ADJUSTED
ADJUSTED
FCEs and Balance Testing with Josh Schuette
In this episode, ADJUSTED welcomes Josh Schuette Director of National Workers Compensation Sales and Account Management at Brooks Rehabilitation. Josh discusses FCEs and balance tests and what role they play in recovery.
Season 8 is brought to you by Berkley Industrial Comp. This episode is hosted by Greg Hamlin and guest co-host Mike Gilmartin, Area Vice President, Sales & Distribution, for Key Risk.
Visit the Berkley Industrial Comp blog for more!
Got questions? Send them to marketing@berkindcomp.com
For music inquiries, contact Cameron Runyan at camrunyan9@gmail.com
Hello everybody and welcome to Adjusted. I'm your host, greg Hamlin, coming at you from Sweet Home, Alabama and Berkeley Industrial Comp, and I'm excited to share with you today this rebroadcast with Josh Schuette. Josh is the original legend. Anywhere you go at any conference I'm sure you'll run into Josh. He's a legend in the industry, really focused on functional capacity exams and helping people return to work who have gone through very difficult injuries, and one of the things that we had not talked about in the time that I've been doing adjusted was where functional capacity exams fit and what balance testing is.
Speaker 1:And I think that there may be more familiarity with functional capacity exams than balance testing, and so I wanted to dive into both of those with Josh and have him really dive deep into how to utilize those to figure out where people are functionally so that we can work to have them successfully return to work. So I hope you enjoy this one and if you see Josh at a conference, tell him I said hello.
Speaker 2:Hello everybody and welcome to Adjusted. I'm your host, greg Hamlin, coming at you from beautiful Birmingham, Alabama, where the skies are so blue, and with Berkeley Industrial Comp, of course, and with me is my co-host for today, mike Gilmartin. Mike, I'll let you introduce yourself.
Speaker 3:Yeah, I'm happy to be back, greg. This is Mike Gilmartin. I'm coming to you from Greensboro, north Carolina, where it is sunny and 70 degrees. Can't get much better than that, man, I know.
Speaker 2:Absolutely love this time of year. That's my favorite part about the South is, I feel like the fall lasts for like ever, and, coming from Michigan and Indiana, it's like you blink your eyes, the leaves change and then you're fully in the season of the sticks and then snow. So, anyhow, well, we've got our special guest today, josh Schuette, who's a doctor of physical therapy and director of the National Workers' Compensation, sales and Account Management at Brooks Rehab. That's quite the title, josh.
Speaker 4:Yeah, they keep adding to it every year and I can't fit it on the name tag anymore. Sorry, it's on audio, but yeah, if you see my name tag, even with size six font, they can't even fit it anymore. It just makes me feel better about myself.
Speaker 2:So, yes, Well, I just like to say Josh is Superman, so we'll just call you that. But I've met Josh at the National Workers' Compensation Disability Conference in Las Vegas and reconnected at WCI, and I was actually hearing him speak on. One of the things he was talking about was functional capacity exams and balance testing, and that really made a little light bulb go on for me. I thought you know we have not done a topic on functional capacity exams and balance testing.
Speaker 2:And that really made a little light bulb go on for me and I thought you know we have not done a topic on functional capacity exams and balance testing. And I felt like this is something that is really an important piece to a lot of difficult workers' compensation claims, so I wanted to have an expert on to talk to us about that today. So you're our expert, josh. Thanks.
Speaker 4:I can't wait to tell my mom and dad.
Speaker 2:They'll be Josh. Thanks, I can't wait to tell my mom and dad. They'll be proud. Thanks, I can promise that the one person I know that listens is my mom and she listens as she's getting ready to go to bed. So I always say I put her to sleep so we'll try to keep her up.
Speaker 4:All right, I'll try to liven it up this time For your mom. I'll do it.
Speaker 2:Thank you, josh. So I wanted to start at the beginning. How did you decide to end up in the medical field? Did you know you wanted to enter into physical therapy as a kid, or where did your interest start with that?
Speaker 4:Great question there, greg. Actually, to be honest, if you would have told me at 18, I was a physical therapist now, I never would have believed you, because I originally went into school to be a strength and conditioning coach for like a football team, and that's what I want to do. I always lifted weights as I was younger. It was kind of the classic story of like the scrawny, puny kid trying to build himself up. So I got into lifting weights, competed in powerlifting I go, I would love to make this a career and had a few friends used to do that job as strength and conditioning coach, you know, just making athletes bigger, faster, stronger. And then what happened was all my friends that were in that field, in exercise science, were like I'm going to go into PT, physical therapy. I said no way, I do not want to do that. And kind of a roundabout kind of like. Even you know how you get in work comp where it's not what you choose, but you ultimately kind of fall into it.
