- The autonomy of owning your own practice
- The fun in figuring out what’s important as a clinician
- What makes the Physical Therapy profession so special
- Understanding how to utilize your sub-specialty
- Knowing your limitations when picking your clinical rotations
- How the psychological aspect is part of the physical aspect of rehabbing a patient
- Student’s Q&A
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[00:00:00] Steven: Speakers, Greg Spatz, Doug Kechijian and Trevor Rappa, they are Columbia alumni from classes of 2014 and 2015, and are also founders of Resilient Performance Physical Therapy. They have sites in NYC and Chatham, New Jersey, where they work with a wide range of patient populations including adolescents, active adults, aging athletes, elite competitors, all along the spectrum of performance and rehab. Before I hand it over to them, just a few housekeeping things, please make sure that you are on mute throughout the talk. There will be a chance towards the end to ask questions and you can use the raise hand function. We’ll be able to call on you and you can unmute and ask your question. But if you have questions during the talk, feel free to use the chat box and we’ll try to get to it during the session.
[00:01:00] Also note that this session is recorded for educational purposes. So if you want to mute your video or change your name feel free to do that. And without further ado, please join me in a warm round of virtual applause for our speakers.
Doug: Well, yeah, Steven, thanks so much for the introduction. It’s obviously some strange times now, but I’m glad we’re doing this. And it’s my understanding that this is mostly. Columbia students. So I don’t want to do too much story time because I want to give you all kind of more actionable information and things that you can actually apply and think about. But just for some context you had mentioned that we’re all Columbia alums, Greg, Trevor, and myself. We have locations in New York and New Jersey as I’m going to talk about, I think that people get typecasted into doing certain kinds of PT. And those typecasts [00:02:00] can be useful just to provide some clarity, but they’re also very incomplete, and I’ll kind of speak more on that later, but we are for all practical purposes, more like outpatient, orthopedic, sports minded PTs. The backstory on how we came to be was that I was a year ahead of Greg and Trevor at Columbia and one day I was in the library hammer, which I’m sure it’s probably changed a little bit through some renovations, but fundamentally the same thing is where everybody goes to in between classes and to cram in all that information. And I was studying in between classes and I remember seeing somebody with a Mike Boyle strength and conditioning t-shirt and I kind of had a feeling right away that this was somebody who was probably in the PT program.
As you all know, there isn’t a lot of cross mingling between the different classes. So even though we’re kind of all part of the same program, you really spend most of the time with your own class. But I went up to Trevor who I didn’t know at the time and I was kind of [00:03:00] like, who are you and why are you wearing this shirt? Because I had interned prior to PT school at a another strength conditioning facility, pretty close to Mike Boyle’s and they both had a similar reputation and similar type people that were attracted to those experiences. So Trevor told me that he was a DPT one. I was a DPT two at the time and we ended up talking and it turned out that we shared a similar interest in kind of lending performance training with physical therapy and during that conversation, he told me about Greg, one of his classmates, I think were roommates at the time actually and Greg prior to physical therapy school was a strength conditioning coach for the Arizona Diamondbacks in major league baseball. So we cultivated a friendship initially that turned into a business relationship and our intent wasn’t necessarily to work together as quickly as we did but we always thought in the back of our minds it would be great if we could start off [00:04:00] doing what most new grads normally do, and then find a way to work together and without getting into too many details we ended up sort of getting forced into working together probably earlier than we were ready to and things worked out really well, but when it comes to business and I’ll talk about this more like you really, you can’t script things and no matter how many times people try to reverse engineer the process and tell you this is what I did.
Everything always looks very clear and linear when you’re retrospectively kind of narrating it. But that clarity does not exist when you’re going through that process. So it’s almost like everything looks causative and you’re like, well, we did this and then we did this, but it wasn’t causative, there’s a lot of luck. There’s also some hard work and skill involved, but there’s a lot of just like fortuitous things that have to happen in business and we actually, we got forced into it earlier than we probably, like I said, were ready for, and we stumbled upon success if you want to call it that because we really didn’t have a choice. We didn’t know what we were doing and we ended up without [00:05:00] a facility and we had to kind of figure things out on the fly. When you’re in a kind of survival situation, you kind of just have to adapt and luckily we did. So that was almost five years ago now, which is crazy and now here we are trying to do business in a pandemic with some social unrest and one of the cities where we’re located. So it’s very challenging, but I wouldn’t trade the experience for anything and despite the hardship of; the good thing about running your own practice and being in business with yourself is that you control everything and you have autonomy. That’s also the hard part because like right now we’re facing challenges just like everybody else is and no one was going to solve our problems for us. We have to solve them ourselves.
Even things like do we want to really aggressively pursue a New York location when regardless of what’s been going on the last couple of days, even with a pandemic, [00:06:00] until there is reliable and valid testing or a vaccine, even if local state and federal governments open things up for business, if they open up restaurants and offices, there’s going to be a bottom up regulation where people just don’t feel comfortable coming into places that have large population densities. So even right now, we don’t have the answers we’re trying to navigate as we go along. Even before this happened, we had aspirations of getting into the digital space and one of the benefits of the time off during the pandemic was that we were able to finally finish some products we’d been working on as we made the best of the opportunities, but there’s a lot of uncertainties, but like I said, that the flip side is I could be working for a large facility and I could be furloughed right now and my professional fate would be in somebody else’s hands. So the same things that kind of give me pleasure and joy also keep me up at night but for now [00:07:00] it’s still been kind of a great experience and the stories really, have to be written. I know that there were some, I received some questions and topics that the audience was interested in prior to getting on here. So there are certain things that I want to touch on and one of them, there was interesting kind of the business aspect of things. I don’t want to make this like a business talk per se, because I don’t think that, especially when I was in the seat that you all are in, I had the context to really understand the specific aspects of the business, but I think I can get into some of the general things.
So one thing is, and no matter who you talk to everyone’s going to have a different idea, but I think that when it comes to the business in any field, including PT, and there’s also obviously some discussion of, well, do we even want to call health care a business? And there’s some semantics with that. I kind of look at it like, because money’s being exchanged no matter who’s paying for it, whether it’s a third [00:08:00] party, the government, out of pocket, it is a business and we can, as much as I believe that people should have unlimited access to healthcare and that socioeconomic status, and some of those things shouldn’t be an obstacle to receiving health care, at a certain point somebody is paying for that service. So to pretend that healthcare is not a business, I think is a little bit, it’s kind of naive in a way. So I think we have to face the reality that is a business and with any business, I think that you have to have a good product. So there’s plenty of like courses that are focused on the business side of PT. We’re actually going through a business mentorship ourselves, because I think that we’d kind of reached a plateau for where we were and it’s been helpful. But I think what got us to that plateau point was that we were, in my opinion, good clinicians. That’s why, what you’re doing right now is very important because if you’re not a good clinician; you can be a subpar clinician and make money and be successful if you want to call it that but it’s much harder.
[00:09:00] I think that for us, most of our businesses come from word of mouth referral. We’ve done very little direct marketing. If you do a good job with people and they trust you and they think that you’re competent and ethical, that kind of network effect just grows and grows in a way that I don’t really understand, frankly, but I know that every time somebody submits their information to our website, we can see how they found out about us and 90% of the time it’s word of mouth. We have a couple of, and it’s not even so much referrals from other healthcare providers, it’s usually referrals from other patients. We do have other health care providers that refer to us but even that started out as a genuine relationship where maybe a patient said, I went to this place for PT, you guys should maybe consider having a relationship with them. It wasn’t like we sought out the people that refer to us. The other part of it is too, I think that no matter how much people talk about business and technology and how impersonal it is and metrics, business is still [00:10:00] very personal and even the refer people that refer to us, we also refer out to other people all the time and the people that we refer to are people that fill a skill gap that we don’t have.
So like we need orthopedists, we need neurologists, we need pelvic floor, physical therapists. We need pediatric specialists. Because even though we kind of consider ourselves generalists that are focused on sports, there are certain things that if it’s too specialized, that patient probably belongs in a different office. So, because we want to help our patients we have authentic relationships with people that ended up referring to us. But my intent, when I refer a patient to somebody, it’s not that it be reciprocated it’s that I want to help patients, like the three of us, we all spend time, our personal time, that’s not being monetized talking to these other referral sources and healthcare providers to give histories and you’ll see that when you’re in the field, there are certain people that are more receptive to that [00:11:00] than others. Most of the people that refer to us that we refer to are the ones that we can speak candidly with about a patient. I can text them, I can call them and I don’t need to call a receptionist and get put on hold 10 times and play phone tag, because communication is so important when it comes to patient care and if there are a lot of barriers to communication, then those referral networks and they work both ways, aren’t that authentic.
So I think you need to have authentic relationships and just be a competent provider that cares about patients. I know that sounds really simplistic, but it’s one of those things where it’s simple, but it’s not easy. I think that’s the first place I would start and then you can get into things like marketing and talking about scaling, but you can’t scale a business until you get to the point that people actually want to see you and so we, as far as our business model, I’m not saying that this is good or bad, I’m just telling you what we did. We kind of started out where we had a certain way that we thought would be the most effective from a patient care standpoint and that was treating one person [00:12:00] an hour and not being limited by insurance reimbursements and billing codes and being under a lot of time pressure, because one of those things, no matter how good you are, if you have to treat six patients an hour, it’s hard to actualize your skillset and some people have to do that on a necessity and admittedly. Because we treat one person an hour, we’re primarily seeing people out of pocket or people who have out of network insurance policies that tend to reimbursement better than in network policies and that does limit the population that we can see. But kind of our thought process was at the end of the day, I want to feel like I provided the best possible care that I could without a lot of the external constraints and this model allows us to do that.
