Latest / The Operator | Healthcare Business / Called to Care Spotlight: What if We Got the Prescription Backwards?

Transcript

Called to Care Spotlight: What if We Got the Prescription Backwards? · The Operator | Healthcare Business

0:01
And oh, sorry,
0:02
just behind the scenes of how today is
0:04
going to roll, we will be recording video.
0:07
Luckily, not me or Jimmy.
0:09
This will be y'all,
0:10
but we'll be using some of those video
0:12
segments to be able to chop and change
0:14
some social content.
0:15
So with your permission,
0:16
as long as that's all good, Tim,
0:19
we intend to use those for just promotion
0:20
of the episode.
0:24
Got it.
0:24
Very good.
0:25
So just to confirm that you're in the
0:26
background,
0:27
Larry and I are just going to have
0:28
a conversation and then when we're done,
0:29
we're good.
0:30
Okay.
0:32
We'll be invisible.
0:33
All right.
0:35
The only thing I'll say is in terms
0:36
of production,
0:37
once we're done and I hit stop,
0:39
just hang tight because this will finalize
0:41
the audio.
0:42
We've done this before.
0:42
All right.
0:44
Betsy, anything else?
0:45
There you go.
0:46
Well,
0:47
because this is kind of a non-traditional
0:50
format,
0:51
would you like for us to be a
0:52
little bit more involved with prompting
0:53
some of the questions or you both kind
0:55
of have briefs and just want to let
0:57
it roll from there?
0:58
What would you feel more comfortable with?
1:00
I'm fine just letting it roll,
1:01
but if there's, when it's like, hey,
1:03
we should have asked this, you know,
1:05
grab us at the end,
1:06
then we'll have that conversation,
1:08
and then you can insert it wherever.
1:10
Yeah, we can clean that up.
1:11
And there's also a private chat on the
1:13
right, so if we wanted to do something,
1:14
we can do that, Betsy.
1:15
That's like the producer's, you know,
1:18
earphone thing.
1:20
Okay, wonderful.
1:21
Jimmy and I will buzz away there.
1:23
Let's get teed up just to hop right
1:26
in,
1:26
and if we're all on board with the
1:28
brief,
1:28
we can
1:29
We can basically read from that, Tim,
1:31
if that's what you feel comfortable with.
1:32
All right, Tim,
1:34
just wait till we're out of here.
1:35
And to your show, my man,
1:36
you're in charge.
1:41
Larry, man, great to see you.
1:44
Great to see you.
1:45
How you been?
1:46
I've been great, Tim.
1:47
I understand you've taken up golf.
1:48
What's that all about?
1:49
Well, I mean, everybody I tell that to,
1:52
like, Flynn, you're golfing?
1:54
And it's like, you know,
1:55
you get to that age,
1:56
you're supposed to try something
1:57
incredibly hard because of, you know,
2:00
we'll talk about neurology and whatnot
2:02
throughout the episode.
2:03
It's incredibly freaking hard.
2:05
So, yes, I have taken up golf.
2:06
It sure is.
2:07
It sure is, yeah.
2:09
Indeed.
2:10
Well, thanks for jumping on.
2:11
This is going to be fun, Larry.
2:12
But before we get started,
2:14
I don't get opportunities to take a little
2:17
memory lane journey with you.
2:19
So I would like to, you know...
2:22
Ask, you know,
2:22
it's been about a quarter century and
2:25
what's your memories of how this EIM thing
2:28
started and the evolution?
2:31
What's your origins to our origin story?
2:34
Yeah, you know,
2:35
it has been twenty plus years and,
2:38
you know,
2:38
founding or co-founding it together with
2:41
with John Childs, you know, really,
2:43
I think has had an incredible impact on
2:47
the profession.
2:47
I think it has moved the profession
2:49
forward.
2:50
I mean, people don't remember,
2:51
but we were calling it flipped education
2:53
back then.
2:54
And we were sending narrated PowerPoints
2:56
to folks and say, when you come in,
2:58
we're going to go from two days to
3:00
a day and a half and we're going
3:01
to only do lab and
3:02
You know,
3:03
then the pandemic hit and everybody and
3:05
their mother was calling us to see how
3:07
you do this, because up till then,
3:09
every every academic program said never,
3:11
ever,
3:11
ever over my dead body will I do
3:14
virtual or online education.
3:16
And so I think we had a pretty
3:17
significant impact then.
3:19
But I think from a, you know,
3:20
sort of an incentive standpoint or a
3:22
rationale of why we tried
3:24
to what we tried to do at EIM
3:26
was bring evidence and the evidence,
3:27
not just on the clinical hands-on skills,
3:30
which was largely brought by you and your
3:32
colleagues,
3:33
but also evidence around the soft skills
3:36
and the non-clinical factors of clinical
3:39
success.
3:39
And really a good portion of that is
3:42
what
3:43
what began um call to care and other
3:46
types of things and you and i go
3:48
back to our military days and we certainly
3:50
knew there were other factors than how
3:52
good our hands-on skills were whether or
3:53
not a soldier was going to go back
3:55
to uh to the field so those are
3:57
my best memories we also had a lot
3:59
of good time i remember one of our
4:00
first
4:01
Things we gave out was underwear.
4:02
We had ordered hundreds and hundreds of
4:06
pair of underwear that are still sitting
4:07
in some warehouse somewhere.
4:09
Who knows,
4:10
maybe they went and got shipped overseas
4:11
or something because our message was you
4:14
can teach and learn while you're sitting
4:15
in your underwear.
4:16
That's what I remember.
