Healthcare’s Leadership Trap: Why Promoting Great Clinicians Can Break Clinics

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Everybody in healthcare says they want

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better leaders, but Larry,

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your latest article makes a sharper point.

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Maybe healthcare doesn't have a leadership

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shortage.

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Maybe it has a leadership selection

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problem.

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So for years,

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platforms have rewarded people who can

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talk terms like EBITDA, scale, synergy,

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and then everybody acts shocked when

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clinical culture starts cracking.

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And that's what happens when you take

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maybe the best clinician in the room,

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the mentor, the culture carrier,

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the glue person,

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and you promote them out of the clinic

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where they were good.

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Title goes up, meetings go up,

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clinical impact, though, going down.

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So today...

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And this week we're asking,

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are we developing leaders or are we

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removing the people who were already

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leading?

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So Larry, let's start there.

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You open up with the idea that healthcare

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platforms think they have a leadership

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problem,

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but they misdiagnose it as a talent

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shortage.

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What do you mean by that?

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Yeah,

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so first let me give credit where credit

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is due on this.

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I learned this phenomenon when I was in

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high school and our star quarterback went

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down for an injury.

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And so what did we do?

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We took the wide receiver who was probably

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the best athlete on the team and we

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made him the quarterback.

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Well,

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what you really didn't realize is you're

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really replacing two positions at that

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point.

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And that's stuck with me for a long,

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long time.

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And I've just seen it in healthcare

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platforms all the time.

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When a platform's struggling,

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clinical turnover is high, for example,

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culture is deteriorating,

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your outcomes aren't getting what you

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want.

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More importantly, organic growth,

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which is the ultimate litmus test of how

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things are going is flat or declining.

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The first diagnosis,

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the first place we always look is we

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need better people.

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We need to recruit differently.

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We have a talent problem.

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And I understand why that's the conclusion

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because it's the comfortable one.

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It locates the problem outside the

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organization.

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Nobody likes to look internally.

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The people we hired weren't good enough.

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We need to upgrade, you know,

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all of those gains top grade.

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You hear these terms,

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we need to find better ones.

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What I'm arguing really is that the

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problem is almost never the talent.

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The PTs, for example, the hygienists,

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the nurse practitioners,

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the dentists coming out of programs,

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they're well-trained, they're motivated.

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They genuinely want to do excellent work.

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The problem is what happens to them after

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they arrive.

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And what I see is most companies don't

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have a talent management human capital

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machine.

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And so what they do is they don't

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have the correct compensation structures,

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the leadership of the people above them.

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or the development programs are the

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problem.

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And all these things contribute to an

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organizational design problem.

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And you don't solve organizational design

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by recruiting harder and harder.

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They get solved by designing differently.

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Same thing happens in sports.

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If you have a screwed up organization,

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you're not going to all of a sudden

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recruit better people and think that the

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organizational architecture is going to

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is going to change.

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So the misdiagnosis is very expensive

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because it sends you looking in the wrong

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direction.

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The talent was there.

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The organization wasn't built to keep that

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talent.

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Now you bring up Peter Drucker and his

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distinction.

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Management is doing things right.

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leadership is doing the right things.

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And I feel like I read that several

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times.

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I was like, oh, I should remember this.

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But where have healthcare platforms

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confused these two terms?

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Because they're almost used

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interchangeably,

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but they are not the same.

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No, they're not.

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They confuse them,

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they conflate them and where it happens

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almost everywhere.

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But the clearest example is really what

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happens when you do an acquisition.

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You acquire a practice or you get a

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new practice added on.

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The first thing that gets deployed

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is management infrastructure the systems

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the compliance frameworks the productivity

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targets the billing standardization all

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these kind of organizational you know uh

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connective tissue if you will um all those

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things if you're adding something you're

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buying them for the right reason they

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could be doing some of those things

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correctly

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We assume they're all either being done

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correctly or they're all being done

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incorrectly.

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What doesn't get deployed,

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what often doesn't exist in the platform

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is the leadership function.

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Someone whose job it is,

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is to figure it out.

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It's a very human orientation kind of

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thing where the organization is doing the

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right things after the acquisition.

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Are things running effectively?

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Are they running efficiently?

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Are the clinicians practicing to a

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standard of care that they were trained

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for?

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Is the culture

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Everybody wants their culture to be the

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same.

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Well, that's obnoxious.

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You want each team having their own

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microcultures.

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That's just the way that things happens.

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And the distinction matters because

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management without leadership produces a

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very specific kind of organization,

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one that executes efficiently on

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objectives that may no longer be the right

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ones.

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Healthcare platforms have become very good

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at executing efficiently,

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revenue cycle management for a while, HR,

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paying the bills on time.

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The question is whether they're executing

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on the right things.

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Are they executing on development,

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on growing the clinic organically,

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additional patients converting that to

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cash flow?

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That's a leadership function,

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and it's the one that most consistently is

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missing from the organizational chart.

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yeah well let's talk about this clinical

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leader extraction problem that you

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described it sounds like you just touched

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on it in terms of quarterback goes down

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you bring in the next best athlete which

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is wide receiver but here the best

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clinician gets promoted out of the clinic

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this isn't just a one-step problem though

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why is that so damaging and then in

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what ways is it damaging downstream

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Yeah,

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and I will say physical therapy platforms

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Non-physician platforms,

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behavioral health, physical therapy,

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certainly OT, are the worst at this.

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And let me describe the person we're

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talking about because I think it helps to

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sort of make that person a real person.

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So take somebody,

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take a gal who's the senior physical

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therapist,

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and let's say she's been at the clinic

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for five to eight years.