That said we do pro bono work. We do discount people and we also have a lot of free resources, we have like a YouTube channel and instructional videos. So there are ways that we try to make ourselves accessible to people that might not be able to afford us in a [00:13:00] strict sense, based on our hourly rate, we do make concessions and that’s kind of, we talk to people to see if they’re a good fit and I also have relationships with in network providers that I think do a very good job with some of those constraints because there’s a range of models within the in network system. There are clinics that treat six people an hour, there are clinics that treat two and in my opinion, you could do a much better job at two people an hour than six. I’m not trying to be judgemental, I’m just saying this is what we did and why we did it. I think that ultimately, it’s not that what we’re doing is better. I think that people should have choices. I think the more choices people have the better, because even with people that might be considered more affluent, we value their time and money. So we’re not outside of a postoperative situation, seeing people three days a week for six weeks, which tends to be what in network facilities do, because if we’re being realistic, if an in network facility knows that they’re going to [00:14:00] be authorized 18 visits for a particular diagnosis there’s generally very little incentive to discharge somebody before that.
So we know because a lot of times people are paying out of their own pocket. We’re like, all right, like how do we get these people what they need and a shorter time as possible. And that has forced us to create a YouTube channel, create instructional videos, because we kind of look at it like when they’re in person, what do they really need from us that we can’t provide technologically or remotely and that’s set us up a little bit for success as far as the telehealth thing now, which is a big initiative. I got into this field because I like working with people in person and if I wanted to work behind a computer all day, I would be in a different job that said, I recognize, especially now the importance of telehealth and I think that let’s go on to play a bigger role in all medical care going forward but I don’t know if I would be satisfied as professionally and personally, if all I did was treat people over zoom. That said, I think that remote, [00:15:00] consults can be a better value and if you have the technology and the expertise to facilitate that type of communication, then telehealth can work well and it also makes you accessible to people that might not be able to see you based on geography or pandemic threats. So I think our kind of outlook is we want to be able to keep doing in person, but also provide choices for people that aren’t comfortable seeing us in person or can’t for whatever reason.
So that’s probably as much as I want to touch on from the business standpoint. Unless people have more questions later. The bigger things I want to kind of talk about now are just commonly what people refer to as clinical reasoning and just the thought process. I am not the arbiter of clinical reasoning. Again, this is just kind of what we do and I just believe in being transparent. Ultimately I think that as students and as new clinicians, you should just be exposing ourselves to as many different ideas as possible and you’ll see [00:16:00] patterns that emerge and you’ll see things that you agree with and disagree with but you all should be the arbiter of what you think is useful, not useful. I am not that arbiter, but one of the questions that kept coming up as far as things that you will want us to discuss was the theme of integration and how we learn. This is one of the fundamental dilemmas and it’s a timeless dilemma. I don’t think it’ll ever be quote, unquote, resolved in education is, if we’re looking at a, a complex process, like patient treatment, how do you learn that complex process where the whole is more than the sum of the parts without just teaching and a reductionist way, breaking things down into components and just teaching the parts. I kind of liken it to a sport. If you look at a sport, pick any sport you want, let’s say like basketball. One could make the argument that the best way to become a better basketball player is just to play five on five and [00:17:00] scrimmage and playing games all the time. But the problem with that is, yes, that is the most realistic to what you’re going to be doing in a competitive setting, which in this case, the competitive setting is the clinical setting.
But if all you ever did was just play five on five and scrimmage, you wouldn’t get enough time in the individual aspects of basketball to really develop the skills that are needed that comprise the whole. So, that’s why you look at what most sports teams do, yes, they scrimmaged, but they also, they work on their offense and their defense as a team, they work on their individual skills shooting, dribbling, if it’s a post player, they work on their post play and you can’t, it’s hard to develop individual skills if all you’re doing is the whole task. So part, whole learning is a timeless dilemma in education and I think that ultimately you need a little bit of both. You can’t just play the game, but if all you did was just practice shooting without a defender, that’s only going to carry over so much into [00:18:00] shooting in a game when somebody is guarding you. And so in, in education the analogy is we learn through models and through buckets and through compartmentalization. So in PT school, for example, things are broken down into ortho, neuro and paeds and cardio and the reality is in actual patient care, everybody has a heart. Everybody has nervous system. Everybody has bones and joints. Everybody started out as a kid and became an adult and every adult eventually becomes older or geriatric.
So we like to fit people into little buckets and there needs to be some of that. There needs to be categorization because there are certain conditions that are so specialized that if you have this generalist mindset, if you’re not encountering these very specialized conditions or patient populations frequently, it’s hard to really develop clinical expertise and to develop comfort level with [00:19:00] those patients. But, I’m going to show everybody in a little bit videos of working with one of my favorite patients, if you will, my father, at the time of the video, he was 78 years old. So we could say, oh, well he belongs in the geriatric bucket, but he was also quite active and he was doing athletic things. So does that make him a sports patient? On top of that he had some cognitive impairment. Does that make him a neuro patient? And then he had some orthopedic history where he’d had some orthopedic procedures. He had spinal stenosis with some nerve root compression. So does that make him a neurological patient?
So again it’s hard to fit people into these buckets, and that’s why you need to learn all these models and these subset ways of treating people, but just recognize that there’s a saying all models are useful are wrong, but some are useful as long as we don’t get too emotionally attached to any model or way of looking at things. I think all [00:20:00] of these, think of them as lenses, all these lenses through which to look at people have some merit, but if we take them literally, then we’re going to get in trouble. I think it’s the same thing not just with patient populations, but with things like manual therapy and pain science, if you all familiar with that. Typically for a lot of the history of the profession, the biomechanical model of pain prevailed, where it was like, well, you hurt because you’re posture is wrong or because you have this MRI or orthopedic finding and we kind of know now that biomechanics and posture and orthopedic pathology, isn’t always destiny. We know that if you get in a car accident and break your femur, it’s not surprising that your leg would hurt, but it becomes a much more ambiguous when we talk about like back pain and we see that there are a lot of people walking around with disc herniations that are asymptomatic and then you have like the pain science model, which says that, like [00:21:00] really focuses more on the psychosocial aspect of things. It doesn’t neglect the bio, but it’s like, well, things like back pain are more driven by emotions and cultural factors. I think those things are all true. I think that you can take the pain science model too far where you can neglect biology and I mean, I’ve had, I’ve seen patients where they came in with, with foot drop, motor weakness, sensory alterations and they were told that their back pain was kind of in their head and that it wasn’t real and I’m kind of like, you need to go see a neurologist right now because you can’t actively dorsi flex your foot.
So that was very much a bio component, but they’ve been told to focus more on the psychosocial and emotional aspect of things. So no matter what pain is an emotional experience, but it’s also a biological experience and an orthopedic experience. All of those experiences at once, the fun part about being a clinician is figuring out what’s important. Same [00:22:00] thing with something like manual therapy, manual therapy tended to be driven by the biomechanical model where it was like, well, this is tight. This needs to be lengthened or shortened and now we know that manual therapy tends to work more by a neurophysiological mechanism, which kind of makes sense because if let’s say you have shoulder pain and someone sticks their fingers in your subscapularis and the shoulder feels better, the original explanation for that was well we’re altering the histological properties of the tissue or breaking up scar tissue where we’re changing anatomy with our hands. But if you really think about it, it wouldn’t be good if you could stick your fingers in someone’s armpit for 10 seconds and all of a sudden they have these very acute and rapid histological changes. It should be hard to make a tissue adaptation. It should require a lot of load, a lot of force and a lot of duration because I mean, if we adapted that quickly, then every time we went outside in cold weather we’d grow fur and become bears, [00:23:00] and then we went back inside, we’d shed our fur.
The body can only adapt so fast and the most, the quickest way to adapt in the body is through the nervous system. So we know now that manual therapy works more via that neurophysiological mechanism. That said some people will say, well, that proves that manual therapy isn’t good or useful. If manual therapy achieves, whatever it is that the desired outcome is, if it’s pain relief, it’s increased range of motion, it doesn’t matter how it worked, have your own outcome measures to determine what you think success is. Just realize there’s different explanations for a lot of these things and sometimes I think we can overly fixate on the explanations. Because it’s the truth of matter is really, I don’t know how manual therapy exactly works. We probably never will. We can keep refining the explanation, but if we get so caught up in the theoretical explanation, then we can almost be nihilist where we just take everything apart and don’t believe in anything.
So I think that we need enough theory to know that we’re being safe. We need to do [00:24:00] research to determine that what we’re doing is reproducible and not just something that is like a transient phenomenon. But there’s just a lot of gray when it comes to this stuff, whether it’s compartmentalizing patients in specific categories or buckets, whether it’s theoretical explanations.
So I think that it’s important. I don’t necessarily know if a superior way to learn would be to discard these categories and just be like, okay, we’re going to treat everyone exactly the same and not categorize them. But part of another kind of timeless debate in education is how much context do people need to learn? So if we’re talking about patient treatment, what should we do first? Should we go to the classroom and learn the theory first? Or should we go into the clinic, maybe watch somebody for six months or a year and then go into the classroom and now when you learn anatomy, that anatomy is going to have context. So anytime you learn something devoid of the context in [00:25:00] which that information is applied, it’s much harder to learn because we’ve all studied for tests in school and part of the reason why it’s so hard to learn is because you’re learning something for a test, you’re not learning it because you think that it’s meaningful because you don’t actually know why it’s meaningful. You’re being told that it’s important but you don’t have the context to really know why? Now that I am out of, and this is not a criticism of school, because again, school can only do so much for you. We all have to learn on our own and kind of pursue our own educational resources and avenues but ever since I’ve graduated formal academic programs, any learning that I did it was effortless and that I wanted to know something. Because there was context, because there was kind of an emotional need and there was emotional reinforcement via these interactions with people in the clinic I never like had to study for anything to learn, I just kind of learned it.