4:18
I do remember, indeed.
4:20
Well, I got to say,
4:21
I was super excited to hear you're going
4:24
to put out a second edition of Call
4:26
to Care.
4:27
And I mean, my first reaction was,
4:29
that's amazing.
4:30
And it's just,
4:32
I personally feel it's so necessary.
4:36
But what was the impetus and why now?
4:40
you know it's it's interesting because if
4:42
you really think about it you know your
4:44
goals when you write a book are to
4:45
actually try to move the needle and
4:47
unfortunately i don't think the needle
4:49
really moved from the first book so it's
4:51
going to take going to take some more
4:52
effort and it was written at the peak
4:55
of the pandemic you know it came out
4:57
in
4:59
And a lot of things changed.
5:01
And then you had this post pandemic
5:03
hiccups.
5:04
You know, you had shortages,
5:05
mass shortages in PT,
5:07
mass shortages in dental,
5:08
mass shortages in dental hygienists,
5:09
PT assistants.
5:11
You had burnout and you had really the
5:13
impacts of burnout.
5:15
And then the evidence has moved a bit.
5:17
You know,
5:18
there's now different ways that people
5:20
look at empathy that we're looking at it
5:22
then.
5:23
And so the publisher,
5:25
really about a year or so ago,
5:26
came to me and said, you know,
5:27
this needs to be updated.
5:28
I'm sure there's new evidence and there's
5:30
new interventions.
5:31
And so, yes,
5:31
there's a lot of new psychological
5:33
interventions.
5:34
There's one I love called implementation
5:36
intention,
5:37
moral injury and how it causes burnout and
5:39
how we look at burnout differently today
5:41
than we did in two thousand twenty.
5:44
various things about mindfulness as you're
5:46
well aware of.
5:47
And so the idea was to upgrade or
5:50
update its current version,
5:52
but then along the way,
5:53
a lot of other new content.
5:55
So it ended up being about twenty five
5:56
percent larger book with a lot of new
5:58
chapters.
6:00
And then along that way,
6:01
I was working in dental.
6:03
And I'm like, man,
6:03
some of my dental friends are like,
6:04
you need to have this in a dental
6:06
version.
6:06
Well, that's easy.
6:07
I'll just change the vignettes and I'll
6:09
slap dentist and dental hygienist on it.
6:11
And then you'd come to find out,
6:12
my goodness,
6:13
dentistry is massively different.
6:15
You have this hygiene hygienist, you know,
6:18
dentist relationship.
6:19
Dentist only sees a patient for short
6:21
minutes.
6:21
They're in a power position.
6:22
You got an operatory, you got smells,
6:24
you got more nocebo and placebo than I've
6:26
ever seen in any typical healthcare
6:28
environment.
6:29
And so I had to then sit down
6:31
and look at the evidence around dental.
6:32
So I was writing kind of both books
6:34
hand in hand for a while and it
6:36
became a lot of fun and a big
6:37
challenge.
6:38
And, you know,
6:38
thank God that the hard part of all
6:40
that's over,
6:41
but that was one of the reasons.
6:43
It's interesting.
6:43
You bring it up and we'll,
6:44
we'll talk more about, you know,
6:46
what you're doing now, but this,
6:48
this idea, you know,
6:49
I was at my dentist three weeks ago
6:51
and, you know,
6:52
we'd moved down South from up North and
6:55
in Fort Collins,
6:55
we're down more Southwest of Denver,
6:57
but it's,
6:58
Anyway, I just really love this practice.
7:01
And Sue goes as well.
7:04
And we really dig this practice.
7:07
Everybody's so positive from the moment we
7:09
walk in the door.
7:10
And it brings me to what you were
7:14
so far ahead of the game back in
7:17
front office aspects of healthcare.
7:22
And what you know,
7:24
I assume in the second edition,
7:26
you still like dial up the importance of
7:29
the environment.
7:31
A hundred percent.
7:32
It's more important now than it's ever
7:34
been.
7:35
You know,
7:35
if you think about where we're at today,
7:39
we're just several years ago,
7:40
we didn't have internet.
7:41
We didn't have text messaging.
7:42
We didn't have social media.
7:44
We didn't have all these noise and
7:45
distractions.
7:47
And so what that's done is it's sensitized
7:49
people to experience.
7:51
And so you better have an environment
7:53
where you're leaving an indelible effect
7:55
on their impression,
7:56
their first impression,
7:57
their ongoing impression.
7:59
You know, Jim Nesbitt said many years ago,
8:01
when you have high tech,
8:02
you need high touch.
8:03
Boy,
8:04
can anything be more high touch now
8:06
because of the advent of virtual and
8:07
telehealth?
8:08
But then AI came into the picture and
8:11
everybody sees that as a solution.
8:12
I go back on you and I are
8:14
a little bit older now.
8:15
We remember when the Internet was going to
8:16
change health care.
8:17
And before that,
8:17
we when the Clinton administration was
8:20
going to change health care.
8:21
And before that,
8:21
HMOs were going to change health care.
8:23
So these are, you know,
8:24
different different bottles of wine,
8:26
same wine, different products.
8:28
different cover on it.
8:30
And it's absolutely more experiential now
8:33
than ever.
8:34
And healthcare has become a little bit
8:37
more transactional.
8:38
People do searches now.
8:40
People run scenarios on their AI.
8:42
They come in with the answers.
8:44
They use bots to schedule for them.
8:48
And so that really changes the way you
8:51
have to think about it.
8:52
At the same time,
8:54
providers are trying to cut their costs.
