¶ Rising Together
In the last 10 years , our field has gone from an unknown specialty to a household name . This brings unprecedented opportunities , but we need to rise up to meet them and give our patients the care that they deserve . In order to help others get better , we need to be better .
This podcast will help you to become more confident with your patients , more successful in your practice or business and a leader in pelvic health , and we're going to have some fun along the way . Join us as we rise together .
We're Jesse and Nicole Cozine , founders of Pelvic Sanity Physical Therapy and the creators of the Pelvic PT Huddle , and this is Pelvic PT Rising .
Hey guys , welcome back to another episode of the Pelvic PT Rising podcast with Jesse and Nicole Cozine . Hey , nicole , all right , talking today about you need more time , and this topic is actually great . It is inspired by a lot of the leaders in the field that we've been interviewing in this Pelvicon speaker series .
You guys haven't listened to the ones in the past . Go back and listen to Yenny's , jake's , maneerra's incredible interviews .
We've also recorded a couple of more and found that this was a huge common denominator amongst those speakers and the way that they practice , and so we wanted to pull that out and bring it to you in its own separate podcast Before we dive in , so excited .
For those of you guys who are getting ready to join us in Atlanta in not that much time , if you are coming , make sure you have gotten your t-shirts , your swag , your all of the add-ons , all the things that you need to have a great time . If you are not able to join us in person , please make sure that you have checked out the recordings .
This is going to be an incredible conference . All of the speakers are going to be recorded , both talks . You're going to get the whole breadth of everything . You can find out all the information about that at Pelviconcom . So , nicole , as an outsider to the rehab space , this is perplexing , to say the least .
Where does this attitude of work yourself out of a job , get people out your door , get them good enough and kick them out ? Where does that come from ? Because that , to be honest , seems absolutely insane to me .
You know it's a good question . I think I've been reflecting on that quite a bit as we've been building the accelerator program and especially as we've reflected on the talks with the speakers , like you mentioned . I think this comes from .
I mean , if you really boil it down , it comes from this insurance-based mindset and for those of you who practice in an insurance-based model , this is not a quote-unquote bad thing .
You're not a bad therapist , but you are working under some constraints and some assumptions that you're being fed , that you have to work within this system that incentivizes essentially getting people out the door as quickly as possible , not overutilizing services and doing only quote-unquote skilled therapy .
You are putting that together with things that you've heard in PT school , probably very much undermined by the insurance mindset as well , with work yourself out of a job . You are a coach . You can't be handholding your patient all the time . They're individuals too .
They need to take some responsibility for what they're doing and while that is true , I think some of the through line that we've seen and some of the experts in our field .
So if you look up to the people that are speaking at Pelvicon like Manira , like Jake , like Jessica Drummond , like Michelle Lyons , like Jessica Rial , like myself , like all these people , then I think that if you would ask us how long you're treating your patients , we would all say as long as they need to be treated .
Yeah , that can take months , years even , and we're there for them in a capacity that doesn't . It doesn't let insurance mindset dictate what we do .
I think it's worth going back to . On this Like this is one of the great con jobs of our day and I feel like we need to actually call it out .
I don't know if we've ever actually said that , but if you were going to design a mindset and attitude that was going to make insurance companies as much money as possible , if the CEO of United or Blue Cross or whoever else was going to come up with a soundtrack for everybody , it would absolutely be hey , work yourself out of a job , Get them better and get
them out of the clinic . The faster you get somebody better , the better a therapist you are .
Get them doing their home program so they don't have to come back Like you don't need to do this . Put them off into the aid because that's a you know , non-skilled work and all of that . Like there's a lot that can go into that .
I think it's so . It's fascinating that that is just percolated into academia , that's percolated into the way that people train , it's percolated into just the general thought and I don't know .
I think that's one of my benefits honestly on this podcast of which there aren't very many , but that is one is that I can come in with an outside perspective and just say wait , that's a little bit crazy . Like what other profession devalues how much they know so much ?
And here's the other thing I think is just hilarious about this we should train them to do our job . We should train them and work ourselves out of a job . Right , them being patients . Upt's know everything . You've been to school for three years for this . You've been to all the con Ed . You are the worst patients , nicole very much included .