Speaker 4:Long story short is I was working with athletes but at the same time I had to take a class where I held back kids with disabilities outside and I really got into that, just trying to make those kids, rehab them and just showing the joy and the beauty of how you can be included in different physical activities. And I went back and got a master's in exercise therapy. And then, next thing you know, I got accepted into the beginnings of the PhD program in special ed. But I was kind of going broke at that time and go. I did a Google search literally one night and said how do I get into helping kids with disabilities and make money? I think it was my Google search and physical therapy came up and I applied that night, got accepted the next day and the rest is history.
Speaker 2:That's awesome. That's an awesome story, Josh, and I remember and you're going to have to correct me if I'm wrong on this that your was it, your father, that was a football player, collegiate football player.
Speaker 4:Yes, okay, yes, that's my Indiana University connection. He is a first team All-American in Indiana. He always points out, though, that the team was always one in 10, all four seasons he was there, and then they finally went to the Rose Bowl the season after he left. But he did really well. I don't think it was because of him, but first-team All-American very proud of him and then played 11 years in the Canadian Football League.
Speaker 2:Well, I would say that sounds about right for Indiana 1-10. That's about what we do. We're pretty good at that.
Speaker 3:Now I know why Greg invited you.
Speaker 4:It to know why Greg invited you. It's all making sense now. Hang out after Mike, we're going to watch. Breaking Away just to hang out Breaking Away at Indiana University starring Dennis Quaid.
Speaker 3:Yeah, that's an interesting story. I don't know that I ever Googled like how do I make money in insurance before I chose this profession. I just kind of fell into it. But tell me a little about Brooks Rehab. What do you guys do? What do you focus on? You know, give us, give us a lowdown on what you guys do.
Speaker 4:Yes, Brooks Rehab, we actually we hit our 50 year anniversary a year ago but coincidentally of course, it happened during COVID. So then they had to carry it over and make it a two year celebration. So it actually meant something to somebody. But right now we've got a bunch of facilities. When I met Greg, the biggest thing I was actually there to talk about was a rehab hospital and we have two rehab hospitals now located here in Jacksonville, florida.
Speaker 4:I can't quite celebrate the weather like you guys it is muggy and hot, like it is 361 days out of the year, but we make the most of it. We basically see catastrophic work, comp or any kind of injuries from around the country. So major multiple trauma, spinal cord injury, brain injury, amputees, those major injuries, patients coming from all over. But we've got two rehab hospitals and it's going to sound like the song, you know a partridge in a pear tree when I finish up but two rehab hospitals, two skilled nursing facilities and a sister living facility, 45 plus outpatient clinics and a home health division with a bunch of specialty programs. But we basically treat you know the worst of the worst injuries and we try to make those patients, those injured workers, feel whole again. So I'm very fortunate to have this job and help people out every day.
Speaker 3:It sounds like your Google search paid off from what you just said.
Speaker 4:I definitely got to say I'm blessed. Even though I don't work so much with kids anymore, I do see a lot of kids every day in the waiting room and I make great friends with them and it's awesome and actually I get to take them out running. We got a great organization called Ainsley's Angels where we take kids with disabilities and run them in 5k races here locally and it's a national organization, so I'm loving it. Just did it over the weekend actually met some great kids that were able to help out and help me out.
Speaker 2:That's awesome. So, josh, when it comes to physical therapy, I think we all know that sometimes surgery is all want to be able to push a button, have a surgery, get better and then move on. We're so used to everything being now and fast that sometimes this piece I think it's underemphasized the role of it and I would love for you to talk about what you've seen and how it plays into people's recovery.
Speaker 4:That's a great stage, you said there, greg. I totally agree with you. And in this day and age, it is to be honest with you it's a tougher sell for a lot of people because like, hey, we sent you for physical therapy, why isn't my injury work? Or why? Or you know, or even the patients you haven't worked out in five years, and then within one week, 10 days going, why don't I have the body of an Adonis right now? It takes time. I mean you get out what you put in and it does take time. So in this day and age of instant gratification it is much tougher.
Speaker 4:But to go back to your question, physical therapy can be very appropriate for a lot of injuries. I mean I've been fortunate to help out. I still treat even today, but mostly on the functional capacity evaluation side. But for neurologic injuries somebody's had a brain injury, spinal cord injury those patients, those injured workers, need that rehab to be able to what you set the stage for earlier the balance, to get that balance right, to even get weight bearing right.
Speaker 4:If you've got somebody that's been bedridden for weeks or months, sometimes they're not just going to get right up and get up and move out the door. It's going to take step-by-step safely to get there. And then going back to your part about surgeries if somebody's had a shoulder surgery, if we're talking about an orthopedic condition, they need that shoulder rehabbed a little bit at a time, because they can't go from shoulder surgery, that shoulder immobilized for weeks on end and all of a sudden be like, hey, now you're ready to throw a football. I mean, you look, that's what happens. I always compare work comp to just what you see on the athletic field. Athletes get injured, they go to rehab. They are not back out in the field, typically the very next day. Sometimes, depending on the injury, it could take a full season before they come back, because you want them to come back right.