8:56
And so you do that through technology,
8:58
right?
8:58
And so as they're cutting their costs,
9:00
what is left in the experience side of
9:02
things and matching them up is to be
9:04
the most effective is the long-term.
9:06
But the great news is your number one
9:10
indicator of your future patients are
9:11
still your current patients.
9:13
and their friends, family,
9:14
and former patients.
9:15
And so that relationship side of it is
9:18
never more important in an environment
9:20
where the transaction side,
9:21
particularly in dentistry, by the way,
9:23
but healthcare going that way as well.
9:25
And I hate that,
9:26
but the reality is those providers who set
9:29
themselves up by relationship-oriented
9:31
practices,
9:32
not just the experience of the
9:34
environment,
9:35
but the experience of the care are going
9:37
to be the winners long-term.
9:40
Indeed.
9:41
Well, you know,
9:42
I'd like to pivot a little bit because
9:45
this book from, you know, looking through,
9:47
and by the way, it's been,
9:48
it's just a pleasure to read.
9:52
But it distinguishes moral injury from
9:55
burnout for the first time, I think.
9:57
And why does that distinction matter?
10:00
And why does it really matter now?
10:03
Yeah.
10:04
So if you think about it burnout is
10:07
sort of curdled into moral injury.
10:10
And the interesting thing about, you know,
10:12
the evidence is that the evidence around
10:16
moral injury and I'll,
10:17
I'll do a little deeper,
10:19
you know dive on that in a second,
10:23
but that really didn't start to,
10:24
it kind of was another one of these
10:26
things that kind of came out of COVID
10:27
a little bit.
10:27
You started reading about moral injury,
10:29
maybe in the late nineties,
10:31
and it became more and you know the
10:33
term really came out of uh wendy dean
10:36
brought this incredible book that i really
10:38
highly recommend this to folks we'll put
10:40
it in the show notes um then she
10:42
started dealing with this i think in
10:43
around but the idea behind all this is
10:46
it's you carry this wound from knowing you
10:50
know what you want to do for the
10:52
patient but the system
10:55
because of its constraints doesn't allow
10:57
you to do what you want to do.
10:59
It's sort of around control.
11:01
And so the, so it comes with,
11:02
you know,
11:03
the reframe is because it moves the
11:05
responsibility off of the clinician
11:07
shoulders and onto a system where it
11:09
frankly belongs.
11:11
You can't yoga your way out of this.
11:13
And so it helps us understand burnout
11:15
because burnout has always been an
11:17
internal thing.
11:18
Oh, you're working too hard.
11:19
You're not taking enough mindfulness
11:20
breaths.
11:21
You came into the clinic being burned out.
11:23
The system depersonalized you to where,
11:26
honestly, the impetus and the blame,
11:29
if you will, ought to be,
11:30
which is external to you.
11:32
Now, the reality is to calm burnout,
11:34
you have to deal with both.
11:36
But you're going to continue to see and
11:38
hear more about this connection and the
11:40
trigger.
11:42
And just remember,
11:42
burnout blames the clinician,
11:45
moral injury blames the system.
11:47
And the reality is you have to deal
11:49
with both if you're going to kind of
11:50
want to weave in and out of a
11:53
broken system, frankly.
11:55
Well, following up on that, you know,
11:57
the new research you present in this
11:59
edition,
12:01
it suggests empathy protects providers
12:05
from burnout rather than draining them.
12:08
And you talk about the, quote,
12:11
exquisite empathy finding.
12:13
Does that surprise you?
12:15
You know, honestly, it did,
12:17
because for a while, as you recall,
12:19
we had a lot of teachings around empathy.
12:22
And I'm real proud to say the
12:24
multidimensional construct.
12:25
I really was on a soapbox around this
12:27
for a long,
12:28
long period of time and love it and
12:30
still believe in it.
12:32
But there then became a little bit of
12:34
evidence,
12:34
but really more academia coming out and
12:36
saying, well,
12:37
it's those who are overly empathetic that
12:39
are burning out and they're pointing to
12:42
proxy and correlations rather than
12:44
causality.
12:45
Well, as it turns out,
12:48
because I was somewhat of got a little
12:49
bit absorbed in that opposite story and so
12:52
did healthcare.
12:53
And so we were taught compassion fatigue,
12:55
that empathy is a
12:57
you know,
12:57
kind of a finite tank rather than a
12:59
muscle.
13:00
And that the more you feel with patients,
13:01
the faster you'll burn out.
13:02
So you protect yourself by detachment,
13:04
right?
13:05
Remember when we were all trying to detach
13:06
from our patients.
13:07
And that, as it turns out,
13:08
is a joke.
13:09
And then, you know,
13:10
some researchers by the name of Harrison,
13:12
and I think Westwood flipped it entirely,
13:15
and they studied this thing.
13:17
extensively,
13:17
particularly about clinicians,
13:19
the ones that were, you know,
13:21
sort of the most emotionally,
13:23
in the most emotionally demanding work,
13:25
you know, which is oftentimes, you know,
13:28
mental health.
13:29
And they found out that they didn't burn
13:30
out.
13:30
And what they found wasn't distance.
13:32
It was a particularly kind of engagement.
13:35
And they were the ones who really turned
13:36
this idea of exquisite empathy, which is,
13:39
you
13:39
Being highly present, deeply attuned,
13:42
that's the key word, and well-boundaried.
13:44
In other words,
13:45
you're not carrying this with you from
13:47
patient to patient or from patient to your
13:49
golf game.
13:50
You deal with it as a patient
13:52
individually.
