In this episode, Founder and CEO of CARR, Colin Carr, talks about commercial real estate for healthcare professionals.

Today, Colin talks about the top mistakes healthcare providers make with their office leasing, the financial side of real estate transactions, and important considerations when making decisions on lease agreements. Should business owners buy their space or lease their space?

Hear about how and when to negotiate, the importance of having representation, and hear Colin’s advice to his younger self, all on today’s episode of The Healthy, Wealthy & Smart Podcast.

Key Takeaways

• The best time to negotiate the lease is typically 12 months before it’s going to expire.
• “If you were serious about capitalising, you would’ve engaged an expert.”
• “You should not be telling the landlord anything that hurts your posture or position.”
• “When it comes to real estate, talk to real estate professionals. Don’t talk to other doctors about that stuff if they don’t know what they’re doing.”
• “Realise what’s on the line. If you make a mistake in it, the world’s not going to end, but it will cost you hundreds of thousands of dollars in additional payments that you could have avoided.”
• “Surround yourself with the most successful people that’s you can get around.”
• “There’s no substitute for hard work.”
• “Work it as hard as you can and then learn from your mistakes.”

More about Colin Carr

Colin Carr is the founder and CEO of CARR, the nation’s leading provider of commercial real estate services for healthcare tenants and buyers. Every year, thousands of healthcare practices trust CARR to help them achieve the most favorable terms on their lease and purchase negotiations.
Colin has been involved in commercial real estate for over two decades and has personally completed over 1,000 transactions. Colin educates thousands of healthcare professionals, administrators, business owners and students on an annual basis through national meetings, conventions, study clubs, associations, universities, and webinars.

Suggested Keywords

Healthy, Wealthy, Smart, Healthcare, Commercial, Real Estate, Negotiations, Representation, Leasing, Finance, Business,

To learn more, follow Colin at:

Website:          https://carr.us

LinkedIn:         Carr Healthcare

Facebook:       CARR

Instagram:       @carrhealthcare

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Read The Full Transcript Here: 

00:02

Hey Collin, welcome to the podcast. I'm happy to have you on today.

00:06

Glad to be here.

00:08

And so today we're going to be talking all about commercial real estate for healthcare, healthcare practitioners. So this is something that you've been doing for quite some time now since 2009. So before we get into the top mistakes healthcare practitioners make when it comes to their office space, can you give us the quick version of how you got into this space working particularly with health care professionals when it comes to their commercial real estate and office needs?

00:38

Yeah, absolutely. So started in 19, Managing apartment complexes back in East Lansing, Michigan, little bit away from where I grew up, moved to Colorado, my early 20s started managing some mid rise, high rise complexes, downtown Denver, and I got into brokerage about 23. And I worked for a gentleman that did a lot of large national retailer. So Walmart's Wendy's blockbuster. And that's how I got into brokerage over the years, I started doing more industrial, more office. And a couple years in, I started doing medical office buildings and working on hospital campuses, Class A medical buildings, and just fell in love with working with healthcare providers. And after a number of years of doing that, I realized that the healthcare industry was one of the largest, most unrepresented segments and all of all of real estate, you know, every time there was a listing, there'd be four or five brokers trying to get that listing, whether it was office or medical. But when it came to actual doctors running around town trying to find space or trying to negotiate, I didn't see anyone doing it. So I've made a focus made an intentional effort to start helping more healthcare providers, and then in 2009, launched our company.

01:47

That's excellent. And as most health care providers can say, we did not go to school for any of this stuff. I can say, as a physical therapist, I didn't go to school to understand how to negotiate commercial leases, and office space and things like that. So having professionals with the best interest of the healthcare provider in mind is so incredibly helpful. And I'm sure you're quite busy. But now let's get to what are the top mistakes healthcare providers make with their office space and their leasing needs, so I will hand it over to you.

02:20

Okay, so we'll have a couple there's, there's more than a few. The first mistake that healthcare providers make is they don't know when to start the negotiation. You've got healthcare providers that are trying to negotiate with two, three years left on their lease, and there's no leverage, there's no incentive for the landlord to do anything for them, the landlord knows they're locked, and they're on the hook in that lease contract for another two or three years. And so they have no posture, they have no leverage. Other side of the coin is they try to negotiate when there's two, three months left in the lease. And the landlord is assuming that they're not paying attention. They haven't hired representation. They don't know the market, they're behind the eight ball. And so you can start the transaction too early. And it's a it's a sign that you don't know what you're doing. And you can start it too late, which is a clear sign you don't know what you're doing. And either scenario, the landlord is gauging how serious you are. How savvy Are you? Do you have other viable options? Are you willing to move? Do you really understand the market? And are you going to fight hard for the terms that are commensurate with the type of property with the the market you're in with the economic climate? Or are you just bartering or bluffing? Are you just hoping for a better deal and guessing? So starting the transaction at the wrong time? That's a that's a big one right there. And

03:38

where and where is the sweet spot then? So it's like, it's like, what is that? Is it the the three bears? Goldilocks and the Three Bears like one bed was too soft, one was too hard to kind of have to find that sweet spot in the middle. So when it comes to negotiating, when should healthcare providers be thinking, Alright, now it's time to reach out to my landlord and start this process?

04:01

That's great question typically is right around 12 months from when your lease is about to expire. If you go outside of 12 months, again, the landlord's just don't have any real incentive to negotiate, because in their mind is I'll deal with it later. They can't go anywhere for 12 months or longer, and so they don't pay attention. But again, if you get too close, if you need to relocate, you don't have time to make that transaction happen. If you need to go to a new property, the negotiation process, the site selection that can take several months on average, you know, getting landlords to respond and negotiating the terms, getting an architect involved to look at the floor plan that takes a few months, it can take a month or two just to negotiate the actual lease contract Once you agree on terms working with the with the attorneys. And then if you need build out and you have to pull a permit or get contractors involved that can take another three or four months as well. So the ideal time is right about 12 months, that gives you enough time to handle each one of those steps that I just mentioned, but it's not too far out there.

04:56

Right. Excellent. All right. So Mistake number One not knowing when to negotiate. Now we have a better idea. What's another mistake?

05:06

Another mistake? And I'd say it's probably the top mistake. It's the do it yourself approach,

05:11

do ya probably be that would probably be was something I would do? Yeah.

05:15

Well, and there's a lot of reasons people take the DIY approach. Number one, it's typically because they're so busy, they don't know who to contact, they don't have time to do the research or due diligence in their opinion. And then it just comes up if the lease agreement shows up in the form of a landlord knocking on their door or property manager saying, Hey, listen, your lease is coming up, what do you want to do, and they just say, hey, send me a proposal. And that that starts the process of them doing it themselves. Or maybe you're looking for a new location or your first office, he started driving around, and you pick up the phone, and you start calling the listing broker landlord, asking questions, and all of a sudden, you have engaged and start the process all by yourself. The problem with this is that that is not the game plan for successful companies. If you take any national retailer that people would respect and say, hey, they do a great job, you take a Starbucks or Chipotle, they don't have some random person calling on properties or asking for proposals. They have a team of in house professionals and they utilize outsource experts that all these people do is negotiate professionally for a living. So when a landlord gets a phone call from a doctor or an office manager, no matter how well meaning that person is, the landlord is going to assume they don't know what they're talking about. And it's not, they're not trying to take shots at the person, they're just going to assume, Hey, you don't know the market, you've not want to look at 10 or 15 properties, you're probably not negotiating with three or four landlords simultaneously going three or four rounds of negotiations. And at the end of the day, if you were really serious about capitalizing and saving $100,000, on your next commercial lease, you would have engaged an expert, it's it's similar to, if you get audited by the IRS, if you don't get a really good CPA involved, you're probably not too serious about getting the outcome you're looking for. If you go to court, and someone's bringing a claim against you, or they ask you to go to mediation and arbitration, and you show up by yourself, you get your signaling, I'm probably willing to accept a much inferior result because I don't have the time, the money, the resources or whatever. And so when a landlord sees a tenant show up on representative, it doesn't matter if it's health care, or, or retail or office, they just assume that that person doesn't know what they're doing. And so that's, that's gonna cost the person a lot of money.

07:31

Yeah, so you really want to have the right professional at your side, so that you're not getting taken advantage of you're not prolonging things. And like you said, I love how you said that they're there thinking that you're willing to accept an inferior result. And as as a health care provider, or a physical therapist, like if, if someone broke their leg, and they need to rehab, well, they're not going to go to their account, and they're going to want to go to a physical therapist, that you don't want to do it on your own, because you're not going to get the right results. So same thing, right? You always want to have the right professional at your side.

08:08

Yeah, I mean, this would be much different than if a patient you know, if you talk to a patient or potential patient, and they needed to rehab something, and you knew it was an advanced rehab, and it's a time you have you have instruments, you have technology of equipment. And their response is, Well, I'm just going to head and figure it out. Like I'm going to search the web and just do some research, your response would be well, there's, there's a better game plan like you can, you can do that. And you can get some type of result or some type of an outcome. Just like a landlord knows, hey, you can you can lease a space without representation, but it's probably not going to be the most effective approach, you're probably gonna waste a significant amount of time. It's probably gonna cost you quite a bit of money. It's very similar.

08:41

Yeah, yeah. Okay, so don't know when to negotiate the DIY approach. What else? What's another big mistake?

08:51

Yeah, another big mistake. And I mentioned it briefly. It's negotiating on only one property. And this is different when you when you compare residential versus commercial real estate, okay. And residential. If you're going to buy a house or buy a condo or townhome, you go look at properties, you search online. And then when you find the property you're interested in, your agent writes a contract for you and they deliver it to the seller. If the seller signs it, you're under contract, you have the ability to cancel that contract with inspection, objections, financing, deadlines, and so forth. But you submit an offer towards one property and if they say yes, you're under contract, it's a binding contract. Commercial Real Estate works on what's called a letter of intent and loi, or a request for proposal and RFP. In either scenario, those are typically non binding. 99.9% of are non binding. There's, there's ways you can make them binding, but they're intended to be a non binding negotiation. And so in commercial real estate, the most strategic gameplan is you go look at X number of properties that meet your criteria. you narrow it down to the top three or four properties that are the best fit, even if one or two property One of your properties are the clear winners, alright, but you still negotiate on three or four properties. And you might even go two or three rounds of negotiations. The reason you do this is because it gives you the true picture of the market. You can't just go off what they're asking as a quote and lease rate on a brochure, because there's too many variables. Is the lease going to be a three year term? Or a 10? year term? Are you asking for no money for improvements? Are you asking for a couple? $100,000? Do you need a free build out period? Do you need free rent Upon moving? Or the annual increases? 2% 3% 4%? Are you going to personally guarantee the lease Are you trying to have your practice or business guarantee it, there's all these variables that are there. And so you've got to negotiate with multiple landlords to get a real feel for what the market offers. And when you do that, a couple things happen. Number one, landlords get more aggressive and competitive when they know they're competing. If a landlord thinks that this is the only property you're interested in, and you tell them, hey, this is my dream location, or you show them your cards, you're not going to achieve the best terms possible. And so being able to leverage multiple landlords against each other, again, respectfully with dignity, not you know, not not doing things in a way that's that lacks integrity, or cuts corners. But if you do it properly, you're going to know if that lease rate is market below or above, you're going to know if that's the right TI allowance, the right free rent package. And if you're getting three or four landlords to do something over here, and another, and another one over here is not one that you can leverage those against each other. And that, ultimately, is how that's one of the top ways that you achieve the most favorable terms possible.

11:31

Got at first, I thought you meant Wait, how many properties Am I getting, but it's not negotiating. It's not for you to have multiple properties. But it's for you to negotiate a single property, but through a lot of different through a couple of different landlords so that you you're kind of getting a better idea of the landscape,

11:52

you're you're gonna pick three or four properties to negotiate with, you're only going to choose one of them at the end of the day. But again, every landlords motivations are different. And so you might have two properties that you like equally, one landlord might be much more aggressive than negotiation. And if you add up all of the economic terms, you might find that two properties that appear very similar, that start out with pretty similar starting or quoted lease rates, you might end up with 100 $200,000 savings on one, or 100 or $200,000, in increased costs on the other. So just because the properties look similar, because they have close to starting lease rates, by time you actually work through all those economic terms, you can end up in a very different economic situation. Oh,

12:34

my God, I love that that is such a good tip. And I'm sure that's something I would never even think about. I would just think, well, I guess I'll just go with one property. So that is a great, great tip. Anything else? What other big mistakes and I know you said there's probably so so many, but maybe we'll keep it to like four or five.

12:52

I'll do two more of this. Okay, you quit, okay, I'm gonna kind of hinted at it. The next mistake healthcare providers make they tip their hand to the landlord, they tell the landlord, this is the property I want, or this would be the perfect space for me, or during a lease renewal negotiation, which is by which is by the way, that's the number one transaction in all commercial real estate, more lease renewals happen every year than any new office or purchase or relocation, okay? The number one mistake they make there is they talk to the landlord, landlord comes their office, the landlord might even be a patient, you know, property manager stops by and they say, Hey, your lease is coming up for renewal, what do you want to do, and the doctor says something along the lines of why don't want to move, or the space works great, send me a proposal. And again, what you have just signal to the landlord is you're not looking at the market, you're not hired representation, you don't know if it's going to be a good deal or a bad deal. And most likely you will accept an dramatically inferior deal. So signaling to the landlord again, you should not be telling the landlord anything that hurts your posture position, and they're looking for you, they're going to ask you questions, trying to get you to tip your hand. So that happens all the time. Here's why healthcare providers get into health care typically, because they want to help people. They're fascinated by the science. They're fascinated by the ability to transform people's lives to help protect lives, save lives, enhance lives. And they're not getting into health care, because they want to be a stone cold killer negotiator. Yet they're going up against landlords that are not playing games that have buildings that are worth 10s of millions of dollars. And those landlords get into real estate because they wanted to be a professional negotiator. So just be very careful what you say the best way to avoid this is to hire representation, let them talk to the landlord for you. And they will keep a very tight posture in the entire process.