Think about how you learn a language. When we learn a second language in middle school or high school, we break things down, we [00:26:00] conjugate verbs, we learn alphabets. But when we learned, I’m assuming most people here English was their first language. If not, I’m sure there’s some exceptions, but whatever your first language was, you didn’t learn it in a formal sense. You learned it through mimicry and just through total immersion. You were around people who spoke that language and you learn to communicate and so it’s obviously not safe and you need some regulation when it comes to education, we need standards. You can’t just throw people in a clinic and be like, learn but as you will all see if you haven’t done it already. How we really retain the information that we’re taught in the classroom is by being in the clinic and doing these clinical rotations. So I think in medicine, no matter what anybody says, and this is my opinion, the apprenticeship model of learning still reign supreme. We could even look at how physicians learn the way that physicians learn, they go to medical school. Medical school is a rite of passage, much like PT school is where you learn a bunch of stuff. You often don’t know the context of it. You memorize stuff for a test, you forget a lot of it and you move on to the [00:27:00] next thing and it’s, again, it’s kind of like in some ways, a rite of passage and in an initiation.
But if you ask any surgeon, where did you learn the most? They’re not going to remember the Krebs cycle from medical school. They’re going to remember well, during the first year of my residency, I wasn’t allowed to touch a patient, but I watched a thousand ACL reconstructions and then the second year I didn’t do the reconstruction, but I might’ve done the suturing and then the third year now they’re doing the reconstruction itself, but they’re being supervised and then after that they’re on their own. So the apprenticeship model still works very, very well that said, we can’t just throw people into that. We need to have some theory, some standardization, some regulation and some structure because the apprenticeship model that’s very hard to standardized because it’s so contingent upon who you’re apprenticing under. So these are all just timeless dilemmas and I think that we’re going through this right now, socially. [00:28:00] Most really important policy discussions come down to this discussion between rigidity and chaos and formal for looking at like learning, just learning in the classroom and learning theory. If you take that to the extreme that’s rigidity, because you don’t know how it applies in the real world, but if all you do is just try to learn the real world without kind of slowing things down, breaking things up into components, that’s the epitome of chaos.
So it’s kind of like, I’m using these examples to kind of drive the point home. Some like border security. I use this example, a soundboard border policy is not to create a wall and not let anybody in and it’s not to just have an open border, let anybody in who wants to come in with no vetting process. Neither of those are really desirable solutions, public policy wise, just like if we’re talking about civil liberties. We all want security. We want to feel safe from people who wish to do us harm. But if we take security to its extreme or its nth degree, now we lose our individual [00:29:00] autonomy. Our civil rights are compromised. These are timeless dilemmas. You can read about these things in Shakespeare, you can read about them in Dickens and we’re going through it right now. No matter how much we have technology and no matter how much things change, they also stay the same and so that kind of ties into the next theme. Which is that like, no matter how much our patients are different, they’re also the same and they’re human beings. So if we’re talking about clinical reasoning and what the thought process should be, it can be very overwhelming in school because you learn, okay, this is a neuro patient, it’s cardio POM and then you get into orthopedics, it’s like, well, this person had an ACL reconstruction. This person had a rotator cuff repair, and you learn protocols for these procedures.
I remember just being so overwhelmed with these protocols because I’m like, everyone’s so different. This person has knee pain, but one’s a meniscus and one’s an ACL and one’s patellofemoral pain. How do we keep track of this? And part of that confusion was driven by [00:30:00] the way that we diagnose as a field. Because in my opinion, and I think this is changing a little bit, the way that we diagnose as a field is antiquated, especially in orthopedics where it’s like, okay, you have this anatomical diagnosis. In my opinion if you’re treating somebody for like a labral tear on their shoulder and the labral tear is the actual pain generator or the limit or a function that patient is in the wrong office because as PTs, we can’t do anything to repair somebody’s labrum but what we can do is if someone has a labrum or shoulder pain or an ACL surgery or a meniscus surgery, we can look at pain or we can look at a surgery or procedure as these things provide constraints. So for coming off of surgery, the initial constraint might be, hey, we have to respect tissue healing. Don’t move the joint passively beyond this range of motion and no active range of motion for four weeks or whatever, that’s [00:31:00] a constraint. But beyond that, everyone’s exactly the same. Everybody that we see, fundamentally I think our profession is about how do we maximize function in accordance with somebody’s goals, their personal goals, their cultural and personal values and then what are their biological constraints.
So if it’s somebody who’s coming off of a neurological injury or a stroke, people who are coming off strokes have to function, they have to be able to, ideally get out of their chair, cross the street. So when someone’s coming off of stroke, whatever neurological deficit they have is a constraint to achieving that function and initially you try to just maximize whatever function is available. You try to restore whatever function was lost by for example, forcing somebody to use the impaired side and then there becomes a crossroads where it’s like, okay, maybe this person might not recover neurologically. Now we have to teach them a compensatory strategy. So now you have a new constraint, but when [00:32:00] you start to look at things, as people are indifferent, everyone’s the same, but they have different constraints it makes this whole thing a lot easier. That’s why it takes reps treating patients to get that context, because it’s really hard to get when you’re only learning these things in a theoretical environment. So like now I’m working with somebody who dove into a pool, had a cervical spine injury, had some neurological insults. Now I wouldn’t feel comfortable treating that somebody the day after the injury, because that’s not like, I don’t specialize in acute care neuro, but this person has recovered enough neurologically that now I just treat him kind of like an athlete. He has athletic goals and we just use his neurological impairments as a constraint.
So, for example, right now, like he has a hard time gripping, so we have to use a hook to get him to, if I want to have him deadlift we have to use a hook to get him to load his lower body so we can get an adaptation, [00:33:00] strength wise and neurologically in his lower body. We just look at everything as a constraint. So I think it’ll be easier to kind of see how this stuff works in practice if I show some videos. So like I mentioned, I’m going to use my father as an example and when he was able to kind of consent of this, he used to like being put on Instagram and he’d always ask like, hey, can you put me on social media? So I don’t feel bad sharing. I had his consent when he was a be able to offer it. So I’ll just show you all kind of what I did with him and you’ll see, it’s really just using his orthopedic pathology. His neurological pathology, his cognitive pathology. These are all just constraints and it’s like, how do we maximize this individual’s function without basically causing any harm?
The constraints are important because the constraints allow you to, like, these are the things that if you don’t abide by these constraints, you can harm the person. Otherwise everything else is fair game in my opinion. [00:34:00] And again, it comes down to the person’s goals, personally and culturally and ethically and that kind of thing. But, so here’s my dad at 78 years old with; if you labeled him as any of these things, you would say, well, he shouldn’t be doing these things, but we did them and it was safe. And in my opinion, especially as people age, the way to maintain dignity, because that’s probably another conversation I’d like to have with you all. Because when I learned about Alzheimer’s and dementia in PT school again, I had no context. I didn’t interact with a lot of elderly people. I work mostly with young healthy athletes and I was in the military before PT school. So I didn’t; aging to me wasn’t something that was, it was abstract. It wasn’t a real thing and I’ve learned so much through my own personal experience with my father. But you can typecast these people and almost like baby them in a way where you say, well, this person shouldn’t be able to do something but I think that there’s so many things about medicine we don’t understand and [00:35:00] going through this experience with my father, we go to neurologist and they’re all well-intentioned, and he’s on all these medications, but we’re talking about like evidence based practice. There’s very little evidence these medications do anything and the reality is we’re probably not going to find a medication that totally reverses Alzheimer’s or dementia.
No matter how much we hate to face the reality and it’s, I think a cultural thing in this country, we’re all going to die. We’re all going to get old and we’re all probably going to suffer a little bit when we’re older and we should obviously do things to mitigate that. But the one universally accepted that thing is exercise for the most part is good for almost anybody and movement is good for almost anybody and as soon as you stop moving a lot of bad things start to happen. That to me is what makes our profession so special. Is that like we’re the only profession that really focuses on that and it’s like undeniably good for pretty much everybody. So here’s something at 78 years old working on just kind of like a lateral movement or a lateral [00:36:00] shuffle using the box. So we could call this weight shifting. We can call this changing levels, whatever buzzwords he’s kind of showing off there and I’ll show you all later how we would scale this for someone who is a little bit more athletic, but I felt safe doing this. We talk a lot about like fall prevention and things like that.The reality is like people are going to fall no matter what, I fall. We want to make the cost of that, of the falling less consequential and we have to load people to do that. You can’t develop the annotations to make falling less consequential if all you do is just stand on one leg with your eyes closed and hope you don’t fall because real life is not predictable.
You’re going to have your balance disturbed when you don’t expect it. If you don’t do dynamic training, all the static balance training in the world is not necessarily going to help you. So here’s my father sprinting with a sled, we used and sometimes this is pretty slow, the Google drive, but so we’re using the sled because it [00:37:00] provides some balance. We’re using a little bit of load, the load, actually, in this case, makes it safer because it slows them down and so this is sprinting, or this is power training for somebody with my father’s constraints. But we’re trying to be as aggressive as possible without hurting somebody, I’m there guarding, but I felt safe with this setup that nothing, that he wasn’t at a fall risk. Here is working on kind of upper body, upper body power, if you want to call it that. This would be an upper body plan metric for somebody who’s a little bit older. So don’t let your face hit the wall. We’re obviously scaling this by having him basically vertical. If we wanted to make this harder we would do like a regular push-up or we would make it much more explosive, but again for him, and you can even call this rotator cuff training. We’re learning how to decelerate the shoulder. Whatever bucket you want to put it in, we’re doing a lot of things. A lot of times it becomes semantical.