13:53
The clinicians don't just survive that
13:57
empathy, it invigorates them.
13:59
The surprise is that we had the
14:00
prescription backwards.
14:01
You know,
14:02
we told a bunch of clinicians for a
14:03
long time that caring less would save them
14:05
and detachment would help them.
14:06
Well,
14:06
the evidence says that the right kind of
14:08
caring is the protection.
14:10
In fact,
14:10
that's a substantive part of this book is
14:12
kind of a return to teaching practitioners
14:15
about empathy,
14:16
because what we know that really is a
14:18
muscle that you develop skills over time
14:21
and that the correlation between medical
14:23
school, physical therapy school,
14:24
and by the time you get into practice,
14:26
you've actually downgraded your empathy.
14:28
Now what we do is have to teach
14:30
and really impute and really encourage and
14:34
empathize the opposite.
14:36
Boy,
14:36
you said there's like five pearls you
14:39
dropped there.
14:40
This one,
14:40
the three key elements that you ended with
14:43
that boundary around,
14:46
could you just reiterate just a little bit
14:48
more on that?
14:49
Yeah,
14:49
so when I think of exquisite empathy,
14:51
I do think of it in terms of
14:53
three different things.
14:54
The first one is you're highly present.
14:57
Well,
14:57
that alone is a game changer because as
15:00
you well know,
15:00
our younger generation of therapists and
15:02
doctors
15:04
Their minds are scattered.
15:05
They have this,
15:06
I call it the anxiety brain,
15:08
where they're worried about what the
15:09
insurance will cover.
15:10
They're worried about productivity.
15:11
They're worried about their text message
15:13
that they just got from a friend on
15:15
what social thing is happening.
15:16
They're worried about a like on social
15:18
media.
15:18
So the whole idea of being present is
15:21
its own teaching point.
15:24
And it's important.
15:25
That's why a room is still really
15:27
important to the patient element, right?
15:30
The second thing is deeply attuned,
15:31
which is really the idea behind empathetic
15:34
listening and understanding and listening
15:36
at a level where you're able to pare
15:38
it back and reframe and you base it
15:40
on your other experiences.
15:42
And it is the softer side of the
15:44
interpretive,
15:44
but it also takes skills and reasoning
15:49
That's the deeply in tune part.
15:50
And then the third one,
15:51
which is the one you asked me about,
15:53
is well boundary,
15:54
meaning you're not going to carry that
15:57
episode of your empathy with that patient
16:00
to either the next patient or at home
16:03
or to your golf game.
16:04
You're going to you're going to understand
16:06
it.
16:06
And that's when you detach.
16:08
So the detachment prescription wasn't.
16:11
entirely wrong it just was overemphasized
16:15
as you should stay detached from the
16:17
patient and not let any of that and
16:19
be teflon coated as it turns out it's
16:22
those three elements of it that really
16:24
make for a stronger patient interaction at
16:26
every level i mean some of the research
16:28
even shows its influence on the clinical
16:30
outcome which is uh which as you know
16:32
is is something that we've we've been
16:34
emphasizing through our evidence-based
16:36
approach for years
16:38
Boy, you know, as you're talking,
16:40
literally,
16:40
you've taken me back to a nineteen eighty
16:43
three, eighty four,
16:43
eighty five at Brook Army Medical Center.
16:46
And the tremendous I mean,
16:48
there was tremendous physical therapists
16:51
there at the time for mentorship.
16:53
And you look back and yet there are
16:56
some, you know, were excellent,
16:58
but they were in certain elements and they
17:00
started to detach.
17:02
And, you know, I
17:03
And I saw it,
17:04
and they would be getting burned out by
17:07
the end of the day.
17:08
And again,
17:09
part of it was because this part of
17:12
the clinic,
17:12
you couldn't really have a private
17:14
conversation with someone.
17:16
You couldn't be there,
17:18
so the presence was difficult.
17:20
But boy.
17:21
You know, it's these themes, you know,
17:23
you look back now through a career of
17:25
you've seen elements of them in the great
17:28
practitioners and the ones that have
17:30
struggled that were great and then quote
17:32
unquote went that pathway.
17:33
But boy, you know,
17:35
that's that's that's excellent.
17:37
Well,
17:38
I'd like to shift gears a little bit,
17:39
Larry,
17:40
and talk about one of the fun things
17:42
that I was honored to do with you.
17:44
We had an article on placebo nocebo back
17:49
in JOSPT a number of years back.
17:51
And I feel like it got the conversation
17:55
moving in a positive way.
17:58
What are your recollections and what kind
18:00
of got you to, hey, Tim,
18:01
what do you think of this?
18:03
Yeah, I think, you know, interesting,
18:06
you know,
18:06
one of the one of the more best
18:08
clinical advice I ever give to somebody is
18:10
your language words that harm worms that
18:12
heal.
18:13
And that's all about the nocebo and the
18:14
placebo.
18:15
And the one thing that I loved working
18:16
with you on is the depth that we
18:18
went into.
18:20
I remember even being at Menopalooza and
18:22
asking the question,
18:23
how many people are trying to influence
18:25
placebo and mitigate nocebo?
18:26
And a lot of people were like, no,
18:28
we don't ever want a placebo effect in
18:29
your patient.
18:30
Well, that's absolutely untrue.
18:31
You a hundred percent, you do.
18:33
And, you know,
18:33
so that was one thing is that placebo
18:36
isn't bad and nocebo or isn't good and
18:38
vice versa, right?
18:39
That they're not twin evils of one
18:41
another, that they, they both are present.