14:43

Excellent. Okay, what's number five? Five, the

14:46

last one? Yep. Five. The last one is healthcare providers love talking to their peers and colleagues. And then they take that information that becomes the standard. And that's a really bad way of doing business. So So you might be in a building with with other tenants might be a dry cleaner could be another healthcare provider could be a restaurant. And they'll ask those tenants or neighbors, Hey, what are you guys paying? Or what did you get on your last negotiation, and then they share that information. But what they don't realize is they're asking people who may or may not have gotten a very good deal. We had this scenario, once we were helping a doctor in a building, it was a completely medical building two floors, six or seven doctors on one floor, six, seven doctors on the second floor, and we were talking to the doctor, we were looking at his lease, and he was significantly above market. And we said, hey, who's negotiate and what the last two or three renewals you've done? And you said, Well, I've done it myself every time. And we said, you know, how do you feel about these terms? Because this is exactly where the market is. And I said, How do you know that he goes, Well, I'm, I'm good friends with three out of the six doctors on this floor, we talk to each other all the time, we refer patients back and forth, we've we've swapped leases, everyone's paying the same thing. We're all paying $30 per square foot. And I said, well, like just so you know, their marketing space in the building, way lower than that. And we just negotiated a brand new lease on the first floor for a doctor at $21 per square foot. So you're gonna dollars a square foot above market, okay? And you haven't got any free rent your last couple of renewals. You haven't got any tenant Premadasa, renovate your space, and you're telling me you didn't get those because no one gets those I'm telling you right now, you and your three or four friends have been consulting with each other, you just have no clue what you're doing. So taking advice from somebody who is bad at negotiating or getting a really bad deal is super common. And so people share stories. They're on all these, you know, Facebook groups throughout all these threads, and everyone's sharing their experience, and it is their experience, but it might not be the best gameplan. So that's another big one we see too is talk to your friends about things clinically, when it comes to real estate, talk to real estate professionals when it comes to legal things, talk to attorneys comes to financials, talk to CPAs don't don't talk to other doctors about this. If they don't know what they're doing.

17:05

What a gut punch is, right? That guy must have been like, what $9? Over? Oh my gosh, what a Yeah, what a kick in the pants. That is. Okay, so those are really great. Five Great tips, five mistakes that people often make with their commercial real estate. And throughout that one theme certainly seem to emerge. And that is having representation on your side. So when it comes to commercial real estate agents, let's start with number one. How do you choose the best commercial real estate agent? And then how much does it cost? Because the cost is probably why people end up doing mistake number two, the DIY approach, right? Okay,

17:48

both both great questions. There's a handful of ways to find a really good real estate agent. Number one, if you're a healthcare provider, you want someone that has healthcare experience, it's very different talking to a real estate agent that focuses on million square foot distribution centers for Amazon, than it is someone who's working on a 2000 square foot physical therapy space, very different transaction. And commercial real estate, you got people that all they do is apartments, all they do is Office, all they do is retail, you want to find someone that understands healthcare that works in the healthcare space, number one. Number two, you want to find someone who's only going to represent your interests, commercial real estate, and residential real estate are known for agents that try to work what we call both sides of the deal. They're trying to represent the lammeter seller, and also the tenant or buyer, that is a clear conflict of interest. You can't negotiate for two opposing parties. It doesn't work that way. And so this is the idea of saying if somebody is suing you and you're going to court and you're asking the prosecuting attorney, if they'd give you advice, like that's literally what's happening, their client, the landlord or seller, they have a fiduciary to help that person or that group, make as much money as possible in the transaction and protect their interests, they cannot do the same for you. So you need to find someone that's not going to have a conflict of interest, someone who works in the tenant buyer side, who doesn't have listings with landlords in the area that you're looking because you want an unbiased approach with someone who's going to protect you right now. So those are two really important things. The next thing you say is, well, how do I find those people? You can search online, but typically, in any healthcare industry, you're going to have people that if you ask them, Hey, who do you know that specializes in healthcare, real estate for doctors, you're gonna have lenders that tell you, hey, this person or these people do, you're gonna have architects, contractors that have worked with these agents on a number of deals. And so there's a lot of referral partners in the industry that can weigh in on the topic. And so if you ask a handful, you should be able to get a few names very quickly, people that specialize in that area, and then what you need to do again, and that process only takes a little bit of time. It's not it's not no one's asking you to take a whole week off to spend dedicated towards that. But once you find a couple names, you need to speak with these people. You need to interview them, you need to talk them and say, what would your strategy be to help me maximize my profitability in my next transaction? How are you going to protect my interest? How can I know that you are the best fit for me? And like any other relationship or service provider, you're going to know quickly? What their responses just like a patient would say to you. Hey, how are you going to? How are you going to get me healed up? What is your game plan for me to get restored? Or to get you know, rehabilitated? What do you want to do, and you've got to earn their trust, it's the same way in real estate. And I tell doctors this all the time. If you talk to an agent, and you don't think that agent is the best fit, move on to the next one. And I mean, that's what we do for a living, I tell doctors, then if it's not us move on to the next person. Like it's, there's too much on the line for you to for you to just take whoever's there, don't settle in this area, find the person that you trust that you want to work with, that you believe has your interests in mind. And then that's how you get engaged. Yeah,

20:55

great advice. You beat me to the punch, I was going to ask you what questions to ask how do you vet and you just gave us those answers. So that was amazing. Now, let's talk about the money side of things. Because health care practitioners, yes, we get in to help people, we have our own business, it's also a business. So we want to make sure that we're maximizing our earning potential, if you will. So let's talk about one How much does it cost to hire a Commercial Real Estate Agent?

21:24

Okay, so that's one of the best parts of this entire conversation, it will not cost you as the doctor any money to hire a real estate agent. It's just like residential real estate. If you are a buyer, or a tenant residential real estate, you engage an agent as your exclusive agent, and they receive a portion of the commission from the landlord of the seller. So commercial works just like residential, again, for anyone in residential that's ever owned a house, when you hired an agent, you agreed to pay two Commission's one to your agent, and one to the buyer's agent, Sandman commercial real estate. And this is one of the biggest mistakes that healthcare providers make as well, we could put this as number six, if we wanted to, is they assume they're going to save money by not having an agent. And so they say, You know what, I'm not going to hire an agent. So I'm going to save money. But here's the reality, you're not determining whether or not a commission is paid or not paid. You're not determining what that commission amount is, when you go to a property, that landlord already has money set aside for every transaction. Even if they don't have a listing agents, they're doing it internally, they still have a commission set aside for every transaction. And if you do a deal as a doctor all by yourself, the listing broker gets a double commission, not one, but two, they double up to take both sides of it, or the landlord just keeps that money. And this is this is what happens is, you know, a lot of doctors have this like the do it yourself mentality. I always joke, it's like, every time you see a U haul moving truck, it says move yourself and save, right. But if you're moving yourself and give you a U haul, yes, you save money because no one's offering to pay your $3,000 movie bill. In commercial real estate, there's a commission set aside for the listing agent, and for the tenant or buyer's agent. And when the doctor the tenant doesn't have an agent, listing broker takes a double Commission, or the landlord just pockets that money. So it's 100% free service, it's not going to increase the lease rate for you, it's not gonna cost you money, it'll save you a significant amount of time. It'll help you avoid costly pitfalls, and it should save you a significant amount of money as well.

23:27

Okay, and that leads perfectly into my next question. So you had said earlier that lease negotiations or lease renewals, I'm sorry, are the thing that happens the most when it comes to commercial real estate? So how can healthcare providers or anyone for that matter, save $100,000? Or maybe more on their next lease renewal?

23:52

Great question. So we're gonna take, we're gonna accumulate my prior answers, and we're gonna, those are all the ingredients in that. And then here's what it looks like. So 12 months prior to your lease expiring, and you're going to look at your leisure going to figure out when you're when your dates show that you expire 12 months before expiring, you're going to start the process of finding an expert, commercial real estate agent in your area that represents healthcare, attendance and buyers that knows your industry, you're going to you're going to, you're going to call x number of people until you find the right person that you want to go forward with, you're going to engage that agent and you're going to have an exclusive relationship with that person, okay? That agent is going to take your requirement, and they're going to go to the market and we're going to find every property that meets your requirement. And they're going to whittle it down to the top three or four properties, even if you don't want to move. Even if you think that moving would be a convenient, they're still going to do their due diligence, and they're going to they're going to take their time energy and they're going to negotiate with three or four landlords simultaneously. And they're going to get to what's called best and final term so we're you know, if you were going to move to the property across the street, or down the street or across the city, you're going to know exactly what it would cost to do that, and you're gonna know what the economics would look like if you wanted to transact there. Once you have that information, you can now go to your, that agent can now go to your current landlord, and can negotiate with factual data, and with a very specific game plan. And here's why this is so important. Again, you can get this thing backwards. If you go to your landlord, and you ask them for an offer, you start negotiating. Here's the question, compared to what, how do you know if it's aggressive? You can compare it to what you're currently paying. But again, what if you're above market, and they say, well, I'll bring you down $2 a square foot, you can say why just save a bunch of money? Well, if you can move across the street don't say $5 a square foot. Or if you get a better landlord, or a better space or a larger space, you can't compare your current economics unless you are comparing them to other properties. So your agent goes, the market gets the top options negotiates, and then goes to your current landlord, and says, Listen, we brought to the market, we know what's happening. I'm a market expert, my clients now educated, and we got three or four other viable options, we'd like to have a negotiation and discussion with you, but it's gonna have to meet our criteria, because we've got two or three other properties, that could make a lot of sense for us, if you don't want to get competitive. And when landlords know that you're not an idiot, you know, you're not, you're not ignorant, you're not, you're not, you're not just gonna take whatever they give you, they come to the table with a much different approach. And when they know you're represented by an agent that is an expert, they're not going to waste their time trying to convince an expert that their deal is good if it's not good. So that that's the process. In a nutshell, there's a lot more to it than that. But that's how you get to the landlords, that will actually give you a good deal. Because at the end of the day, if you do move out of that property, they're not going to get the next tenant to pay above market, they're not going to get away with not giving them a tenant proven allowance or not giving them free rent, or trying to gouge them, because the new tenant won't take it, they'll just have go somewhere else. And so the landlord, if they think they've got you know, pushed into a corner, you have no other options, they will stick it to you. If they think that you have the freedom to move that you're willing to move, you got the help to move, they will come with a much more aggressive offer. And typically, at an average space of two 3000 square feet on a five or seven year deal. Those those numbers add up to usually a minimum of $1,000. And oftentimes hundreds of 1000s of dollars, that can be one in

27:23

your favor. Amazing. Again, having the right people in your corner doing your research coming to the table with facts and figures so that you have leverage to negotiate. All makes perfect sense. And now as we start to wind things up here, I just have a one, I think really interesting question, because I hear this quite a bit chatter on social media, when it comes to at least physical therapy business owners is do you buy your space? Or do you lease your space? So can you talk about that?

27:54

That is a great question. That's probably one of the top questions that we receive. The answer to that is you should look at both your options, don't pray determine one or the other, because every markets different, every economic climates different. And you could be in some markets where where you have multiple options to own and it's phenomenal other markets, there's not one option to own. So I mean, if you're doing real estate in a suburban Tulsa, that's different than if you were downtown Manhattan. I mean, you've got to know the different markets. What we tell healthcare providers is listen, we're going to go to the market for you and find the top properties that meet your requirements. And we're going to look at office options to lease and options to purchase, we're going to look at retail options, we're going to look at office options. And we're going to show you the top of what's available, you then are going to choose which properties that you're the most excited about. And then we're going to negotiate on three or four properties simultaneously. And then economics will tell you very quickly which property is going to make the most sense for you. If you can find a property to purchase. That's that's a top property if you love it, and the economics makes sense. We are a huge proponent of owning commercial real estate, you're building an additional asset, if you sell your practice, you can lease out the space. And typically that real estate is going to sell for more than your practice will sell for. We track this across the country, we work with 1000s of providers every year, and the real estate sells for more than the practice over 75% of the time. So if you could be an immediate to pay rent or mortgage either way, you've got to pay a landlord or or pay a company a mortgage company. So you're basically paying yourself in certain aspects of it. You got to make a payment either way, if you can own real estate and economics work phenomenal. A lot of times what you'll find is are you willing to pay more to own than to lease because of the upside. And so you might have scenario where it costs you an extra couple $1,000 a month to own and you get you have to decide is it worth that? Is it worth the extra expenditure to pick up some additional tax deductions to pick up that principal pay not every month you got to check X number of dollars go to pay down principal on the loan, your net worth goes up every month. And so we have those scenarios, if it's if it's 6000, or 6000, at least that's a no brainer at the back, right? If it's 10,000, or 6000, at least, you got a decision to make there a lot of times it's, you know, 12, or $15,000, or 6000. The least. And you have to decide which makes the most sense for your practice. And then you get in another 10, different evaluations, what's the downpayment? What's the cost of entry? What are the economic financing terms available to you? Is this space gonna fit you for three years? Or five years? Because if so, we don't want to purchase that we'd rather lease for three or five years, and then have you purchased the next location, if it's gonna fit you for the next 20 years? Again, that's a different story. So there's all these different variables, there's no one size fits all. There's there's groups that we help lease a couple spaces for that purchase, purchase couple spaces, then lease a lot of variables there.

30:48

Yeah, and and again, that's where coming together with your team makes a lot of sense, and and doing your pros and cons. But I hear that quite a lot. So thank you so much for your input on that question. And now, if you could put a bow on this conversation, what are the top things you want healthcare providers to walk away from when it comes to their commercial real estate questions?

31:17

Yeah, that's a great question. I would say, just realize what's on the line. We're not talking about, you know, did you overpay for a box of gloves, you weren't paying attached, you ran out and you know, you overpaid by $2, for a box of gloves, and you can go, you know, buy in bulk next week, or you have your supplier set, you know, whatever, we're talking about a transaction that you engage in every once once every five, seven or 10 years. If you make a mistake in it, again, the world's not going to end. But it will cost you 10s, or hundreds of 1000s of dollars in additional payments that you could have avoided. And there's a lot of other things that are on the line. Like there's economic terms, there's also business terms, what happens when you want to sell your practice, can you get off the lease, or you get stuck guaranteeing a lease for the person that buys your practice, because you don't have the right assignability class. So I would say this, make sure that you're treating your commercial real estate with the respect that it's still again, I mean, you can still do a lease, you can still stay in practice, etc. But again, the world's not gonna end. But there is a cost or a penalty to messing up here. And it's pretty high. Find a good agent, find someone that you trust, and that person will save you literally 3040 hours of your valuable time, they'll save you a significant amount economically, it's usually usually a minimum of 10s of 1000s, if not hundreds of 1000s. They'll also help you avoid complications and delays that come up all the time in commercial real estate when people are not paying attention. And then the last thing I'll say and I think this is more important than all these is that person's going to give you peace of mind. You're not going to have to wander every night you go to bed and put your head on your pillow for the next 10 years, you're not going to wander Did you get a good deal or a bad deal? You're going to know exactly what what terms you negotiate and how they compare to the market, you're not going to wander if you miss seeing a better property and you should leave somewhere else you chose, you chose the third or fourth best product in the market, he's just would have gone to market you would have known better, you're gonna have that peace of mind. So we can talk about saving time saving money, avoiding complications, delays, pitfalls, but I think ultimately, that peace of mind is invaluable. And for me, that's that's what I'm trying to deliver every time that I work with a client.