Speaker 3:You hit on something really interesting there and I have to admit, my sister is actually a physical therapist and runs a clinic in Maryland, multiple clinics in Maryland. So her and I talk about this all the time. But you know, athletes they do the therapy. It takes them a while to get back and they're kind of the best of the best in terms of just their physical abilities and everything else. You see it all the time where somebody might go to one or two visits and they come back to the adjuster, whoever they're like.
Speaker 3:I'm in so much pain. It's not working. I feel worse. You know all that kind of stuff. How do you, as a physical therapist, kind of combat that? Right Cause it's, it's, in my opinion, it's kind of common sense. You're going to go, you're working on working out an injury and doing movements that are going to push you a little bit but in the end are going to actually make a difference and help. How do you manage and coach through that so that it's not to your point? Well, I just want it fixed now. I want it fixed now. How do you deal with that? Because it is interesting.
Speaker 4:No great point there, mike. That's where communication I think that's going to be the underlying answer for a lot of the things that we'll probably talk about today Communication is key, whether it's me talking to you guys or me talking to the injured worker, which is you know I mean it all comes back to the injured worker. Without them, we don't have a job. So when that injured worker, that patient you know if they're coming in for commercial insurance comes in and speaks with me, I'm very upfront and honest. I tell them hey, I'm going to tell you some things you probably don't want to hear, because sometimes they're like, hey, I thought you were trying to sell me on this and I go well, the one thing I don't want to do is set your expectations where I can't achieve them. If I come in and go, hey, it's going to be, I tell them upfront you're not going to walk out of here without some pain. I just want to lay that on.
Speaker 4:Is, people sometimes stop me in the middle of the conversation when we first start and they go Josh, should I stop when I'm hurting and I go? I'd be lying to you if I told you yes, and here's the reason why Because you're like everybody else that's walked in the building here over the last three months, three years, you're already hurting to some degree. So I said stop when you're hurting. We'd already be done at this point. So you're already in pain, and now I'm going to take that body that's already that joint or whatever, is hurting, and now I'm going to try to take and move it a little bit farther. There's going to be some pain involved with that, so I'm not going to lie to you. However, we're going to keep you under that injury threshold. So the one thing I always tell them I'd be lying to you if I said there was no extra pain.
Speaker 4:However, I'm not here to make you injured again. I'm not. We're not here to re-injure you. So we're here to keep you safe, we're here to build into it. But the other thing I point out, though, is if they do not exercise that body part like, let's just say, right now, all they could do is, you know, pick up their cell phone, and that's the heaviest thing they can lift without hurting. If they quit even doing that, imagine what's going to hurt for them. You know just. You know, basically even moving their arm without holding anything is going to hurt. So you got to get in and move the body to some degree, or else even those basic movements are going to start hurting. So I'm just upfront and honest with them. I'm like, hey, you're going to hurt some, we'll keep you under the injury threshold, but you got to move, or else it's going to. You think you're hurting now. It'll be even worse than the future.
Speaker 3:It all goes back to Greg and I talk about this on multiple podcasts setting expectations. Man, it's as simple as the same thing for an adjuster when you first call an injured worker and outlining what they can expect and when they can expect things to happen, and like it's just funny to hear it's the same in every profession, like set normal expectations and reasonable expectations and in general, it's going to set you up better than than you would have.
Speaker 4:So, absolutely, yeah, I mean, it's just like you. You got to set everybody up or you're setting yourself up for failure when it's all said and done. So I'm just like. I remember even trying to bring on the same lines of it my patient's family member because I was their family member was debating on coming to the hospital, you know, or having their loved one come to the hospital, injured worker, major injury and I remember meeting that loved one and I said hey, I want to ask you some questions up front. I started like asking, like, how long do you think your loved one's going to be here? How long do you think the rehab process is going to take? And she literally stopped me. She goes what are you doing? I go. Well, I want to figure out your expect. I want to find out your expectation. She goes this is weird. She goes.
Speaker 4:I've been to three other hospitals and everybody immediately tried to sell me on the hospital, didn't even give me a chance to speak. They just kept saying they got the best outcomes, they're the best, they're the best of the best. Now you're almost not selling me on it. I go well, here's the thing I got to follow you and your loved one all the way through this episode of care.
Speaker 4:If your expectations, if you're thinking one thing and I know up front I can't meet that, you're going to be hating me three weeks from now. So I need to lay all that out on the table. Find out what you're looking for, because if you think your loved one's going to be done in two weeks with a major brain injury, it's not going to happen. So I want you to know you're probably going to be sitting here for maybe two months waiting on that recovery that you're expecting in two weeks. So I'd rather lay that out to you. And it was interesting after an hour long conversation she actually said I appreciate what you said, I actually trust you, because everybody else just kind of gave me a guarantee that my loved one would be better in two weeks and you're actually laying it on the line, saying it's not that easy.