18:43
We have to deal with them.
18:44
The second is that it's a real measurable
18:47
psychological response, right?
18:48
The whole, I think it's called Nlexone,
18:52
which is an opiate block that can
18:55
absolutely reverse the placebo pain.
18:57
That was found in the seventies, I think.
19:00
And so your body does release its own
19:02
opioids.
19:02
You can't block something that isn't
19:04
chemically real.
19:06
And then I would say the other part
19:08
of that physiological thing is seeing the
19:09
centers light up on PET and functional MRI
19:13
imaging.
19:14
you know, when you say something like,
19:16
you know, this might hurt, what shows up?
19:18
You know, think of it,
19:19
think of me now, Tim,
19:20
I work in dental where how many times
19:21
a day do I walk into an operatory
19:23
and I hear a dentist, oh,
19:23
it's going to hurt a little.
19:24
Oh my goodness.
19:25
You know?
19:26
So even the nocebo placebo effect in
19:27
dentistry is more real than it is in
19:29
healthcare, I think.
19:30
And so I think that, that,
19:32
You know,
19:33
that was what I remember best about what
19:36
you and I did.
19:36
And things have evolved a little bit,
19:39
you know, is,
19:40
and I would say the mechanism from a
19:42
research standpoint, just like, you know,
19:45
just like you've seen,
19:46
the evidence has actually gotten better.
19:48
We used to think that placebo required
19:50
deception, you know,
19:51
open label placebo research shows that it
19:53
works even when the patients know.
19:56
Like I do this times when I lecture,
19:58
I say something, I'm saying,
19:59
I'm going to use a placebo effect on
20:01
you.
20:01
The placebo effect is at the end of
20:03
this lecture,
20:04
you're going to have a five question test.
20:08
We know the placebo impact will be,
20:10
they'll pay more attention and they'll
20:12
remember more.
20:13
Use it to your positive effect and you
20:15
can still use it.
20:15
So I think, you know,
20:17
since we published that article,
20:19
all the evidence has done nothing but
20:21
support our contention and our premise.
20:26
And on the bigger issue of that,
20:28
it is amazing how, I guess,
20:32
for the word I'm probably searching for,
20:34
more paternalistic nature of why nobody
20:39
raised their hands because, well,
20:40
then it wasn't me that had the effect
20:43
or my hands or something.
20:44
It's kind of crazy that we felt we
20:47
shouldn't, you know,
20:49
use effects that we didn't fully
20:51
understand for the betterment of the
20:53
person in front of us.
20:54
Right.
20:54
Again,
20:55
it's kind of that I fix you mindset,
20:57
if you will.
20:58
It's kind of part of, I think,
20:59
why people saw that as a negative,
21:02
you know, where, no, we don't,
21:03
we walk with, we don't fix.
21:05
Yeah, it's even worse, Tim,
21:07
because now even the researchers,
21:09
even the academics,
21:10
they've shifted a bit and they like to
21:12
call it the meaning response now.
21:13
Yeah.
21:14
You know,
21:14
the body responding to the meaning of
21:16
care.
21:17
I actually prefer to use placebo and
21:18
nocebo because I think it incites pay
21:21
attention.
21:22
This is important on how you talk to
21:23
patients and and it shifts it a bit.
21:25
You know,
21:26
meaning has the word meaning has multiple
21:29
constructs as well.
21:30
So, yeah,
21:30
that's that's what's that's what's evolved
21:33
since we published that article.
21:35
Yeah, that's great.
21:36
I like that concept, too,
21:37
because I do think on the nocebo side,
21:40
it gets people to wake up while you're
21:41
harming.
21:42
Your outcomes are going to be worse,
21:44
you know, so, you know, pay attention.
21:46
So, well, very good.
21:47
Well, you know, I think the...
21:51
I'd like to move back to a little
21:54
bigger picture here now.
21:55
And, you know, I've been fortunate.
21:57
I've watched your career for decades and
21:59
been, you know,
22:01
part of it literally since the beginning
22:03
of, I think,
22:04
wrestling on the floor of our house in
22:07
San Antonio when you're in grad school.
22:08
I think we're watching.
22:10
Nineteen eighty five.
22:11
Nineteen eighty five.
22:12
Yeah, that's right.
22:13
Yeah,
22:13
I've known you longer than I've known
22:15
anybody in my life, Tim, I think.
22:16
Yeah, that's crazy, man.
22:19
It is really wild.
22:20
And I just always have felt you're always
22:23
ahead of the game.
22:24
And I mean,
22:25
vision's thrown around way too much when
22:28
it's not –
22:29
appropriate um you truly have been a
22:32
visionary you've always been ahead and saw
22:35
around the corners and i've clearly as you
22:38
know pushed back and thought and and and
22:40
we would argue passionately like i thought
22:43
you were wrong i'd always like damn right
22:46
on this one you know and uh you
22:48
know and that's what i love the the
22:50
ability for you to always see down the
22:51
line but
22:53
What would you say is kind of the
22:54
through line from your,
22:56
really your back from your military days
22:59
to your moving into electrodiagnostics and
23:02
into, you know,
23:03
building incredible private practices
23:05
across the country,
23:07
into evidence in motion,
23:08
into more large operational confluent
23:11
health lines,
23:11
and now really in Dental Care Alliance
23:14
team,
23:14
moving into different sectors of
23:17
healthcare.
23:18
And what do you really see as kind
23:19
of the through line through that
23:21
trajectory?
23:22
You know, it's interesting.
23:23
I've tried to go back and see,
23:26
you know,
23:27
what is the underlying commonalities to
23:30
all them?
