Ben Lynch: G'day, good people. Welcome to the Grow Your Clinic podcast by Clinic Mastery. Here's what's coming up inside of this episode. This episode will be right up your Allie if you're looking to fill your books with appointments. We're diving into the patient visit average. And trust me, you want to hear Mic's take on a three-part framework that helps practitioners get great outcomes with clients, even if they're a new graduate. Plus, stick around for when we discuss how to avoid under-servicing your clients.

Mic Rizk: Practitioners, I would say 9 out of 10 will get turned off if you use the term PBA.

Ben Lynch: Business is a spiritual game, I think. Often you're doing these things that are boring, that are repetitive, and I think you need to find joy in those small mundane things, right?

Mic Rizk: We created the Private Practice Apprenticeship, which is covering a lot of common papers to help give young physios the confidence that it actually is normal in physio to see people for 6 to 12 weeks. I'm running my first half marathon. These are the whys, start with why. That's a big thing we're noticing is we're not mentioning the why in every session, and then patients drop off after two or three visits when the pain reduces.

Ben Lynch: So they're feeling a little bit better, and so the patient goes, oh, I don't need to come back. Before we dive in, today's episode is brought to you by AllieClinics.com. If you're the kind of clinic owner who loves to feel organized and stay ahead of the chaos, you'll love Allie. Think of it as your digital clone. It's the single source of truth for all your clinic's policies, systems, and training. Test it for free at AllieClinics.com. And in other news, applications are now open to work with us one-on-one at Clinic Mastery. If you want support to grow your clinic and bring your vision to life, just email hello@clinicmastery.com with the subject line podcast, and we'll line up a time to chat. All right, let's get into the episode. It's episode 376. My name is Ben Lynch. I'm again, joined by Michael Rizk. Mic, you're joining me from Japan. How is it? The work, the play, the combination of both? It's good.

Mic Rizk: Ohayou gozaimasu. No, I love Japan. We get here for a bit of a holiday and then we do a working holiday. And the time zone's good, so we can do all of our team meetings from over here. It's a good time.

Ben Lynch: And you're wearing the hat that says explore and Adapt. Adapt. You posted this on Instagram, what, yesterday, and it was a very thoughtful post underneath. Just talk me through that. We haven't had a moment to debrief. You added me as a collaborator. I gladly accepted, but… I'm pulling it up because… Yeah, read it. Read it. I've forgotten. I've forgotten. We're going to get into patient visit average in a moment, talking about over-servicing and under-servicing, and this is something you've spent a lot of time teaching, thinking about, you know, creating structures around mix. So we'll get into that, but just read us this post that you wrote out.

Mic Rizk: All right. All right. All right. So it's a picture of the hat. And I said, read if you feel tired and like you're on the business hamster wheel. And then I said, I got this hat for 250 yen, which is about $2 Aussie. How good? The thing I noticed in myself and other owners was a tension, a tension that said, I've done this before. I'm sick of looking at my website. I'm sick of training people. I'm sick of recruiting on seeking, getting nothing. I'm sick of repeating myself, chief reminding officer in brackets, CRO. And that tension creates sadness, loss, comparison, and ultimately leads to below par leadership. So I think that part really resonated with a lot of owners. But then I've written here the reframe, and it was actually a video by Leila Hormozy that helped shift this for me because she was describing this exact process. That that feeling is business. You improve your website as much as you can with the tech and knowledge you have now, and then you move on. You create the best possible interview and induction process that you have now, and then you move on. You try to create a sustainable pay and career pathway, but you know it will need changing in three to five years. and you do this for each area of your business, three to six months at a time, then you need to circle back and do it all again. What if that was the game, I asked the question, and there was no tension, but the opposite. In realizing that is the game, you could experience joy. So enjoy that infinite game, and that is what it takes. And enjoyment is derived from revisiting each element and improving it. The last reframe for me was instead of visualizing a hamster wheel that we so often hear about from business owners and being stuck, Each time you revisit an area in your business, visualize upward spiral of growth and progression. So having that image in your mind makes it easier. That was the reflection. Not as good as a 250 yen hat, but pretty good nonetheless. I can't believe I wrote that. It doesn't sound like me.