33:19

Yeah, you had me at saved 30 to 40 hours of your time. You could have ended it there. But I love having that peace of mind being able to sleep at night knowing that you really got the best deal that you possibly could because you started 12 months ahead of time you hired someone you had a team by your side. So perfect sense. So now, Collin, where can people find you? If they want more information? They have some more questions. What's your contact?

33:49

Absolutely, the best way to get ahold of us is our website. And that is car that US ca rr.us. On our website in the upper right hand corner, we have a couple options on our navbar that are of importance. Number one, you can click the Find an agent in your area. We've got agents coast to coast, we represent 1000s of healthcare providers every year, and we are working, we're working literally in all 50 states plus DC. So click Find an agent in your area. And then that's a great way to start. Another thing we have is a free lease evaluation. If you want to know where you stand in the market, even let's say you signed a lease last year and you got nine years left, we can still do a free lease evaluation for you. And we'll tell you where you stand based upon the market currently, if the market corrects, as we've seen some crashes last two years, who knows what we're going to be tomorrow, let alone five years now we can update that over time. So if you want to know where you stand in the market today, in a few years, we do that all the time, we can do it very quickly. And again, we can give you the peace of mind knowing where you're at and if you're way above market, then we're gonna try to capitalize on the next transaction. If you did a good job in your last deal, again, that gives you peace of mind knowing that you're in a pretty good position. We want to protect that or reserve that in your next negotiation. And then the third thing is we have a ton of resources if you want to study up, if you want to get educated, we got literally hundreds of articles, blogs, educational videos. And if you're interested in commercial real estate because it affects your practice, and you want to know more, we will give you information that will make you the subject matter expert.

35:21

Excellent. That was perfect. Now I have one more question that I asked everyone. And that is knowing where you are now in your life and in your career. What advice would you give to your younger self? So let's say that 19 year old in Lansing, Michigan, what advice would you give to him knowing where you are? Now?

35:39

That's a great question, I would say, surround yourself with the most successful people that you can get around. If you can get around them personally, and they'll spend time with you then do it. If you can't, then get around them through watching their podcasts through reading their books, you know, following their history. And then I would say that there's there's no substitute for hard work, you're gonna make mistakes, you're gonna fall down, you're gonna you're gonna do things that in hindsight, were less than intelligent to say them politely. But you just that's part of the process, owning a practice, you know, becoming a professional, anything in life, working as hard as you possibly can, and then learn from your mistakes.

36:17

I love it. This was so great. Thank you so much for taking the time out. I mean, I was taking notes furiously over here because I think this is such great information for certainly for healthcare providers, but I would say anyone that is looking to get into a commercial space, this was wonderful. So thank you so much. Absolute. It's been a pleasure to be with you. And everyone. Thanks so much for listening, have a great couple of days and stay healthy, wealthy and smart.

In this episode, Dr. Jenna Kantor interviews Dr. Sherrill Williams about diversity, equity, and inclusion in physical therapy. 

Mabout Dr. Williams here: 

A lifelong dancer and lover of the performing arts, Dr. Williams committed most of her life to studying Ballet, Modern, Jazz, and Hip Hop. It was not until her commitment to losing 90 lbs that she fell in love with fitness, and wanted to find a way to fuse her love of dance with health and wellness. This new mission sparked a fire that led to Dr.Williams receiving her Doctor of Physical Therapy degree from New York University. Shortly after she founded Leg Up Fitness and Wellness, an online fitness company for performers that want their workout to feel less like exercise and more like dance. Leg Up's client credits include but are not limited to The 1st US National Tour of Aladdin, Hamilton, Lion King, Lizzo, Jidenna, John Legend, Todrick Hall, and Complexions Contemporary Ballet. Dr. Williams is a passionate advocate for dance injury pre-habilitation and rehabilitation and loves helping dancers around the U.S. virtually and in person.

Follow Dr. Williams: 

www.leguppt.com

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TikTok

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Read the Full Transcript Here:

00:07

Welcome to the healthy, wealthy and smart podcast. Each week we interview the best and brightest in physical therapy, wellness and entrepreneurship. We give you cutting edge information you need to live your best life healthy, wealthy and smart. The information in this podcast is for entertainment purposes only and should not be used as personalized medical advice. And now, here's your host, Dr. Karen Litzy.

00:35

Hey everybody, welcome back to the podcast. I'm your host Karen Litzy. Today's episode is brought to you by Net Health. So when it comes to boosting your clinics, online visibility, reputation and increasing referrals, net house digital marketing solutions, has the tools you need to beat the competition. They know you want your clinic to get found get chosen and definitely get those five star reviews on Google. They have a fun new offer if you sign up and complete a marketing audit to learn how Net Health Digital Marketing Solutions can help your clinic when they'll buy lunch for your office. If you're already using that health private practice EMR Be sure to ask about its new integration, head over to net health.com forward slash li tz why to sign up for your complimentary audit today. And like I've said before I actually use this product it works man did a bump me up in the Google search was awesome. Now on to today's podcast, which is being hosted by the ever wonderful Dr. Jenna cantor. And in today's episode, she interviews Dr. Cheryl Williams, a lifelong dancer and lover of the performing arts, Dr. Williams committed most of her life to studying ballet, modern jazz and hip hop. It was not until her commitment to losing 90 pounds that she fell in love with fitness and wanted to find a way to fuse her love of dance with health and wellness. This new mission sparked a fire that led Dr. Williams to receiving her doctor physical therapy degree from New York University. Shortly after she founded leg up fitness and wellness an online fitness company for performers that want their workout to feel less like exercise and more like dance leg UPS client credits include but are not limited to the first US national tour of Aladdin, Hamilton Lion King Lizzo Jidenna John Legend Todrick Hall, and complexions contemporary ballet. Dr. Williams is a passionate advocacy for dance injury, pre habilitation, and rehabilitation, and loves helping dancers around the US virtually and in person. So big thank you to Jenna and to Sherelle for coming onto the podcast so everyone enjoys today's interview.

02:42

Hello, healthy, wealthy and smart. This is Jenna cantor. I'm here with Dr. Sharon Williams, and I cannot be so grateful. So much more grateful right now to be on here with you. First of all, thank you, Sharon, for coming on to talk. Thank

02:54

you. Thank you for having me. I'm excited to be Yeah,

02:59

I love it. I'm really grateful on so many levels, the one we're friends to. And I think this is where I'm starting with where I'm comfortable and where I need to expand. So I'm just owning up to this. In physical therapy. I don't know a lot of black physical therapists, like holy crap. And so you're one of my few. And when I really took account, I took accountability. And I was like, Oh my God, a few people that I know who are black. So I'm starting with people I know. And then I'll expand out to more and more and more and more and more people and increase my network. But that is sad. After calling myself out. I am really excited to be talking about diversity equity inclusion. I feel like that was a pretty good segue because that is yeah, that is legit. So let's go back. You are a new grad congratulations. Thank you. We made it. We made it made it Sherelle is one of those people who thinks big and then achieves the big. So she's a nice person to be regularly inspired by and I'm super grateful to know you Sherelle. So diversity, equity and inclusion. What rehearing that whole statement in as one what are some first thought that comes to mind when it when it comes to physical therapy? There is no wrong answer. I just want your truth.

04:29

Well, I was gonna say when you like yeah, you're like one of the few black people I know that's a physical therapist. I was like me too, girl. Oh, no, me neither. Oh, I didn't know. Yeah, um, to be honest, I think it was CSM where they had a, a networking event and I was like, oh, there is a little community of us but we're just all scattered or you know around the world. But when I think of the Diversity, Equity and Inclusion within physical therapy, you know? No, I don't want to say non existent, but it's just, it's very small. You know, when I went to NYU, you know, I did visit a few schools. When I was doing the audition process when I was

05:22

Joe and I both are performers, as well. So that's what why audition process came to her mind. That's hilarious.

05:31

When I was going through, like the interview process, and I was looking at different schools, and like NYU, you was one of the few schools that you know, I did see quite a few black people. And I had, there was seven of us in my class, and two men, two black men, which is like crazy that I'm excited about to black men. But like, you don't see it at all.

05:59

No, you don't.

06:02

And it's an it's unfortunate, because it's such an amazing field. And I'm still kind of at the point where I'm like, is it that we are not applying? Because we don't know? Or is it that? You know, they're not letting us in the door? And I haven't really figured that out yet. But I do I do feel like a part could be, we don't know. Because a lot of times I feel like especially in the African American community. And you can also say African because those communities are very different. Culturally, you know, people No, go go be an ND nd ND, ND, ND nd? Or what do we need to do to get more people of color in or black people. Because I think that's going to do wonders when it comes to the community and getting people up. And, and healthy. Because unfortunately, in our culture, not many of us, I think my generation is more, it's a lot more active, but the older generation, not move until I think when we get more more people of color in into the field, and then we're talking about it. And we're excited about it, you know, then the community will come to and we'll see, you know, more people being active. And that's just my theory. That's what I've seen based on, you know, my family when I started school, that's what I'm talking about. I'm talking about moving. And my mom is like, oh, yeah, I'll go get a trainer. Or I'll do this or I'll move or they you know, they see me we can lead by example.

07:42

This is so helpful. Because everything and what you're calling rambling I call a more clear insight into what's true in your mind regarding diversity, equity and inclusion. And it's not just one component that it there's a need to be looking upon. First of all, with defining diversity, equity inclusion for you, like it seemed as though we're talking about black people, right now, we're just in which is that's absolutely, we're not seeing it. i There were very few in my class, and I didn't think anything of it. You know, to me, the fact that there were some people who are black, there were some people who were Asian, there were some people of some sort of Indian descent was like, wow, look at us, but there could be more. I agree from what, yeah, I still as a white person, I did not feel like a minority at all. In that group. In that setting. I felt just like, you know, hey, which is Yeah. My point is, from all these little things, let's start separating out different things that you were mentioning, first of all, with getting people in getting people into the profession, how did you get reached?

09:05

I, to be honest, I sort of think I got into NYU, praise God, I did apply to like 13 schools. I only got into NYU, and I honestly think it's because they had an interview process. Because on paper I didn't have like a four Oh, and I had some C's and I had to retake some classes. But when you get me in person, I can tell you and and why you happen to have an interview process and and I was able to shine in that way. And I think that speaks volumes. I hope that maybe other schools can adopt that because sometimes our paper with we don't, you know, I mean like but that doesn't have anything to do with, you know, how compassionate we are or how smart we are what will be Be like as, as a physical therapist, especially based oh my god, we had the GRE, I

10:08

didn't do the grade on that either. It's interesting, you're saying that because everything on paper only shows part of the picture. So when the schools are making it like that, and they're just looking at paper, I mean, right there, we are automatically going to be leaving a lot of people out, because our school systems are not equal. Yeah, what people are learning are not equal. So if you're just going off of what they happen to be born into, we're really cutting people off. We're really, really cutting people off from opportunity, and therefore, just continuing the cycle of a lot of whiteness in our field.

10:47

And something that I saw that I think would be also be great, like, okay, let's say we don't have time for the interview process, some of the HBCUs. Or if you don't know, historically black colleges and universities, they did like a video, like you had to send in a video and answer a prompt. And that way you get you get to show yourself. And I thought, you know, that was that was great. You know, I mean, it's something that could also be adopted by other schools. To give us a chance, you

11:24

know, I mean, absolutely, I think I think that that's a great idea as a way to be the change be the change. I don't know if you've ever heard this where it's, you know, God, it's a very I don't like this rhetoric, but it's the one where people are saying, not everyone, but people are saying, Oh, well, now people are just getting in because they're black. Can you share some thoughts to that? Because for so you know, I have an angry look on my face and Sherelle rolled her eyes. We're not shy about that. All right, would you mind response to that? Because, I mean, it angers me, but let's talk about this.

12:08

And on that note, we're gonna take a very quick break to hear from our sponsor, and be right back with Shirelles response. When it comes to boosting your clinics, online visibility, reputation and increasing referrals, net Health's Digital Marketing Solutions has the tools you need to beat the competition. They know you want your clinic to get found get chosen, and definitely get those five star reviews on Google. Net Health is a fun new offer. If you sign up and complete a marketing audit to learn how digital marketing solutions can help your clinic when they will buy lunch for your office. If you're already using Net Health private practice EMR, be sure to ask about its new integration, head over to net help.com forward slash li tz y to sign up for your complimentary marketing audit.

12:52

Wow, I've also never discussed this. I mean, if I was just to like speak, honestly,

12:57

yes, please.

13:01

White people get things because they're white all the time. Like not based on merit, not based on skill based on who they know. Or a back door. You know what I mean? And I as

13:17

a person who has benefited in that way, I can absolutely agree. It's Yes, yes. It's true. It's legit happened to me. I like I'm grateful. That's amazing. But like, also, that's so true.

13:32

And, and we're like we said this, the schools are not always even, we don't always have, you know, these connections. But a lot of times when you give us a chance, we go above and beyond, because we're like, hey, my ancestors didn't die for this. So I mean, like, and we deserve the chance, I just think we deserve the chance. The playing field is not going to even and this is our opportunity to try and be able to own probably, I think it kind of goes deeper than just Oh, black you let Black people in. But for so long. We couldn't get education. You know, we were enslaved. We built this. We literally built the US, you know, we couldn't own property. So now it's like, Hey, we're trying to get in these professions, so that we can make something of ourselves we can start building generational wealth. Like for me right now. I am like the person. I am the person right now and 2021 that is trying to start building generational wealth for my family, but why people have had this opportunity to do this and save and know about mutual fund all these different things and I'm just now learning and having the opportunity to get to you've been able To do that,

15:01

oh, for a very long time, and for anybody who says, Oh, the history that you're mentioning, I'm just acknowledging this history that you're mentioning from a bit ago that how black people came into, it's still not 100% there for basic rights for black people, they don't have access to the education that I got, you know, in this, I grew up in California, in a small town, California, if you don't know, if you buy a shed of your own, it can be worth a million cost a million dollars. It's ridiculous. It's a running joke. California is not it's just a well off area to be living, and which is unfortunate. And from that, we are lacking diversity in our areas, and they are people are not getting getting that access. I also feel like that there's an assumption when people are saying, Oh, now black people are getting in just because they're being black. What if? Let's say this black person, maybe it's just one? Oh, you know, come on, like, you know that Gatson is extremely intelligent and more intelligent than you and has had to put a lot more work in to get into prove themselves just to get in? And you actually don't belong? What if? What about what that? What about that? What about that consideration that there could actually be a lot of people of color, who are more intelligent than a lot of people who've been regularly led into school.

16:30

Everything that you just said? That was awesome. Like,

16:36

I love that we're sitting on this for a bit, because getting people into PT school is like the base, you know, how do we reach them? How do we access them and everything. And if then we have people saying it's because they're black. They're people who are black are already dealing with so much this is from what I've learned not experienced, obviously, like you're already dealing with so much discrimination on a regular basis. So to So to finally get that opportunity to come in and then be discriminated against, you've worked your tail off more than the average white person is just preposterous, and we need to call ourselves out on it, in order to be the change. Sure, I was just gonna read this smile. She's

17:25

emotional mom, because you know, it's like, these are the conversations and these are the things that are said within our circles. But then when you have the ally, say, and you see it, and it's like, oh, it's just so nice to be seen and heard. Oh, and then somebody gets it.