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She doesn't just have great clinical

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outcomes and rapport with her own

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patients,

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she's changed

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The culture around her,

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she's lifted everybody up.

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Her attitude,

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the way she conducts herself,

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the way she mentors.

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New graduates come in and they learn

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faster because she's built that.

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She's mentored and she's out in the

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community and she's doing all kinds of

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things.

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She runs the staff meetings.

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All of this thing around culture.

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She's just great at it.

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The patient who's not adhering,

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she knows how to do it.

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She's not just a great clinician.

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She's a force multiplier.

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Her presence makes the clinic better.

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Then what happens?

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She gets promoted.

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Not because they want to diminish the

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clinic.

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They think that's the only way they can

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develop her or keep her.

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Well,

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we can only keep her if we put

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her in a different position.

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The title changes, the pay goes up,

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which is real and matters.

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And she leaves the very room that she

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was at.

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What leaves with her?

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All the informal intricacies, mentorship,

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case review, the way she interacts,

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her friendliness,

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her relationship with patients,

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her relationship with physicians.

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But we think the only way to get

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her to be better is to move her

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to a different position.

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So again,

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we've taken the split end and made him

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the quarterback, or in this case, a she.

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None of that shows up on the dashboard.

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The dashboard shows you now got a new

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regional director.

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Sometimes I've seen with board certified

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therapists,

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you move them into these kinds of

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positions and you never really sit down

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with the person and say,

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do you want to be a clinician or

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do you cut out to be a leader

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manager?

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We just assume they want to be a

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leader manager.

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And that's not only wrong, it's damaging.

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Yeah.

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You had this line that I loved and

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I read it a couple of times.

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I think I even emailed you and said,

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this is it.

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Your line in the article was,

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it's like training chefs to read

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spreadsheets and then wondering why the

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food tastes like PowerPoint.

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And that's fantastic.

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So what are healthcare leadership programs

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training people to actually do well?

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Let's go to the positive side before we

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come back to how does it need to

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change?

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What are they doing well while completely

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missing the thing that actually makes a

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clinical team work?

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We've sort of touched on that,

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but what are the leadership programs doing

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well?

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So we'll get into leadership programs a

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bit,

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I think with some additional conversation.

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you know,

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they are training clinicians to be fluent

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in the language of the organization,

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right?

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P&L, EBITDA, scheduling optimization,

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productivity,

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how to read a variance report,

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how to run a performance improvement

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conversation, how to present, you know,

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as sort of a regional director.

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So we've taken this massive clinician,

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probably board certified,

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and we've taught them a new language.

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And you know what?

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I'm not against teaching financial

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literacy for clinicians.

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I think it's important that they

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understand that.

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I think it's important that they

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understand the insurance and the

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reimbursement system.

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All of that better positions them to

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advocate for patients and to be a better

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teammate.

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That's a legitimate skill.

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The problem is that the curriculum stops

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there.

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What the programs are really never

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teaching is how to build psychological

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safety into a clinical team,

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how to develop another clinician,

00:09:39.630 --> 00:09:41.511
how to have situational leadership,

00:09:41.812 --> 00:09:43.972
how to have culture diagnostic,

00:09:44.013 --> 00:09:46.153
how to take personality inventories and

00:09:46.254 --> 00:09:49.014
mesh them into a functioning collaborative

00:09:49.075 --> 00:09:49.475
group,

00:09:50.174 --> 00:09:51.895
how to preserve clinic culture through

00:09:52.296 --> 00:09:53.876
change, how to manage change.

00:09:54.716 --> 00:09:56.437
How to recognize sort of all these moral

00:09:56.498 --> 00:09:59.860
injuries before the person drops out.

00:10:01.001 --> 00:10:02.883
When you identify when somebody's probably

00:10:02.923 --> 00:10:03.503
going to leave,

00:10:03.763 --> 00:10:05.124
how to hold tension between the

00:10:05.183 --> 00:10:07.745
operational team and understanding and

00:10:07.765 --> 00:10:10.187
what I call normalizing discomfort and

00:10:10.227 --> 00:10:12.249
holding that tension honestly rather than

00:10:12.288 --> 00:10:13.210
just ignoring it.

00:10:13.549 --> 00:10:14.931
These are leadership skills,

00:10:14.990 --> 00:10:17.173
and those aren't part of that development.

00:10:17.513 --> 00:10:20.534
The development is teaching spreadsheets

00:10:20.774 --> 00:10:23.356
to get to the PowerPoint in a clinician.

00:10:23.797 --> 00:10:25.639
We want to teach leadership skills,

00:10:25.899 --> 00:10:27.340
tacit knowledge skills,

00:10:27.779 --> 00:10:29.260
what we call soft skills,

00:10:29.301 --> 00:10:31.462
these new smarts, as they're often called.

00:10:32.043 --> 00:10:33.624
That's the kind of programs you want.

00:10:33.964 --> 00:10:34.484
And right now,

00:10:34.504 --> 00:10:36.105
we're just not seeing that in the

00:10:36.144 --> 00:10:36.686
curriculum.

00:10:36.966 --> 00:10:37.846
It's promoting,

00:10:38.326 --> 00:10:39.947
teaching them financial literacy,

00:10:40.326 --> 00:10:41.868
empowering them to make those kind of

00:10:41.908 --> 00:10:42.469
decisions.

00:10:42.889 --> 00:10:44.429
And you've now taken the split end and

00:10:44.470 --> 00:10:45.210
made them a quarterback.

00:10:45.761 --> 00:10:46.643
So now I'm going to hit you with

00:10:46.863 --> 00:10:48.183
the hard question, which is why?

00:10:48.283 --> 00:10:51.245
Why are organizations continually moving a

00:10:51.306 --> 00:10:52.506
wide receiver to quarterback?