Ben Lynch: It's very nicely put because we often hear it. We're in a very privileged position to work with hundreds of clinic owners navigating different stages of business, and each stage brings a new set of challenges that are kind of unique to that stage, but have also been handled by a lot of clinic owners over time, right? What I love about that in Explore, one of the things I often think about is that curiosity as a business owner, like when you start out, everything's new, you're doing it for the first time and there's this like excitement in the growth that it stimulates you. I'm learning about my P&L and my Xero. I'm learning about how to create a recruitment pipeline. I'm learning about marketing. There's this growth that you get. And then I think back to a post that you did maybe on the Facebook group several years ago that we actually mentioned. I put it in the book as well. You recall that one of the cynical owner? I think it was. Great excerpt. Please go check that out, folks that are listening, because it did resonate. It went viral. That's why I put it in the book, right? I just think back to that beginner mindset that you often talk about of just being like, you're probably one of the most open-minded sort of curious business owners that I know. How do you keep that front and center for yourself? And, you know, sort of maybe pick yourself up when you do head down that like, ah, I've had enough, I'm on the hamster wheel there. Patterns, are there systems, are there things that you find yourself doing to navigate out of that?

Mic Rizk: Yeah, I think the first thing is it's normal and it's a really common feeling because every business owner we've, we've spoken to has said the same thing at some point and you, you experience it multiple times a year sometimes. I'm very visual and I love listening to others. So that's why I liked that post by Layla and Alex. I like when Alex and Layla say, when you feel that way, that's the trigger to stop yourself and remind yourself that that is what it takes. That's the journey of a business owner. And that's actually the good part. I feel like I'm actually reprogramming my brain. It's a bit of NLP, isn't it? It's like when you feel that. reframe it that this is why you're a business owner. This is why you have some of the perks that you have. This is the thing that will give you the chance to build the life that you want if you're not there yet. And that's why we're business owners. The last part I think is the visual metaphor. I like thinking about the bamboo tree or the upward spiral when I'm doing that because I think a lot of business owners will do the same thing and feel like they're in the same place, but you're not. If you never cross the same river twice, is that the saying? Every time you revisit one of those things, it doesn't mean you're stuck or you did a poor job. You're actually evolving. You've changed. You've got time. You've got experience. You've probably got some new knowledge. So, instead of feeling like, oh, I'm doing this again, it's like, I'm making this better. So, visuals help me and listening to others helps me a lot.

Ben Lynch: It's a really great point. I found myself. often coming back to the practice, this idea of the practice. Seth Godin wrote a book literally called The Practice. It was more around content. I think you did a post also recently on this around how much do you really want to help people. I'm probably butchering it here or simplifying it, but actually create the content if you want to help people. But really, the focus was Stop focusing so much on the outcome and actually focus on like the input or the output that you have and the practice of doing that. And business is a spiritual game, I think, in the sense that often you're doing these things that are boring, that are repetitive, that you need to keep doing. And I think you need to find joy in those small mundane things, right? Anyway, in a similar vein. We're going to talk about patient visit average, which is a metric that a lot of clinic owners will look to measure. It's an outcome, but we're going to talk a little bit about some of the inputs or the outputs that arrive at that patient visit average number. Now, for some clinics, it matters more than others or it's emphasized more than others. For those clinics that, let's say, for example, work with NDIS patients that have sort of year-long funding, it's not really going to register too much as a key metric that they want to put front and center because they're often seeing those clients maybe weekly for a year or fortnightly for a year. So, nurturing them through a journey of care is kind of baked into the funding model. But it typically is a metric in the MSK world, so physios, chiros, osteos, EP, podiatry, where this is a metric we hear a lot of clinic owners talk about with us and by extension talk about with their therapists. Now, I guess in my mind, one of the key problems they're trying to solve is white space in the diary. They go, I want my practitioners to be more utilized. And it's just unsustainable for me to keep spending aggressively on marketing or marketing efforts to drive new clients if those clients come in for one or two visits. It's just not sustainable. And now I think so much of the subtlety here that we'll cover is that it's not about just trying to increase patient visit average because it's a number, but actually understanding what it means, how to interpret it, how to think about it, how to talk about it with your practitioners as an extension of the client journey and clients going through a journey of care ultimately to achieve their outcome. When you've talked about patient visit average, how do you make sure that it doesn't come across that you're about over-servicing and it's all about the money?