Speaker 2:So, coming back to the stages of recovery, I think that that makes a huge difference and I agree with both of you that you know, setting the expectations is so important if you're going to get cooperation, which is to me really important for recovery. So, josh, when you one of the things that and this is me maybe admitting, confessing here I hurt my shoulder it's probably been 15 years now and my primary care doctor sent me to some physical therapy and they gave me some TheraBand, that physical therapy. They sent me home with them. They told me what I was supposed to do and I'm going to be honest, I wasn't very compliant in doing what needed to get done there and I think it really did impact my recovery, you know. So I know home exercise is an important component.
Speaker 2:I guess there's two thoughts that I wanted you to talk about. One, how does it play a role? Because obviously you have the visits where you're going to the physical therapist and you're being worked with with a physical therapist or a technician of some kind, and then you have the home exercise program, which should be happening on its own theoretically. So two things, I guess. Talk a little bit about home exercise. And then, what are your thoughts on just the general compliance of home exercise from your experience?
Speaker 4:No, that kind of hits the nail on the head. As far as somebody recovering, I appreciate your honesty. I think I've got my own story like that, greg, so we'll just kind of lay it all on the table today as far as our backgrounds. But I'm a big fan from the beginning, even when I tell patients, I'm a big fan of what I call value-added care, and this is across the medical spectrum. What I mean by value-added is, if you come in to see me, you better be getting something you couldn't do for yourself at home. So let's just talk about a home exercise program.
Speaker 4:There are those people that I meet and you can tell they're just go-getters. You know they could be that, that athlete that's trying to get back to um, you know. Or just that busy mom, busy dad, they got 20 other. Hey, I got five kids at home. You know, I got all this other stuff. Josh, tell me what I need to do and I will do it, and we'll do a little test run there, and if they can do it, boom, you don't need to come in and see me. There are those other ones, though, that are just you know, you can tell like they have never really, and I'm not judging on you, greg, because I don't even know you that well, buddy, but I'm just saying there are those people that I see where you're going there, josh, yeah, yeah, pile on, pile on for you, for you, buddy, I just met you but I'm already trusting you now.
Speaker 4:But there's people he meet and you do like during that first initial eval. A lot of it's just that interview where you're just trying to find out what makes somebody tick, and that's the, I think the coolest part about my job is find out what makes somebody tick. Certain Certain people you're like I meet them. I'm like dude, what motivates this person? Certain people are motivated by money. Certain people are motivated by family. Certain people, you know, want to look good in front of others. I mean, you got to find out what makes somebody tick.
Speaker 4:So when I'm talking to somebody, there are certain ones that it's just like I can't even tap into it, just feel like the second. They leave me, they're going to go home and you know what. They're motivated by Not hurting at all. So they don't want to push, you know. And when I say not hurting at all, I'm talking even emotional pain or any kind of psychological pain. So they're the kind of people that are going to, you know, just totally just go into their cocoon If they have a problem with their kid. They're not going to confront the kid because they're like dude. That's going to cause like a shift here. It's going to cause me some psychological, some emotional pain. Today I'd rather forego that and just totally avoid the conversation and I'll just go lay on the couch, play video games and drink beer. Tonight and I've had patients literally say that I play video games to escape. You know, I don't want to do the chores, I don't want to take care of my kids, I want to avoid all that.
Speaker 4:So that person there for value added, the value added might be making them come in and see me so I can make sure they're actually doing it. So the good part is these days I know there's some technology out there. I know I've talked to some of your team, greg, about some of the technology out there that can actually monitor patient compliance when they're not in the clinic, which I think is key. Because, again, for value added, should somebody come in and see me if they can do it all on their own? No, but if they're just not motivated at all. But the cool part with the new technology is at least we can track them, track that compliance. So that kind of comes in to the one part there as far as just kind of making sure that the patient's actually compliant.
Speaker 4:But as far as value added, if there's another reason for a patient to come in and see me, mike, I might go back to like we're talking about a surgery. Another reason for a patient to come in and see me, mike, I might go back to like we're talking about a surgery. After that shoulder surgery, the only way to really get that injured worker and that patient moving again is they have to do what's called passive range of motion, which means somebody else a skilled therapist actually has to move that arm for the patient. This can't be addition off to the family member. The worker themselves can't be doing it. So that is value added. But once they get past that stage, if they're independent, let them go home and do it if they're motivated, but otherwise, if they're not, they might have to come in and see me. So I'm a big fan of value added.
Speaker 3:So I guess my big question is I agree with Greg a little bit you see a lot of people who you know it's the doctor should fix it for me or the PT should fix it for me. Why do I have to do stuff on my own? And I guess I mean I agree with you and those people you probably want to see them more often. But if you're doing everything you can do as the PT and you're, you're working them out as best you can and they're still not doing what they need to do at home, how do you I mean is, can you then make up for that? Like in the office, or is it gonna like I guess you see it all the time where people are like, well, I'm not getting any better, and the PT will write in there well, you're not doing your home exercise program, you're not doing the things that, to your point, continue to get the motion better and continue to get you feeling better. How do you deal with that?
Speaker 4:And first I want to go on record. I heard you say you agree with Greg, so I don't know how often that happens, but we just want to go ahead and document that right now it's very rare I'm defending you, brother.