23:30
And I would say it divides itself into
23:32
a couple of different things.
23:34
I go through with my team now,
23:36
my executive team,
23:38
really drilling down on their why
23:40
and also our company's why.
23:42
And it's very different in our current
23:44
company than it was in Confluent.
23:45
Confluent was different than EIM,
23:46
all had some commonalities to it.
23:48
And so my why has always been trying
23:50
to find a better way through simplifying
23:53
the process and building trust in the
23:55
people you work with through partnerships.
23:57
And so that's been a commonality.
23:59
And I think every one of these companies
24:01
had the same bet.
24:02
If you take care of people,
24:04
who take care of patients,
24:06
everything else compounds.
24:07
And in the military,
24:08
we learned that when we went through
24:10
Officer Basic.
24:11
You take care of your soldiers who take
24:13
care of everything else,
24:15
and things compound.
24:17
And so I think that's been really,
24:19
really interesting.
24:21
You know, I will tell you honestly,
24:23
I started my career in the military.
24:25
I obviously had no ownership of the
24:26
military.
24:27
I will likely, maybe not, who knows,
24:29
end my career as a CEO of Dental
24:32
Care Alliance,
24:33
a company that I didn't own, didn't start.
24:36
and you want to see and during those
24:38
intervening years did the playbook that
24:41
you developed with your team through
24:43
collaboration and through fierce argument
24:46
and settling it and then instituting it
24:49
like a benevolent dictator in some cases
24:51
does that playbook transfer does it work
24:55
and the playbook transfer issues are
24:58
culture caring loving your team having a
25:02
vision
25:03
You know, working with people,
25:06
finding out what drives them,
25:08
all of those things really do make a
25:09
difference.
25:10
And, you know,
25:11
people who are successful in business,
25:13
they will themselves into success,
25:16
but they also do it through three or
25:18
four or five common underlying principles.
25:21
And that's what it's been for me,
25:23
you know, finding that better way.
25:25
through simplification and building trust
25:27
and caring in the process and then
25:29
figuring out you know along that way what
25:31
makes people tick and you know we were
25:34
fortunate at confluent i think tim what we
25:36
had seventy eighty physical therapists
25:38
that you know joined our company and you
25:40
know uh really found uh not only success
25:44
in terms of their their clinical and
25:46
professional but also material success and
25:48
their wealth
25:49
And that's something I'm incredibly proud
25:51
of.
25:51
But I'm also proud of, you know,
25:53
seeing I just had like thirty some
25:55
dentists in the last four months through a
25:57
strategy we put together called Pathway to
26:00
Partnership own a piece of their clinic.
26:03
And so when they're doing everything from
26:04
a restoration to a cleaning to a
26:07
consultation, you know,
26:08
I've just found that those who own a
26:11
piece of the rock manage
26:13
best and the managed best managers,
26:15
the ones who manage least.
26:16
And so that's been a commonality too.
26:18
And that's a long winded answer,
26:19
but I had to give that some thought
26:21
and some ideas triggered along the way.
26:23
No, that is excellent.
26:26
And as you alluded to this, is there,
26:32
when it comes to effective clinical
26:34
leadership in these various sectors,
26:37
now you've moved from a physical therapy
26:39
world into a dental world,
26:41
do you see the same commonalities there in
26:44
terms of effective clinical leadership
26:46
across industries?
26:48
Yeah,
26:49
I talk about this actually quite a bit.
26:52
And I have a chapter in the book
26:53
called High Quality Connections,
26:55
which is the literature basis in Shelley
26:58
Gable's work and Marty Seligman's work and
27:01
Angela Duckworth's work and all these
27:03
luminaries.
27:04
But the idea is really pretty simple.
27:06
And that is that the first sixty to
27:07
ninety seconds are a clinical
27:10
intervention, not small talk.
27:12
And, you know,
27:12
like I like to say to the dentist
27:14
is connection is dosage.
27:16
And your desire is to give as much
27:18
dose in connection as you can.
27:22
And it really resonates with them because
27:26
now I see the dentist in between patients
27:28
doing five mindfulness breath.
27:29
I see them coming back and understanding
27:32
that connection is therapy,
27:34
is the intervention.
27:35
It isn't just their intraoral skills,
27:38
it's their oratory skills.
27:40
And I would say the same thing to
27:41
physical therapists or to doctors.
27:43
We overemphasize hands-on clinical skills
27:46
to the detriment of non-clinical skills.
27:49
And that's really hard for somebody who's
27:51
in, you know,
27:51
you and I are kind of have a
27:53
left brain academic approach,
27:54
research approach.
27:55
But the reality is the soft skills are
27:57
every bit as important.
27:59
And I've always wondered,
28:02
and you triggered me, Larry, sorry,
28:05
that when we use terms such as soft
28:07
skills, those are freaking hard skills.
28:10
Where did that word ever come, right?
28:12
This idea of those skills were, to me,
28:15
they sound secondary, right?
28:17
When in fact,
28:18
as your work shows that actually these are
28:20
the primary skills first,
28:22
and then we can teach you technical
28:24
skills.
28:25
And you said that way back when,
28:27
I mean,
28:27
this is over two decades ago where I
28:29
was really, you know,
28:31
I still consider science an expert manual
28:34
therapist and believe passionately about
28:36
the laying on of hands.
28:37
But, you know, it's like, well, hey,
28:40
if you have a good skill set of
28:43
communication,
28:45
those hand skills are a lot less
28:47
important.
28:47
Yeah, no, it's fascinating, Tim.