Mic Rizk: I'm still working on it. It's hard. And I think I've learned there's different personalities in business owners and in team members. Some business owners and team members will understand that PVA is just how many times a person came for a new episode or a new injury. And I'll say, cool, what's the average? What do you think we should do? What does that look like? If the national average is eight, I want to be 12. And that was me in a personality. I liked numbers. I liked knowing the averages. But incorrectly, I just assumed we could then go out and talk about PVA and numbers and it wouldn't be taken as unethical and it wouldn't be taken as over-servicing because people knew my values as a practitioner and my values as a business owner. But I very soon learned that I would say that's a small percentage of people that can enjoy talking about PVA. Practitioners, I would say nine out of 10 will get turned off if you use the term PVA and talk about how many times a patient comes. It is a tricky conversation to have. I start with what is PVA? What does it mean? What are the averages I see in the clinic mastery world? Where do we sit? Just so we know. And I'll say that to my team. It's a number that we can get an average on and it's healthy to know where we sit. And here's other clinics that are like us. I'll also look at our clinicians and say like, we all know Josh is a great clinician and we all would love to run our consults like Josh and he gets great outcomes. He's very ethical and he loves the evidence and his PVA is around 10. So that's an interesting benchmark. I would want to know if I was working with Josh and I had a PVA of three in the same clinic in the same population, that would be interesting to me. But again, I was a numbers person. Um, so I do try to explain all those things to my team and then I put it in a box and I put it aside. So I said like, that's the PVA chat. This is what it means. Here are some averages. Here's how we range as a clinic. But I don't really want to talk about that too much. I want to talk about what's our ideal journey? What are the type of things we like to do for a patient? What's our style of physio? What are the outcomes we want? How will we get there? And if we look at all those points of service and we offer the best plan to get there, the PVA will take care of itself. If we just say your PVA is five and we need it to be 10, and you need to see people weekly for the middle period for six to eight weeks, that won't land with therapists most of the time.

Ben Lynch: So let's double click on the client journey piece because that sounds pretty integral to it all. Just take us a little bit deeper. How do you do that? Because you're seeing a range of funding types. You're seeing a range of condition types, which can often change how many visits a patient's going to come in for. So just talk us through what you mean when you say we would look at the client journey as one of the pillars to talking about patient visit average. What does that actually mean?

Mic Rizk: I think we would look at the outcomes we want to achieve as a brand. So if I use iMove Physio as an example, a big pillar of what we wanted to do was help people be independent, be stronger than what they were before, and help prevent future injury. Now, we were lucky because that was kind of new and unique and innovative 10, 12, 15 years ago, and it really resonated with young physios. But I would say most physios have that goal. Then we look at muscle physiology, evidence, and the clinic champion. Muscle physiology says it's going to take four to eight weeks for muscles to get stronger. That's just how long it takes. I wish I could do it quicker for you, Ben, but this is how long muscles take to adapt. We look at evidence, so like we look at some of the key papers around Neo-A, around neck pain, around shoulder pain. Most of the actual studies in physio were done over 8 to 12 weeks. So it's nice to mention these things to team and have examples for the team, particularly for young team members if they feel a bit nervous about seeing people, which is normal. And the third part is the clinic champion. And normally this is the owner. So normally you've got a founder story, an owner story, why you got into the profession, your experience with the profession, and you carry that through to your first batch of patients and your list. And the people that come to work with you will normally be attracted to your values or your style of treatment. And there'll be something that if you can break down what you do, how you do it and the pacing, you want to try and emulate that for your team members. So an example for us is like, I still really valued hands-on care in physio and like that's changing depending on physio and physio clinic. But I always like to see people early and often to do lots of good hands-on care. So I might see someone three or four times in the first two weeks to really settle them. And then I lean on that muscle physiology piece is it's going to take six to eight weeks to get you stronger. And that kind of became our treatment map, our framework. I never dictated what would happen in an individual session, but we had this framework of our values, our evidence, how we treated and how that matched up to our goal of getting patients stronger. That became the map. And we talk about that often instead of just talking about PVA being 10.

Ben Lynch: And so you're talking through specific conditions and what is the treatment map, the best recommended treatment map for this, knowing that everyone's an individual, but you're saying what would be typical and what would be best practice for a presentation like this? How would we go about it? And is that the sort of thing that you would define in your CPD sessions as a team? Or is this something that you and say the leadership team are coming up with? And then it's more about training the teams. To what degree is it collaboration from the whole team, or does it kind of come from the top down?