Are you kidding me ? You can't get yourself better , you guys just tough it out for forever until you finally get something bad enough . And then you go see another physical therapist . You don't sit there and say like , well , if anybody was going to be able to work themselves out of a job , it would be the person who's been trained for that job .
And you can't even help yourselves . What do you mean ? Patients should do this by themselves .
Well , and , jesse , I think what you're hitting on too is that what we do as rehab professionals is so much more than just identifying an impairment and treating that impairment . We are also providing for the patient or ourselves as the patient accountability . We're providing education , we're providing context for why something super important we are building habits .
We are breaking bad habits , we're building new ones . We are we're helping people to have a healthier overall lifestyle . I think we would all agree that we got into this rehab field to have our patients come out better than when they walked into our doors , and so that is really juxtaposed with , and we can also do this in a super short period of time .
I think that if you really look at what we're providing to patients and what our unique value proposition is to those patients , we have to have time in order to make those changes , and not only make those changes one time , but make them over a series of weeks , months , and so that the changes are going to stay for years .
One of the things you mentioned in there that I'm always talking about is the difficulty of creating habits , and there's a BS saying floating around out there it takes 21 days to create a habit . In fact , the research shows it's , on average , 66 days . It can range anywhere from 18 to 254 , which is the better part of a year .
And if that's the average and if you think about how many habits does your quote unquote average patient need to break or start in order to have the kind of life that would provide optimal health ? I mean I'm guessing it's more than one . I mean I don't know .
Correct me if I'm wrong , nicole right , but you're not just like hey you know what , you should stop doing that thing .
And they're like , oh great , that's fantastic , I'm done here .
The other thing , too , is this , which is why I'm such a huge proponent of like stop giving your patients so many effing things to do , because it's just all it creates is overwhelm , and then we lose context of why something's super important . That's why I have at my clinic we have a rule . It's like maximum three things .
If you are giving somebody to work on actively at that time , more than three things , you better have a frickin great reason and you better have an exceptional patient . And most of us don't have an exceptional patient . We have a very average patient that is having a really tough time doing life , much less anything that you pile on .
¶ Importance of Time in Patient Treatment
So even something as simple as , oh , just do some breathing exercises . It's like that's not as simple as it sounds to the average person Because , guess what ? You're having to break a habit of their poor breathing pattern .
You're having to give them context to why it's important and how the hell it's related to their urinary urgency frequency which , by the way , most of you I'll skip over and just say just do this thing , it'll help your pelvic floor and you miss the whole point of talking to them about how it's related .
And then you have to get them to do the thing and do it for a period of time so that it makes actually makes a change , and like that overall takes a shit ton of time and I'm so sick of everybody acting like four visits , six visits , eight visits , 12 visits is like an eternity in working with patients .
To me that is like a given , a minimum , a Duh , like of course I'm gonna see somebody for that long . Like are you kidding me ? Look at all these things I have to work on . I don't know what else I can say . Like I feel like I wanna shake you all through the whatever this thing is , this microphone , through your earbuds , whatever .
Like in fact , if you're doing something right now , I want you to friggin' stop , unless you're driving . Stop and friggin' just shake it off for a second and be like whoa , what the hell am I doing ?
Making something happen , trying to make something happen that's super complex , involving a complex system in the pelvic floor , involving a complex or the pedic system in the hips , this SI joint , the low back , the nervous system , in a complex human being , and we're like yep sure , eight visits like that's it , you should be fixed , done , problem solved forever , like
no , that just sounds absolutely ludicrous .
You have to be more than a blip in your patient's life Right cause .
If you think about the time , I want you to think about this time life . I'm into these timelines , okay .
I use these timelines all the time in my clinic either , in helping somebody see , like , their pelvic health history visually on a timeline so they can actually see all of the things that have contributed to potentially this one period of time where something happened quote all of the sudden . But let's think about another timeline here .
I want you to think about a timeline in your head just from starting and an ending time and think about that as like the length of time that somebody's had their problem . Okay . And then I want you to think about if our insertion in that timeline it cannot be just a blip .
We have to take up a lot of that timeline as a percentage in order for us to make change with people's symptoms .