17:42

Oh, my God, I do. I do make mistakes. As I go. I've made I've made plenty. And I will continue to do stupid things. But I keep learning and making the changes as I go. But I so grateful that you're on to talk about this. What have you seen, that you think schools are doing that is working to bring in dei and that in schools versus we're taught we've talked a lot about what's not working? What are the schools doing that is working? And what could we do more of pull it out of your buttons fine. Just like brainstorm like, what are the things?

18:15

I mean, like I did say the video. I'm having professors,

18:22

oh my god, I had a black professor. That was the most amazing thing I had ever had one. I remember

18:29

it was so funny. She came in and I was like, Are you a grad student? And she was like, no, actually, I'm a new professor. I remember Mike, one of my classmates, she walked out. We were like in the computer lab. And she was like, now that I see this woman as my, I know, I can do anything. That's what she said. Yeah, so having more black African American ever, professors. If if there can be some type of outreach, I know with my class, so my class isn't good class because I graduated in the middle of a pandemic. So our plan was like, we had many plans and COVID killed the plans. But one of the conversations that I had with a good friend, classmate of mine, she wasn't black, she was a Puerto Rican. And she was like, Oh, I would love to go out to high schools. Let's get a group together and go do it. And then COVID happen and killed everything and we couldn't go anywhere. But I do think in the future. And I know you know, PT school as hard as it is and stressful, but doing some type of outreach in in PT schools and just saying, Hey, this is what you know, get to make it like

19:47

a career day kind of thing. When people come and visit and say, Hey, this is a career you can I do think yeah, definitely. Especially in neighborhoods where my dad's a dentist, okay. I have a family of dentists do Wish total stereotype halacha just brush your teeth, Jenna. So what's my upbringing? Look, I oh my god,

20:10

I missed you.

20:13

The the, but because I had, I grew up with that with people living these amazing careers, I didn't need somebody to come visit because I was surrounded by their neighbors doing a chiropractor friend, one of my best friends her dad was a chiropractor. This was just commonplace. Just in my world. People don't have that. So, uh, yeah, I can even see more. Having people in the profession, someone like my dad even coming and saying, Hey, this is something you could do is great. I think that's, I think that's a really great idea, just literally coming to the schools coming to them. And people don't like if you sit there and just do a social media post and be like, here come to us. Like, it doesn't work that way. Nobody, including any listener, or Sherelle, or myself, we'd like people to just come to us, as we're living our lives.

21:06

This is something I just thought about. I don't even know if it could actually happen. Ooh. Like, can we have like a work study? or some type of like, even be volunteer like work study. And like a student? A student runs an Instagram and it's specific for that school. And it's specifically for, like, adding teens or, you know, people of color and and making content that's relatable. Yeah. So that it's, you know, a track. It's attractive, so people learn more you know about it. I think social media is just such, it's just a force right now.

21:54

It really is it really,

21:56

I don't know what that really looks like. But, you know, yeah. But in talking about, you know, I don't know it just in a creative way.

22:08

No, I get what you're saying. I just, I just recently had a big screening with a ballet company. And I contact a local school and had PT students come volunteer and take measurements and everything was awesome for them to get to experience that would have killed for something like that as a student, but things like that, that other businesses are doing schools are doing, they can have events of some kind to bring that in that that could be I don't know what but because we're like in the like, no mode. But I love that. I love that. Let's let this lay as like the EU, we just let this kind of drop as a potential idea. I have only a few more minutes left with you. I would love to two more things. What have you personally been doing to help bring more dei into the profession?

23:00

I don't know that I necessarily have because I was so engulfed in school by having this conversation. Literally while you were saying that I was like, Oh, I have some ideas. Like I want to start doing this. But I definitely you know, I speak within my family on my social media. You know, I I talk about, hey, let's be more active, I do a lot around how we can move instead of having to go to the MD The MD is going to tell me to take a pill and then sit you don't have bed rest. But I definitely can do more. I can call myself out about that. You know, when I'm back up, you know, hey, I'm going to be very intentful about a purposeful about doing this. I'm excited actually, unfortunately, I passed my boards. I I kind of had this injury and then I wasn't able to do everything that I wanted. So when I'm back up and I'm full, I'm like, Ah, let's go. Let's add this to the list. I'm happy that you asked me that question, which made me get you know, the juices going and Right,

24:09

right. Uh, yeah, I love it. I love it. I give complete credit to Lisa van who's for that question. She said ask this question. I said okay, okay. Where can people we are now coming down to an end. Where can people find you? Sherelle on social media. They can follow you connect. Where can they find you?

24:29

You can find me on Instagram at Lego fitness. I believe Oh, well. I do search my name on Facebook, which is Sherwin Williams. Those are the two places that I live right now. At my website is you know is what is it like up pt.com If you want to see a little bit more about me there.

24:56

And then if anybody might want to email you some people do prefer the email

25:00

Oh yes, my email is right now is just Sherelle w@icloud.com

25:08

I love it. Wonderful. Thank you so much for coming on. You are a force. I frickin love you.

25:16

Thank you for having me. This is so amazing.

25:20

A big thank you to Jenna and Ciara for a great interview on D AI initiatives in the world of physical therapy and of course a big thanks to Net Health. So again when it comes to boosting your online visibility, reputation and referrals, net Health's Digital Marketing Solutions has the tools you need to beat the competition they know you want your clinic to get found, get chosen and get those five star reviews. They have a fun new offer if you sign up and complete a marketing audit, so they can help your clinic when they'll buy lunch for your office. Head over to net help.com forward slash li T zy to sign up for your complimentary marketing audit today.

25:57

Thank you for listening and please subscribe to the podcast at podcast dot healthy wealthy smart.com And don't forget to follow us on social media

In this episode, Founder of FitBUX, Joseph Reinke, talks about financial planning.

Today, Joseph talks about financial planning technology, the three buckets of financial planning, and the importance of focus. How can FitBUX help people with financial planning?

Hear about thinking about percentages, self-employed financial planning, and get Joseph’s advice to his younger self, all on today’s episode of The Healthy, Wealthy & Smart Podcast.

Key Takeaways

• “Money is always relative.”
• “The big takeaway is percentages.”
• “If I focus on one, maybe two things, I’m going to accomplish things much faster.”
• “The more you concentrate on something, the sooner you’ll realize it.”
• “This should be complementing your life, not dictating it.”
• “Focus.”

More about Joseph Reinke

Joseph Reinke is a Chartered Financial Analyst (CFA) Charterholder and is the founder of FitBUX. FitBUX has helped more than 11,000 PTs manage $1.6 billion in debt and assets. In addition, FitBUX recently partnered with the APTA to provide APTA members with awesome discounts on their technology.

Joseph has appeared on numerous industry podcast, been an author for various industry publications, and has done over 200 student loan workshops at university graduate programs, SIGs, Conclaves, and annual conferences throughout the country.

Suggested Keywords

Healthy, Wealthy, Smart, Physiotherapy, Finance, Financial Planning, Income, Expenses, Debt, Money, Technology, Retirement,

Resources

FitBUX Investment Round: https://republic.com/fitbux

To learn more, follow Joseph at:

Website:          https://www.fitbux.com

LinkTree:         https://linktr.ee/fitbux

Instagram:       https://www.instagram.com/fitbuxofficial

Facebook:       https://www.facebook.com/groups/FitBUXOfficialGroup

Subscribe to Healthy, Wealthy & Smart:

Website:                      https://podcast.healthywealthysmart.com

Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264

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Read the Full Transcript Here: 

00:03

Hey, Joe, welcome back to the podcast. I'm happy to have you on again.

00:07

Yeah, I'm glad to be here. It's been a long time. It's the very first time. I think there's like a third time, maybe the fourth time. But yeah, it's been quite a journey. So glad to be back.

00:18

I'm happy to have you back. Especially because today we're going to be talking about financial planning. Now, I know a lot of people might be like, oh, gosh, this is so boring. But regardless of whether you own your own business, you're working for someone else, you have to have a good financial planning, because you want to be able to get through the rest of your life and have the security of knowing you're financially sound. Right.

00:46

Exactly, exactly. So we'll make it we'll make it exciting. We'll give you some, some tidbits that you don't hear anywhere else. So

00:54

yes, excellent. Well, let's let's start out with what are a couple of tips for the audience, that you counsel people on when it comes to financial planning?

01:06

Yeah, so a lot of us to help is all about the technology, and we're there to guide them through it. And it's really geared around a lot of stuff that I learned when I was in wealth management. You know, everybody always talks about, oh, the problem in financial planning and financial education, and this and that. And basically, what I look at used to look at is everybody in the financial industry, they just double down on using the same stupid stuff. And then when the technology comes out, they just put some cute interface to it, and it just doesn't work. Okay. And there's, there's two areas that I could, you know, illustrate on that. One is like, on these apps, so like these budgeting apps, I won't name any names, I won't pick on anybody, but there's a lot of big popular apps out there. Or maybe you just use Excel. And a lot of times what they do is they just throw a bunch of stuff in basically an Excel sheet, and they put a user interface around that. And it's like, okay, well, where does all my money go? Like, this doesn't make any sense. So that's the first issue that we've seen in the second one, I used to joke around about this, this is where financial technology that I used to have, like, you know, a 60 year old client would come in with like, a stack of paperwork with like, an inch or two thick and say, Okay, what am I supposed to do? And to me, all FinTech did was take that makes file and put it on the internet. And just make a pretty little graph around it. It's like, okay, this doesn't tell me anything. Like, what if I want to buy a house versus rent? What if I want to pay off my loans versus well forget? How am I supposed to look at these things? Like, am I supposed to decide this? And so those are the two big areas that is like, how do you do this. And so the first big tidbit on financial planning to satisfy that first problem, just one big thrill plus, you got to think of things in almost buckets when you start stretching out your plan. So you have things like your income and your expenses. And I'm not talking about like your debt expenses. I'm literally talking about your day to day expenses, like food and rent and utilities. So that's like, step one is your income and your day to day expenses that is happening today. The second step is to say, Okay, how much is going towards investments and how much is going towards debt? And that's the step two is over the long term. And then step three is, well, what am I doing to protect my financial plan? Those are things like insurances. So life insurance, long term care, insurance, disability insurance, home insurance. And so the way you can think about it is, this is day to day, this is long term. And and this is risk management, because protection. And when you start thinking about it that way, it makes life a lot easier to do it. And then you know, we'll pause there, and then go into also, you know, what happens like, Well, what about projecting? What about managing this over time? What's an easy way to set this up from there, but that's the primary the main component of in terms of just setting up the plan itself, of those three buckets when you start thinking about this stuff?

04:09

Yeah. And so you suggest people kind of sit down and look at all of those things and kind of write them out. So they have they know their income, they know what their expenses are. They know what they have asset wise, debt wise. So when you're talking debt, can you be a little more specific? Are we talking long term debt like loans or short term debt like credit cards, or bony

04:32

any real debt, I mean, credit card. So with credit cards, if you're paying them off monthly, we don't even consider it that we just consider that day to day stuff. But we're talking about where like you have a monthly payment, so car loans, student loans, mortgages, if you do have credit card debt, and you refinance it, for example, into a personal loan, and you're paying that off over time, if you have business debt, whatever it may be, that's the debt that we're that we're talking about in that step two.

04:56

Yeah. Thank you. Thanks for the clarification on that. And then of course, All the insurances and things like that, that we all need, that we all should have moving forward, I would say especially if you're a physical therapist, and especially if you're in private practice, boy, do you need those insurances to be on point?

05:16

Yeah, exactly the biggest, like the most overlooked one is disability insurance. Because it's like, what do you do if you go to say, well, I can't do my profession anymore. It's like your financial plan completely just ruined if you don't have that. And that's the way you can think about insurance is okay, well, I did my step one, I did my step two. Step two happens over time. What happens if I don't have time because of whatever it is. So like, what happens if I become disabled? My financial plan crumbles. What if I'm married, and I pass away or my spouse passes away? Like we have children like our plan crumbles? What happens if I have a car and I don't have the proper car insurance and I get in a car accident? I don't, I can't buy another car. Now my plan crumbles because I gotta get all this auto debt for another car. So that's what you can think about insurance is protecting just in case time doesn't happen?

06:03

Yeah, fair. Okay, so great. Tip number one, just to recap is to break up into three areas, income expenses, assets, debt, and the third protection, or, and that's where all your insurances come in. Okay, what other what other tip do you have when it comes to financial planning?

06:22

This one is one of the most important and this, this makes life so much easier, both when you're setting up a plan. And also when you're actually like monitoring your plan. Oftentimes, somebody will come to me and say something like, you know, I'm paying $1,500 a month on my student loans. Is that a lot of money? And it's like, I don't know, like, Well, what do you mean, you don't know you're an expert? Don't you know if that's a lot? It's like, well, no, what I mean by that is, do you make $300,000? Or do you make $30,000? Because it's all relative to your income. And money is always relative. Another example of that, like investments, somebody can't come to me and says, I made $10,000 on my investment. And it's like, okay, is that good? It's like, I don't know, like, Did you invest? 20,000? I'm like, Yeah, I'll just do that. But if you invested a million and only made 10,000, like, that's horrible. Like, don't quit your day job, like, what are you doing? Right? So it really just depends on percentages. And you can take that knowledge and apply it to your financial plan. So when you're actually setting these things up, especially on step two, where you're saying, where's What am I investments? Or what am I debt, when you look at percentages of where your money is going and allows you to say, hey, like, I want to focus on, you know, paying off my mortgage? Well, if that's not your biggest percentage of where your money is going, and you're not focusing on that, okay, and this is like, it's funny, because people like, how did you come up with that percentage thing? And I'm like, well, one of the ways I did was when I first started working, I put all the percentages there. And I realized how much money was going to taxes. It was like, Holy crap, like, what can I do to reduce that? So I'm the financial dork that I am, I went and read the IRS tax code. But it's like, those percentages that I assume realized, from a financial planning aspect, it makes life easy, not just setting up your plan, but actually following it. Because if you say, Look, I have 20% going towards my student loans, I have 5%, going towards savings for a down payment for a house, I have 4% going towards my 401k. Over time, your income should be going up. So it makes it very easy. You don't have to think about how much of my money should be going where you just keep the percentages the same and increase how much you're doing in those categories. Or if you get a bonus or a tax return, say great, I take the percentage, I put it to those categories. If I want to do more, I'm fine. But I don't need to I can go out and actually enjoy this money if I want to and not feel guilty about it. Cuz I know I'm following my plan. And then once you're following that plan, let's just say you have a good life event happened. Like let's just say you paid off debt, you paid off a student loan, you paid off an auto loan, well, then great, you just look at the percentage and say, Okay, where do I move this now to meet my next goal? Very quick and easy. Or maybe you have a negative life event, like you get a car accident, You wrecked your car, and you need to buy a new one, where it's like, okay, well, I have I was focusing on this. But if I've moved this percentage and this percentage here, I'm good to go. And that's it. And then you can actually go out and simulate that and I'll talk about simulating that in a minute. But that's the key thing. One of the biggest takeaway that you can take from this podcast as percentages, what percentage of my money is going where and then from there, instead of tracking your dollars and cents, every single place that goes track the percentages are my percentage is going to where I said they're going to especially going towards your investments and your debt. Some people really like looking at those percentages on their day to day expenses too. That's fine if you want to go that into it for me, as long as you're following the assets and debt sureselect don't enjoy. That's the way I look at it. Because that second floor of the building assets and debt, that's the financial plan. So that's the key thing. There's that percentages, percentages, percentages. And, you know, I wish I could talk to everybody that's like 40 and 50 and 60 that have been doing like the dollar amount their entire life. And it's like, I just switched to this. It's easier, like, do that. Yeah. So that's the big takeaway is percentages.