Mic Rizk: It's both. And we tend to touch on it every year at retreat, like who we are, who we love to help, what's our style of treatment. And every year or so, clinic owners will experience this, but there'll be something new that you've maybe you've got a new tech, maybe you've got a pre-patient form, something new that sits in the client journey. And that's a really valuable thing to do as well is we've got fingering forms, we've got text messages, we've got valve force plates, we've got our hands on, we've got dry needling, we've got exercises, actually thinking, how do all these things fit together? And if you do all of that in the first one or two sessions, people just get overwhelmed and they get no value for it. So a lot of it's actually about pacing When do we want to do a really good subjective? When do we want to test people on the treadmill or on VALD or on Strength by Numbers? When do we want to progress their exercise and how does that happen? So each year at retreat, we kind of go through our, how would a journey look and where do all the pieces sit? And we created the Private Practice Apprenticeship, which is covering a lot of common papers to help give young physios the confidence that it actually is normal in physio to see people for six to 12 weeks, if your goal is to get them stronger, rehab them, help prevent injury. So I was just doing this over and over again in my induction with all of our team members and we kind of standardized it and made it a school program. where you kind of learn about pacing, you learn about the evidence, you learn about PVA, but then we talk about outcomes and treatment pacing and how to get there.

Ben Lynch: It sounds like the philosophy part, you said values part, we've often referred to it as like the philosophy because let's say the evidence isn't complete, there's always more evidence to be gleaned and captured and noted and then shared, you have to kind of connect the gaps with your philosophy and your experience and sort of say this, and this is now my approach because not every clinic is going to approach things the exact same and that's why there's so many disagreements in the community. So, Just talk to me about the process that you've gone through to articulate that part of it, the values, the philosophy, the approach to care that you have, because that seems to be the really guiding set of principles that you then use for you know, applying it to the physiology and then ultimately to the plan that you mentioned. So just talk a little bit more about how you came to articulate the philosophy and does that change or was it sort of a set and forget type thing?

Mic Rizk: We wrote it down. That was the first piece. I think it was Darren Goralski who's a CM member. Yes. Very successful clinic doing great things. I saw him post the other day in Slack. I believe he has one of the best treatment maps I've ever seen, which is- It's incredible. I think he's gone into detail of every condition and all the possible things that he would do for that condition and even the order. I remember that inspired me to think about, well, there's probably top 10 conditions you could write down. Yep. And then I got into the habit of writing down the pacing. What would I do in consult one? What's too much in consult one? What's just enough? What would I do in session two, three, and four? Now, if I'm in phase two, which is what we would call the strengthening part, how would I progress those exercises? Where would they start? Where would they end? And how long would that take? So, there's massive value if there's an action from the podcast is to write that down, start with one. of how you would treat in your philosophy, in your style. If you can think of papers that you're pulling from, include those papers. So you can start to put together a bit of a treatment map and those treatment maps live in our induction. So when we have a new team member join our team, Part of what they do from week one to week six is review those treatment maps. And again, we describe them as frameworks. This is up to every business owner individually. We've chosen not to dictate what happens in every session, but more of a framework of like, this is what eight to 12 sessions would look like for back pain. And then we kind of ask our therapist, like, how does that land for you? How's that pacing? Would you agree you'd like to get someone here? Cool. Would you agree you do that much hands-on? Sometimes I do less, sometimes I do more. How does the middle look? Other clinics, Ben, I think your early podiatry experience was like you knew what you were doing every minute of the consult. Yes. I think both can work.

