you identify those burnt out, you have to put some more resources towards them.
Larry: You have to put some intervention in place. And the other thing I would tell you is even if you do a really good job on a mentor that understands behavioral health issues or understands burnout.
You still might get some folks that get buy in. That's where the survey can come in because it's a validated instrument and it could lead you to tell whether somebody is in fact, burned out. But along the way, you have to be intentional about the remind of doing other kinds of things, never delaying gratitude, always expressing the work that they do.
Patient reunion days are a good example of a technique. That sounds like a marketing technique, but it's actually an anti-burnout technique. We’re gonna have a day where everybody's gonna share a story about a patient.
What did you do that really changed the pace of how somebody cared. Everybody today's gonna share a thank you note that they got from a patient. Give us some context about the patient, get people talking about it. Simple things.
Marla: Ah, that's great. It's like the, just put the focus on the clinical excellence and sharing those stories.
It makes you feel better as well. Exactly. And reminds you of the work you’re doing.
Larry: It create the narratives all around the meaningful work folks do. And it really, it goes a tremendously long way. Now you still gotta deal with documentation and compliance and all those kind of things, but I always tell you know, managers, I know no therapists that went into this profession to be the best at compliance, to be the best documenter to be the best at all.
Those kind, I don't know anybody who did it. So try to mitigate those as much as you can by scaling them. You will find a therapist that loves to do chart review and documentation. Give 'em the ball and let 'em run with it, right? Because you will find there are some that like it, right? Really get the folks who are really good.
Don't get anybody who just raises their hand. Get somebody who likes doing that, but try to take all that, those things that really change for meaningful, purposeful clinical work to nonclinical work.
Marla: So you're a big proponent of looking at innovation and different technology that can help limit all of those different pieces.
Larry: A hundred percent. That's where AI can really help is dealing with all the compliance issues, really dealing with all those instrumental control things that happen that we have to comply with. But take that off the back so the therapist as best you can. I do believe that AI will have a significant role in that and already is.
Marla: Yeah. And I would recommend to people that there are already tools out there and they may just be using some of the older legacy ones, but not realizing that those tools are out there and they should be looking for them. They shouldn't be just settling with what they've used forever.
Larry: A hundred percent. If you're still doing chart reviews in your organization, that you've not embraced any kind of technology.
Marla: Absolutely. Absolutely. Now some owners may hear us talking and saying, okay, now they told us to add more mentoring. They told us to, be more personalized, to add technology, which is all money.
Let's talk about the ROI on keeping your clinician verse having to hire a new clinician. Walk us through that.
Larry: Yeah, so there's a variety of ways to look at ROI, but I'll give you some simple ways, simple statistics to look at it. So if you, it takes you 60 days to onboard a therapist and then you have to consider their ramp up to, like I said, if you get to a therapist at this roughly $300,000 net revenue per year, and the numbers, again, are gonna fluctuate, that doesn't happen day one.
That takes place over 2, 3, 4, 5 months. That's why I think you ought to do a six month guarantee. That's at a rate that they can live with. That would be about the equivalent of a starting salary, currently PT now and then after six months, maybe keep the guarantee there, but it's the guarantee or the greater of, what you produce.
Let's say that takes four to six months to produce and you have a turnover of 30%, which is what a lot of places have even higher when you consider involuntary turnover. Let's talk about that just for a second. I'll get back to that in a minute. But what I see a lot of employers do, oh, our voluntary turnover is 25%.
Yeah, but what about the people you're firing? You gotta add them to the mix. So it's probably 30%, maybe even 35%. If it is 35%, then that effectively means that every three to six months, you then have to set the clock back to the next four to six months. So just think of one PT.
The cost of that is about 40% of their salary. That's just for one PT. Do it multiple times and it is a extremely costly problem. Turnover is right, and so you can make the investment and decrease that from 40%, let's say to 20, decrease the 30% down to 20%, which is very realistic and it's pennies on the dollar.
It really is an incredible investment. It's a much better investment than about anything else you could do. There isn't any other modality or any other exercise machine or anything you can do traction. Nothing's a better investment than the ROI You get on retention, invest in your people.