10:26

Yeah, I switched over to percentages a couple of years ago, and it's like a no brainer. You know, so like, when, like you said, for example, a tax return comes in. So I had a tax return. I know it was last year, the year before. And I knew exactly where all of that money was going. Because it was in my percentages. Yep. So it just makes life so much easier. And you'll see you'll accumulate wealth in the places that you need to, because that's your plan.

10:53

Yep. And you'll realize, while if I focus on one, maybe two things, I'm going to accomplish things a lot faster. And so that's where the the behavioral side of finance comes in to. And it's a proven fact that more you concentrate on something that the sooner you're able to realize it. And so one of the big mistakes that we see people make, especially on that step two, they're like, Alright, I'm going to save in a Roth, I'm going to save in a 401k, I'm going to save for my child's 529 plan, I also need to save for a house and I want to save or pay off my student loans. And it's like, you're going to do none of those. Like, if you're trying to do all that good luck. Like seeing the percentages and how thin they are, and how long it's gonna take you to accomplish those is a red light to a lot of people, it's like holy cow, like, will instead I just focus on like, paying off my loans, for example. And your my retirement for the time being, you're gonna be able to accomplish a lot more sooner. And then you can get to those other things down the road. So that's another big takeaway is focus, focus, focus, focus.

11:55

Yeah. And it's okay to move those percentages around as your life changes. And as things change in life. It's good. Yeah. Okay, cool. Yep. So now, yeah. What I mean, this all sounds great. And I'm sure a lot of people are wondering like, oh, okay, how am I supposed to keep track of all this? How am I supposed to do all this? This sounds complicated. I don't work in Excel. QuickBooks makes me nauseous. What can I do? Like, so explain to us how fit books, can I help people with some of this financial planning stuff?

12:28

Yeah, this is where I'm so personally excited. Because this is where we always wanted to take the company even like, it was one of like, five years ago, I first came on the show on your podcast, we specifically we knew this technology was gonna take a long time to build. And so we specifically started the first piece of the technology around student loans to help students, new grads, and then we've been building it, especially during COVID, we've been building out more and more, as long as we don't lose engineers that COVID Every other week. But we've been building out more and more, and we launched the first version out of beta last November. And it literally does all that for you. So when you go to build your plan, like step one is income expenses that two is is your asset contributions, your debt contributions, that three goes into risk management. And then we took it a step further, actually, on step four, you can add in goals and life events. So everything from like getting married or buying a house, or whatever it is that you're going to do. And what that allows you to do is it allows you to say, Hey, this is the plan that I want to follow. And you can actually build out the entire thing and see in the long run what it does, or you can run simulation. So if you're trying to say Hey, should I pay off my loans versus loan forgiveness, or should I rent versus buy, or I'm married, and we just had a child should myself or my spouse stay at home instead of working so we don't have to pay for daycare, you can simulate all those to decide what you want to do. Okay. And then with the technology, once you say this is what I want to do, we take all these complex components, so like your income and your expenses and your assets and your debt. And we bought them all into one data point we called the fitbug score. So you can really easily compare everything and what the fitness score is in the short run, it looks like your risk and your profile and everything else. And then by the time you hit retirement is basically the probability of you hitting retirement and not running out of money. Okay. And so once you say this is the plan that I want to follow, you can then link your financial accounts into the hitbox profile, track yourself right on your profile, and it literally tells you step by step each month, are you doing this right or not. And then if you have one of those life events where you have to change your percentages around you just go back in and have your plan with the percentages around hit save and go back on with your life. So that's why I'm so excited because we've been building that literally for like two and a half years that that bigger technology and it's finally out. So I can actually smile and have a few more gray hairs because of it but it's out So that's where we're at right now.

15:03

Yeah, it sounds it sounds like definitely makes life a little bit easier. And now does this connect to your bank accounts or to your QuickBooks and all that kind of stuff so that it's constantly updating? How does that

15:17

work? Yeah. So it doesn't connect to QuickBooks, it connects to bank accounts, credit cards, some debt. So it connects almost everything not, you know, there's some credit union stuff that it doesn't link into. Some accounts are more thorough. So like the bank accounts, or the savings accounts are all in there. Some debts, like some companies, like first of all, some companies are there, some aren't. Even if they're not, you can still manually put them in. And I just tell people updated like once a month with your transactions. So it can up to date tell you, the big thing is, is making sure that your gross income is in the technology? Because that's how we base everything, are you following your your plan, based on these percentages, and the only way we know that percentage is if your gross incomes, they're not your net, your gross income. Because we want to see, we want you to see where your taxes are going and everything else in your entire paycheck. And so yeah, you can link your accounts, we do it through a company called plaid, which is, you know, the other major banks use them and everything. So that is who we use to link the accounts.

16:17

And can you quickly just for people who don't know, define gross versus net income?

16:24

Yeah, so gross income is what you get from your employer on quote, unquote, that top line, so it's what you're actually paid. And then from there, they deduct out things like your taxes, your Social Security taxes, your unemployment taxes, your Medicare taxes, any contributions to your 401k that you're making, anything that you're paying in terms of like medical care, dental care, whatever it is. And then after that is your net pay. So when you get a deposit into your bank account, that's what we see as net pay. And so you have to reconcile that the gross income. And so what we try to do on the technology to make it easy is is once you put in one of your gross incomes, so like if you get a net pay of like two grand, and then you reconcile it to say 3000. Next time we see $2,000, we automatically reconcile it for you. So you don't have to keep doing it. But yeah, we need that done a few times. So that way the technology updates and can start learning what that is and make those adjustments for you. But yeah, that's the difference between gross and net income.

17:27

Perfect. And let's say you're self employed, and maybe you're so you're not getting a steady paycheck, but maybe your pay can fluctuate slightly from month to month. So how does the technology work with that? Is it like, on our end, when it comes to a little

17:45

bit more, yeah, a little bit more, because you don't know what that income cash flow looks like. But what I tell everybody, like when you're setting up your plan, and you have variable income, so you might not even be self employed, you know, just be based on commission or commission. And what we tell people on that is be very conservative. So like, if you typically make like 80 grand a year and commission or self employed income, do your financial plan based on 60 grand, and do those percentages. And then every month, when you get those waves of money coming in, just take the percentages, and that's what you do. And so again, it makes life very easy. Like if you're putting money to the SEP IRA, or whatever it is, you just know what those percentages are. And that's what you put in. Instead, try where I see a lot of commission based or business owners where they make mistake is actually on twofold. They try to do everything monthly. And then they ended up in a month. It's like, oh shit, I don't have any money. Like, oh, or they go the opposite. They say, I'm gonna do this every six months, I'm gonna see where I'm at, I want to put money into these things. And then six months go by and they're so busy, they just forget. No, they don't do anything. And then all of a sudden, they have 50 or 100 grand sitting in cash, just not doing anything for them. And they don't even realize that it's sitting there. It's like, fantastic. And so, yeah, that's another place where those percentages come in into play big time.

19:09

And do you suggest people looking at, look at all of these percentages every month.

19:16

If they're following the percentages every month, the only real time you need to change them is when one of two things happen. The first one would be is if you have a major life event happen. So things like you get married, you have a child, there's a debt, you're inheriting money, whatever it is, those are major life events, that's when you go in and change it. Or you hit a major goal. So you pay off one of your debts or something like that, and you have a lot of money now that you need to move around. So those really are the two times and that's one of the big reasons why I'm so excited about the technologies because when I was in wealth management to me, it's like this whole model is messed up like you pay 1000 to $3,000 to a person to come up with a plan and then you walk out and it's completely obsolete. And in some of these guys charge $100 a month, but they don't track anything. They don't have any technology to actually even track anything. So what the hell are they doing for $100 a month? So we were like, Okay, well, we give out the financial planning technology, it's free to build your financial plan, you can even talk to a coach, and it's free to build it. And then when you track it, we could charge a monthly subscription fee, that's, you know, 20, or $30, whatever we charge on that. And it's there, you don't have to worry about spending $3,000 a year, any of that garbage. It's like, oh, it frustrates me so much when I talk about it, because the whole model is just like, completely upside down. And actually, the stuff we're coming out with Next, we just started working on it. As far as investment recommendations for allocations and how you had your investments allocated. And I had heart, I'm an investor, I mean, that's what I've been doing since I was like 12. And so I'm just starting to get my tea sharpened on that one, I'm hoping to have it out by March or April this year, where you can literally build your profile. And then it will tell you how your allocation should be on your investments, how much risk you shouldn't be taking. And the big part that's different, we didn't touch on this. We factor in this thing called human capital into our analytics. We ask everything from like, what's your profession to things? Like do you run marathons? Because that all goes to speak about behaviors. And just like healthcare 80% of outcomes and behaviors, it's the same thing in finance. And so there's no point in our technology saying, Hey, you should do this complex plan, when the behavior is not necessarily there yet. And so we factor all that into our algorithm. And that's part of what we're going to be coding next with the investment allocation. Which that's a whole minefield that to me, is that all traditional advice, like, Hey, you're young, like you can afford, you know, to put everything in the stock market. It's like, No, you can't like you know, what happens if you have $5,000 in emergency fund, and you have $5,000 in a 401k and COVID hits and your 401k goes down 50%. And you also just got laid off that $2,500 that just went out the door might be pretty valuable. So why were you aggressively invested at that point in time? Like, it makes no sense? Yeah, so I, yeah, I can go off for hours on that investment allocation stuff. But that might be a far whole nother podcast.

22:27

And that's okay. We'll have you back on. That's not a problem. Well, it sounds like a lot of exciting stuff and a lot of stuff that's really user friendly, and really good for people who aren't financial planners, right? Who like they didn't go to school for this. And they need a little bit of guidance, a little bit of coaching. And this certainly sounds like it makes it very easy for people to do that. Now, what are I know that you said this before? But I'll have you repeat it. If people take away anything from this, what is a big, big thing that you want people to take away from this talk?

23:01

Yeah, keep it easy in terms of how you set it up. So again, today, what's your expenses? What's your income today? What are you doing over time with your investments and your debt? And then the third piece is what am I doing to protect my financial plan, that's insurance. The second big takeaway is following your percentages of your income, it will make your life extremely, extremely easy. And then to your key point, caring. This stuff should be complementing your life not dictating it. And it should be easy. And again, that's one of the hours that retirement of it for a PT when I decided, yes, I'm going to launch the company. And the main reason was because I was like, I always wanted to invent something in terms of technology to help people like, but I'm not. I can't like I'm not Elon Musk, I'm not gonna build neuro link or some of these other companies, right? It's not gonna happen. But I know finances. And it's like, okay, well, if we can develop a technology that reduces the amount of time you need to think or stress about money, that means you can do what you're supposed to be doing when you're going to school, like being a PT. Or if you're an engineer, and you're the next Elon Musk, you don't have to think about money because that part of your life is actually taken care of. So it's my small contribution, if you will, to the technology world. Just funny because everyone's like, you're a founder of a technology company. I'm like, I'm a finance guy. I know algorithms. I know math, and I know money. And I'd like I give it to coders and engineers, right? They do it. Right, right, right.

24:31

Hey, listen, that's why it's we always work better as a team, right? It's hard to do everything on your own, if not impossible. And now where can people find more about all of this info and how to sign up and how to start using this?

24:45

Yeah, so Bostock comm just go on build, your profile is free to go on and you can build like all the tools are accessible to you to build your plan. You can schedule a call with a coach which we highly recommend because this version of the technology We built specifically for people to actually call us and have them help us walk you through the technology to make sure you're using it correctly. And then as we grow, we're building out more and more automation. So that way, it's easier. And then once you want to sign up and say, This is the plan I want to do, that's where you start the subscription and go from there.

25:19

Perfect. All right, so that's fit bucks fit bu x.com. Yep, you're right. All right. So before we end, before we wrap things up. Last question, I asked everyone, and that's knowing where you are now in life and career, what advice would you give to your younger self? I know you've answered this question before answer it again, come up with a new piece of content, you get to say more advice to your younger self instead of just one piece.

25:47

Yeah, this one, I touched on it earlier, and I can't stress it enough as focus. You know, I'm the type of person that like I was at CSM last week. And I pretty sure that I wrote down like seven or eight business ideas. And I'm the type of person that just wants to start working on everything. Like, I used to joke around with my wife. I was like, you know, this was back when I was doing my investment trading. I was like, if I come up with something, I will literally be up for 72 straight hours researching this and figuring out if it works or not. And sure enough, the very first time like, I came up with something, I stayed up, I was on our 71 I thought it was gonna work. And then our 72 is when I found out that it will work. But focus is we're so distracted with things. We're so distracted. You know, that's one of the behavioral things I'll share is like, when you start saying, This is what my focus is, and you have a fundamental reason of why you're doing it. And it's not because you're, you think you're gonna make a lot of money or you think you're gonna do this, but you have a real fundamental, real reason why you're doing it. Focus actually becomes very easy. Like you no longer care about watching TV, like I'm a big sports person. I haven't watched sports in about eight years. Just because there's like, I won't play I was watching a football game. I'm like, Well, this sucks. I'm wasting four hours. And the game's only an hour and a half and watching commercials. So let me TiVo it. And I started TiVoing. And I'm like, wow, they're still wasting an hour watching this thing. Like, I'd rather be doing something else, which I stopped watching sports. And so it's like, if I could go back, I just think about it. Like if I had that same mentality when I was like, 20, instead of getting that mentality when I was 28 or 29. I'm like, my life would be looking a lot different right now. So focus, focus, focus, focus.