Ben Lynch: Much more prescriptive. And I think this is where the nuances in layering on your philosophy and your approach. I think the exercise that you outlined there of actually documenting it is just a really practical, easy one to do. I think we did that in one of the sort of recent immersions for members where we were exploring their client journey. And actually people walked away having documented their philosophy and found it so useful then having the conversations. with their team, because I so often think and share that incredible TED Talk from Simon Sinek. The viral popular one is one of the top 10 sessions ever viewed. And he talks through why, how, what. It's not even a great production video, but the substance of the talk is so brilliant. to cut to the chase. Essentially, he talks through effective communication, starts with why this matters or why this is relevant, how we're going to approach delivering on that, and then what specifically should we do. In a way, I see this captured in your framing here, and we created this triangle to simplify it. I think maybe we put it in the book as well. which is philosophy, is kind of the why behind things. Then how is a lot around the physiology, like, well, how does the body work? How does the body go through healing? How does the body change and adapt? And how would we, you know, implement various assessments or interventions that align with that? And then the what is the specific plan, like, this is the spacing, the sequence of things that we're going to do. So I quite love how that framing works. And to almost address the point that you started with, if I go into a therapist and say, your PVA is 5, it needs to be 10, I'm jumping straight to the what. And that is Simon's message is don't start there, especially start with the why. I think another element to the why that you and I have talked a lot about over time has been, we so often ask the question to practitioners or clinic owners, why do you do what you do? Tell me the story of how you ended up in physio or speech or psych or podiatry, whatever the case may be. And so often it's a version of, well, I love helping people. And I think the extension of that is like, well, tell me more. What would that look like and how do you know you're actually doing a good job of that? And so I think even just having that conversation where it's less telling and more asking for therapists, especially that are skeptical, actually allows this conversation to be open rather than you're met with resistance straight away. And so often it goes down the line of, well, I'd have a good reputation, you know, with my colleagues and, you know, my clients and referrers. And it's like, well, what would lead to getting a good reputation? What would that mean? Well, it's some version of getting clients outcomes that they're satisfied with or they're achieving meaningful goals. It's like, well, then how would you know that you've done that? Well, I will have had to have captured that, you know, the initial visit or the second visit. And I would have to reassess whether that was true, you know, several visits later. And so you start to end up from this sort of zoomed out perspective, this sort of like, why all the way through to the what, very specifically, if you go through an asking framework as well, and not just a telling framework, because like you said, this can take some time for people to get on board with. It's not necessarily a flick of the switch and everyone's like, yes, we're going to change the way we approach this. In terms of documenting, say, how you connect the three D.O.T.S here, Where does that live? How does that work? Just talk me through some of the mechanics and pragmatics here. Are these all Google Docs on a hub? Like, where do you store this? How do you share this? How do you maintain this? Just talk us through some of those elements.

Mic Rizk: Yeah, there's a few processes. We have our 0 to 100 Google Slides deck from Clinic Mastery. Which is onboarding new team members. Onboarding new team members, six to eight weeks. Each week is a slide. You have three columns. You can change the name of the columns. We have clinical, which is more the clinical stuff. We have a leadership column where we actually have that Simon Sinek video. We want our team to have watched the videos we watch and believe around team and leadership. So, each week there is a video like that and we ask them to reflect and give us their takeaways.

Ben Lynch: I think you do this a lot and it's awesome. You're constantly sharing videos into the Slack community for members. Yeah. It's such a great way to leverage your time as a clinic owner. because there are people who've said it far better than we could have ever said it. And you get to share 20 years of their experience in 20 minutes with a YouTube clip of them talking through a set of principles or a discussion that a lot of your training and onboarding can actually be outsourced through YouTube clips. Obviously, you've got to vet those things, but it's a wonderful way to add to this suite of support that you've got for your team members. I interrupted you as you were saying the one percenters. Just go there for me.

Mic Rizk: No, it's so true. I'd really encourage people to look at their induction and put it into three parts, which is your clinical, your values and leadership section where, yeah, we just inducted an awesome physio, Lexi, and she said, I've never seen these videos before. Did you just watch all these videos? I'm like, well, it's kind of 12 years of business owner content and Simon Sinek and Brené Brown. But she said, why is that in? She actually asked, why is that in there? She was the first person to ask why that was in there. And I said, because I want you to know the culture and history and values of our clinic. And we've all watched these together over the last 12 years at retreat and alignment days. And these are things that have shaped us. So I think it is really valuable. And then the admin column, we have our systems or our 1%ers, it's actually called 1%ers. But think about your processes, your systems, your admin, your 1%ers, the things that your physios need to do daily, weekly, fortnightly, monthly. They might be things like dashboards, follow-up text, patient without upcoming. So that lives as a hyperlink in the Google Doc. and the hyperlink takes them to Allie where there'll be both a doc and a Loom video showing them how to go through it. So I'll have a screen share going of me doing, this is how we send a text to a patient next day. We go into Cliniko, we click their name, we click send text message. Here's the template that we've already got for you. You'll do this once a week. And then because Loom now has the doc feature, you can just turn it straight into a doc. That's how we do our induction. In the clinical column, just to go back to PVA conversation, we have a treatment map a week. Week one is a back pain treatment map. Week two is a shoulder pain treatment map. We also have videos from my private practice apprenticeship course where I cover things like the numbers, the averages, how we see a lot of young clinicians, patients cancel at visit three or four and they're not actually getting their outcome. The papers that we believe reflect we should be seeing someone eight to 12 times. Our philosophy about there is a discharge date. We do want our patients to be independent. But we feel like that happens best over eight to 12 sessions, not cancelling after three or four. So we go over the harder objective numbers like PVA, but we go over our philosophy and then we provide examples like treatment maps.