I wouldn’t have a [00:38:00] 78 year old jump onto a 50 inch box like you see on the internet with younger athletes, but for my father, this was appropriate. We’re learning how to express force quickly and dynamically. I’m not having him jump up and down, he’s jumping up, stepping down. This was the limit of what I felt comfortable with from a safety standpoint. But if we don’t do these things, then people are going to deteriorate quickly and that elasticity is one of the things that diminishes the most as we age and if we don’t train it, I’m not saying we’re going to reverse this stuff, but if we don’t train it, it’s going to be diminished a lot quicker. This is like, I think the humane thing that we do is we try to preserve these qualities. Here we’re doing a squat variation, a front loaded squat with a higher level athlete. I would just do this with a lot more weight and somebody who had better hip range or motion, less arthritis would be able to get to a better depth, but you could even call this loaded mobility training he’s using whatever available range of motion is there in his hips. He’s loading it. So we’re getting strength. We’re getting mobility. We’re getting [00:39:00] ankle dorsi flection, we’re getting knee flection, extension and now I’m having them work on some lateral movement, dynamic balance, weight shifting he’s going side to side. So we created this medley here starting kind of lost his balance there. So keeping it safe.
But if we underload people, whether it’s an athlete or an elderly person, we’re not doing them any favors. We’re not setting them up for success when it comes to their functional goals. This is pretty, in my opinion, bad-ass for a 78 year old, just trying to work on some hip extension and hamstring strength. Some of you have heard of the Nordic hamstring exercise, here’s a regression of that and these were taken two years ago when cognitively, my father was much more able to follow instructions. Now, even though I think he’s physically capable of doing some of this stuff, it’s just, I wouldn’t be able to communicate it as [00:40:00] effectively. So that’s why everything has a place, even machines that are kind of demonized because they’re considered, non-functional, if you have somebody who has got major cognitive impairment, if you put them in a machine that only moves one way now you can load that person in a safe way without that cognitive challenge, because when you work with this population of realize that whatever you did a minute ago, they’re going to forget the next set after they rested and with the machine, it’s just much easier to make the intent clear of what you want done.
Here’s a higher step up working on that hip extension strength and knee extension strength, even hip range of motion. Because for my father, this was probably the limit of what his hip flection would be actively. Working on some explosive throws here, haven’t been tall kneeling just to kind of train some [00:41:00] postural things and this stuff is fun. It’s fun to slam a medicine ball to the ground as hard as you can. So things like sleds and medicine balls that have a low learning curve That are mainly concentric don’t cause lot of ecentric stress and soreness. Great for a lot of populations, especially elderly, in my opinion. Lastly, for just some abdominal training, you’d call it scapular, stability, training, whatever you want to call it, just working on a bear position, working, on getting along through the arms, maintaining some routes in the upper back. It’s kind of an antique extension exercise, which somebody with stenosis, their problems, their sims are typically exacerbated by end range extension. So we’re trying to get them out of that and reduce some symptoms and also just build some function at the same time. So that’s what I would do with my with my father and now I’ll show you how we [00:42:00] scale that stuff for higher level athletes.
So we just saw the bear. Here’s like, when I trained myself, how I do the bear. Now I’ve got opposite arm, opposite leg up in the air. I’m working on some hip extension. It’s a way to make that much more challenging. But it’s a continuum of the same thing. We’re talking about the lateral movement, here’s just a lateral jump. This is when I was quarantined jumping over some paper towels because equipment was limited trying to stick the landing. So working on balance, working on stability, working on forced production, the philosophy end of the spectrum, all these things, every exercise, every category is scalable progression from the exercise I showed my dad doing. Here’s kind of the Nordic hamstring exercise. Now we’re working with longer levers, so it’s more challenging, more range of motion, taking that step up [00:43:00] and now making it more dynamic, it’s like being on a bouncy castle as a kid, these were a lot of fun. We would do this from a higher level athlete, and even this can be scaled by making the box lower. So I’ve done stuff like this with my father, but on maybe a three inch box. Let’s see what we got here. So taking like a push-up or a push-up fall. Now we’re doing; we’re using rings, which are the less stable making a handstand type push-up in a pike position, challenge the leverage.
So here’s an upper body progression of a push-up. Some of the dynamic stuff we’re going to show is a lot of fun. So here’s Trevor he’s typically, we always take people that are the best at certain things and show them on Instagram. So Trevor’s are changing direction and agility guy. So taking some of the weight shifting and lateral movement that I have my father do now here’s how we would train like a professional athlete in a return to [00:44:00] play scenario. Work on accelerating laterally, stopping, deceleration. We’re not going to do that obviously three weeks after an ACL surgery, but that’s what N range, ACL rehab should look like. If you can’t do that, you shouldn’t be playing sports. More of just, you can call this strength and conditioning, you can call it rehab. It doesn’t really matter because if someone’s goal is to be explosive in a team sport and the field of play. These are the kinds of things in our opinion, people should be doing so working on decelebration here, you can call it dynamic, bouncing call, whatever you want. You’re seeing similar themes.
Steven: So Doug, that’s actually a nice tie into Jeff’s question. He wrote in the chat box, once you progress into the [00:45:00] later stages of a patient’s rehab and you’re working on activity, sports, specific goals, what differentiates the physical therapist from the strength and conditioning specialist?
Doug: That’s a great question. Let me show the rest of these videos and I’ll answer that. So, now this is more linear, you kind of get the idea. We’ll just show a couple more, just so you guys can kind of get the picture of it. Trevor’s initiating that lateral movement with a hip turn, that’s working on hip trunk association, which is kind of like the main stream of athleticism and most sports and change the direction, learning how to dissociate your hips from your torso. Now I had my dad pushed the sled. We have athletes, younger, healthier athletes, have to sprint at maximum velocity, everybody talks about hamstring pulls. If you’re not spraying the maximum loss and training [00:46:00] it makes sense that you’re more likely to pull a hamstring in a game if you’re not used to run at that velocity. So this is just it’s stress inoculation. We need to run a maximum velocity is to get the hamstrings to adapt. Then lastly an upper body progression of like; I have my father doing like a row. I don’t know if I show that video, so here’s kind of like, you can call it end stage shoulder rehab. Here’s kind of like an advanced pulling type exercise. It’s basically kind of like inspired by the gymnastics, the front lever, combining that with the pull up. So you see how all this stuff is scalable.
So I’ll answer that first question then I want to open up, let Greg and Trevor chime men because I’m sure they’re going to have some things that they would like to share as well. So as far as, how do we differentiate between when someone should be with a PT or a strength conditioning coach? The [00:47:00] easiest way to answer that is you have to obviously respect scope of practice. So in my opinion and like a strength conditioning coach, shouldn’t be doing postop rehab day one, but after three months, there are a lot of strength coaches that could probably more competently rehabilitate an athlete than some PT. So you have to respect, scope of practice and make sure you’re not violating any laws in your practice act. But then beyond that, it really comes down to knowledge. If as a physical therapist you know that you’re working with a high school athlete, let’s say, and that athlete has to change direction on the field. If you don’t understand change of direction to adequately and ethically prepare that athlete for sport. You either need to learn that, learn change of direction stuff, or refer out to somebody who does, because, and there’s a lot of pressure to get people discharged. A lot of it is driven by insurance. If we’re just getting people range of motion back, getting them like five in a five NMT in their quad [00:48:00] and then saying, okay, you’re done, you can go play football now. That’s a big leap of faith. You can get away with that sometimes, but I don’t think luck is a good strategy.
So I think, you know, there’s a lot of overlap between professions and a lot of this stuff is very political. I get, like to be fair, and you will all see in school, there’s going to be physicians that don’t like physical therapists having direct access, because frankly, they’re going to say it’s unsafe. It’s a threat to their market share because we all have overlapping skillsets and having physical therapists as direct access providers, now if someone’s nonsurgical and they see a PT first instead of an orthopedist, that’s tapping into a pretty lucrative market. But to be fair I get emails from the New York State board saying athletic trainers want to have more autonomy, sign this petition to block that. So everyone’s kind of trying to crap on everybody else; personally, as a consumer of [00:49:00] healthcare, I like people to have choice as long as things are safe. I think that a lot of times safety is brought up kind of to fearmonger and to suppress conversation and it’s really not about the patient it’s about, we want to protect our market share. So we say somebody else is unsafe. I think that the safety thing it’s a reality, but also overblown. So when it comes to these things, whoever is competent should be working with the person and then respecting scope of practice. So anything let Greg or Trevor because I’ve talked enough and I want to open up to questions, anything Greg or Trevor that you guys want to add on any of those themes or even the last question and I’ll shut up now.
Steven: Yeah Trevor you’re breaking up big time.
Speaker: I think it’s your microphone or headphones.
Steven: Just go with computer audio, microphone and then I didn’t really hear much from the beginning. I don’t know if anyone else did. Yeah, I’d say just restart it. I would say do it over Trevor. Trevor, you came in kind of muffled so can you just repeat what you said without your headphones?