Speaker 4:I got you so anyway, that's Indiana right there. So to go back to that, the one thing, mike, that's a great point there, and you know, coming back to that is I always come back to the time equation and again I'm just kind of a basic guy, kind of like I said, I like to find out what makes people tick and another one of my concepts is value added that I always go by. Another concept is the time factor and that is this I tell people let's just say you come for a typical physical therapy prescription three times a week, you know, for an hour each time. So what is that? That's three hours total. Look at how many hours we have in a day 24 hours in a day, times seven days a week. So we're talking over 100 hours.
Speaker 4:It doesn't, I mean, it doesn't matter what I do in that three hours. It does some to some degree. But if somebody does everything wrong for those other 23 hours in the day and that other day of the week, it's totally going to undo that. So the patient, the injured worker does have to be compliant, and I always look at it. They got to start. You got to take care of your body throughout the day anyway, even when you're sleeping. If somebody you know wakes up and their arms up by their head, you know, after the shoulder surgery it's good. I mean eight hours on a painful you know, in a painful position could totally undo whatever I did for an hour that day. Eight hours is going to trump one hour any day of the week. So there does have to be some degree.
Speaker 4:And that's where, again, it comes down to that communication part. And I'll sometimes lay it out with a patient. I'm like, and I'll literally do that math equation and go how many hours a week am I seeing in three hours I can try to do everything. I will give you all I got for those three hours. I can assure you that. That's all I can guarantee. I'll give you all I got for those three hours. Call me those three. You got my time.
Speaker 4:But look at what if you go home and you do everything wrong in the next 23 hours, is that one hour going to trump the other 23? And when people get that, then I'm like that's why you got to take care of yourself. You got to. I mean, that's why I'm a big fan of a lot of these athletes that are getting older and really taking care of themselves. They realize I mean, look at Tom Brady, you've got to do, whether you like him or Scott. The guy is doing activities outside of the typical realm that he gets just in coaching. He's doing the nutrition. He's doing the sleep. I mean you never heard athletes talk about sleep 10 years ago. But they realize you got to give all, you got for all 24 hours no-transcript.
Speaker 2:Great points, great points, josh. Well, one of the things and you talked about this a little bit, but I know we've all seen it that's been handling workers' compensation injuries is sometimes you have injured workers that they're in physical therapy a long time, like maybe they've either had surgery or they haven't, and you've already had 36 visits of physical therapy and now they're recommending 48, and then the 48 get approved, and now they want another 12. Recommending 48, and then the 48 get approved, and now they want another 12. And so at a certain point you're wondering like, okay, well, is a different surgery needed? We're not really seeing gains anymore.
Speaker 2:Talk a little bit about functional capacity plans and where they fit in the recovery of an injured worker to maybe help diagnose or, from a diagnostic standpoint, look at where this patient's at, because I think that's some of the things that we struggle with. Obviously, our goal is to get people back to work and back to life, and we want that for them. And sometimes there can be psychosocial components that maybe are layered in there. There can be actual misdiagnosis, where maybe they need a repeat surgery or there's something else wrong that's been missed. There's so many different things and figuring that out is sometimes the challenge of trying to help somebody recover. So where does functional capacity exams fit in all that?
Speaker 4:Great question as far as that. I mean, I know there's going to be kind of a spectrum there as far as an ideal time. But the one thing one of the statements you made earlier one of the words was diagnostic diagnosis. The one thing I'll tell you is an FCE is not, by the true definition, diagnostic as far as an actual physical diagnosis. And that's something else I communicate to the patient up front because they're an injured worker, because a lot of times the injured worker will come in and be like I've been to three different specialists, five different physical therapists. Nobody's telling me what's causing my pain. So I expect you to tell me today and I go oh, we're going to lay this on the table too. This is not diagnostic in nature. This is not me finishing this test and going. You know what? Somebody missed that rotator or the slap lesion you got on your shoulder or that torn meniscus you got on your knee. This is not what the test is about. It's more diagnostic in the fact of where is that injured worker right now as far as functioning? So it's more diagnostic in terms of functioning. But it can also give some insight in terms of consistency and inconsistency brought forth by the patient or injured worker and what I mean by that is classic example is an injured worker comes in and I'm like, hey, can you bend over for me? And I'm using a bunch of diagnostic tools, inclinometers, goniometers I'm trying to measure it to the exact degree because I want to be objective with everything I do, and I'll get some injured workers maybe. Give me like 20 degrees, which means all they can do is barely touch their thighs. That's as far as they can bend forward. And all of a sudden we'll finish up the exam and they'll go out in the waiting room and they'll talk to somebody else that's coming to pick them up and they'll have a bag on the ground. They will bend all the way over and pick up that bag. So 90 degrees of flexion. They went from 20 degrees when I asked them to give it all they got. Now all of a sudden they're picking up a bag and 90 degrees and they head out. That's an inconsistency. I asked them to give me all they could when they're back in the room and now I didn't even say give me all you could when you're out in the waiting room and they can triple the range of motion. So it also helps out as far as outlining what are inconsistencies.