And so if we're talking about four visits , six visits , eight visits on somebody that's had a 10 year problem , that's 10 years of habits , that's 10 years of nervous system changes , fricking brain changes , we have anatomical brain changes of somebody that's been in chronic pain and we're thinking that that's just gonna get better if we give them some breathing exercises
and tell them that like , oh yeah , just relax your pelvic floor . Isn't this nice that the diaphragm works together .
It's like , oh my gosh , that's not enough time to take up a significant portion of like how long they've had symptoms so that we can make meaningful change , we can help them along a path , a journey to better pelvic health and better health in general . We have so much to give to these people that we cannot just be a blip in that timeline .
We have to take up more real estate than that .
In hearing you say that , nicole . One other thing that occurs to me with this is I think sometimes this feeling of having to rush through a plan of care could also be a major contributing factor to some of the whether it's anxiety , whether it is just really wanting to do a good job .
Some of the questions we get in the huddle and we love those questions , keep them coming . But oh , I haven't even seen this person yet , but they seem so complex and what am I gonna do about this ?
It's kind of based in that timeframe where if you kind of reject the idea that you have to get that person better in eight visits , then the pressure's off to some extent , like you still wanna provide the best possible care , you still wanna do the best for your patient , but you can go through some growing pains and some learning with them and guiding them
through something , and there's not the pressure that at visit eight they're gone .
So you better have gotten them better by then , yeah , this is actually a really important topic that Jessica Jermyn and I talk about , which you'll hear in an upcoming podcast .
But talk about our burnout , right , our burnout as practitioners is a lot of times based in this anxiety over oh my gosh , I have all this stuff to do and the patient isn't quote unquote complying and I can't get them to do this .
And they don't seem like they wanna come to their appointments and they're just like they're not ready to make a change , except for , by the way , they called you and they're in your office . So that's as about as ready as you're gonna get some people .
But you know , jessica Jermyn and I talk a lot about the fact that if you can assume this timeframe , if you can assume that you're not the one to have to implement all of this stuff , that you have to help them to come along for the ride , then it takes a lot of the pressure off of us , right ? It would take a ton of .
If I told you all that you had a year to get someone to where they need to be , everybody would be like , oh , for a huge exhale , I bet . But I think that the problem is is we put these artificial limits in some cases and some cases they're hard and fast limits with insurance reimbursement and this person only has 12 visits .
And then you're all worried about like , oh , if they have a shoulder problem also , and then you can't take up all their visits , which is a legitimate thing to be concerned about . But I will also say that , like , is it more important for you to pee poo and have sex than it is for you to reach up into a cupboard ?
I'm thinking that the pelvic floor stuff is pretty important there , but that's what we're talking about here .
It's like we can't , just we have to be seeing people for more time in order for us to be making a bigger , better change with folks , and it can be really like you can take a huge exhale if you realize that you actually have more time than this artificial limit that somebody has put in our heads .
That reminds me of what you say in the essentials . Right Is that you were basically spending the first three to five visits figuring it out .
Yes , that is like the phases of treatment . I don't even know all of the things for the till , the first three to five visits . Did someone ask me how long is it gonna take , how long is this taking ? And I'm like I don't know , Like I do know here all the things that I wanna look at , but I'm not sure yet . I literally just met you I just met you .
Like that to me is like a really it's not a dumb question , because I understand why people are asking it , but it's certainly not something that I'm like it's a silly question . Yeah , it's just silly . It's just like that's so silly that you asked that patient . Oh , you silly patient , like you know , it's just kind of like that .
It's like I'm not actually not sure yet , but here's what I do know , I know that I wanna look at this , this and this , because you've told me ABC , and once we know those things , I can give you a much better depiction . Meanwhile , I will also have known them now for three to five weeks more and I'll be able to tell , like , what their role is .
Are they ready for change ? Are they ? Am I gonna have to do a lot of hand holding ? Is this gonna take a long time ? Is their life such that it's challenging to get to therapy and stuff like that ? Well , that's fine , I'm willing to just friggin' wait . Cool , come in . Anyways , I don't care if you've done your exercises or not .