Greg: I think he’s trying to, trying to figure out that second part of it. Trevor, can you hear us? [00:51:00] well anyway, what I believe Trevor was saying, hi, I’m Greg. What I believe whoever was talking about, he was referring to just how we might have some sub specialties as physical therapist. So I, myself played a lot of baseball. I worked in baseball, so there’s a lot of contexts around working with the baseball athlete that I might understand that Trevor doesn’t because he didn’t play baseball, he played football. So then there’s that sort of same thing with him. If I don’t have the context around a position that that a football player might play, because I didn’t play it, or I’m not as educated in football as it is. Then it’s something that he has more context to go off of and he can maybe prepare that person better for their sport and their end stage rehab. So that just goes back to exactly what Doug was saying where it’s really just expertise and the more you can expose yourself to various experts in various specialties within, if we’re talking [00:52:00] sports and ortho, that’s the best way you can learn from everybody.
So for an example, Trevor, Doug and myself, we all went and we had Trevor work with a running coach and all of us were there and we said, okay coach Trevor, let’s see what you do and that’s in our opinion, I think the best way to see what other professionals are doing, other clinicians are doing is by letting them do what they do best and asking questions to them while they’re doing it, or maybe afterwards, if that’s more appropriate for the setting. So that’s just one example of how we look for expertise from those who have it in certain areas that we don’t necessarily have. So I don’t know that there’s too much of a distinction. There’s a large gray area between when does rehab and physical therapy finish and when does sports performance and strength and conditioning start? And the real answer is the more you know the better because then you can help prepare that person for a longer period of time but you should also know [00:53:00] your limitations and have a network of people who you can refer out to like that running coach, for example, who maybe we would refer out to if we needed that. But now that we’ve exposed ourselves to that specialty and we’ve learned and poured over running information, now we feel like we are able to prepare a runner, whether it’s a sprinter, a long distance runner that maybe we now don’t need to refer out unless it’s maybe more of a programming thing or an elite athlete where it’s like I’m not a powerlifting coach, so I’m going to have you work with a powerlifting coach because I’m not that, and that’s just a little bit different and that’s just sort of taking it a step further.
I’m not going to be a tennis instructor because I can hold a racket and swing it. I need somebody who knows exactly what they’re doing, the technique in the sport, and the technical, the tactical components on the sport. Trevor you’re back, was there something else you were…?
Trevor: Can you actually hear me now?
Greg: Yeah we can hear you.
Trevor: I just think to kind of add on is like knowing where your limitations end because I [00:54:00] think where athletes kind of get mistreated in this is when the PT doesn’t take them far enough and the strength coach is trying to start them too far ahead. There’s this big gray area in the middle that I think people really misjudge about the time that needs to be spent doing certain activities and certain tasks that will allow them to be more successful once they get back out in the fields. Like Doug’s examples, just because you can do a 5-10-5 in a closed environment at 50% speed doesn’t mean you’re ready to go and be, you know, full limitation and practice. There are so many different forces and different stresses that the athlete needs, tons and tons and reps of to have like in whether it’s with the physical therapist if that’s their skillset, or whether it’s with our strength coach if that’s their skillset that they need to do. So it’s just athletes need the exact same thing from the start of the rehab, to being back on the field. It’s just how far can you take them and then where can the strength coach kind of start them? So, like Greg said, it’s just having different skillsets, knowing what your limitations are and then trying to build upon that.
Yeah and I think [00:55:00] like a lot of it is just self-awareness and being self- reflective. I do want to clarify that like all three of us are comfortable working with any kind of an athlete where we would refer out amongst each other as if we were working with like an elite athlete. Trevor and I are comfortable working with a throwing athlete and doing the rehabilitation. But if we had a major league pitcher where like that extra 0.1% is worth millions of dollars, I have no hesitation saying that Greg’s more qualified to work with that person than me. I feel comfortable with change of direction athletes but if I was working with like an NBA player, and Trevor was able to do their change of direction, he’s just better at that stuff than me. I’m comfortable with it. But I think that we all, we should all feel responsible. We should know about all these things, but if it’s like that really, really unique case where they need to have the quote unquote, the best thing that’s when we refer out. But we don’t use that as an excuse to be like, well, I don’t need to learn about running, or I don’t need to know about throwing because really, I mean, even in a specialize athlete. Most of what we’re doing with [00:56:00] them is still very, very basic. We’re still trying to get them to move well, however you wanted to define that and then add some load speed and capacity to it.
That’s fundamentally what we’re doing. We’re trying to get them to access and control range of motion. That’s important for health and their sport. We’re trying to load that through strength work. We’re trying to do it rapidly and dynamically through speed work and we’re trying to add capacity through endurance type training, whatever that looks like for the sport. We’re all comfortable working with all kinds of athletes and populations, we just refer out in the very specialized cases. So Aries had the question about the apprenticeship model, great question. So the question is about do we think specialty fellowships and residencies should be required? I don’t know if they should be [00:57:00] required because personally, and this is just kind of my bias, I think that when it comes to this stuff some regulation is needed. I don’t want too much because I want to be able to choose kind of what I think is important. When you mandate that a residency is required now instead of creating that own educational, I think that like physical therapy school gives you the tools to learn on your own and at a certain point you can only outsource your own learning for so much.
It’s great to have structure, but no matter what, ultimately you’re going to have to figure out what you need to learn. A residency could be a way there, I just think that to mandate it could also put people in a difficult position because we all are in different levels of debt and financial hardship when we graduate and now with a residency, if you do that, yes, there will be an educational benefit, but there’s an opportunity cost in terms of paying off loans and reduced salary and for some people now, if you require that residency, now [00:58:00] you might have people who otherwise would have entered the profession, who won’t, because you’re just increasing their financial hardship. That said it probably would elevate the standard of care in the field. So it’s one of those things where I don’t know if there’s a right answer. I think that; the way that you asked the question, I can answer it definitively when you say should, I would probably say no, I don’t think you should, in that sense, in a dogmatic way, but I think people should have the choice to do it certainly because right now the difficult part is there’s not a lot of; you don’t increase your earning potential by doing a residency and it’s only a really respected within the field, not externally. It doesn’t mean you shouldn’t do it, but there is a cost to doing a residency as well and it’s really up to the individuals in my opinion, to determine whether that is a good investment or not.
I’m more of like a self-directed learner and I went to PT school when I was 30 years [00:59:00] old and graduated when I was 33. So I didn’t feel like I needed that kind of direction. But if I had gone to school seven years earlier, I might’ve wanted it. So I don’t, I don’t, I’m not trying to be evasive, but the should thing is what’s problematic to me because there’s a downside to mandating it, but I do agree that it would elevate the standard of care and it would create some uniformity, but I also liked the fact that I cannot be uniform and that’s part of what makes your patients seek you out too? So it’s again, one of those kind of timeless dilemmas. I don’t think I want to touch on that.
Greg: Just jumping onto that too. Something to consider, would be maybe figuring out and exposing yourself more to the things that you don’t already know, as a student and then using those points and having that knowledge of your limitations when you’re then picking your clinical rotations, maybe you can find somebody who works primarily with runners if you feel like that’s something you may want to do, and you’re currently not that great at and that’s a good way to then [01:00:00] figure out sort of what knowledge you need to acquire, where you’re giving yourself a residency through something that’s already in place where you can self-select where your clinicals are. Obviously some programs are different than others, where you can choose to do your clinicals and I know we were fortunate where Columbia helped us set up some clinicals with people in maybe some specialty markets and some specialty populations where we benefited greatly from it and I think it’s definitely contributed to our quote unquote success as clinicians now.
Doug: I think what the residency offers more than anything is now it’s like signing up to have a mentor or mentors.
Doug: Right, it’s accountability. You can do that informally it’s just harder. But I think for a lot of people a residency is a great fit and I’m glad that I think the profession is better off, [01:01:00] that it’s available to people. We do a podcast, I want to interview people who have gone through some of these residencies because I hear about what they’re learning and it’s awesome. There’s also a lot of redundancy, a lot of it is a repeat of what you’ve already learned. So again, it’s such an individual decision, but the should thing is where it’s kind of like, well, I don’t know if it should, because now everybody has to do it, but it might make the profession more respected too, because yeah it is political and safety and efficacy is not, there’s no way to like say, okay, look at all individuals and say, this person’s safe and knowledgeable. What do medical people do when they get political? They say, well, I have X number of years of education and this profession has Y. So now if you say, well PTs have five years of postgraduate education. Now it gives them some bragging rights, but you’re also capitulating to, in my opinion, a flawed way of evaluating safety and competence too, if you do that, but you also, it is political and when things are political, you have to play the game [01:02:00] to a point. I will let Greg or Trevor, I want you guys take the next question first then I’ll, because it’s a really, it’s a great question and I’ll chime in when you guys are done.
Greg: From Corey? Okay, yeah. You’ve come across oh, Corey, I know Corey. I know that name. Do you come across situations where your athletes sports specific coaches or strength coaches prescribed things you may not agree with? Oh, yes, a lot. How do you approach this with your athletes? So this, I think goes way back to something Doug initially touched on was relationships. Over anything else whether it’s business success, your patient success, communicating with other sport coaches or other professionals is relationships and no matter what, that’s going to be the most important thing to either A, getting across what you think is best for your patient or understanding better why their other provider or your coach or whoever decided [01:03:00] to tell them a certain piece of advice or coach them a certain way. Because maybe you aren’t wrong, maybe there’s something that you definitely disagree with. But maybe you don’t have the depth of knowledge that this specific sport coach has, where when you then talk to them, they can communicate it to you in a way that you’re like, oh, wow, yeah, that does make a lot of sense. So that’s definitely a piece of it, is definitely exposing yourself to other providers, other professionals and the coaches and your community, the patients that you’re working with.