27:36

Great advice. Joe, thank you so much for coming back on the podcast, giving us great tips for financial planning. I'm sure everyone will take a lot away from this podcast. So thanks so much for coming on. Yeah, thank you for having me. Anytime and everyone. Thanks so much for tuning in and listening and have a great couple of days and stay healthy, wealthy and smart.

Today, Lorimer talks about his many streams of research, assessing cognitive flexibility, and his MasterSessions. What is cognitive flexibility and how does it affect pain?

Hear about the social determinants of pain, COVID’s impact on Pain Revolution, the complexity of chronic pain, and the responsibility that comes with doing pain research, all on today’s episode of The Healthy, Wealthy & Smart Podcast.

Key Takeaways

• “One of the biggest determinants of your health in the US is your zip code.”
• “[Cognitive flexibility is] the ability of your system to change its behaviour when the task requirements or conditions change.”
• “If you’re going to label something, it should be what it says it’s doing.”
• “[chronic pain] is one of the most burdensome health conditions in the world.”
• “There’s genuine, realistic, scientifically-based reason to hope things will keep improving for people with chronic pain.”
• “Love and be love.”

More about Lorimer Moseley

Lorimer is Bradley Distinguished Professor at the University of South Australia. He is a pain scientist, clinician and educator. He has made seminal contributions to how we understand pain and why it sometimes persists and has developed treatments that are now considered front line interventions in clinical guidelines internationally.

He has authored 370 research articles and seven books. His contributions have been recognised by government or professional societies in 13 countries.

In 2020, he was made an Officer of the Order of Australia for distinguished contributions to humanity at large in the fields of pain science and pain medicine, science communication, pain education and physiotherapy.

He lives and works on Kaurna Country in Adelaide, Australia.

Suggested Keywords

Healthy, Wealthy, Smart, Physiotherapy, Pain, Research, Cognitive Flexibility, Chronic Pain, Perception, Responsibility, Recovery,

Notable Mentions

Caitlin Howlett.

Dan Harvie.

Pain and Perception, by Dan Harvie and Lorimer Moseley.

Epiphaknee, by Lorimer Moseley, David Butler, and Tasha Stanton.

Participate in research (it takes just 20 minutes).

MasterSessions.

To learn more, follow Lorimer at:

Website:          https://www.tamethebeast.org

                        https://www.painrevolution.org

                        https://people.unisa.edu.au/Lorimer.Moseley

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Read The Full Transcript Here: 

00:03

Hi, Lorimer, welcome back to the podcast. I'm so excited to have you back on.

00:08

Good. Thanks for having me.

00:10

And so today we've got a lot to cover, because we are going to be talking about some of your current projects, new developments that maybe happened since 2021, where you had well over 30 publications. So you had a very, very busy year, I would say. But as we go, as we kind of go through and talk about some of the things that you're working on, I just want you to let me know if there's anything that you're like, Whoa, hey, I can't talk about that. Or if there is reason to be a little vague, because things might be ongoing trials and things like that. So we'll definitely keep that in mind. Now, let's say you've had a lot of publications over the last year, what are some current projects, or discoveries or developments that really stuck out for you in your most recent research?

01:08

Ah, nice question. Um, one of the things about being a scientist in a clinical field is that here, it's not often that you get a revolutionary discovery, it's quite unusual. So what I think the things that I'm most excited about are not, not so so much particular papers, although there, there are some really tiny phones, there's one that's not published yet, but will will be out in the next couple of months that I'm particularly excited about. And I can allude to that. But I think sort of like these, these streams of research in which I'm involved that are turning me on a bit, the moment and one of those is a continuation of the whole explain pain thing. But over the last sort of four or five years, we have discovered, we've looked really closely at but at the the outcomes of clinical practice in where people are delivering great educative interactions and, and I've had a fair degree of, of influence over them. So I feel really confident that I did, they're supposedly doing well. And those data from a big cohort of people suggests that, in about half of the people with chronic pain, they see they have this shift in understanding of the problem, but a real flip. And it's in a predictable way, you know, shifting towards really deep in your belly can conceptualizing pain as a protective feeling that's being produced for a reason. And we need to work out what that reason is, and it will almost well, it will certainly not be a single reason, there'll be all these little contributors. So real flipping, understanding. And, and I guess, understanding that as pain persists, the system becomes over protective, and, and really embracing that as a reality. And that's a really hard thing to do. But those those half of the people who do it has great outcomes a year later. That's a for me, that's a really exciting discovery. The half of the people who don't don't have great apples. So for me, again, it's a really exciting discovery. The problem is that we're only winning in half the people. You know, we're only nailing it in half the people and the interventions good across seems to be good across everyone. So clearly, our markers are what's good intervention, they're not accurate. So my gut feeling about that was not accurate. So we've been looking deeply at how, how can we expand that group from half to bigger and, and unexpectedly for me, doubling down on the on the criticality of learning. So I've been learning a lot about learning. And that's been infiltrating our research and infiltrating the whole way we go about helping people with chronic pain or at risk of chronic pain. And so I'm really excited about that. And we're seeing its scientists talk about seeing a signal amongst the noise. And in chronic pain, there's just so much noise, right? Because chronic pain is this truly, in my view, truly bio psycho biggest and it's more or less social thing. And if we can intervene and see a signal in that group, that's a really exciting development. And

05:03

I, I'm more excited than I was maybe seven or eight years ago about the potential power of of new and better ways to get people to give people understand. And I started banging on about this in conferences and stuff maybe three or four years ago. And I have this slide that that is intentionally slightly provocative, particularly to the physical therapy world. And that sort of pain science education world, I think in in the US the brand name as popular as paid in neuroscience, education, p and E. These are all brand names, right? PMA expired pain is a brand name. So I like to avoid the brand name. So I call it sort of pain science education or modern pain education. So this slide is meant to be slightly provocative, in say, has education become the objective, instead of learning being the objective, and I think for me, education became the objective. And that was a mistake that, that I made. And I think my research made that mistake, and my clinical practice probably made that mistake. And my own outcomes over the last 10 years, and I get I keep really tight audit data, I can see the benefit of my own development as a, as a clinician, educator, and probably as a human on outcomes. So I'm excited about that, for sure. And I can give a little, a little teaser to the paper that we expect to come out the next couple of months in a big journal near you, which looks at a clinical trial of chronic back pain, where we have done two things that I think are really unusual for our field. One is we've tested, I think, a new complex intervention. And it's made up of less new interventions, but they're all sort of put together into a package if you like. And the other thing that was different that we did that, that are Yeah, I think I'm really proud of the team led by James McCauley is the senior author on it. And Ben once and I were important in sort of formulating the treatment, but Ben's been really critical. But we were all very keen to make the control group the best placebo intervention, we could. So we put a lot of effort into credible brain targeted treatments, matching the educative component. And testing whether people had different expectations or perceived credibility or beliefs about whether they are in treatment or not. So from my perspective, it's a very tight trial. And James and I were fully expecting that we would not see a signal in this. But we would be interested in secondary analyses which tell us mediating effects like what, even though there wasn't an overall effect, where what worked, what what might have been helpful. So that's what we were expecting, but in fact, we saw a clinically important signal. And that's very unusual in back pain trials. It's if you have a control group where you've got a waiting list or usual care, or you've gotten there's been a couple of trials published slightly, or you've got open labeled saline injections, you know, these treatments that will have some sort of effect, but they're no match. Right? So you're not really asking, are the particulars throughout this treatment? Important? All of those treatments will show a signal they all they always do they show exactly the same signal. I've done those randomized control trials. So that's one thing, you can design a trial in a way that you'll show signal. But it's a bit meaningless to us as real world clinicians. Or you can design a trial that we would call an explanatory trial that says, Okay, we've kept all of these things the same in the two groups and the things that we kept the same were as much of that nonspecific therapeutic alliance engagement, credibility expectation, which, which I think is a big part of the whole pain science education thing. So I do think we have to monitor that. You might hear my dog the other

09:38

room. Right. All right. We're pet friendly around here. What's exciting

09:42

about that is that it means there's some sort of delivery bandwidth to be won, I think it might be this new piano that I discovered even better. Yeah. So anyway, so that will be coming out. I can't say anything more about that, but, but it's a really exciting development. And we've got we've got a few trials that are testing versions of these sorts of things for for different conditionals. But uh, going at the moment and the way we're constructing the education component and integrating it with the movement and loading and anti inflammatory component. So that is three pronged approach. Really exciting for me, as I, you know, I've been doing this for quite a while that feels like, I still feel like a kid. But, you know, I have been researching for a while. And this is a really exciting time, I reckon, in the chronic pain world, because I think we're starting to chug forward again, I feel like the field was stalled a bit. But jumping forward. That's one thing. And then then on the other other side research streams, one of our team called Dr. Emma Karen is doing really difficult and really important, work really well investigating the influence of social determinants of health on chronic pain outcomes. First focusing on low back pain. She's published a couple of systematic reviews, and mixed method study on that, that is pretty intimidating. For those of us trying to move the the outcomes in a positive direction, because as we were talking about before, caring that the social determinants of health are very powerful, and they're powerful in back in back pain and pain outcomes. They're really hard to shift, you know, they're very hard to do much about so. At our field, the pain, field musculoskeletal, the the sort of arthritis field has or has engaged with, it's way better than then the non Arthritis, Musculoskeletal pain, pelvic pain, Fibro fields, we, you know, it's remarkable how little attention, it gets the biggest social and when we talk about the biopsychosocial model, we nearly always conceptualize that as a smallest session and the people around you social, which is important. But we haven't really integrated the biggest social Yeah, the world in which you live in your access to health care, illiteracy. Poverty.

12:29

Yeah, that sort of stuff. Absolutely. And I think you kind of hit the nail on the head as clinicians, oftentimes when we talk about the bio psychosocial, we think of the socials, what's your support system at home? You know, do you have, you know, can you get to, can you get to therapy? Do you have access to therapy? But what we're not asking is, do you have access to other medical care? If you need it? Do you have access to fresh foods and vegetables, which we know can play a part in, let's say inflammatory responses in the body? Do you have access to a pharmacy? Do you have access? I mean, all of these things make a huge difference, you know, or do you? Is your social part of that bio, psychosocial? Are you working three jobs and raising children and not having time to fit some of this stuff in? Right? So social part becomes a really big S for a lot of people. Certainly in the United States, like I said before, one of the biggest determinants of health of your health in the United States is your zip code.

13:37

Yeah, it's remarkable.

13:40

So social determinants of health is is high priority. And I think maybe people shy away from it, because it's can be so overwhelming. So I don't know what you guys are finding research wise, if there are way and how you can address that?

13:56

Oh, it's it's overwhelming, for sure. And I totally understand why there is a reluctance to go there. And there are also I think there's very complex ethical considerations about going there. We've we've been planning a study in the northern suburbs of Adelaide where I live, which is an area that's really different to the say, the inner suburbs of Adelaide with respect to all that sort of predictable social determinants. But one question that we've had to look in the mirror about is if if we develop this so we're working on developing a screening tool. If we start to identify people that have significant unmet social needs, and we can't do anything about it, is that is that a ethically defensible position? Yeah, we were able to say to people, okay, we know what the problem is, you know, this, you can't have because we got no mechanism Have of meeting that need. So it's quite a challenging area to move into. Because if you if you imagine that the understanding and overcoming persisting pain is a very slow step by step journey. And now we really have to imagine that instead of going in a straight line, we're almost going in a circle, and we're making slow step by steps of the entire circumference of the circle, you know, and you move a little bit, then you have to stop and move a little bit more somewhere else. Otherwise, you're going to break. And the people who suffer when you break will be the same people, you know, the, the more vulnerable people. So it's a really challenging field. And yeah, I can't, I'm excited to be getting dragged along by Mr. and her colleagues on on this. But I'm also so impressed with how, how robust the approaches to it. So yeah, there's a couple of her papers out already and more, more coming. And I think there'll be really influential in the field. Because no one there are people there. There are people who are engaging in this, but very few people are thinking to themselves, I'll take on that challenge. Yeah,

16:28

yeah. Very, very difficult.

16:31

It's relevant to it's really relevant, or I guess my interest in it was sparked by our work with pain revolution, which is an outreach project program for rural areas. And it sounds like it's similar in the US. But there's there's areas in Australia not far from big cities, what we would call a big city of Adelaide a million people. There's areas two hour's drive from Adelaide that cannot get a GP or a physio, or a psychologist or an occupational therapist, to worth it. And they've got, you know, wanting four of them have a persisting pain problem that affects their lives. There's no, what do we do? What do we do about that. And so pain revolution is, is really trying to ultimately build workforce capacity. In giving people health professionals have some description, when I care what description, in fact, we were, were looking for money to try our non healthcare professional, being coached and becoming a rural coach. But the idea of that is that if people we know I think from other areas of the pain field that if if a healthcare professional of any persuasion, understands deeply contemporary pain, Science and Management, and takes a defendable, scientific, and now evidence based approach, then outcomes can be better for sure. And outcomes will be promoted by engaging in in care locally, the moment the only model we've got is a fly in fly out model, which is where, you know, the health professionals go from the city and spend a day in the country and come back a month later, in my view, of very limited benefit. Or we've got a full five model where the patients, that consumers come down to the city. And in many cases, that's a 810 12 hour drive. Get an assessment? Yeah, there's no there's no way of training those people or providing effective care for these people. So yeah, yeah.

18:55

And I, you know, yeah, no, no, you know, it this, this conversation about this kind of rural outreach and, and maybe training someone who's not in the medical field, reminded me of a documentary that I saw, Oh, gosh, I can't remember the name of it, if I can ever And i'll put it in the show notes. I can't remember it right now. But it was on it was more psychology based around loss and trauma. And there was a woman in Africa, who was not, not a psychologist, she was not trained. But she, she, I think she was trained in some basic coaching skills, but she lived in the community. And people there were more likely to go to her because she understood the community. She was part of the community and they had really good outcomes. So I'm wondering even if training someone who is not a medical professional, but if it's possible to train them even in you know, you don't have to be there in person, but would that person because they're part of this rural community, maybe have better results and someone just flying in for the month and flying out where you have someone who knows the community understands the struggles, and maybe has known some of these people their whole lives. You know, we talked about therapeutic alliances and trust and beliefs. So with people they're more likely believe someone who's part of their community than someone who's doing a fly in fly out. I don't know, it just reminded me of that documentary.

20:24

Yeah, I totally get that. And I guess we were really embracing that in, in one aspect with pain revolution, because we're training rurally based healthcare. And that was the impetus you know, they're connected to their communities and their communities are really well connected more so than certainly in Australia, in the cities. You know, you're the physio, if there is a physio will be on the sideline at the Netball day or the football game, way with the consumer, you know, these, these people's normal lives and accessibility and those things that I think reduce the power differentials that that contaminate a lot of healthcare interactions. Was it a part of our drive to drive pain revolution rurally, to tap into this already, and you know, the vision that we state, the pain revolution is that all Australians and I think we're going to change that to all people will have the skills, the knowledge and access to local resources to prevent and overcome persistent pain. And that's the real emphasis that we embed the knowledge and skills locally. And, you know, that's, you know, I've been talking to 1010 years about recovered consumers being coaches, not the healthcare person, but recovered consumers, because they have all this knowledge and expertise that no one else can have. Right.