It also gets me so riled up If people are like take a bit personally , someone hasn't done their exercises . I'm like all right , cool , like that's fine , let's talk about why not and let's talk about how we can . Can we pick one thing then ? Let's try this one thing . Let's try this twice a week .
Let's try this two times between the next time I see you Between now and the next time I see you . Can we do that Like it's just a game that you play with patients . It's not like anything that's written down in stone , it's not like I have to finish in this certain period of time .
And to think that anybody that's dictating that that doesn't know the patient , doesn't know you , is just absolutely asinine .
So the fact that we think that insurance company can say like , yep , that should take this long , or these dumb clinical practice guidelines that are like , oh , this should take approximately 12 weeks and it's like okay , really , because you weren't sitting in front of this person when they were friggin' crying their eyes out for the last four visits of my treatment
session , you still think it's gonna take 12 visits ? I think not . So don't talk to me about these like friggin' guidelines .
And one of the really cool things is about getting to interact with all of these incredible trailblazing leaders in the field for Pelvicon is getting to talk with them and hearing what I would say convergent evolution . It's not like you guys all got together and took the same class on how long should you see patients , but it's the subtext .
When we talk to everybody we've talked to , the subtext has been there of this is taking a long time .
I mean remember one of our first interviews from this series that Erin was with Yenny and she was talking about making sure she was starting tracking people's monthly cycles and seeing two , three , four of those to see what the changes were , and I actually pulled her up and I said well , wait a second .
That means you're assuming that you're seeing somebody for a minimum of three to four months .
Yeah , and she was like yeah , like duh .
And then same thing we were talking with Jake and he said something similar where some of his patients were coming in and it was only after he had had enough time to build trust that they actually started talking to him about oh , I was doing this and anal play and this toy and all the stuff that he never would have gotten out of if they were just pushing
them out of the office . Like you can't rush that trust , you can't rush those aha moments . Michelle Lyons has talked about this with a gift of time . I know you and Jessica Drummond talk about this in your upcoming interview with her .
Jessica Real and I talk about this all the time offline when we're shooting the shit about something else other than Pelvicon . Like it's so ingrained in us that like , oh yeah , that's just so silly to think that anybody would get better at like four visits . And if it happens , it's like wow , that's an anomaly . Whoa , you surely were ready .
And like that problem wasn't as complex as I thought . And then we're almost like let's actually let's have you come in for a little bit more , just to like make sure . Are we sure ? If someone got better in like that amount of time , I'd be like let's just like schedule a few more , just to be sure .
I almost like wouldn't even believe it , right , yeah , so I just feel like I want you all to like hear that , now that you have heard it here , I want you to either go back and listen to those things . I want you to see where it's popping up in your own practice , for better , for worse .
I want you to just see , like all of the comments in the huddle that are producing anxiety because you're assuming that you're only you have to get something done in a certain period of time , or you have to be done in a certain period of time where somebody has to be better in four visits because that's how long you've been seeing them and oh my gosh , it's
all they have scheduled and I'm gonna have to tell them to schedule more . Heaven forbid . It's like , yeah , I'm like telling people to schedule more visits all the time .
It's like , in fact , at my clinic I'm like my line is like I want you to schedule once a week for the foreseeable future and we're just gonna just go from there , we're just gonna start there and then we'll be in contact weekly about if that plan needs to change . But like , get yourself on the schedule , because this shit's real .
You know you're here , we made it and let's go .
So that's the question for you guys in this moment of introspection here Are you rushing people out ? And if so , is that because you've heard some of these soundtracks and they are so ingrained ? It's been fascinating working with so many practice owners , and we're almost up to 500 practice owners .
We've helped on the business side and I feel like every single one has had something an issue with this mindset , and it's because it's so ingrained in the field . So don't feel bad if you're recognizing this . This is the first step is recognizing what .
¶ Length of Therapy and Dependence Examination
Is that voice in my ear saying why can't I get them better ? If I was better as a therapist , they would be out of here by now .
And it could be a person . It could be your boss . It could be somebody talking about productivity , like you need to get more evaluations in . It could be an insurance company denying visits past a certain amount , making you feel like , oh , you have to justify your treatment . I'm like the patient's still fucked , so does that not justify my treatment enough ?