Ben Lynch: It's going to be different for every profession and maybe even within Izio. But just talk me through the discharge point there, because how do you frame that up to the team? How do they need to think about the discharge side of things? What do you recommend? You've said, we're not dictating things explicitly, but we provide a framework for their thinking and how they can create these maps. How do you frame up the discharge side of things?

Mic Rizk: There's three concepts. We have a start with why, a North Star exercise, and 90% better is not better. And these are all separate videos. The start with why is the Simon Sinek thing, which is whatever the patient came in for, and this is part of shared decision making, which is ethical practice, patient says, I've got a really sore shoulder when I'm painting ceilings at work and I'm a painter. So it's really important. That's the why. I've got a sore knee. It swells up after I was running with the grandkids. I'm running my first half marathon. These are the whys. Start with why. That needs to be documented in every clinician's notes at the bottom of every session, and it needs to be verbalized every session. So this is part of our training because so often young therapists will know very explicitly what they want to do. But one, they don't articulate it, or if they do articulate it, they don't link it to the why. So it's just like, hey, Ben, come back next week and we'll review your exercise. We'll make you a little bit stronger. That's not bad. You understand what we're doing. But if I haven't said, because we want you at this level, that will give you the best chance to play with the grandkids, to be a painter without pain, to run your first half marathon successfully. That's a big thing we're noticing is we're not mentioning the why in every session and then patients drop off after two or three visits when the pain reduces.

Ben Lynch: So they're feeling a little bit better, and so the patient goes, oh, I don't need to come back, and especially if the therapist hasn't articulated perhaps the full journey, as you said, then that's how we end up with some cancellations or people self-discharging. Is that such a bad thing that the patient discharges themselves because they're, quote, feeling better?

Mic Rizk: No, not at all. Not at all. And we talk about informed consent. So this is where one business owner has the same heart and the same ethics and they're very ethical and they don't want to over service, but they talk about PVA and it comes across terribly. The other business owner is talking about the why. discharging a North Star exercise and people feeling 90% better is probably not the ideal outcome. They're actually both talking about the same thing. It's just articulated differently. And this is where team members can get offside because if you use the wrong words or the wrong language, even though you've got a great heart and you've got great ethics and you're evidence-based, it just comes across as numbers talk. And health professionals more than anyone have this radar for numbers talk. Um, and to answer your question, it's not. a bad thing because we're in a profession that is shared decision-making. If patients self-discharge after three or four sessions when they're feeling 90% better and they just want to manage it at home, that's completely okay. We don't force patients to come back. Our rules are informed consent and 90% better. We talk about these two concepts. Informed consent is I would like you to get to this stage because I think it will give you the best chance to insert the things that the patient wanted. If the patient said they wanted to be stronger or they wanted to reduce injury, then we tell them the best plan for that. You also give them the informed consent on the downside. If you discharge now, that is okay. I just think you're about 90% better. Your strength scores aren't at your population norm, or they're not the same as your other side, or I don't think you're stronger than you were before. So the chances of this popping up again are higher. So that's the informed consent on the upside and on the downside and you leave that decision with them. And some patients do just want to get out of pain and they don't want to do a six to eight week strength training program and that's okay too. So that's where the framework helps rather than saying everyone has to come eight to 12 times.

Ben Lynch: Just talk to me about the 90% better. If I heard you, you said 90% better is not better. What do you mean by that?

Mic Rizk: Yeah, these are our philosophies. So the first one is to start with why, so mentioning, identifying and saying at every session why they came in. The second one is the North Star exercise, which is try to pick a goal that the patient can achieve that's challenging, that you know makes them stronger, that helps them with the why. So how I'll link these two things together is Hey Ben, I want you to do a single leg step up with 20 kilos on your back because that will indicate to me that your knee's pretty strong. It's the muscles around the knee have gotten stronger. And that will tell me that you've got a better chance of doing your half marathon either faster, quicker, or without injury. And that's the reason you came in. So we're linking these two concepts. I'm setting you a milestone, a North Star goal, which is in the future, but I'm only setting that for you based on my knowledge of your knee and your goal. It wouldn't make sense to do that with someone who doesn't have any of those goals. I think that's an important part of the philosophy. The third part is the 90% better is we just see a lot of patients and physio patients and all business owners will have experienced the patient that comes to you and said, I had three or four sessions and I was kind of 90% better, but I didn't get better properly. We articulate this to our patients, is like, around that third or fourth visit, that's when your pain has decreased, but if it's a soft tissue injury, you're at maximal risk. And studies show this, that that's the period where you get re-injured the most because your pain has gone down, but your tissue isn't at capacity. We verbalize this to patients as muscle physiology 101, and we say, hey, like, stay with me here. You're feeling good. And that's great. The inflammation settled. That was our job in the first two weeks. But that tissue is still scar tissue. It's still not strong. We need to build capacity so that you can get painting, so that you can run with the grandkids, so that you can do the half marathon. So we actually talk about that. Stay with me here. I know your pain's down. This is where the tissue needs to get stronger." And we link it to the North Star exercise and the why. You can go through all of that if you did that case by case with your therapists. You are talking about PVA. You are talking about rebooking, but it feels completely different. You're just talking about the goals that the patient had set and how we would get there clinically. In my brain, because I'm very logical and straight up, I'm like, Why did I have to learn to do it that way? They're the same thing. So frustrating. I can't just talk to my team about PVA. But yes, it makes sense. It makes sense that we we are very concerned about being over services and being ethical and evidence based. So it's a better way to talk about the patient.