00:10:52.547 --> 00:10:55.950
Why aren't they growing people who want to

00:10:55.990 --> 00:10:58.152
play a position and leaving the people who

00:10:58.192 --> 00:11:00.513
want to do another thing well alone?

00:11:00.553 --> 00:11:01.754
Why are they trying to have everybody go

00:11:01.774 --> 00:11:02.495
the same path?

00:11:03.515 --> 00:11:03.696
Yeah,

00:11:03.716 --> 00:11:05.677
I think it's in general a compensation

00:11:05.717 --> 00:11:06.118
problem.

00:11:06.697 --> 00:11:09.399
If you look at the groups and the

00:11:09.440 --> 00:11:10.942
practices that do that,

00:11:12.078 --> 00:11:14.480
What they say is we will tap a

00:11:14.539 --> 00:11:16.600
clinician out at their salary.

00:11:16.660 --> 00:11:18.601
We may even have an incentive program.

00:11:18.962 --> 00:11:20.682
We may even give them a two percent

00:11:20.802 --> 00:11:21.823
a year raise.

00:11:22.244 --> 00:11:23.804
But none of that was shaped around

00:11:23.845 --> 00:11:24.806
clinical excellence,

00:11:24.966 --> 00:11:27.106
about understanding what they do in the

00:11:27.167 --> 00:11:28.407
bigger picture of things.

00:11:28.967 --> 00:11:30.388
And so I think it's a compensation

00:11:30.427 --> 00:11:30.769
program.

00:11:30.788 --> 00:11:32.229
And I think what happens is if you

00:11:32.269 --> 00:11:34.811
started paying clinicians more like they

00:11:34.850 --> 00:11:36.912
deserve, you would need less management.

00:11:37.511 --> 00:11:39.212
because they'd be so busy seeing patients

00:11:39.253 --> 00:11:40.393
and doing productive work,

00:11:40.832 --> 00:11:42.094
they have less management issues.

00:11:42.474 --> 00:11:44.375
Hire business people to do business

00:11:44.414 --> 00:11:44.754
things.

00:11:45.095 --> 00:11:45.394
And yes,

00:11:45.414 --> 00:11:46.215
you're always going to have some

00:11:46.235 --> 00:11:48.556
clinicians who sometimes are better at

00:11:48.635 --> 00:11:49.777
business and leadership.

00:11:50.616 --> 00:11:52.317
I'm not saying you absolutely should get

00:11:52.357 --> 00:11:53.057
rid of all of it,

00:11:53.398 --> 00:11:54.438
but you need to get rid of the

00:11:54.458 --> 00:11:55.859
whole notion that the only way you get

00:11:55.918 --> 00:11:57.620
better here or make more money is to

00:11:57.659 --> 00:11:59.600
be promoted into a position that takes you

00:11:59.640 --> 00:12:00.421
out of the clinician.

00:12:00.880 --> 00:12:02.761
And that's what I see happen all the

00:12:02.822 --> 00:12:03.062
time.

00:12:03.341 --> 00:12:05.102
The fix is not complicated.

00:12:06.583 --> 00:12:08.985
it is difficult to execute because you're

00:12:09.005 --> 00:12:10.947
now going to pay clinicians differently.

00:12:11.248 --> 00:12:12.969
You're going to pay your, you know,

00:12:13.009 --> 00:12:15.130
you're going to reward them in a much

00:12:15.230 --> 00:12:16.653
more compensated way.

00:12:17.133 --> 00:12:18.553
But, you know, other platforms,

00:12:18.614 --> 00:12:21.897
primary care, orthopedic surgery, dental,

00:12:22.238 --> 00:12:24.399
they all have migrated to that model.

00:12:24.419 --> 00:12:25.419
But for whatever reason,

00:12:25.461 --> 00:12:27.743
physical therapy and ancillary care

00:12:27.802 --> 00:12:29.364
models, they just don't.

00:12:29.783 --> 00:12:30.485
Yeah.

00:12:30.504 --> 00:12:32.606
Are healthcare platforms overmanaged

00:12:32.626 --> 00:12:32.726
today?

00:12:33.399 --> 00:12:34.580
and under lead?

00:12:34.820 --> 00:12:35.341
And again,

00:12:35.380 --> 00:12:38.364
management is doing the things right,

00:12:38.484 --> 00:12:39.985
leadership is doing the right things.

00:12:40.085 --> 00:12:40.725
And if so,

00:12:41.647 --> 00:12:42.988
what does that look like inside a clinic?

00:12:43.779 --> 00:12:45.159
Probably wouldn't have said that some

00:12:45.179 --> 00:12:48.341
years back, but now with AI and data,

00:12:49.120 --> 00:12:51.142
I actually think they might be

00:12:51.522 --> 00:12:52.322
over-managed.

00:12:53.442 --> 00:12:54.602
I mean, look at the clinics,

00:12:54.623 --> 00:12:55.923
they have metrics for everything.

00:12:55.942 --> 00:12:57.563
We have data for everything.

00:12:57.583 --> 00:12:58.024
It's like, oh,

00:12:58.063 --> 00:12:59.504
don't show me anything unless you show me

00:12:59.563 --> 00:12:59.884
data.

00:12:59.923 --> 00:13:01.524
Patients per day, cancellation rate,

00:13:01.605 --> 00:13:03.085
documentation, compliance,

00:13:03.164 --> 00:13:04.024
net promoter score,

00:13:04.424 --> 00:13:06.446
all these being tracked and reported.