Speaker 4:Now here's another part about it, though Greg is. I'm not. I mean again, I'm not a psychologist. I'm also not diagnosing why those inconsistencies happen, because sometimes I get I used to get an angry case manager we're always good friends outside but she would definitely get angry with me, one of those ones. I've been doing it for 35 years. You know that feel and start yelling at me and she goes how come you never put it? You know she used some, definitely some great language there regarding my anatomy. Why don't you have the to put your nickel down and say that the? You know the injured worker is a malingerer. And I told her. I said do you want me to make this paper, this 20-page report, null and void? Right now I can write they're a malingerer. And it just made it null and void. Why is that? Because the malingerer is actually a psychological diagnosis. It's not me as a physical therapy diagnosing that injured worker, because I'm just saying that the patient's inconsistent.
Speaker 4:The part about malingering is implying intent. I don't know what the intent is, why that injured worker was inconsistent. I mean, I had a guy the other day. I said walk as fast as you can for 100 yards. It took him over two minutes, and this is at the beginning of the exam when he claimed his pain level was lower. At the end of the exam, he claimed his pain level was lower. At the end of the exam, he claimed his pain level was through the roof. And I said hey, man, test is over, you're free to go. I hit my stopwatch and then I watched him go all the way out to his vehicle. He could walk 100 yards faster, walking out to his car, than he did earlier in the test when I said walk as fast as he can. That's an inconsistency. Now I don't know why he walked out to the car, because I mean, for malingery, he literally had to. Hey, why'd you walk faster?
Speaker 4:And him yell back to me oh, it's because I want to get a better claim, because I want to make more money. That's why I'm faking you out. No injured worker is going to tell me that. So all I can basically do there's two main things. I'm diagnosing as far as theirencies or inconsistencies. That's where, if there are inconsistencies, we probably you know in some patient Greg has gone on and received 80 physical therapy visits. It's probably more involved. At that point you might need to enlist, you know, some other specialists. You know, if you want to find out intent, you might need to get psychology involved, even though not everybody's always into that. But you really want to get a few other people involved to really diagnose that. Because I tell everybody, if something's going on a year, it's probably not going to be solved in a day. You probably need a couple people to really look into this if you really want to get a good benefit out of this.
Speaker 2:Great points. And I'm glad that you corrected me on the diagnosis piece because that's important. But I guess the other thing maybe for people who don't know what a functional capacity exam is what are the kinds of tests that you're doing in a functional capacity exam? What's all involved? How long does it take from beginning to end, Just to give people a general idea of what that is?
Speaker 4:Now to go back to it. Yeah, functional capacity evaluation. It's a detailed, objective physical measure and I tell the injured worker or the patient I'm here to see today what your maximum safe physical abilities are on this given day. So I also emphasize, on a given day. This is not, you know, it's not prognosticating either. I mean, people are like you think this is where I'm going to be two years from now. I don't know. You know I don't have a crystal ball for that. But on this given day, the exam itself one-on-one typically lasts me four to five hours one-on-one with the patient. That's not including the final write-up.
Speaker 4:The exam literally starts. The second I see that injured worker if I see them out in the parking lot, the test starts then. If I see them when they first come in the waiting room, the assessment starts then. Because a big question that you know I'm asked is how long can the patient sit for, stand for, and it's amazing how often I'll see an injured worker out there in the waiting room sitting for 30, 40 minutes filling out their paperwork no shifting, no signs of pain. But the second I bring them back to hang out with me, they're shifting within the first minute going. Do I have to sit here all day. You're killing my back, but yet I saw him out there, no problem. So the test starts the second I see them, the test ends the second they finally get in that vehicle. In the last second I see them Because, again, a lot of the stuff I can see out in the parking lot is very, you know, diagnostic in terms of how they're functioning in nature too.
Speaker 4:But basically what I'm here to look at is any kind of physical functioning. So I know in the state of Florida we have a sheet that DW, dwc 25 form division of work comp form. It says sitting, standing, walking, lifting, carrying, pushing, pulling, bending, squatting, kneeling, reaching, grasping. I got to look at all those different physical functions. And then what is that injured worker, what is that patient capable of doing across those spectrums? So how much can they lift, how often? That's what I'm here to see.
Speaker 3:I did not realize they take that long. I assume it was like 30 minutes.
Speaker 4:You come in you do a couple of tests and you move on. No, that's a great point, mike, and the reason why it takes so long. I always tell people you can see, I mean I've seen a lot of injured workers, you know, and again, I'm looking at consistency across hours and I get some people that can come in and they can shift around the whole time for the first half hour hour. But it's amazing, like three hours into it, four hours into it, that's when I can really see, because that's when the person starts fatiguing a little bit and kind of gives up any kind of maybe pretense they had before. I can actually see what they're capable of at that point.