I know I work with a lot of, like, we’ve already touched that I work on a lot of baseball players. So I hear a lot of different schools of thought from different pitching coaches or hitting coaches and there are definitely certain biases I have towards the things that I like or don’t like. But again, somebody might tell me, a patient might tell me one thing, but the coach is actually saying something that doesn’t necessarily line up with what that patient is telling you. So it’s almost like you’re playing telephone a little bit. So definitely give the benefit of the doubt if [01:04:00] it’s something that you don’t completely buy into, but you definitely have to understand where that message is coming from for the patient. There could be a certain reason because I know there’s certain things that I do that potentially two years ago, I might’ve scoffed at as a clinician and maybe I just didn’t understand that there’s a certain context that this specific patient that’s in front of me right now is going to need that thing that I scoffed that and I don’t know until it’s in front of me. So I think that’s a huge thing to consider as well, communicating to the athlete and definitely, you try to be as professional as you can. You don’t trash anything that someone else is doing because you want this athlete to be on your team. You want to be on their team, if you shut them down and for some reason their coach is someone who was already in their inner circle and they have an extremely deep relationship with you’ve already shut yourself out and there’s no longer, potentially no longer a way for you to help this [01:05:00] patient when you might be the best provider that they have access to. So that’s really important that you don’t say something that you’re going to regret because whether or not you believe what they’re doing or not is the right thing. So Trevor, Doug, yeah go for it, jump in.
Trevor: Yeah. I think that communication between like the game of telephone that Greg mentioned between the coach to the athlete, to us, is often, especially with high school and junior high kids, they can’t remember, or they don’t understand some of the things that we tell them. It could be the exact same thing when they go back to tell their coach and maybe the coach and I are on the same page, but the telephone that is the athlete is kind of miscommunicating everything. So I think that’s often a big thing and not being afraid to ask for the coaches number, to be able to talk about it because we always want to learn from somebody else and I love learning from sport coaches because they see way more of whatever that is than we do. When it comes actually beginning with the athlete, I think there’s a big; most of the people that we see don’t [01:06:00] come to us unless they have some sort of symptom that they’re dealing with. So oftentimes the way we coach them in what we’re giving them is. Some sort of modification possibly because of the symptoms that they’re dealing with. So some of my basketball players where they have hip impingement, their coach is telling them to get deeper, get deeper, get deeper in their defensive stance, but it bothers their hips.
So I tell them to just stand up a little bit more. It doesn’t impinge their heads and it makes them move a little bit better on the court. Like the coach may be right in the context of what he’s seeing, but in the context of what we’re seeing, it’s very different. So we are coaching an individual where oftentimes sport coaches are coaching groups of athletes, not necessarily an individual. Then when it comes to more of the strength coach side of things, oftentimes a strength coach, kind of the same thing, they don’t have the opportunity to be one on one with an athlete for an hour like we do. So even though they may have given an athlete a great program and made a really good exercise choice, either the athlete could be executing it [01:07:00] poorly on their own, which again, it’s something that we can help the athlete execute that move better or there may be some sort of change that needs to be communicated to the coach that we are then in a place to communicate to. I know recently who, because of the whole COVID situation hasn’t been able to train with his coach in person. So he’s just been training on his own and he was feeling terrible physically and I talked to the coach and we kind of made, and the coach didn’t know that because the athlete never told him. So we just made some training modifications and he’s felt better since then.
Doug: I’ll just add to that, like Greg said, you never bad mouth anybody. There are certain situations where you’re going to have to work with other providers in a team based care and there are a lot situations where an athlete might say, well, my sport coach or my strength coach said this, but you’re never actually going to have to interact with them and sometimes it doesn’t always make sense too; that’s kind of an individual situation. One thing I like to give the athletes is choice and even patients, because I have patients who were like, [01:08:00] well, my chiropractor said this, my ortho said this, my acupuncture says this. I never tried to, unless I think it’s like truly dangerous, which it often isn’t, it’s more just difference of opinion, I don’t tell patients that somebody else is wrong, but I’ll say, look, this is what I believe and I kind of look at it like I worked for the patient or the athlete. The burden is on me to demonstrate that what I’m doing makes sense. What I’m doing makes sense and so you should see whoever you want. I don’t get offended when people get second opinions or want to see other PTs because a lot of times there’s a psychological aspect of this and people will come to you because they want to hear a certain thing and that oftentimes is more important than actually getting the result they want.
So if they go to you and you don’t tell them what they want to hear, they might say, can I go to somebody else? I’m not offended because I want you to get better. I mean, if you go to somebody else and they give you what you want and need, then that’s great. I’m not always going to be the [01:09:00] right fit for people. So I’ll have to give people a choice and to say, look, this is what I think, it’s your decision. If you want, or need me to talk to somebody else you’re working with, I’m happy to do it. I leave that up to the athlete, but I never say that what somebody is doing is like is wrong or bad unless it’s a real safety issue. Then on top of that, sometimes, and I’ve had this happen, as an ethical matter, if I really don’t agree with what somebody else is doing, on the athlete’s team and there’s no way to change that, then I’ll just say, look, I’d rather not work with you. Sometimes you have to make that decision too. I’ve had situations where I’ve had to do that and at the end of the day, you have to feel like you’re delivering value to that person and doing the best job that you can and if you think you’re constrained by whether it’s like political circumstances or. something that another member of that athletes team is making you do or something that just won’t change. Sometimes the best thing to do in the most, like in my opinion thing with the [01:10:00] most integrity is just to say you know what, I’m sorry, I don’t think this is a good fit, but I wish you success with whoever else you want to work with, but it’s like individual circumstances always prevail here, but communication is a big thing. I think just being transparent because you don’t have to feel comfortable with everything, but if you don’t, you shouldn’t be passive aggressive. You should make that very clear.
The next one, how important do you think it is for clinicians to have a network of trusted professionals? Actually the one from Jen first, former athlete, how do you manage relating to an athlete’s feelings of well-being and wanting to get back to the sport ASAP without a quick fix? So I think that’s really kind of touching on the psychological aspect of rehab and return to play. That’s one of those things where again, it’s fundamentally, there’s no difference between the physical and the psychological, because if you do good rehab, whatever that looks like [01:11:00] as people progress through their rehab, they are going to gain physical confidence, which should translate into psychological confidence because for example, it’s really hard unless you’re delusional to have psychological confidence if you didn’t get your quad strength back after an ACL reconstruction. So I think that if the rehab is systematic and it’s progressive, when people meet certain benchmarks and now when you put it back in the field, it’s like, oh, well, like I’ve already kind of been doing this stuff.
Now there are objective criteria and questionnaires, I think even as it pertains to ACL, they have those. Those are fine if you want something like a way to quantify that stuff, you can do it and I think it’s good, but least you’re asking the question like, hey, how am I addressing the mental aspect of rehabilitation, but really if you’re doing the right rehab, physically, the psychological part, the psychological aspect is necessarily a part of the physical because you’re challenging people and when they gain that confidence, when they’re doing the things that Trevor was doing those videos [01:12:00] versus not, they’re more likely to be confident when they go back into the field. So the more you can bridge the gap between what their goal is and what they do on the field and what you do in the rehab setting I think the more confident they’re going to be.
Trevor: I think that’s a great answer. I think it’s just throughout the whole return to play process, especially whether they’d rolled their ankle and they’re going to get back in a couple of weeks or whether they had an ACL surgery and they’re not going to get back for closer to 12 months. It’s really communicating with them the entire time and making sure that they feel comfortable and confident with each step of the process and they know why we’re doing what we’re doing, because I mean, athletes want to know what’s going on and they want to know why can’t I be back right now? And it’s like, well, because you can’t do these really simple things before we got to do the harder things. I think just explaining to them and helping them understand the entire process from start to finish really goes a long way.
Doug: [01:13:00] Yeah. So kind of making it like criteria driven and not time driven, because if you say like; anytime someone says, oh, four weeks, how do you really know? It’s like, you’re ready to play when you’re ready to play and so you can spell out communication wise, here are the benchmarks I want you to meet before you go back versus getting an arbitrary timeline. That from a motivational standpoint, it’s like, now I’ve got to be able to do these things. People can get complacent when you’re like, oh, just in four weeks, it will be better. Well, okay then you can just do nothing for four weeks, if it’s four weeks, it has to be criteria driven and that can be as like objective or kind of more subjective, an eye test as you want, but there should be some kind of a criteria before you progress to the next phase.
How important do you think it is for clinicians to have a network of trusted fitness professionals, trainers and how often do you find yourself referring to them? So [01:14:00] yeah, I mean, it’s important, again, because there’s overlap between what we’re doing and what we would call like fitness training, I feel the three of us could do things that look like fitness training. We’ve had people that we’ve worked with that after they rehab and they’re no longer symptomatic, they have stayed on for kind of follow on training as a different service. It’s not something we do a ton of, but when people really want it, we’ll do it. We do have trainers that we trust to work with our patients. We think are a little bit more like responsible and educated and so also like there’s different price points because different trainers charge different things. So if someone’s like, hey, I want to work with a trainer, but here’s my price point. We have a network where we can say, okay, like we think this person is really good they’re within that price range. I think that it’s really important to address fitness and whatever their follow on routine is after you discharge them and it comes down to, [01:15:00] do you have the expertise of the desire to do it yourself? Or do you want to kind of have somebody else do it?