00:13:07.046 --> 00:13:07.265
You know,

00:13:07.306 --> 00:13:09.106
therapists are getting their daily email,

00:13:09.147 --> 00:13:10.187
how many units they build,

00:13:10.206 --> 00:13:11.807
how many patients they saw, blah, blah,

00:13:11.827 --> 00:13:12.447
blah, blah.

00:13:12.888 --> 00:13:15.708
The management infrastructure has been

00:13:15.769 --> 00:13:16.590
pretty thorough.

00:13:17.669 --> 00:13:19.551
But what the clinic does not have someone

00:13:19.890 --> 00:13:20.811
whose job it is,

00:13:20.850 --> 00:13:22.772
is to ensure that the culture is intact.

00:13:23.172 --> 00:13:25.232
Someone who knows whether the new graduate

00:13:25.633 --> 00:13:27.393
is developing at the pace that it should

00:13:27.413 --> 00:13:27.594
be.

00:13:27.913 --> 00:13:29.214
Somebody who treats people like

00:13:29.333 --> 00:13:31.294
individuals rather than a collective

00:13:31.315 --> 00:13:31.695
community.

00:13:31.774 --> 00:13:32.475
you know, group.

00:13:32.816 --> 00:13:33.875
You're a physical therapist,

00:13:33.956 --> 00:13:34.697
you're all the same.

00:13:34.716 --> 00:13:36.077
Your personalities are all the same.

00:13:36.118 --> 00:13:37.698
You're a dentist, you're a hygienist,

00:13:37.719 --> 00:13:39.120
your personalities are all the same.

00:13:39.559 --> 00:13:42.341
And someone who really has to look at

00:13:42.361 --> 00:13:44.243
the plan of care completion rate and say,

00:13:44.643 --> 00:13:45.923
how do we improve this metric?

00:13:45.984 --> 00:13:47.184
What are the patients actually

00:13:47.625 --> 00:13:48.625
experiencing here?

00:13:48.666 --> 00:13:51.668
These are harder conversations and harder

00:13:51.687 --> 00:13:52.548
to execute.

00:13:53.089 --> 00:13:54.750
And they're much more difficult strategies

00:13:54.791 --> 00:13:55.370
to implement.

00:13:55.390 --> 00:13:58.014
But one of the key strategic undertones in

00:13:58.073 --> 00:14:00.596
business is that strategies that are more

00:14:00.655 --> 00:14:01.856
difficult to imitate,

00:14:01.876 --> 00:14:03.317
that are harder to execute,

00:14:04.315 --> 00:14:06.937
and that have sustainable competitive

00:14:06.956 --> 00:14:09.217
advantage in the marketplace will always

00:14:09.258 --> 00:14:12.200
have sustainable, you know,

00:14:12.240 --> 00:14:13.941
competitive advantage in the marketplace

00:14:14.280 --> 00:14:16.001
simply because their strategies are so

00:14:16.261 --> 00:14:18.783
difficult to imitate.

00:14:19.004 --> 00:14:20.705
And so there's a reward for doing it.

00:14:20.725 --> 00:14:21.985
It's a premium in the market.

00:14:22.024 --> 00:14:23.446
That premium is in growth,

00:14:23.907 --> 00:14:27.948
in valuation and in compensation.

00:14:29.269 --> 00:14:32.331
It's hard to show where that person exists

00:14:32.591 --> 00:14:34.173
on the org chart, though.

00:14:34.552 --> 00:14:35.813
They sort of have things that are not

00:14:35.854 --> 00:14:38.135
necessarily always in the job description

00:14:38.196 --> 00:14:41.458
or easily described in a job description.

00:14:42.678 --> 00:14:44.400
You argue that many leadership development

00:14:44.421 --> 00:14:46.581
programs are really management courses

00:14:47.442 --> 00:14:48.583
with better snacks,

00:14:48.783 --> 00:14:50.546
which of course helps people.

00:14:51.245 --> 00:14:53.207
What are these programs teaching and what

00:14:53.248 --> 00:14:53.947
are they missing?

00:14:53.988 --> 00:14:54.808
Where's the lack?

00:14:55.514 --> 00:14:55.955
Yeah,

00:14:55.975 --> 00:14:57.797
and it goes back to doing the right

00:14:57.836 --> 00:14:59.438
things by, you know,

00:14:59.519 --> 00:15:01.080
it goes back to that quote as well.

00:15:01.440 --> 00:15:02.181
What they're teaching,

00:15:02.201 --> 00:15:03.903
they're teaching financial literacy,

00:15:04.163 --> 00:15:05.583
operational analysis,

00:15:05.624 --> 00:15:07.225
how to optimize scheduling,

00:15:07.285 --> 00:15:09.967
productivity metrics, scale, efficiency,

00:15:10.048 --> 00:15:10.509
growth.

00:15:11.308 --> 00:15:12.989
how to speak all that language.

00:15:13.149 --> 00:15:14.090
And yes,

00:15:14.149 --> 00:15:16.649
there needs to be a level set to

00:15:16.690 --> 00:15:19.110
clinicians who do need to understand some

00:15:19.150 --> 00:15:20.211
of the sources of those.

00:15:20.270 --> 00:15:22.932
But clinicians generally didn't go into

00:15:24.892 --> 00:15:26.832
health care for that language.

00:15:26.852 --> 00:15:28.753
They did it for the language of helping

00:15:28.793 --> 00:15:30.033
people and working with people.

00:15:30.354 --> 00:15:31.234
So what are they missing?

00:15:32.153 --> 00:15:33.715
Everything that determines whether a

00:15:33.754 --> 00:15:35.115
clinical team actually works.

00:15:35.514 --> 00:15:37.275
How do you build psychological safety?

00:15:37.436 --> 00:15:39.116
How do you have empathy and compassion?

00:15:39.337 --> 00:15:41.139
How do you have difficult conversations?