Ben Lynch: Why? So when you're having the conversation with a skeptical therapist about over servicing and under servicing, how do you draw the line and make the distinction between the two?

Mic Rizk: Did the patient get to their goal and did we provide the best possible management plan? Now that best possible management plan is what's up for debate here. No one knows or can guarantee that. And some therapists will say, well, I can just see them once a fortnight and they'll do their exercises. and that'll be okay. And I think that's true. I think some patients might get there that way and this is where we lean on experience rather than evidence. I think most patients don't get there that way. I think most patients discharge themselves if you don't articulate clearly their why and what the goal is and why we need to go through this period of treatment. And we see that in cancellation rates. We see patients cancel at three and four. We hear their feedback on our text campaign saying, I'm 90% better. I'm just focusing on X, Y, Z. And how many patients have we had come back that say they're doing their exercises wrong. They were 90% better. The pain came back after whatever treatment they had six months ago. And we called our patients that discharged at three and four, and it was a common theme that they felt like the pain was gone, they would handle it themselves, but they're 90% better. So then when we asked the therapist, was your goal to get the patient 90% better? Almost all therapists say no. The ideal thing would be to get them to 110 or 120% of where they were before they're injured.

Ben Lynch: Just tell me a little bit more about that. What do you mean 110, 120% better?

Mic Rizk: Well, this might come back to your values and philosophy, but if someone tears a muscle, our goal is to not get them to where they were. Our goal is to get them stronger than where they were before they were injured. So we might do that based on population norms, or we might do that compared to their other side, their good side, quote unquote. And this comes through in our verbalization and our philosophy when we meet someone. Again, this is not about forcing them, we present. I think, Ben, based on what you've said running that half, not only would I like to get you back to this capacity, I'd probably like to add 10% or 20% capacity so that when you push harder or you run further, you're sweet. How does that sound? Does that align with your goals? Is that part of what you wanted to do here? And some people, they're up for it. Some people don't want that. Some people say yes, but they're just a bit scared to say, I can't afford it or I can't come six to eight times. But the goal is to present the best management plan for each patient. And by and large, if your therapists do that, the PVA will go up and patients will get a good outcome.

Ben Lynch: What do you say though to the therapist that is saying, well, I don't know what's going to work for them. How can I provide a management plan into the future? I only know what I can see here today and I'm going to do an intervention. Then they can come back if they need me. I don't know what to prescribe them in a week or two weeks from now. I don't have a crystal ball. How am I meant to have any confidence over what the plan will be six weeks in the future?

Mic Rizk: That's hard when you don't have experience. That is a hard thing that comes up a lot for the young physios I'm coaching. I like to give them confidence that they are still the best person to see the patient. And it's okay just to get the patient to the next session. But this is where the philosophy of framework is, you don't even need to be that specific. we can say, hey, Ben, in these first few sessions, I want to reduce your pain, restore your movement, have you feeling comfortable. Then we're going to reassess from there. And the goal from there is to get you stronger and add that buffer so we can insert the why. And that framework can be said and is understood by most young therapists. And they agree with that, even if they don't know what to do each session. The other thing I like to add here is certainty and uncertainty, which is we never actually know, even a therapist with 20 years. Therapists with 20 years doesn't know how the patient's going to show up at the next session. None of us know. But there's a way to communicate that confidently and there's a way to not. So it's okay to just give the next step. Hey, Ben, I want to see you on Wednesday to see how your knee responded to the hands-on today and to see if you're ready to start the exercises. I might have no idea how you're going to show up or what to do next session, but that sounds confident and calm to you. It also makes sense and it's also exactly what we're going to do next session. We'll see how you respond and prescribe something from there.