I mean, the reality is like most people it’s a pretty high barrier to be able to afford consistent fitness or personal training. So it’s a pretty exclusive population. So I mean, people who want that and can afford it, yes I think it’s important to have a network, but you should also have solutions for people for whom that’s not available. So that’s why we have YouTube videos, we’ll write discharge programs for people we’ll say, okay, like your knees, it doesn’t hurt any more, but for the next four to six weeks, do this and here’s the progression and then go back to doing kind of whatever you want. But we try not to let people, we don’t like discharge people without some kind of a plan, whether that’s handing them off to somebody else or giving them the tools that they need to succeed on their own.
Greg: And sometimes I definitely deal with a lot of other trainers, probably more than Doug and Trevor do because the facility I [01:16:00] work out of predominantly, we’re actually only in Chatham, New Jersey, we’re inside of a sports performance facility and there are six, but then I think six sports performance coaches there. I see a lot of the baseball athletes that are in the facility, they come to me for whatever they need. It might be postop, it might be just my shoulder hurts, whatever it is and then I know their coach. I already know their strength coach. So they’re in my network. Oftentimes I’ll also get patients who’ve never been to the facility before who come again after it’s postop or some sort of pain that they have. Then I have the trainers in the facility at my disposal to recommend when the time is right where it’s based on insurance, based on my ability to give them what they need, the price points. There’s a lot of different factors, but it’s definitely helpful to know that I have trainers that are in the same exact building as me, which it’s a huge luxury for me. I know that’s not very common and it’s not regular [01:17:00] for physical therapists to have that, but it’s definitely important to know, okay when I’m done with this patient and I think about it ahead of time too.
I’m thinking about it weeks in advance before I’m quote unquote done with this patient, that they’d be a good fit for this trainer or that trainer. So it’s definitely something that’s important to have and then we’re also getting, we get referrals from these trainers too. They like what we do, because we like to get them back to their training. We don’t want to keep them like Doug was describing three times a week for six weeks. Because right there, that takes up all their training time and now they’re not working with their personal trainer or their sports performance coach. So in the cases where they can continue to do that stuff, we can just be a resource for them and see if any frequently it’s huge where we can help the trainer keep their client and then they’re going to keep referring back to us because they like what we do and we continue to provide value.
Trevor: I’d say, just as an addition to that, like a lot, especially in New York city, a lot of the referrals we get are from people we know [01:18:00] just in the fitness space in general and they, like Greg just kind of alluded to it’s like they send us their clients because we help them keep training. Because they don’t come to us and we’re saying like, no X out, all training, we do a pretty good job of coming up with modifications that we know will be safe for the client to be able to do with their coach or with their trainer to allow them to keep chasing their goals. Because our goal, like Doug said is during some of those waves, it’s like movement is good for everybody. So we try to keep people moving as much as they can as safely as they can with as little pain as they can.
Doug: Yeah, and I mean I don’t know how much of like the chronic pain stuff, you’ve all learned, but one of the easiest ways to create a chronic pain patient is to tell them all the things they can’t do. Unless someone’s really, really debilitated, they can always do something. So you have to start with like, what are you like even with a trainer, like, what do you normally do with your trainer? Okay, I do back squats, but my hip or my lower back hurts. Well, like, okay let’s try a different kind of squat. Did that hurt? No. Okay. Well, I’ll talk to your trainer and [01:19:00] let’s have you swap out the back squat for a front squat or goblet squat. So, I think that’s why trainers like working with us is because we’re not like fear mongers. We don’t tell people they shouldn’t do things because very seldom is complete rest and lack of activity a good thing, but you’d be surprised how many medical providers, including some PTs will tell people like you shouldn’t do this, you shouldn’t do this, you shouldn’t do this and it’s also, again, the word should is it’s a very kind of dogmatic thing where it’s like, who am I to tell somebody what they should, or they shouldn’t do. I see plenty of patients they do workout classes that I think are like kind of insane and I would never do them myself, but I kind of look at it like, all right, if you’d like to do that, my job is to prepare you for it, I’m not telling you that you shouldn’t do it.
Again, there comes a line where it’s like, alright, if someone has foot dropping, neurological weakness and back pain, it’s like, well, you probably shouldn’t be doing this class until this gets better. I will draw a hard line sometimes, but my values are not [01:20:00] my patients’ values. I start with like, what are your values? What are your constraints and then your goals and how can we get you from point A to point B? I’m not trying to project what I think is fun or useful onto somebody else unless they think there’s a real safety issue, but I think that again, the safety flag is raised a little bit too quickly and too hastily and a lot of cases, when, if you’re creative, you could work around some of those things.
Steven: I think we have time for one more question and I know Doug, you mentioned that you’re willing to stay a little bit longer to answer some folks.
Doug: Yeah, we don’t want to hold anybody hostage, but I can stay on for a little bit longer beyond 7:30 if people have extra questions.
Steven: Okay, cool. I think the next question is from Nirvana.
Doug: I think, well, Trevor, why don’t you take that one? I think you have the best story when it comes to kind of just like being all in, on the business.
Trevor: So the question, can you talk a little [01:21:00] bit more about the business part of starting your own practice? Did you work at other clinics to try to gain experience first before starting your own clinic. The answer is no for all of us, oh Greg worked a little bit part time.
Greg: I worked for six months part time while we were also doing this stuff.
Trevor: Yeah, I mean, like for myself, I come from a family that’s owned a business my entire life. So I’ve known that I was always going to at least going to start my own business at some point in time and I was very fortunate enough to meet Greg and Doug in school and we kind of all shared the same vision, the same passion. But yeah, I mean, we went all in. I was living off of whatever little loans I had left, whatever little savings I had left and pretty much just went all in. So I was on Medicaid for the first year of owning our practice before things kind of got better and we started making money and could pay ourselves a little bit. But yeah, we just kinda went all in and that’s not for everybody. I’m not saying that that’s the way to do it. My fiancé graduated with Greg and I, and she [01:22:00] just started her own clinic after five years of working for somebody else but that was her path. Like for me, I’m much more of a risk taker and I was very cool to just kind of betting on ourselves.
Greg: Yeah. And it’s much better. I mean, starting out for your fiancé, like she’s already fully booked, she’s got a full case load. So she’s developed a reputation over the years where she doesn’t necessarily have as big of a risk potentially or when we started, we didn’t really have much to lose, so to speak. So it was more like everything to gain and something that we wanted to try anyway. So we can always fall back on something else, work somewhere else if we need to.
Trevor: Yeah, exactly. And I think like without going into too much detail on what our initial situation was is we thought we were going to be getting a lot of help from people that didn’t end up kind of coming through, which kind of gave us like Doyg said, we’re kind of forced our hand a little bit and that’s pretty much exactly what happened. It was like, well, it’s something we hadn’t always discussed and always kind of talked about and what seems to be like now is a great time it’s kind of now or never. And then [01:23:00] the people who were kind of pushing in that direction left and it was basically just kind of the three of us to fend for ourselves, which we ended up doing. But yeah, I wouldn’t trade that for anything in the world. It’s been a great experience and I’ve enjoyed all of it. It’s been awesome. But, yeah, I mean, it’s not for everybody to own their own practice. It’s not for everybody to just start it right away. That’s just kinda the path we went. So many things happened organically for us to be able to get to where we are that if we were to write a book about what happened over the last five years, it would not have been what I would have pictured predicting what happened at that point in time.
Doug: Yeah. And I mean, I let Trevor talk first because he did, I don’t know if I would have done what he did in his position. Greg was working somewhere else so he had a safety net. I had a safety net because I had, I was still in the in the reserves with the military. So if I wasn’t busy seeing patients, I could go make money and do that. I didn’t have any debt because I had the GI bill to pay for PT school. So I had a bunch of money [01:24:00] saved, but Trevor had a bunch of debt and I was kind of like I said, we were forced to work together. I didn’t even have enough patients for myself and because they kind of got like screwed in this situation. I’m like, well, I’ve got to try to make this work for everybody. I was like, I can’t even guarantee myself employment, I can’t guarantee you anything and he’s like, I don’t care. I’m all in and I’m like, alright, but I would necessarily recommend that to everybody and neither would he. I’m just saying that this is what we all did and I think when I looked back, I realized how clueless we actually are. We actually were and it’s kind of scary, but experience was the best teacher. But you know, you can make a case that the time to do it might be when you just graduate when you’re already in debt anyway, and you don’t have a lot invested in something else like that again, it’s an individual decision. It’s really hard. The situation is so unique.
Greg: Yeah. If you feel comfortable and confident with a full case load, then there’s no wrong reason to do it.
Trevor: [01:25:00] But the bigger thing is like, if you’re going to start your own business, regardless of how secure you feel financially, you should feel secure treating people on your own without a ton of mentorship. I think we had really good mentors. I mean, I kind of like cringe at some of the things that I did when I first started out. But I think that we were more ready than some other new grads because of the mentors that we had. Admittedly still the learning curve in the first two years of training independently is just beyond anything else you’ll experience.
Greg: Whether you have that mentorship or not just being in the clinic regularly and seeing patients every single day is going to make you way better clinician very quickly.
Trevor: But it’s hard to do that and learn business at the same time. It can be done, but it’s very hard. Do you want us to take James’s question because it seems like it’s the last one.
Greg: Yeah. I would say sure. Yeah, let’s do it.