00:15:41.418 --> 00:15:43.399
How can you tell somebody is burned out?

00:15:44.140 --> 00:15:45.522
How can you tell when I need to

00:15:45.562 --> 00:15:46.481
promote somebody?

00:15:46.783 --> 00:15:48.663
How can you talk to somebody about

00:15:48.764 --> 00:15:51.865
compensation or about care differently

00:15:51.905 --> 00:15:52.586
than you do?

00:15:52.986 --> 00:15:54.927
So one is financial literacy.

00:15:55.008 --> 00:15:56.408
The other is people literacy.

00:15:57.028 --> 00:15:59.931
And what we're lacking is all of those

00:15:59.971 --> 00:16:02.293
soft skills or what are called new smart

00:16:02.332 --> 00:16:05.174
skills that make the dynamics of it,

00:16:05.595 --> 00:16:06.434
that much better.

00:16:06.735 --> 00:16:08.556
It's a failure of curriculum design.

00:16:09.316 --> 00:16:11.255
So if a candidate can show all the

00:16:11.296 --> 00:16:12.517
things, EBITDA improvement,

00:16:12.557 --> 00:16:13.256
cost reduction,

00:16:13.297 --> 00:16:16.337
all the things that should show up,

00:16:16.778 --> 00:16:19.558
what question should or could a board ask

00:16:20.619 --> 00:16:22.619
to tease that out if they have those

00:16:23.119 --> 00:16:24.919
new soft skills,

00:16:25.159 --> 00:16:26.700
assuming that person is actually good,

00:16:27.080 --> 00:16:28.301
to figure out that person is actually a

00:16:28.321 --> 00:16:28.941
good healthcare leader?

00:16:30.030 --> 00:16:30.350
Yeah, no,

00:16:30.370 --> 00:16:33.511
it's a great question because you have to

00:16:33.591 --> 00:16:36.273
look, remember things evolve over time.

00:16:36.332 --> 00:16:37.173
One of the interesting thing about

00:16:37.214 --> 00:16:38.014
healthcare platforms,

00:16:38.033 --> 00:16:39.695
they have no history that is meaningful.

00:16:40.075 --> 00:16:41.815
What you did yesterday may not have any

00:16:41.875 --> 00:16:43.615
effect on the next day unless you have

00:16:43.635 --> 00:16:44.316
a great leader.

00:16:44.677 --> 00:16:46.397
So the single most revealing question is

00:16:46.476 --> 00:16:48.018
what did the organization look two years

00:16:48.118 --> 00:16:50.239
after you achieve those results?

00:16:50.438 --> 00:16:51.818
Not the moment of the results,

00:16:51.899 --> 00:16:52.659
two years later.

00:16:53.139 --> 00:16:54.100
Was EBIT improved?

00:16:54.120 --> 00:16:56.321
Was organic growth being generated?

00:16:57.642 --> 00:16:58.663
At month,

00:16:58.722 --> 00:17:00.585
the turnover cohort is sort of gone.

00:17:00.605 --> 00:17:02.246
You've kind of worked your way through all

00:17:02.267 --> 00:17:03.347
those kinds of things.

00:17:03.388 --> 00:17:05.871
And the financial statements have to be

00:17:07.112 --> 00:17:07.652
analyzed.

00:17:08.032 --> 00:17:09.394
So what I want to see is walk

00:17:09.413 --> 00:17:11.316
me through, it's now,

00:17:11.355 --> 00:17:13.057
walk me through the same store performance

00:17:13.097 --> 00:17:14.659
in and .

00:17:15.640 --> 00:17:17.421
That period had the fastest rate hike in

00:17:17.441 --> 00:17:18.001
forty years.

00:17:18.061 --> 00:17:19.481
Labor costs spiraling,

00:17:19.801 --> 00:17:20.883
reimbursement pressure,

00:17:21.363 --> 00:17:22.703
shortages everywhere.

00:17:23.144 --> 00:17:25.444
You know, that's where operators really,

00:17:25.464 --> 00:17:26.425
really got sorted.

00:17:26.445 --> 00:17:28.487
It's kind of like builders during a bad

00:17:28.547 --> 00:17:29.086
recession.

00:17:29.407 --> 00:17:30.548
You know who the good ones are because

00:17:30.567 --> 00:17:31.409
they're still working.

00:17:31.548 --> 00:17:31.929
Right.

00:17:31.969 --> 00:17:32.949
And many of them aren't.

00:17:32.969 --> 00:17:35.550
And the ones who really maintain,

00:17:36.131 --> 00:17:36.351
you know,

00:17:36.411 --> 00:17:38.152
performance and semblance during that and

00:17:38.211 --> 00:17:39.252
pull the team together.

00:17:40.452 --> 00:17:41.153
Absolutely.

00:17:41.173 --> 00:17:41.374
You know,

00:17:41.453 --> 00:17:42.914
one of the examples I give is

00:17:43.894 --> 00:17:46.115
I was fortunate enough to work with some

00:17:46.135 --> 00:17:50.380
really great folks who during that COVID

00:17:50.420 --> 00:17:51.721
time period where you had,

00:17:52.561 --> 00:17:53.982
it was to advantage to a lot of

00:17:54.022 --> 00:17:55.403
companies to lay people off.

00:17:55.443 --> 00:17:58.205
They got unemployment, they got PPP money.

00:17:58.246 --> 00:18:00.107
If you remember the PPPs of the world

00:18:00.147 --> 00:18:01.548
and you had all that stuff going on,

00:18:01.950 --> 00:18:04.172
we made a conscious decision not to lay

00:18:04.211 --> 00:18:04.892
anybody off.