21:56

They're very deep understanding of pain.

21:59

Absolutely, yeah. And pain, and not not only the lived experience of pain, but the lived experience of recovery. And I think that's a untapped massive resource. But there are significant regulatory medico legal barriers to us just pushing forward on that, that we're still negotiating. So that's yeah, that's been at least a decade. My perspective. But paint ray of is is so exciting. It's, it's really cool. Like, we are doing it on a shoestring. And I think we now at the end of this year, we will have, I think we'll have about 35 Local pain collective. So these are networks of healthcare professionals around geographical regions that get together, learn more about how pain works, and the best ways of treating it collectively problem solve pain, rave feeds them. curricula, but really, it's a collective problem solving facilitated group. And yeah, I think the panorama was responsible for delivering around about around about 400 community outreach sessions, amazing Australia, in the middle of COVID.

23:17

I was gonna I was gonna ask, How has COVID affected? What pain revolution has been able to do, let's say last year, as opposed to previous years?

23:29

Yeah, it's, well, it's had its impacts, for sure. And depends where you live in Australia. So two of our states have had a longer period of of living in a COVID world I guess. And in those places, there's there's been no face to face. stuff. They are 2021 outreach tour that we do. So we run this circus that gets a lot of attention raises a fair bit of money on our level of what a fair bit of money is, it's got in the commercial sector be like someone's bonus for the week. But in our sector, it keeps us alive. And we go from town to town, and we run these public outreach and health professional outreach events. We're all dressed up in library, we ride our bikes, and it's all this cool thing. And that's part of a wider program with two other projects that dovetail into that dedicated to the region. And we didn't run that in 2021. And we won't run that in 2022. And that's a big hit for us because it's our main fundraising Avenue. So that's that's a real challenge. Some states in Australia have had basically no COVID And one state still basically there's no COVID Western Australia they They pay us closed to the rest of Australia in the world. And I think they're aiming to reopen in February. Tasmania has recently reopened and they're starting to get cases. But now we're where I live. We are, we're at the beginning of our wall of Omicron. And we really don't know what this year looks like. So we don't have the experience that a lot of places do. And we're very grateful for that. But we also clearly like deer in the headlights at the moment. Federal governments are going everything. Rules are changing all the time, we and you know, we're not as prepared as you would expect us to be having had a month's notice. So that will impact pain revolution for sure. The we're a really small outfit we have I think we have 1.5 full time equivalent staff delivering hundreds of programs, or events, and we're very resilient. And yeah, well, yeah,

26:11

we'll you'll get this done. And And if people want more information, they can go to pain. revolution.org, correct. Correct? Yes. All right. So pain revolution.org, if you want more information about what pain revolution is doing, and maybe how you can help or contribute, if you so if you see if it if it aligns with what you believe in, then I suggest go for it because it is a very worthy cause for sure. And now, it's kind of switching gears a little bit something that we were speaking about sort of before we hit the record button here. And it's a concept that I had to kind of look up a little bit before our talking here. And it's that concept of cognitive flexibility. I think it's interesting. I think it's worth talking about. So I will hand the mic over to you to sort of talk a little bit more about what that is, and how does cognitive flexibility fit in with people living with pain and maybe with practitioners treating those living with pain?

27:21

Yeah, well, thanks. And again, yeah, I feel like I don't actually actually do much of the good work, it feels a little bit like because this work is has been done by Caitlin halat, who's a PhD student about to finish and has a background in psychology. We embarked on a new direction probably three years ago, with with a really sensible prediction, I think that possible contributed to not recovering after an acute episode of pain based on if people familiar with Bayesian or other predictive processing models, based on the idea that the outputs that we generate predictions and the system is influencing itself according to predictions, then we need to update the internal models of the models in order to resolve so if I was to cover that really quickly, if we, if we said, when you bend over and you don't have pain, that what what could be happening there is that your brain predicts that this will be safe, your brain produces a feeling that's consistent with that mn let's say you tweak the annulus of a intervertebral disc or something, you get no sensitive data that are that are within the sensory load. And I like to say within the Tampa symphony of Dallas, extraordinarily complex, beautifully evolved system of of information about what's happening in the tissues, we get data that says this is not what I predicted. The evaluator for this is not what I predicted. So we update the internal model to say the back is vulnerable in some way, let's say. And then the new prediction is, well, let's make pain. And let's influence the system differently. And then if we go in the other direction, and every time we've been able to get this nociceptive data within the symphony, and then one day you don't I know you've been over and and you don't get that. And now the theory is the system detects that error says Hang on. That's not what I predicted. So it updates the internal model to say the back is less vulnerable. And now your brain doesn't produce as much pain or produces no pay, and then you've recovered fantastic. So one potential barrier to recovery according to that theory is failure to update yourself. Title model. And and that should happen. If, excuse me, that shouldn't happen if you if you don't detect the error. So if for some reason you don't, your system doesn't detect that the predicted data, the predicted data, which was not receptive, in part hasn't been hasn't eventuated. And therefore you don't update your internal models. So on the basis of that, we became quite interested in this broad field of flexibility, cognitive flexibility, which has been defined in many ways. But I guess the way that we were thinking about it was the ability of your system to change its behavior are when the task requirements or conditions change. So in the language of have that sort of Bayesian idea, and to your ability to update your internal model of things. So we started digging around in this field, or Kaitlyn really started digging around in this field. And often in a PhD, you'll start with a systematic review of the literature on a question that's most most aligned with what our hypothesis will be driving. So. So Caitlin took on what we thought would be a reasonably straightforward job to review the literature in cognitive, mental and psychological flexibility. So the barrel phrases that are used, often interchangeably, particularly cognitive and mental flexibility. And with the question that would help us determine which is the best way to assess it's what's the best way to assess flexibility. And there's two broad approaches to assessment. One is self report, questionnaires. And they have they were developed out of a line of research, starting with personality tests in the 1960s. And that's this sort of this long line of stuff. And someone I can't remember who but in the, I think in the 60s or 70s.

32:18

proposed that I think it was empirically based but propose that good communicators perform the answer these sub questions in a certain way. And that research would describe them as positive and flexible people and are good communicators. And then that infiltrated the field. And we eventually got to this situation, we've got cognitive, cognitive flexibility scales, things like that. The CFS or, and there's a few of those, completely independently from that was the development of behavioral tests. The most famous and most common is a thing called the Wisconsin card sorting test. In that, in that test, you you sort cars according to one of three criteria, shape, shape, or number, I think, sorry, shape, color, or number. And the rules for sorting change, and you only realize that change when you make an error. Yeah, that so you put a card in a certain pile, and the tester or the machine goes about anything, what should work, and you have to work out what the next set of rules. And the people doing these studies somewhere in the 80s. Or maybe it was a bit later than that, call this cognitive flexibility. So we've got two independent lines, joining a company flexibility, and then that's then all the whole field just went nuts cross contaminating and all that. So Caitlin has now published and once just been accepted last week, to systematic reviews that are massive. And she had to contact authors for nearly every single one of these studies to get data, asking the question How well do those two approaches to testing 100 Flexibility correlate? Because if the system the same thing that should correlate quite well, one of those systematic reviews is in Healthy People. And one is in people with a diagnosis clinical groups. And in both of those studies, there is absolutely no relationship between those two approaches.

34:39

So you have two different tracks on how to assess cognitive flexibility, and there is no correlation between them.

34:47

Not at all. And actually a lot of the tests, there's no reliability data for them. Now, there are some cognitive psychologists who won't be surprised at that finding. And they're the informed one Who, who have been working in this field? I guess. But for people like Caitlin and I and the rest of the team on this project, where clinically, it's such an attractive hypothesis, right? Like if if people can't change their, that if people don't easily change their beliefs, explicit beliefs, their implicit beliefs about the vulnerability of their body, what pain means that the targets of pain, science education, then we know those people who don't, don't change some of those targets of pain science education, don't do as well, when we know that. So it's such an attractive hypothesis that they might be less cognitively flexible. But the barrier with hit is so how do we find out? Because we don't actually know what any of these tests are actually.

35:56

What are they actually test

35:57

measuring? Yeah, yeah. So so the direction for that, and I've asked for money haven't got it yet to do that is to devise a a new way of assessing the ability to change your decisions when there is some sort of risk evaluation involved, because I think for, for pain, I think we talked about the meaning of things being important for painting. And I think one way to distill the meaning is about just a risk profile, that every nanosecond, our system is evaluating risk, and its risk, that determines our feelings. And I would categorize pain as a feeling bad. So my anxiety, fear, fatigue, lead to the toilet, lead to a thirst, all these things, in my view, feelings generated on the appraisal of risk. And, and if we don't have any risk, in an evaluation of our ability to change your behavior, under changing circumstances, and I'm even, I'm nervous to use the phrase cognitive flexibility now, because I know that whoever he is that there are three or four main ways that you understand that. And some of those would be totally different from otherwise. So I would prefer to say, if we keep assessing the ability to change your behavior, according to changed demand or environment. without risk, then I think we might not capture what we need to capture for understanding a potential contribution to the development of chronic pain or recovering from initial pain. So so that, you know, that was one of those, one of those PhDs where it's such an important discovery, actually, and and Caitlin's contribution to the field is very important. But it won't get the citation impacts and the Roth IRA. Because what the country contribution says is, hang on everyone. Why, you know, there are a whole journals dedicated to this. But what is it? What is it, we almost have to go back and start again and say, Okay, let's get really clear on what we're talking about. Let's use these phrases. Anyway, so but that's relevant to the very first question, what are you most excited about? I guess I'm, you're tired to be excited about, clearly, deflationary discoveries like that, but they're so important. They're really important, and they're harder to publish. But they shouldn't publish, in my view, they should publish top journal. In your face. Journal. Yeah. Well,

38:49

it's, it's like, yes, it's sort of this deflated response, if you will, to, to the systematic review, but it is important because it's important to use the right words, and to if you're going to label something should be what it says it's doing. Otherwise, why are you doing these tests? And why are you you know, labeling someone as very highly flex cognitive flexibility or low cognitive flexibility when you don't really know. And then exactly, so how do you then so then your treatment, I look at it from a clinician standpoint, how do you formulate a treatment plan around something that's, that's not accurate or unknown? So I think it makes it really difficult but it's it just underlines the importance of this kind of research.

39:41

And oh, go ahead. No, I was just gonna say I think that um, it Kayla's research doesn't doesn't tell us that these tests are uninformative. But what it does tell us is that we don't We don't know exactly what they what they mean. So that speaks to your point exactly Karen, that that. So what do we do about it? That's a difficult thing, because we don't actually understand them well enough, I think. But can I put in a plug for? Yes, a research project of Caitlin. So final project for a PhD that we desperately need participants form? Yeah. Because it's an online study. Okay. And it's, it's to do with this kind of flexibility. And we need people without pain, as well as people with pain. Well, that's a lot of types of it. But basically, everyone, anyone who has 20 minutes spare. It would be great if they just went and did Caitlin's experiment online. And maybe I could send you the link.

40:48

Yes. Yeah, you send me the link, I'll put it in the show notes. And also put it out on social media. So that girl can can take this online study. So if it's people with or without pain that takes in quite a lot of people, like you said, like, one? Yeah, so I'm assuming she wants a robust number.

41:11

We need lots. Yeah. Because we think the signal will be small amongst the noise. Yeah, but yeah, if we did it, and then ask one of their family members or mate, yeah, that'd be fantastic.

41:25

Yeah, I'd be happy to send you the way about that. Yeah, definitely do. And as I was, you know, as you were talking about this cognitive flexibility, or the ability of to adapt your behavior, and let's say cognitive strategies in response to a changing task, or to a threat or something like that, it, it always reminds me of this experience that I had. So most people who listen to this note that I had a very long history of chronic pain, I think you're well aware of that as well, about 10 years or so of neck pain, chronic neck pain. And it was this was a couple of years after I could say I was recovered, you know, of course, those times when you have flare ups and things like that, but largely recovered. And I was I was at Disneyland with Sandy Hilton and Sarah Hague. And we had waited in this long line, like an hour to go on what I thought was like a jungle cruise. You know, this very, like, get on a boat and cruise around the water kind of thing. Yeah. And we get up there. And all everywhere. Once we get inside, plastered everywhere was date, big danger signs, you know, the yellow dangerous sign, the red X, if you have neck or back pain, you know, this guy. And I was like, you know, so talk about a threat, right? So my normal behavior, and like, my hands were sweating, my heart rate was up, my eyes were dilated. My normal response, I guess, would maybe show my inflexibility would have been to find the nearest exit and leave. Yeah, yeah, get out as fast as possible. Right. And so I think, Sarah, and luckily, I was with two very incredible women who are very well versed in pain science, and I think I am as well, but when it's you, you're you're like, a big, you know, mashed potato, you know. And Sandy and Sarah just looked at each other and looked at me, and I was like, almost shaking. And Sandy's like, Okay, listen, it only tilts about 12 degrees, and it stops and goes, you're in taxi cabs, they stop and go, you're fine. It's this much of a tilt, you'll be fine. And then Sarah's like, yeah, and the person in front of us like six, you know, there's nothing over your shoulders. It's not that dangerous. And they kept playing down the danger. And so I did end up getting on it very, very nervous. And then I got off and I was fine. They were right. Then it allowed me to be flexible enough to then go on another ride after that. Whereas if I went with my original strategy, which would have been to leave, then I wouldn't have done anything else for the rest of the day. Yeah, so that threat, if left to my own devices would have gotten the, I don't want to say gotten the better of me, but I would have reverted back to the behaviors I had during the that sort of 10 years of living with pain.

44:24

Yeah. And, you know, I respect I respect both of those approaches where it makes sense for an organism when you see credible evidence that this is a dangerous situation to take a variety of action. Yeah, makes total sense. And I guess the, I think about the flexibility thing was evident, as Sandy and Sarah are problem solving with you gathering more data. And, and then your choice changed. That's the stuff that seems consistent with in quotation marks flexibility, you know that right? In the face of new data. So the new data, it could work both both ways. And I think there are some people with persisting pain problems where they behave the same way, even in the presence of significant danger cues. And that works against them because they the danger, for example, right, right. Yeah, can work both ways. Yeah, I think I think there's a rich there's there's a rich stream of, of understanding in there somewhere for us to, to uncover. But it does feel a little bit like that's going to require the the archaeologist among us to get out. This is a metaphor, obviously, to get out our brushes and blowers and slowly reveal what that stream of gold is, as distinct from the earth blasters obviously just want to revolutionize in a in a rapid way. And I fit more into the second category. You know, I lose steam on the very slow, the finite, made tool discovery thing. I'm very pleased to be around researchers who are excellent at that. Yeah, it's not so much.