28:50
Actually,
28:50
that's the area where I think healthcare
28:52
has gotten a lot worse.
28:53
Because what I see practitioners do and
28:55
physicians do and therapists do is they've
28:58
moved the treatment intervention.
29:00
They've outsourced it.
29:01
Dentists do it as a matter of routine.
29:03
And what I mean by that is the
29:05
whole time they're thinking,
29:05
does insurance cover this?
29:07
What is going to happen if I say
29:09
to the patient?
29:10
So what I've seen surgeons do and others
29:12
do is they'll say,
29:13
we want to do this shoulder surgery.
29:15
I'm going to bring somebody in here who's
29:17
going to walk you through what the
29:19
insurance cover, what they won't cover.
29:21
And they're effectively outsourcing the
29:23
entire conversation to a non-clinician.
29:25
And I see this so routinely,
29:27
and I just,
29:27
if that ever happens to me, I'm running,
29:29
man.
29:29
I'm not just walking.
29:31
I am running.
29:32
You know,
29:32
I want the orthopedic surgeon or the brain
29:35
surgeon to explain absolutely what needs
29:39
to be done and why,
29:40
irregardless of what the insurance covers,
29:42
irregardless of that.
29:43
And that's what's this revenue anxiety,
29:45
Jimmy McCain, I talk about sometimes.
29:48
It's that voice in the head that's going
29:49
on there.
29:50
And I hopefully...
29:51
AI agents and other things have an ability
29:53
to mitigate this a bit.
29:55
But that's where I see healthcare gotten
29:57
worse.
29:58
It's again, this moral injury effect.
30:00
We've effectively given it up.
30:05
And poor Medicare patients,
30:06
they have it the worst.
30:08
Offices are now built on what Medicare
30:10
will accept and what they won't accept,
30:11
and they're not built around talking to
30:13
the patient.
30:14
Our elderly are getting,
30:15
and as I'm approaching the elderly,
30:17
we're getting the worst, you know,
30:19
I'm not Medicare yet,
30:20
but we will be getting the worst of
30:22
the treatment and the worst of the
30:24
coverage because everything has been
30:26
administratively outsourced.
30:28
The conversation there is no longer part
30:30
of the treatment.
30:33
You look about how we went.
30:35
I mean, again, well,
30:37
let's step back to the EMR revolution,
30:39
right?
30:39
When it was first going to change our
30:41
life,
30:41
where we went for literally the note cords
30:44
at the troop medical clinic was like,
30:45
you know, like, you know,
30:47
literally ten words.
30:48
But man, you knew who you saw this,
30:50
what their problem was,
30:50
and you'd see them throughout, you know,
30:52
to this, you know,
30:53
spend and the amount of time you could
30:55
spend and the amount of people you could
30:57
see because you were spending your time
31:00
doing what you were trained to do.
31:02
And not trying to, and boy, what a,
31:05
what a crazy way we've, we've become.
31:08
So, well, as you know, as,
31:10
as we come to a wrap here,
31:12
is there anything that you'd like to, to,
31:15
to mention Larry that we haven't,
31:17
we haven't covered here or any closing
31:19
thoughts?
31:20
No, I don't think so.
31:21
I think, you know,
31:22
one of the things that we hope to
31:23
cover in, you know,
31:25
some podcasts and special guests,
31:27
we did this last time, the book,
31:29
but now we've got some topics that I
31:30
think will move some really cool,
31:32
you know, conversation.
31:33
We've already talked about burnout and
31:35
sort of moral injury,
31:36
but AI and connection.
31:37
I think is a big one.
31:40
What does it mean across it?
31:42
I'm currently running a series on
31:43
Substack,
31:44
and you helped with some of this writing
31:45
as well, Tim,
31:46
about AI agents and their ability to
31:48
mitigate these voices in the head and
31:50
other kind of things that might have a
31:51
chance.
31:52
The placebo and nocebo obviously has a
31:55
highlight there.
31:56
Can't ever leave out the peak end rule.
31:58
That's just such a, you know,
32:00
a good starter for those high quality
32:02
connections and things that go with it.
32:04
I also like this, you know,
32:05
some of my favorite chapters,
32:06
ironically enough,
32:07
around goal setting and how using
32:09
implementation intentions and other kind
32:11
of newer age research backed interventions
32:15
are really, really helpful.
32:16
So it's going to be a lot of
32:18
fun.
32:18
that sounds great that sounds great well
32:21
as we close with that you spoke briefly
32:25
about this dental edition uh can you like
32:27
throw anything little uh hints out there
32:30
and how that will be i'm fascinated by
32:33
how the market might take it up on
32:35
the dental side yeah i've been having the
32:37
book reviewed by lots of dentists and lots
32:39
of hygienists right now it has been
32:40
approved for for publication it's in that
32:42
stage
32:43
you know,
32:44
the painstaking proofreading stage.
32:46
And it'll be same, you know,
32:47
out the later this year,
32:48
same framework rebuilt for dentists,
32:51
dentistry realities,
32:52
which are a lot different.
32:53
Like I said, the relationship,
32:56
the hygienist spends a lot more time with
32:58
the patient than the dentist.
32:59
So there's a lot of choreography there,
33:00
the operatory and the meaning effect,
33:02
placebo, nocebo.
33:04
You know, in some cases,
33:05
thirty to seventy percent of the patients
33:07
come in with anxiety to see the dentist
33:09
and a lot of shame,
33:10
a lot of guilt.
33:11
And then the dentist puts them in a
33:12
position where they're laid back like
33:14
this, Tim, and they're standing over them.