00:18:04.932 --> 00:18:05.873
We may have reduced their

00:18:05.952 --> 00:18:07.894
clinical hours and so if they work forty

00:18:07.934 --> 00:18:09.816
down to twenty because of all the stuff

00:18:09.836 --> 00:18:11.317
happening during COVID so be it we could

00:18:11.337 --> 00:18:13.220
then supplement it with unemployment and

00:18:13.240 --> 00:18:15.642
other kind of things and therefore after

00:18:15.682 --> 00:18:18.463
that we really took off in terms of

00:18:18.523 --> 00:18:20.566
organic growth because we didn't lose

00:18:20.586 --> 00:18:22.867
clinicians where the shortage at least

00:18:22.907 --> 00:18:24.589
went down you know fifteen to eighteen

00:18:24.650 --> 00:18:26.431
percent nationally at least on an

00:18:26.510 --> 00:18:28.932
outpatient basis so that's cultural

00:18:29.594 --> 00:18:31.955
You have to really think about long-term

00:18:31.976 --> 00:18:32.736
sustainability.

00:18:32.776 --> 00:18:34.376
But what's happened in private equity in

00:18:34.396 --> 00:18:34.916
particular,

00:18:34.957 --> 00:18:36.698
it's all about the burning bed of private

00:18:36.778 --> 00:18:36.979
equity.

00:18:36.999 --> 00:18:38.839
Are you having a transaction every three

00:18:38.880 --> 00:18:41.781
or five years and teeing up your company

00:18:41.801 --> 00:18:44.702
to have this so-called great transaction

00:18:44.722 --> 00:18:44.823
event?

00:18:44.943 --> 00:18:46.384
That's not how businesses are built.

00:18:46.464 --> 00:18:47.565
You need patient capital.

00:18:47.904 --> 00:18:49.685
You need to have long-term sustainable.

00:18:50.027 --> 00:18:51.027
Fortunately, right now,

00:18:51.047 --> 00:18:52.448
with interest rates still high and

00:18:52.488 --> 00:18:53.229
transactions

00:18:53.769 --> 00:18:55.971
being pretty paltry in the marketplace,

00:18:56.351 --> 00:18:57.732
you're starting to see things being

00:18:57.792 --> 00:19:00.595
rewarded for sustainable patient capital,

00:19:00.835 --> 00:19:02.676
putting things in succession vehicles and

00:19:02.777 --> 00:19:07.882
other ways to keep the investment thriving

00:19:08.182 --> 00:19:11.065
while also keeping the company thriving as

00:19:11.125 --> 00:19:12.286
well.

00:19:12.365 --> 00:19:14.728
So it sounds like the player on the

00:19:14.748 --> 00:19:16.490
field that matters is the great clinician,

00:19:16.910 --> 00:19:17.170
right?

00:19:17.490 --> 00:19:19.352
If you weren't going to promote them out

00:19:19.372 --> 00:19:20.173
of clinical care,

00:19:20.836 --> 00:19:22.396
How would you design a better leadership

00:19:22.436 --> 00:19:24.157
pathway for them?

00:19:24.178 --> 00:19:25.659
What would it look like so that great

00:19:25.679 --> 00:19:28.661
clinician could grow without being pulled

00:19:28.921 --> 00:19:30.362
out of clinical excellence,

00:19:30.402 --> 00:19:31.241
the thing they're good at?

00:19:31.261 --> 00:19:34.003
Yeah, I'm going to mention a couple,

00:19:34.023 --> 00:19:35.064
three things here.

00:19:35.144 --> 00:19:37.486
And I'll start out by saying none of

00:19:37.506 --> 00:19:38.767
these are easy to implement,

00:19:39.446 --> 00:19:40.647
but they're critical.

00:19:41.428 --> 00:19:42.509
So the three things...

00:19:43.634 --> 00:19:44.776
in order of importance.

00:19:45.115 --> 00:19:47.176
One is you have to have a clinical,

00:19:47.238 --> 00:19:50.019
call it a clinical advancement track with

00:19:50.160 --> 00:19:52.060
real compensation attached.

00:19:52.141 --> 00:19:53.902
It does not require a management title.

00:19:54.281 --> 00:19:56.364
It does not require a bureaucracy,

00:19:57.044 --> 00:19:58.384
you know, senior clinician,

00:19:58.444 --> 00:19:59.566
clinical specialist,

00:19:59.645 --> 00:20:01.586
distinguished practitioner,

00:20:01.606 --> 00:20:02.667
call it whatever the hell you want,

00:20:02.688 --> 00:20:04.409
but make it a real career with real

00:20:04.449 --> 00:20:08.051
pay that deepens clinical mastery, okay?

00:20:08.311 --> 00:20:10.613
The message has to be your clinical work

00:20:11.534 --> 00:20:13.474
has a ceiling only if we failed to

00:20:13.535 --> 00:20:14.596
design it around you.

00:20:15.175 --> 00:20:15.756
Other than that,

00:20:15.776 --> 00:20:17.257
it shouldn't have a ceiling because right

00:20:17.297 --> 00:20:19.157
now the ceiling is real and every,

00:20:19.698 --> 00:20:21.358
every high performing clinician knows it.

00:20:21.618 --> 00:20:23.039
That's why they leave to go to another

00:20:23.079 --> 00:20:24.880
employer for an extra two thousand dollar

00:20:24.921 --> 00:20:26.020
sign on bonus, right?

00:20:26.320 --> 00:20:29.001
You're competing on benefits when you

00:20:29.063 --> 00:20:30.762
really ought to be setting up your design

00:20:30.823 --> 00:20:31.523
compensation.