46:25

And I always always think about that. What did I think David Butler said they were what did he call them? Oh, I don't know why I'm blanking. I have the book right here. Super. Ah, I'll think of it. It'll come up. It'll come up later. It's from explain pain supercharged, you know, the graph and everything leads. So if you have more, yeah. Dangerous safety Sims. He called them Super Dungeon Sims. Yeah. Jensen says, so he was like, Oh, I think Sara and Sandy were your super Sims at that moment, which is maybe what you needed? Maybe? I don't know. But like you said, it would have been just as valid as if I was like, I can't do this. It's too stressful. You know? Yeah, it's too dangerous. Too dangerous. Yeah. Because those

47:14

were the cues that you were, you're getting? Yeah, yeah. And just take it off. I always say it's important in a situation like this to take a moment to reflect on the contrast between the resources available to you in that moment. Right. Which, okay, Sandy and Sarah? Unique, exceptional, exceptional resources. Like, yeah, scrub exceptional. Yeah. But even without them, take your own resources. You know, you're informed, you're, you're resourced with intellectual and other capacities and understand how things work and biomechanics, you've got incredible resources, and then just take a moment to reflect on the contrast when you and most people? Yeah. And is it? Is it any? Is it any wonder at all that people face those situations? And yeah, there'd be a lot of people with chronic neck pain, even if they're on a recovery journey, who would get into that situation and their neck pain would flare up, they wouldn't even do the rod, that's right, leave and they kind of flare up and, and the rest.

48:24

And everything that comes after that, go back

48:27

to the doctor, get a new script, you know, and we do we attempt to, or they I think there's a tendency in our field to, to look, look down on that approach in some way. But, you know, as they are, that's substantive people. But it's totally predictable. And an excellent, excellent biological organism doing that. And we have to overcome, we just always have to remember the resource differential.

48:58

Yeah. Oh, that's, I never even thought about that. But that is so true. And, you know, it just goes to show you why people living with chronic pain, why the burden of disease is the high one of the highest in burden. It's the most one of the most burdensome health conditions and diseases in the world. In most countries. I mean, just low back pain alone, the burden of disease in the United States, I think is third, that's just low back pain. We're not talking about oh, a and other knee or neck pain, other chronic conditions. It's third Well, I mean, things might be different now with COVID. I don't know. But um,

49:38

you know, it's usually with disability. And they usually for disability metric for iPads way out in front. Yeah. Yeah. Yeah. I mean, on other metrics to use last year's lost, which includes mortality, then it drops down, right, just a bit.

49:56

Right, right. But you know, it just goes to show all of the things that you that you've been working on in 2021 and that you're excited about coming up, let's say in 2022 and all the incredible researchers and PhD candidates that you get to work with it just shows how complex and complicated chronic pain is. And that one or two sessions of pain science education in clinic cut it for most. No, absolutely. And it just shows the complexity of it and how difficult it is from a research standpoint, a clinician standpoint it is a tackle these problems on an individual basis and society as a whole. So I mean, keep keep doing that. Keep fighting the good fight, as they say.

50:40

That's scary. Because yeah, gobsmacked, nice weeks that I get to do this for a job and I get paid for it.

50:52

Yeah, speaking. And speaking of helping people around the world, you've got master sessions coming up. So you did this in 2021. So now you're doing it again in 2022. It's going to be May 13. To the 16th. Depends on where you live in the in the world. But you want to talk a little bit more about the master sessions, who's involved and what it's all about.

51:13

Well, yeah, that I mean, that was that was really cool. We sewing in 2021. No one's traveling, obviously. And noi group UK put, to me this idea of doing something a bit different. And it was really different like I was so that it it, we had two broadcasts, and they were timed friend friendly time zones for Europe or for the Americas. And then Australia and Asia sort of could go to one or the other with not quite as friendly. So for one broadcast, I was starting, I think at 6am. For another broadcast, I was finishing at about 11pm, something like that my time, but it was really well planned really well resource like they are, I'm in a studio basically, I was in that it was in the NOI group offices in Adelaide, but set up like a studio with a producer and sound people and a couple of cameras and Tim Cox working as emcee does a beautiful job on that. And we had a team of people downstairs ferreting around for the papers I was mentioning and all that sort of stuff. And it we were we didn't know how it would go because it was it's not like it's not like a zoom conference. Or, or cause it's really quite different from that there's a fair bit of interaction and it went, it went really well was really good fun, really well received. And the feedback has been overwhelmingly positive. I, I was joined by two people for 2021. social pressure Tasha Stanton came to speak. And she so she did a about a 30 minute talk. And then she and I chatted for about 45 minutes and and then we open it up to q&a and and that conversation between Tasha and I and then the other person who contributed that our two people were Mark Hutchinson, who's professor of everything. Adelaide University, one of the one of the exceptional communicators on neuro immunology, related to pain and defense, personal defense. And so same sort of format with him. And then with David Butler, who everyone knows, if you don't know, David, you, you're missing a key part of life you should have. So it was amazing. It was yeah, it was a really well, it's lots of comments like, I never thought online education could be like this and that sort of stuff. So that was really positive. So in 2022 in, and I think the dates you mentioned are probably the Americas day, so that we're doing to broadcast again, where we got feedback that we're responding to, so the schedule is changing slightly. Mark Hutchinson and Tasha are both coming back to do longer stints. And then we're also having in people with really interesting research and great clinical engagement. So for example, Dr. Jane charmers who's done some excellent work in pelvic pain. So she'll come and she'll do a talk and then we'll, I sort of interview them. So it's the massive sessions are a massive amount of work for me because I need to have my head around everyone else's stuff as well. So I can ask meaningful questions, but the, the feedback is is about how useful those conversations are as well. So yeah, so this Jen channels there's Haley leak, Haley leak has has started working with investigate what people who are recovering from paying value in learning about to publish one paper on that in pain, a beautiful paper, I think that I think should shift research direction of a few groups. Haley also has the probably unique among pain scientists brag point of winning the Australian survivor 2021. So she, she survived. And part of the reason for her survival, I think was her deep understanding of how pain works. And there was some great episodes where she there was one where she I think she was standing on like Pogi point things, Poles, they were all doing this with a with another thing coming slider down lower and lower for six hours.

56:08

And lead athletes x s as people have already fallen out and and so she's she's actually done an incredible job in disseminating modern understanding of pain to the wider community because they've all said, How did you do that. And she's able to talk about her understanding of pain. And pain does not mean damage pain is because it was a thing. So no wonder the host is making these comments like that they're trying to rev up my payment system. So incredible impact and she's got a high profile among the people who watch on Survivor on telly. So she's able to integrate that experience with her research. And she's very interesting person. So she's she's coming Sarah wall works doing really interesting work with younger kids. Looking at how how we can engage with young kids on everyday paints in a way that will help them be resilient later. So really fascinating work that she's doing. And then I'm on there as well. So I think I'll cover about half of the time. And it's great fun. Yeah. And you know, people go look at the reviews and all that sort of stuff. But yeah. Love people to to get involved in that. That's in that's in May. Yeah.

57:30

And is there? You may not know this, but is there like a cutoff date for signups? Or can you sign up like the day before? If you wanted to?

57:39

I think there's a right shift. Okay. I think there's an early bird, right. I think I actually don't know much about that sort of stuff. But they they do have to. I mean, the earlier they get a feel for numbers that they they're able to judge sure how to do it, because it takes a lot of bandwidth and all that sort of stuff.

57:59

Right? Yeah. All that behind all the behind the scenes production stuff. You're the On Air talent, you don't have to worry

58:05

Exactly. Worry about any of that. But But noi group, if they get annoyed by it, they'll learn everything

58:12

about it. Yeah, yeah. And again, I'll put the links in the show notes here. And we'll put it out on social media as well. So that if people are interested, then I highly suggest signing up because it what a great, what a great lineup. And it's not until May. So you have plenty of time to shift your schedule and try and figure out, you know, kind of block the time off so you can be part of it. And one other thing, I believe this is true, you can correct me if I'm wrong. But if you if you're in the Americas, and you you paid for it, you live in New York City, let's say I pay for I live in New York City, I can also watch the other, also get the recordings of the other broadcast.

58:55

That's correct. So you get both and you you don't have to be there live watching it in bed. But if you're not you, you're not engaging in the q&a and all that sort of stuff. Yeah, but you get access to both broadcast and you get access to the thing called the Padlet, which is it was an amazing resource from the first time because this is all of the stuff that the team downstairs is getting while the master sessions around. So let's say Professor Mark Hudson mentions this are really exciting new study from so and so which show this then someone downstairs will get that study put the paper on the Padlet. So it's some incredible resource as well. And they have access to that. I don't know for how long afterwards

59:40

Yeah, yeah, but you but you have it Well, it sounds amazing. And I think it's so great that this is probably something if not for COVID Maybe you would not have done and it's made a big impact, right so

59:54

and and when COVID no longer what it is I'd prefer to do it this way.

1:00:02

Yeah, yeah, amazing. Amazing. And now, I don't want to monopolize any more of your time. But is there anything that we didn't cover that you were like, Oh, I really want the listeners to know this or, or is there a big takeaway?

1:00:18

Ah, I think the takeaway is, it's really consistent over years, actually. Whenever I have an opportunity like this to chat, with such an informed and, and clever interviewer, like you, I'm always struck by how, how important people like you are for our community, because I see my role sort of knowledge generation and, and dissemination in sort of conventional ways, you know, books and articles and things like that. But we need people like you, to spread it, to play the critical role and getting it out to the, to the world in a way that's accurate and engaging and, and it's people like you who put in so much so much effort for your community. And whenever I think about takeaway, I just am reminded of of the potential benefit we can still bring to humanity by doing this chronic pain thing better. And we have made progress, know that we made progress. But it feels to me like were climbing up a really, really tall mountain. And now when we look back, we can see we've actually come quite a long way. But when you look ahead, there's still still a bloody big mountain. So all of these things would have hope. I think there's genuine, realistic, scientifically based reason to hope things will keep improving for people with chronic pain, that will people will have better outcomes. So that's my take home. But can I give a plug to a book that I'm an author on? Yeah, it's a self plug. But I'm not the main author. So Dan Harvey, a truly innovative scientist. And I don't say that lightly. There's not many innovators out there. But Dan Harvey is an innovator. And he's the first author on a book called pain and perception. And the Americans can get that through IPTp. Elsewhere, you can get through no group. And it's a I think it's a beautiful book. It's all about understanding through illusions, and sensorial experiences, more about how pain works, sort of like a coffee table, book waiting area book. The feedback has been fantastic. So yeah, I'm really excited to be involved with that with Dan. And I'll just mention another book that's available in in North America, but not in Australia. And it's called Epiphany. And test Stanton has joined Dave Butler and I to, to write a consumer focused book around the osteoarthritis.

1:03:17

And I will say, I, when I first saw this epiphany, it's not how you would normally spell epiphany. It's, it's, it's an what do they call it? It's an acronym an acronym? Yes. So it's explaining pain to increase physical activity in knee osteoarthritis.

1:03:39

Correct. It's spelled AP IPH a knee,

1:03:45

right? Yeah, very clever. Cuz I was like, epiphany. What did I say? Episode? I don't even know. What's epiphanies? And you're like epiphany. I'm like, oh, yeah, that definitely makes more sense. That definitely makes more sense. But yes. And we'll have we'll have links to all of this stuff, again, in the show notes. And, you know, one last question and talking about, you know, all of the work that you do that isn't in very important work, and it can impact not one or two people but millions of people living with chronic pain. So do you as a researcher, how do you deal with maybe feelings of overwhelm with the responsibility that that place is on your shoulders? Or do you think about that at all? Or am I just projecting what I would feel if I were in your position?

1:04:36

I think you're projecting. I don't, I don't feel overwhelmed in the slightest. I don't feel any sense of responsibility to humanity. That's, that's changed because of what I do. I feel I feel that I have a responsibility. I don't know if I feel I have responsibility. I want to use my resources and my knowledge and my skills, and my connections and my relationships to, to be the best Lorimar I can be if that makes any sense and, and the values by which I judge that are not at all on chronic pain outcomes. I'm a very sort of process driven person, I want to make sure that today I did the best thing I could do. And I don't have any illusion that I, I could use outcomes as a marker of, of how well I've lived my life. Because I just think there's too much noise for, for me to have a measurable signal in the world. So I want to make sure that in this moment, I'm being authentic and true and real. And today, I'm doing my very best, I do my very best. But I do that, because I like myself more when I'm doing my very best. But I feel any burden to humanity. That's different from the burden that I think anyone who grew up in my in my world and life with my skill set, and my influences would have.

1:06:24

Yeah. And I think that's great, universal advice for for anyone. And, you know, normally when we finish the show, I always ask people, What advice would you give to your younger self? So I don't know if any piece of what you said would be maybe part of that advice. But is there anything else that maybe you would give to a young a young Larmour? fresh out of university for first time University, not? Subsequent?

1:06:48

Yeah. I think that I would, I think there would be advice, I don't think it would be remotely relevant to my work, I think it would be love a beloved, look for that, and express and, and value that with the entire depth and breadth of your being. And for me, that includes being a neuroscientist and paying dude with a extraordinary fortune of being able to do the things I enjoy doing for work and resonate with my values and all that sort of stuff. And ultimately, I think we're such a sophisticated organism that, that we may want to one one day discover that it's all just to love and be loved. And I don't know, great advice.

1:07:43

Great advice. Thank you. I'm sorry, not a sage. But no, no, it's amazing advice. I appreciate it. Thank you so much for taking the time out to come on and talk about all the stuff you have going on. And is there a place where people can find you? If I don't know they have questions, websites, something like that.

1:08:07

Yeah, so finding and I've got a homepage at the University of South Australia they can find out about personal pain revolution is doing some good stuff on Annabelle, what we're doing that I I get a lot of emails and I just can't possibly respond to them.

1:08:26

We're not here to give out your your emails, or your personal phone number or anything but I think pain revolution, Oregon and the University of South Australia are great ways for people to find out a little bit more about you because as we said, before we get on the air you are not on social media. So there is no Twitter handles or Instagram or tic TOCs none of that stuff. None of that. So people can find you again, pain revolution.org or University of South Australia's website or you can just do a Google go to ResearchGate read all your papers. There's plenty of ways to find out more about your research and and what you have coming up. So plenty of ways to do that. So again, thank you so much for coming on. I appreciate it.

1:09:12

Oh, thanks so much for having me. You're a legend. Keep it up.

1:09:17

Thank you. Thank you so much and everyone. Have a great couple of days and stay healthy, wealthy and smart.