33:15
And it's this power position.
33:17
And by the way, the patient can't talk.
33:18
Yeah.
33:19
And then you have DSOs is kind of
33:22
the private equity back to how to call
33:24
two hundred plus.
33:25
And there's a corporate practice of
33:26
medicine issues and things around it.
33:28
And so, yeah.
33:30
Yeah,
33:31
I think the principles are somewhat
33:32
universal,
33:33
but operatories are a different
33:34
environment.
33:35
And so I've had an enormous amount of
33:36
fun.
33:37
And I did differently this time as I
33:38
took two or three characters in clinical
33:41
vignettes.
33:42
And I kept them the same characters
33:44
throughout the book.
33:46
as we do the interventions.
33:47
And so I've made the assumption that
33:51
physical therapists are maybe a little
33:52
smarter and don't need it and dentists do,
33:54
but no, I'm just kidding.
33:54
My dental friends, we go back and forth,
33:57
but at the end of the day,
33:58
physical therapists and dentists are twin
34:00
sisters of different mothers of the same
34:04
mother for twins.
34:04
And so there's a lot of common,
34:06
they're doing the profession for the right
34:07
reason.
34:08
That's why I'm really,
34:09
really wanting to spend a lot more time
34:11
on convincing payers and others on the
34:13
damaging effects.
34:14
There's the intended consequences and the
34:16
unintended consequences of what they're
34:18
doing to health care.
34:20
And I will spend my waning days,
34:23
even after I'm done being in leading
34:25
companies,
34:26
spending time on the bully pulpit,
34:28
really going after that.
34:29
That's my mission in life, I think.
34:31
Well,
34:32
it gets me excited as you talk about
34:34
this because, as you know, I mean,
34:35
the oral hygiene and health,
34:37
cardiac health, brain health, I mean,
34:41
it's huge, right?
34:43
But also, I'm wondering,
34:46
are there many studies like just what you
34:49
threw out there saying,
34:50
This may hurt a little.
34:51
I mean,
34:52
have they gone through like RCTs
34:54
comparing?
34:55
This may hurt a little bit.
34:56
Oh, I'm going to do this, you know.
34:58
Are there some studies?
34:59
Oh, yeah, there are definitely some.
35:00
Well,
35:00
there's definitely some placebo research
35:02
on that.
35:02
But the last thing you mentioned,
35:04
I spoke at the largest dental conference
35:06
in the U.S.
35:07
just last weekend in Denver.
35:08
And one of my take-home points was the
35:10
biggest opportunity in dentistry is the
35:13
oral health combination.
35:15
The fact that every patient doesn't come
35:17
in and get a saliva test to tells
35:19
them how many cleanings they need a year.
35:21
What are some underlying diagnosis that
35:23
needs to be dealt with?
35:24
You know,
35:24
generally patients only need dentistry
35:26
when they're young, when they're old,
35:27
and when they're old,
35:27
you have a lot of comorbidities and such.
35:29
And all the areas around cardiac disease
35:32
and everything else stems from a lot of
35:34
oral health issues and just the ability to
35:37
diagnose things alone and to really be
35:39
more prescriptive about it through a
35:41
twenty cent saliva test.
35:43
And there are some DSOs and others that
35:44
are routinely doing this.
35:46
The technology is also amazing.
35:48
The AI underwriting of imaging
35:51
I could take five pictures of your mouth
35:53
with the iPhone, Tim,
35:54
throw it to an incredible scanner.
35:56
You and I have worked in a world
35:58
of healthcare where it's been
35:59
over-diagnosed and over-medicalized and
36:02
way over-treated.
36:02
Dentistry is the opposite.
36:04
It's the most under-diagnosed and
36:05
under-appreciated from an oral health
36:07
perspective.
36:08
I used to think it was a prevention,
36:10
you know, profession.
36:11
I no longer think that.
36:12
I think it's a profession that is
36:13
preventing conversations with their
36:14
patients.
36:15
You know,
36:15
let's wait on that tooth and see what
36:17
happens.
36:17
That's not prevention.
36:18
That's elimination of a conversation.
36:20
And so I have found a lot of
36:22
things in dentistry you get real
36:23
passionate about,
36:24
but so much of it relates to the
36:26
world we've lived in for the last forty
36:27
years.
36:28
Outstanding.
36:30
Outstanding.
36:30
I look forward to reading that one as
36:32
well because you, like me,
36:33
I'm just interested.
36:34
I spend my time.
36:35
I'm interested in making health care
36:38
better.
36:39
Well, we're sick care.
36:40
We're in the actual health care world.
36:42
And there's so much opportunity with small
36:46
nudges to make a difference.
36:48
And you have a big nudge with this
36:49
book and it coming out.
36:52
And like I say,
36:53
it's just been a pleasure to speak with
36:55
you today and really look forward to
36:57
getting the bound cover and seeing that in
37:00
print.
37:01
Yeah, well, Tim, thanks.
37:02
And I can't wait to get you on
37:03
a golf course and find out how many
37:04
strokes that you want me to give you.
37:06
That's going to be the conversation.
37:07
It'll still be a lot.
37:08
All right.
37:08
Take care.
37:12
Awesome.
37:13
All right, buddy.
37:13
Thanks, Al.
37:14
We'll talk to you soon.
37:15
Leave that tab open, Tim,
37:16
because Jim's got this whole thing on
37:18
there.
37:22
How'd we do, Betsy?
37:23
You're the judge.
37:25
Well, you're doing great.
37:26
Jimmy and I are in a