00:20:31.564 --> 00:20:32.384
So that's number one,

00:20:32.423 --> 00:20:34.045
a real advancement track tied to

00:20:34.065 --> 00:20:34.704
compensation.

00:20:35.204 --> 00:20:37.467
The second is a mentorship structure

00:20:38.487 --> 00:20:41.048
that formalizes what the best clinics are

00:20:41.067 --> 00:20:43.990
already doing informally and pays for it.

00:20:44.430 --> 00:20:45.391
Mentoring stipends,

00:20:45.451 --> 00:20:47.551
protected time for case review and

00:20:47.592 --> 00:20:48.051
teaching,

00:20:48.491 --> 00:20:50.452
a career designation that says part of

00:20:50.472 --> 00:20:53.054
your role is developing the clinician next

00:20:53.074 --> 00:20:53.494
to you.

00:20:53.835 --> 00:20:54.755
In the dental world,

00:20:54.795 --> 00:20:57.416
we pay dental directors extra for teaching

00:20:57.477 --> 00:20:59.857
on weekends or teaching in addition to

00:20:59.877 --> 00:21:01.278
their other jobs so that they can be

00:21:01.318 --> 00:21:02.798
compensated and make more money.

00:21:03.180 --> 00:21:04.700
Never heard of a PT company that even

00:21:04.740 --> 00:21:06.020
does that or thinks of doing it.

00:21:07.278 --> 00:21:08.838
And I would say the third is a

00:21:08.979 --> 00:21:10.858
real leadership curriculum,

00:21:11.098 --> 00:21:12.900
not financial literacy training,

00:21:13.200 --> 00:21:15.661
but one that actually teaches leadership

00:21:15.681 --> 00:21:17.320
within a clinical context,

00:21:17.821 --> 00:21:19.001
psychological safety,

00:21:19.082 --> 00:21:20.402
how to get along with others,

00:21:20.442 --> 00:21:22.282
how to have difficult conversations,

00:21:22.663 --> 00:21:24.663
methodology and around the models of

00:21:24.784 --> 00:21:25.304
mentoring.

00:21:25.344 --> 00:21:26.804
And there's been a bunch of research on

00:21:26.844 --> 00:21:27.065
this,

00:21:27.404 --> 00:21:29.224
how to hold clinical values under

00:21:29.744 --> 00:21:32.145
operational pressure when reimbursement is

00:21:32.185 --> 00:21:34.007
down and you're having a bad day.

00:21:35.347 --> 00:21:37.710
EQ and emotional intelligence and

00:21:38.089 --> 00:21:40.393
compassion and all of those soft skills.

00:21:41.834 --> 00:21:45.417
Do that, not just P&L literacy.

00:21:46.419 --> 00:21:48.060
And the curriculum has to really,

00:21:48.121 --> 00:21:50.182
really hone and treat those clinical

00:21:50.222 --> 00:21:50.983
leadership skills.

00:21:51.023 --> 00:21:51.765
And what does that take?

00:21:51.785 --> 00:21:52.746
It takes feedback.

00:21:53.405 --> 00:21:54.788
We use coaching now where

00:21:55.248 --> 00:21:56.268
Take AI,

00:21:56.647 --> 00:21:59.648
and we know we've always had a good

00:21:59.689 --> 00:22:01.809
coaching mentality around our therapists

00:22:01.849 --> 00:22:02.549
and now dentists,

00:22:02.609 --> 00:22:04.351
but how can we get the coaches even

00:22:04.471 --> 00:22:06.590
more supplemental stuff?

00:22:07.111 --> 00:22:09.471
And so we now have humans and AI

00:22:09.711 --> 00:22:11.413
asking the right questions and paying

00:22:11.452 --> 00:22:12.313
attention to them.

00:22:13.113 --> 00:22:14.394
Because at the end of the day,

00:22:14.434 --> 00:22:15.676
those three things matter.

00:22:15.737 --> 00:22:16.498
Compensation,

00:22:16.518 --> 00:22:19.402
a real clinical track that does it, real,

00:22:19.461 --> 00:22:21.545
real leadership, you know, training,

00:22:21.684 --> 00:22:24.209
and then a formal structure around

00:22:24.288 --> 00:22:25.750
mentoring that rewards teaching.

00:22:27.421 --> 00:22:28.942
So it sounds like the big takeaway would

00:22:28.982 --> 00:22:31.085
be healthcare doesn't just need more

00:22:31.125 --> 00:22:31.464
leaders.

00:22:31.484 --> 00:22:32.787
It shouldn't be one ladder.

00:22:32.826 --> 00:22:34.548
It needs to stop confusing leadership with

00:22:34.607 --> 00:22:36.730
management and giving people a pathway

00:22:36.750 --> 00:22:38.673
that they actually value instead of

00:22:38.813 --> 00:22:42.016
pulling them onto a pathway you think or

00:22:42.036 --> 00:22:44.218
a business person might think is the only

00:22:44.258 --> 00:22:45.539
valuable way.

00:22:45.559 --> 00:22:46.160
No, that's right.

00:22:46.220 --> 00:22:47.321
And I think, and by the way,

00:22:47.362 --> 00:22:49.143
I've made all these mistakes in business

00:22:49.163 --> 00:22:49.784
and management.

00:22:51.973 --> 00:22:52.913
But then it occurred to me,

00:22:52.933 --> 00:22:54.654
do you ever see an orthopedic surgeon as

00:22:54.694 --> 00:22:56.555
a regional director overseeing six or

00:22:56.595 --> 00:22:57.675
seven offices?

00:22:57.736 --> 00:22:59.135
Do you ever see a dentist do that?

00:22:59.276 --> 00:22:59.476
No.