Marla: So you're saying clinicians first. And patients next, because if the clinicians are happy and doing well, they're gonna take care of
Larry:A hundred percent. Yeah, you can't take care of the patient unless you take care of the therapist. I really do believe that.
Marla: Yeah. Absolutely. And I do agree with you that investment is just vast, right, to get a new employee. Not only is it gonna be a cost from the marketing, from the hiring, from your whole team trying to find it, but also you're losing all those secondary benefits of having a seasoned clinician who's been there, who knows your system, who exactly can bill correctly 'cause they're already experienced with it.
Who is mentoring people around them. And excellence breeds excellence.
Larry: No, that's exactly right. And there's else makes for a much more fun place to work. It really does. And one of the frustrations I always had as an employer was there's about 300 PT programs, for the most part, teaching 300 different things.
And you could fight that or you can embrace it. And one of the ways you embrace it is a certification program or a residency. I call it a remediation program because you're basically level setting a body of knowledge, a cognitive. And hands-on skills that is somewhat consistent throughout your organization.
Common language doesn't mean you're treating every patient the same way, but you're allowing your clinicians to engage with one another in a way that they can understand and it ha and have it steeped in evidence. And just remember that it's not just the cog, it's not just the hands-on skills.
But the cognitive skills, you really have to put in emotional intelligence, empathy, compassion, high quality connections, communication, listening, all those kinds of things are really critical because if you don't, those are harder to come by skills. I could teach anybody to do a grade four manipulation and manual therapy.
I can't teach everybody to be empathetic. But I can try. And so you as an organization, you really do have to focus on all those kind of things to win. If you really wanna win and you really wanna retain your therapists, otherwise you can't grow.
Larry: In any industry, if you can't grow, you're stagnant, and then you're dying. Because your margins are gonna get crunched.
Marla: Yep. And we really are in an industry where culture means so much. The culture of where you choose to work is because that affects you as an individual. It affects your teammates. And then of course it affects the patients.
Larry: No, it's true.
And the other thing to remember is the days when you had three people competing for one slot in a school are over. Now 86% of the people who apply get accepted in PT school. So you're talking about a different skillset of therapists that are coming on board. And again, the remediation certification program and all those things that go with it.
You have to take that into account. It makes the job tougher, but it makes the rewards even better.
Marla: So give me one takeaway for clinic owners and enterprise owners, and then I'll ask one takeaway for clinicians.
Larry: Yeah. So the one takeaway for owners is really be intentional about this 90 day event, this re-recruiting event where you're trying to accomplish three things.
You're trying to celebrate the milestone that they've been there, you're there to reward them, recognize them, appreciate them. Never delay gratitude. Getting feedback on how their onboarding experience went, and then give them feedback according to your playbook. Those were the expectations. How did they meet the expectations?
Do they have the tools and resources to do their job? All the things on an engagement level. I think if employers just did that, they would get a bump in their retention absent anything else. Talking high quality connections, all those kind of things.
Marla: And then a clinician from burnout perspective, what can you tell them?
Larry: Yeah, I think first of all, I think clinicians should be educated to understand what the warning signs. An ounce of prevention is worth the pound of cure, even in burnout. So they ought to be learning in PT school that these are the symptoms of what is could be leading to burnout.
And here are the antidotes. Because it's a lot easier to prevent than it is to treat. What I would tell clinicians that are burned out and literally diagnosed with burned out is there is a way out. It is finding the right employer that'll get them and reset them to meaningful, purposeful work, understand and have authentic conversations about how they're feeling, understand, and recognize and appreciate, and remind them all the time why they're there.
They're there for their patients. So I do think there are cures for it, but the best cure is prevention.
Marla: I love it. I love it. Best cure is prevention, and really focusing on, like you said, taking out some of those layers and letting your providers really grow, letting them be autonomous, purposeful mastery, and allowing them to do exactly what they came outta school to do.
Larry: Absolutely.
Marla: Great. This was extremely enlightening. I love this conversation. Larry. I could talk to you all day long, learn so much from you. Thanks. So more to come, but thank you so much.
Larry: Absolutely. You’re welcome.