Speaker 4:But the other thing about it is too, mike, is there are so many different functions I got to look at and they're asking me how can they do over an eight hour day? So that's why it takes so long. So, yeah, four to five hours one-on-one. The write-up usually takes another couple hours, so it's almost a whole day thing. But the absolute record for the longest FC I've ever done, not including the write-up, was 10 and a half hours. That was the most extreme one. That did not include lunch, that was straight.
Speaker 2:Oh my God.
Speaker 4:You know how I knew it was going to be an extreme one. I went to market one day and I don't do a lot of marketing because now it's just like people are used to me. They're like hey, we got an injured worker, we'll send them to you. But I remember one time Brooks says, hey, we're doing this big thing at a local orthopedic group, we'd love if you were there. I said, sure, I show up. Now, most of the time you're going to market to somebody, they're not like oh, love to see you. They're just like what do you have to offer? Get out of here, give me your food. You know that kind of thing. But that one there.
Speaker 4:I remember that day I walked in, everybody was welcoming me with open arms, what? And I'm like you're seeing them for an fc, right? And I go, yeah, I'm seeing them next week, oh my god. And then they go grab people from the back office and everybody's like, almost like huddled around me and I go, what's going on here? And they go.
Speaker 4:We've been dealing with this guy for a year and he uses up a lot of our resources. We've actually had security escort him out twice in the last two visits. If you do this test, we won't see him. So you're like a hero to us and I go guys, please don't tell me anymore. Again, I don't want to be biased going in, but they did give me one piece of advice, which is this, which I really appreciate they go, Josh, if you were planning on seeing anybody else during that day, cancel it. You're going to be there all day because this guy's going to give it to you. And, sure enough, 10 and a half hours later, I finished and he kept calling me for the next three days and wanted to make it go even longer. And I'm like the test is over, brother, we are done. That's wild, yeah yeah. The write-up was like at least another four hours. So it was like I mean, we're talking like a 14 and a half hour day.
Speaker 2:I was like brother the report's in. I'm done, I can't do anymore, I'm tapped. And this is me with Superman energy. I'm tapped, I'm done. You pushed me right over. Yeah, well, one of the things you mentioned when I was at WCI. At the conference, you talked about balance testing. And this is something I'd never really heard of and wasn't very familiar with, so I wanted you to talk a little bit more about what that involves when to do it, when maybe we should ask for that test and who's qualified to do it.
Speaker 4:No great point and this is something I've actually, greg, uncovered more and more. This is probably the last few years and it kind of became out of necessity With social capacity evaluation. I'm kind of riding a fine line here because I'm still a physical therapist through and through. I'm here about patient safety. Fces, functional capacity evaluations are great for like orthopedic injuries maybe and some neurological, just depends.
Speaker 4:But if somebody's sending me a patient, an injured worker, where the question is balance, I don't typically like to see that injured worker until the balance part is balance. I don't typically like to, you know, see that injured worker until the balance part is corrected. And the reason for it is this an injured worker comes in and let's just say the question is Josh, I want to know how consistent or inconsistent he is with his balance. So patient maybe comes in a wheelchair and you know, and I'm like, okay, so if the patient stands up, the injured worker stands up and let's just say up and let's just say, if I keep my hands on them, I won't be able to tell how consistent I am right, because a lot of times when you put your hands on somebody, they might just go ahead and drop for you right there, right, because they feel like, hey, he's got a hold of me, I'm going to drop. So that kind of goes against the nature of being a physical therapist. I should be safety number one. But now all of a sudden I'm standing back trying to see what can they do. What can they do If this patient literally just goes? Hey, you know what, this guy's standing back for me. I just want to drop right now, just for the heck of it. What can I document? At that point I'm filling out an accident report. I don't know if it was consistent or inconsistent. So I used to tell people I'm like please don't send me any more of those patients until you can kind of uncover what is the underlying cause of the balance. Is it consistent or inconsistent? So, of course, good point.
Speaker 4:People threw it back on me and go well, josh, do you know a test that can actually test that? And what we found is there's a machine called the Neurocom Balance Master. We got a couple of them here at some of our facilities, not at every facility. It's a pretty specific piece of equipment, but just real basic. It's an actual you kind of step in on these platforms and they're moving platforms. So it actually measures. You know their force plates that the patient is standing on, and then it's got like a TV monitor in front of them and it's got they're kind of boxed in three ways the only part that's open is behind them and they're harnessed in. So the patient is harnessed, so if they fall at all they're caught right away. But what it does is it actually has some built-in consistency measures in that test. So, mike, for instance I know Greg heard like when I was giving the one part of the speech but, mike, for instance, one of the things we do is when the patient is standing on the force plates initially, and we're just hooking them up to the harness, we're actually testing that patient at that point. So because they're already on the force plates, we can tell if they're losing their balance or anything. All we're doing is hooking up, you know, the harnesses.
Speaker 4:At that point, the first test of consistency or inconsistency is the second. We say this, sir, ma'am, the test is starting right now. And what you see sometimes is the second. We say the test is starting. The patient will literally fall right then Because all of a sudden they go okay, the test is starting Now, it's time for me to fall. But keep in mind, for the last minute or two they were standing on those force plates. No signs of imbalance. So again, that's one of the signs of inconsistency built in.