Like come on , the patient wants to come in . I wanna treat them , I wanna treat them .
I have a skill set that can help them like is that not enough ? No , we have to like freaking , tell them that their internal rotation range of motion is- .
Well , is that your goniometer ? I mean , come on no , somebody . I still have never seen one of these , somebody who came in and was asking about this at one of our public sanity interviews recently and I was surreptitiously Googling it while you were talking to them .
I was trying to be all like super nice , I'm like okay , well , we're gonna talk about why we don't really need one of those at this clinic , but yeah , so are you rushing people out ?
Is that consistent with your clinical ethos ? And if you are , then it's the permission that you don't need but might be helpful anyway . To take your time with people Like this is hard . People who are really , really good at this take their time with people Like it's an inverse proportion .
I would actually postulate that the better the therapist , the longer people are coming in in a lot of cases because they're working on second layer , third layer , fourth layer problems . They're getting that trust , that buy-in , they're making lasting change , they're changing habits .
They're doing all of these things that are gonna set somebody up for a different , better life , instead of just trying to get their immediate symptom down enough to the point where you can discharge .
And I would say too that even there's even some prominent people in our field that talk about don't create a dependent patient , and I don't believe that by seeing patients longer that you are creating a dependent patient .
I'm gonna say that one more time Just because you see patients for a longer period of time does not mean that you are creating a dependent patient . Those two things are not what's the word . Every patient that has seen for a long time is not becoming dependent .
You have the ability to control how much dependence the person has on you , and just the length of time is not the only factor in that equation , can ?
I just say I know , nicole , you've been riled up by a couple of the topics here . This one riles me up . That is condescending as fuck to your patients . You guys are not that addictive . Oh my God if I see somebody for 10 , but you guys act like you're heroin .
If I right .
If they try me for 12 visits or more , they're gonna be dependent on me for the rest of your life . What the hell are you talking about ? Like you provide a service . I , as an adult , grown ass man , can decide whether it's worth it to come in or not , and the moment I think it's not worth it to come in , I'm gonna stop coming in . Like I have agency .
You're not the arbiter of my choices . This gets me so fired up . It really is like you guys think that you're crack cocaine over here , right , and then you have to protect everybody from just how you know moth to a flame . It is .
That's true , right .
It's gonna take more than that to give me , like hooked on coming to public floor , physical therapy guys .
So true , that's so true and that's just . I mean , I'm gonna say it even one more time Just because you see someone for a longer period of time does not mean you're creating a dependent patient . I feel like this is like out of the . If I were to sit you guys all down , it's like a scene out of Hunting , where it's like it's not your fault .
It's not your fault . Just because you see somebody for a long period of time Just not mean that you're creating a dependent patient period , end of story , which means that you can see people for as long as that you want .
¶ Examining Constraints in Patient Care
And Now then you can sort of see if you take off those chains of like what do you have to be doing because someone else told you so . Then if you take those off and you're like , what does this person actually need ? What do I , what can I provide ? What skills am I really good at that ?
I can help this person through this thing , and then you really start to see who's trying to get you to stop helping your patient , and that can be the insurance company . That can be your freaking asshole boss .
That can be productivity standards at your clinic that are just really Bass-ackwards about trying to get people out and burn and churn more patients because really , at the end of the day , they're providing a service to the hospital , for instance , that they have to see more Evaluation .
So in order to service that patients without adding more therapists , they have to get you to be seeing patients for less , because you have to get those evals in . Open your eyes , folks . Open your freaking eyes .
Hmm , do you like apples ? Because how about them apples . All right , guys , as you can tell , we get really fired up about this , but , honestly , I think this is such an important topic and we would love to get your guys's thoughts and feedback on this .
So , if you have felt this way , if you felt those negative soundtracks , if that's something that's been playing in your mind or that's been put on you by a boss , or that you feel pressured by insurance company , whatever it is reach out and let us know .
It's a fascinating conversation to have and I think it's something that's really , really important as we grapple with what do we really believe the standard of care should be ? What do we really believe is best for our patients ? So , as always , guys , please reach out , let us know . We want to keep this conversation going and let's continue to rise .