Trevor: Okay. I’ll take James’ and then we’ll do the extra credit [01:26:00] athletics just on another one come in. But the question from James is about do we think strength and conditioning should be kind of part of the curriculum for future clinicians? Again, when it comes down to should, I mean, of course our bias is like, yeah, strength conditioning is great because we’d like it, but as Dr. Stewart can attest. I don’t think, and I don’t even think we appreciate this until afterwards. What are you going to cut out to put that in? There’s just so much to learn, to be a journalist. I consider strength conditioning, almost just like advanced therapy. So do you need to know Olympic lifting to be a good PT? I don’t think so. I don’t even really do that much of it. I think probably you could get higher level of [1:26:40inaudible] than what most entry level programs get. But when you say, okay, this should be required. I don’t know if somebody who goes into PT school knowing full well, they don’t want to do outpatient ortho necessarily needs to do strength conditioning. It’s really hard because I don’t know what you would [01:27:00] cut out to make that happen, but since there’s so much finite time and resources. I think that the exercise progressions can be a little bit, probably more aggressive and it could be maybe like an elective, but beyond that, I don’t know how much more emphasis I’d put on it, because like, are you going to cut anatomy? You’re going to cut kinase? You’re going to cut basic neuro? Are you going to cut basic cardio poem?
Even for an outpatient ortho. It’s easy to say like, oh, well I’m never going to do neuro, but you think that until you’re working with a spinal cord patient. I’m working; it’s not that like, the class itself made me better at it, but I need to have some foundational appreciation of it and to just to see the more models you see, the more you realize everyone’s kind of saying the same thing, using different words. But ultimately again, it comes down to if you really want to learn it, you’ve got to get it on your own. But I think that there is room for it to be an elective and in an ideal world, yes, there would be some more emphasis on fitness beyond just [01:28:00] acute pain management, but the goal of PT school was to create a safe generalist who can then learn more through practice or the residency or fellowship. So the goal is not to make someone a specialist. Now, maybe there can be programs that cater more to that, but again, there’s a lot of like things with CAPD and other regulations that kind of mandate what you can and what you can’t do when it comes to an entry level program.
Steven: Doug, Greg, Trevor, thank you so much for joining us. This was awesome. If any of you folks have more questions? Doug said he’d be willing to hang back and talk through those. I just want to, before I close, I just want to plug our next event, it’s on June 17th from 6:00 to 7:30 it’s our disability awareness, vision impairments, blindness, and movement strategies talk and it would be presented by Carol Mood from a non-profit organization, light house guild and [01:29:00] also a conversation with motivational speakers, Susan Augustin. So I’m looking forward to seeing you all at that and thank you again, you guys.
Trevor: So I think that only one more question from Carmen and this is just so that you all don’t feel obligated to stay beyond whatever the mandated time was, but for the people didn’t get to interact…
Speaker: I am just going to quickly say Doug and Greg and Trevor, thanks so much. I am going to bug out because my family just made dinner, but Doug, you bring up a really good point. Is that if you; I think all of us have a level of frustration coming out of PT school with God, I wish I had been prepared for this or been prepared for this and you were totally right. Is something that some people don’t really think about is that if you’re going to plug something in and something’s got to come out elsewhere, and what we’ve been really good at at [01:30:00] Columbia is packing tons of stuff in. So if we don’t take something out. So then that becomes a big conversation about how’s that going to happen.
Doug: And we all complain that we were doing too much stuff anyway, you know?
Greg: I always tell the story of taking 27 credits in one semester to some of the patients who might be interested in physical therapy.
Speaker: Right, the second spring, you’re there the first spring, whatever it is, impossible amount of credits. Anyway, it’s really good to hear from you guys. It was so, I mean, we went from border policy to change of direction.
Doug: There you go, we covered it all.
Speaker: There is nothing better than that.
Greg: Good metaphors.
Doug: So the question from Carmen, post-COVID. Yeah. So the question is kind of, this is common question with the COVID stuff is like, basically [01:31:00] one of the predisposing factors for injury when it comes to return to sport as this whole acute to chronic load, which basically means that people have tried to figure out like exact ratios, but all intuitively what it means is. If you haven’t been doing that much and then all of a sudden you do a lot, you’re more likely to get hurt because there haven’t been structured practices with COVID, there’s a concern. I think it’s already happening in some of the European soccer clubs that like people are more likely to get injured. So look, there’s only so much control that people have. If you’re working with an athlete who’s not with their team now, then just try to train them as aggressively as possible with the constraints and equipment limitations that you have so that when they go back to practice they’re more prepared. Beyond that a lot of it really is not in our control as like rehab providers, because if they go to practice the first day and the coach is like, I want to see who’s been grinding over the quarantine yeah, people are probably going to get [01:32:00] hurt. I mean that, so that’s probably where the communication piece comes in.
If you have a relationship with the sport coach, you could say, look, you’re probably better off the first week doing, you should feel like you did too little, not too much because people are most likely to get hurt during that initial spike in their workloads. So do the best that you can to maintain a high workload. If you have control over some of their off season training and then beyond that, you’re either just going to hope for the best, or if you have a relationship with the coach, try to talk to the coach about like education about, hey, I know you feel like you have to make up for lost time, but if you get everybody hurt, then you’re making it for more lost time. So better off being conservative when it comes to that than doing too much.
Greg: Yeah. And something I’ve been asking my athletes who are obviously not in season right now is what they’re going to have to do when they get back to practice. What does your day one look like? Because they might know, they might know that they have a conditioning test that they have to do on a certain date [01:33:00] and that’s going to probably dictate a little bit of what I want to do with them to help prepare them so that they’re not going to be injured, but be successful in whatever test it is that’s going to get them playing time. So it’s sort of balancing what you think they need versus what their coach thinks they need and then, yeah, like Doug said do as much as you can with them and ultimately having a proper ramp up is going to be maybe out of our hands, but the best you can do is good enough, I guess.
Trevor: Yeah, I think you guys covered it all. I think those are good answers. It’s just controlling what you can. I think from an X’s and O’s standpoint of in terms of preparation, it’s like people don’t have access to gyms, but you still have the outdoors. You can still do plyometrics outside to build tissue capacity. You can still do sprints and accelerations to make sure that you can handle the velocities that you need to be at once you get back to practice and then just [01:34:00] kind of keep building up the work capacity of that hopefully not get injured when you go back to putting on whatever the coach as you’re do and like Doug said, I think the communication and knowing what to expect from a coaches standpoint when they get back is huge. Because they’re going to get back and they’re just going to do repeat hundreds until the sun goes down and then people are probably going to get hurt. But if they go in knowing what’s going to happen, it’s going to be kind of more of an appropriate dosage that first time getting back into camp and I think things can go a lot better.
Greg: Something else too is a lot of athletes are just doing body weight exercises at home these days and that’s really it because they don’t really know what else they’re supposed to be doing. Probably the number one thing you should be doing is like sprinting and some sort of fast, just change of direction, running back and forth pretty quickly. It’s just a boil it down to make it super simple, if you’re going to have hamstring tears in a sport like soccer, it’s probably because you weren’t [01:35:00] sprinting potentially. So you should probably be doing stuff like that because that’s the stuff that’s going to just drop off faster than anything else compared to strength.
Doug: For Adrian, I just actually sent the link because we did a blog post on your exact question. So rather than like recite the books, which is boring I’ll just leave that for you there. Yeah, and then if for whatever reason you guys lose the link. You can just, Aries has the mailing list and then we could just, we could send that to you.
Greg: And we’ve all done like some level of shadowing and observing other professionals so if there’s ways you can do that, whether it’s locally or you have to travel to get somebody they’ve all done that. Where we would just spend our time watching people do what they do. So that was also very helpful as well.
Doug: It was definitely some good resources, relatively inexpensive [01:36:00] books and blog posts and stuff like that. So I kind of put together an article of almost like a cheap, informal fellowship for people who don’t want to do a real one of things that I think are kind of important reading for a sports centric PT, if you want to call it that. Alright, well, I suppose we’ll give it another couple of seconds if there are no more questions thanks really dynamic audience. I kind of knew that coming in just from the interaction that I had with Aries and Steven. We’ve been in your shoes and it gets better and you guys have it harder than we did with everything going on. Wish you all the best and just excited for what the future holds for all. You’re going through a great program. You’ve got smart classmates, professors who are knowledgeable and care and you’re all going to do pretty well as much as you might not think so right now.
Speaker: Thank you so much Doug, [01:37:00] we need to hear those words. We do have one last question about what’s the best way to contact you guys if you want to answer that, oh there it is.
Doug: Our website will have all the social media links and stuff like that. But email is just our first name @resilientperformance.com.
Trevor: And we are happy to answer questions and help out students. Like Doug said, we were in your shoes, we know how tough PT school can be to go through and you feel like the light at the end of the tunnel is 2 million miles away but it’s not that far and you will definitely get through it.
Doug: As long as you make it through the first semester.
Trevor: Yeah, once you make it through your first semester you’re good.
Doug: There are people I think we’ll have them into the first semester yet. But once you get through that, it’s hard but it’s manageable.
Greg: I remember counting. I think there were 14 semesters. I remember counting and being like, all right, I’m 3/14th of the way through.
Doug: You always think that like what you’re dealing with at the moment is the worst thing you’re going to deal with. It just, I’m not trying to, it gets harder, but kind of in a good way, because when you’re in the clinic you’re going to face real problems and be responsible for people, but it’s different than studying for a test, but it’s not like easier.
Trevor: For sure. I would say it’s more rewarding.
Doug: Yeah. Like I’d rather be studying for a test now than dealing with a pandemic and everything else that’s going on, but have a sense of humor about it. Like at the end of the day you all made it this far because you’re pretty good at standardized testing and good academically. So why is that going to really change now?
Steven: Sweet. Thank you guys again. Take care.
Doug: Take care, be safe everybody.