00:22:59.796 --> 00:23:01.537
Do you see them getting paid for clinical

00:23:01.576 --> 00:23:02.136
mentoring?

00:23:02.196 --> 00:23:02.676
Of course.

00:23:03.057 --> 00:23:04.497
Do you see them getting paid for

00:23:05.837 --> 00:23:07.698
organizing things and doing stuff and

00:23:07.738 --> 00:23:08.679
being more productive?

00:23:08.838 --> 00:23:09.378
Of course.

00:23:09.919 --> 00:23:11.699
We have to apply that to the ancillary

00:23:11.778 --> 00:23:13.019
professions a whole lot better.

00:23:13.500 --> 00:23:16.080
Dental, primary care, orthopedic surgery,

00:23:16.861 --> 00:23:18.441
those didn't get there overnight.

00:23:18.780 --> 00:23:20.461
We now have to get behavioral health

00:23:21.532 --> 00:23:23.295
physical and occupational therapy,

00:23:23.935 --> 00:23:25.998
pharmacy and others, you know,

00:23:26.057 --> 00:23:27.880
tied up in these healthcare platforms.

00:23:27.940 --> 00:23:29.541
Optometry would be a big one too.

00:23:30.643 --> 00:23:32.125
Ophthalmology is in pretty good shape

00:23:32.144 --> 00:23:34.267
because their surgeons are rewarded and

00:23:34.307 --> 00:23:35.548
compensated accordingly.

00:23:36.190 --> 00:23:37.951
But generally the other ones suffer from

00:23:37.991 --> 00:23:38.791
those same models.

00:23:39.173 --> 00:23:40.433
So my goal in working with,

00:23:41.315 --> 00:23:42.976
I've been fortunate to work with Jason

00:23:42.996 --> 00:23:44.857
Wemble that Onus One now,

00:23:44.917 --> 00:23:47.479
they're part of Prompt.

00:23:47.500 --> 00:23:49.121
I can't remember the name of the new

00:23:49.141 --> 00:23:50.020
division they call it,

00:23:50.040 --> 00:23:51.883
but he's on a mission to do that

00:23:51.923 --> 00:23:52.423
as well.

00:23:53.042 --> 00:23:54.805
And I'm right there with him because I

00:23:54.825 --> 00:23:56.665
think it's one of the areas that we

00:23:56.685 --> 00:23:58.926
can gain in our profession without

00:23:59.087 --> 00:24:00.087
sacrificing it.

00:24:00.407 --> 00:24:01.729
Pay our therapists more.

00:24:02.029 --> 00:24:02.990
You pay them more,

00:24:03.069 --> 00:24:04.932
they need less people managing them.

00:24:05.531 --> 00:24:06.772
The only way you pay more is to

00:24:06.814 --> 00:24:08.134
take them out of a clinic role.

00:24:09.415 --> 00:24:10.257
You're in bad shape.

00:24:10.277 --> 00:24:10.938
And in PT,

00:24:10.978 --> 00:24:12.920
only twenty percent of active licensed

00:24:12.940 --> 00:24:14.942
clinicians on an FTE basis are even

00:24:14.982 --> 00:24:15.522
practicing.

00:24:15.542 --> 00:24:16.743
It's quite sad, actually.

00:24:17.424 --> 00:24:19.027
Stop replacing your quarterbacks with wide

00:24:19.067 --> 00:24:19.508
receivers.

00:24:19.528 --> 00:24:21.068
You're going to get people who need to

00:24:21.108 --> 00:24:21.549
pass the ball,

00:24:21.569 --> 00:24:22.510
but they're good at catching the ball.

00:24:24.154 --> 00:24:24.335
All right.

00:24:24.355 --> 00:24:25.556
If this conversation hit a nerve,

00:24:25.596 --> 00:24:27.175
go read Larry's full article on the

00:24:27.256 --> 00:24:27.596
operator.

00:24:27.615 --> 00:24:28.517
That's his sub stack.

00:24:28.957 --> 00:24:31.077
The link is in the show notes and

00:24:31.097 --> 00:24:31.798
the description.

00:24:32.377 --> 00:24:34.659
And if this episode again made you feel

00:24:34.679 --> 00:24:35.500
a little uncomfortable,

00:24:35.619 --> 00:24:37.099
that's sort of the point.

00:24:37.220 --> 00:24:38.181
Larry, appreciate the time.

00:24:38.721 --> 00:24:39.240
Absolutely.

00:24:39.260 --> 00:24:41.862
And by the way, our next series,

00:24:41.922 --> 00:24:44.022
I think there's going to be six different

00:24:44.083 --> 00:24:46.023
articles, is on meetings.

00:24:46.864 --> 00:24:47.263
Wow.

00:24:47.384 --> 00:24:49.944
How to hold a meeting and how inefficient

00:24:50.565 --> 00:24:52.384
and especially under a world where remote

00:24:52.484 --> 00:24:55.526
work for your corporate folks is dominant,

00:24:55.546 --> 00:24:56.606
especially in healthcare platforms.

00:24:56.646 --> 00:24:57.426
I'm not going to tell you what to

00:24:57.467 --> 00:24:58.886
write, but when you said meetings,

00:24:58.926 --> 00:25:00.567
the first cliche that came to my mind

00:25:00.607 --> 00:25:00.728
was,

00:25:00.807 --> 00:25:02.248
could this meeting have been an email?

00:25:02.288 --> 00:25:03.548
And my guess is if the answer is

00:25:03.607 --> 00:25:05.449
yes, don't hold the meeting.

00:25:05.469 --> 00:25:07.348
All right.

00:25:07.368 --> 00:25:08.809
Check out the operator on Substack.

00:25:08.829 --> 00:25:10.150
The link is in the description.