Ben Lynch: It's really interesting because you're framing there that our assumption is, that you are the best person to guide this patient in the next steps of their journey in their healthcare. Even just having that belief as a therapist going, yeah, I am probably better qualified than the patient themselves to figure out what are some options moving forward. And perhaps in a meta point, especially, and I'd say generally in private practice, It means that the patient has determined that whatever they've done prior by themselves is insufficient, and so they've booked in with you. Does that make sense? That's a great point. So many practitioners that are young are kind of like, oh, leave it in their hands. They can come back if they need. But the sheer fact that they've actually booked in with you actually says they've tried by themselves or tried alternatives, and now they're coming to you and they're kind of putting their faith in you to be able to help guide them through their next steps. So why would you push back on that and say, no, go figure it out yourself?

Mic Rizk: Yeah, there's like natural history. A lot of young therapists, we have studies that show like, this is how much of your treatment effect got contributed to getting them better. And then this is how much placebo and this is how much is natural history. And the natural history and placebo part of that pie chart is large. The specific effect of what we do as therapists is quite small. And I think a lot of young therapists interpret that as, well, maybe what we do isn't that valuable. But I love There's a few things I like to touch on. Your point is most people will sit at home for a week or two and they don't get better and then they pick up the phone. So, whatever they're doing is not working. The second thing I like to talk about why we see someone is we have studies that show people forget 80% of a medical consult and what they do remember, the 20%, half of that they misinterpret. One, natural history hasn't worked. Two, when we see them, they're likely going to forget a big chunk, which means it's helpful to see them early and often, particularly if we want education to be at the forefront of what we do. Three, how many patients do you see one week, come back the next week and they're doing their exercises completely wrong? So like there's three really practical points on it is valuable to see people, even if the specific effect of what we do as measured by some studies is only 10, 15 or 20%. That's the 20% that gets them there that was missing when they were sitting at home or trying some stuff they saw on YouTube. So it is really valuable. It's really valuable what we do. And yeah, the therapists haven't experienced that yet. So sometimes these little tidbits help.

Ben Lynch: you spoke to early and often, that's what you want to be able to do with a new patient. What do you mean by that?

Mic Rizk: Yeah, early and often for us is, again, we come back to our philosophy, we want to do a really good interview, a subjective interview, like what's happened? What have you tried before? What are your goals? We want to get deep into that, but we also want to do some treatment on the first day. Then we've got this whole suite of things that we want to be able to do with patients. We normally want to do an assessment, like a running assessment, a movement assessment, a strength test, whatever tests your clinic does. It's normally impossible or overwhelming to do all of those things in one session. And the clinicians that try to do all of those things in one session, their patients are overwhelmed and they forget things and it's rushed and the patient feels that. So the reason we want to see someone three or four times in the first two weeks is like, that's when we can make a big change with our hands. We want the first session to feel calm and not rushed. And part of that is not asking every question under the sun and not doing every assessment under the sun. So we try to do a really good interview, connect and do some hands-on. The second or third session we normally have is a testing session. So I say, hey Ben, now that we've got a really good history and that hands-on session seemed to help you, and maybe we've prescribed an exercise seems to help, let's do that again. But just so you're all clear, on session three, Ben, which might be Monday next week, I want to do a testing session. So we've got the data, which shows us how strong you are now. And from that, we'll know how much stronger we need to get, what exercises we need to do. So that, insert your why. So there's three sessions. And if they're three weeks apart, it's too long. If you try to squeeze it all into one session, it's too much. And that's how we kind of advocate for seeing someone three or four times, depending on the injury in the first two weeks. And generally we call that phase one. And then phase two is more muscle physiology. We're probably progressing exercises each week for six to eight weeks, depending on the goal. So that's how we get to our phases. Yeah, it's a school program. So it's called the Private Practice Apprenticeship. You can find that on school or you can follow my Instagram, that.physioguy. And all of the concepts we've spoken about today are in a digestible six to 10 minute video. You can watch it in one and a half X. The reason I made it that way is so clinicians can watch it in a half an hour CPD break and pop their key takeaways. We also have a live fortnightly call, once a fortnight, where we'll watch the video together in about six to 10 minutes. We'll discuss the concepts we hear from around the grounds. We go over evidence and we go over some of these things we've covered. So it's a really cool digestible induction program for young health professionals. Thank you. Bye.