Speaker 4:Another test is, as the test gets more challenging, I mean it's pretty cool the force plates move underneath the patient as it gets tougher. The whole, you know, basically the whole platform moves around them. So they're getting. I mean, because your balance comes from three main areas of your body your eyes I mean all you got to do is basically not recommend you guys stand that if you're feeling off balance right now. But if you stand there, close your eyes, do you feel a little shift? Yeah, you're relying on your eyesight comes from your inner ears, because you hear about people with an inner ear infection. If you guys ever had one, you feel off balance with that. And it also comes from your feet. That's somatosensory they call it there. It's the bottom of the feet. So this balance master looks at all three individually but to test that it maxes out what that patient has to do. So it actually shifts underneath them and moves everything around.
Speaker 4:The vision's screwed up and what you'll see sometimes is a patient that was falling before, when the test was easier because they're like oh, this is easy. The only thing that's happened is the box is moving. I'll just drop right now. All of a sudden you'll see their balance improve when everything's moving, because now they're legitimately in fear of falling at this point. So they'll actually get better balance as the test gets more difficult, which again should never happen. If you had problems balancing then you should have problems balancing before. You should not be terrible at the beginning and all of a sudden, as we increase that degree of difficulty, you get better. So again, that's another sign of that inconsistency. So I'm a big fan.
Speaker 4:So to go back to your question, greg, is like when to do it and everything. I'll be honest with you. If you got a patient with balanced issues and let's just say you get through I don't know, 20, 30 visits and it comes down to that question of you know, and you actually have good communication with the therapist you ask them that question what's going on here? Is the patient getting better, you know, are they consistent? And if they're like, I talked to one of our therapists the other day, I asked him that too. Those two questions with a balance patient, I go is he getting better objectively? And, second of all, do you feel he's consistent objectively? And the answer I got to both of those were you never want to hear this.
Speaker 4:When somebody starts off as well and I'm like, oh my God, I'm like yes or no, yes or no, and then they're like well, and I'm like okay, if you get that kind of answer, that would probably be a good time to do that balance master assessment. That's why I recommend it to them, because the cool part about mean it's just like you barely. I mean it's not FCE, I'm seeing somebody for like again five, 10 hours at a time. So that is obviously going to cost a little bit more because we're seeing them longer. But that balance master can be done in 30 minutes.
Speaker 4:It's just part of the regular PT part. So if a clinic has access to that balance master, I would suggest doing it right then, because at least that way you'll get some kind of context and some kind of idea in regards to the consistency or inconsistency. At least you can help build, because it's not only the consistent or inconsistent, it's also. Can we use this to help treatment going forward? So what is actually going on? Can we actually treat that and what can we do from here on out?
Speaker 2:I mean, I'm fascinated by the whole thing and I you know, I'm wondering you know how you even go about making a referral for that, just because it means it's something that most physical therapists would have if we were looking at major physical therapy network.
Speaker 4:I would think, because a lot of clinics now are at least like physical therapy kind of networks or big physical therapy settings. There's ones that are just pure orthopedic, you know, they're like they're doing your total knees, your shoulder problems, your knee surgeries, elbows, wrists, but then this is more of a neurologic, you know machine. So obviously it costs more, you know. So typically I would look if you have one of those big physical therapy settings or or networks that you're using, find out if they actually have one. I would just ask ahead of time there, I mean because, like I said, it's a good. It doesn't always get used, so it's good there for the help out, for diagnosis purposes and then also treatment purposes in the future too. So I would just ask I can send it to you guys, but I believe the company's name it's Neurocom. It's a Neurocom Balance Master, awesome, and we're actually just to jump into it.
Speaker 4:The one thing about it is that's more for static balancing. But there's static balancing trying to stay balanced in one position. There's also dynamic balancing, which is trying to keep your balance on the move, and the cool part is with technology now there's actually some treadmills out there that are actually we're looking to see if they can do the same thing with the dynamic balancing somebody walking and see if there's consistency or inconsistency, the same way we do with the balance master when they're staying in one spot. So hopefully that's something we can report back to you in the future, because we're looking to see if we can get one of those treadmills to actually start looking at consistencies.
Speaker 2:And then, as far as the functional capacity exam goes, is it you know we talk about balance testing and FCEs is this something that's standardized Meaning like? Is there one type that when you do a functional capacity exam you're going to get the same sort of thing no matter where you go, or is this something that can vary from facility to?
Speaker 4:facility. It can vary facility to facility. I've found this out just even from my referral sources, because a lot of them just come back and ask for me because they'll be like I went somewhere else, they didn't do this, they didn't do that. I remember I've done a couple of different. I teach the course. I actually got to go teach the course in one of the universities later today on FCEs, but I lay it out there.
Speaker 4:I'm like it's still kind of a young science. I believe it started in the early 80s, but they're still trying to look for a gold standard. As far as FCEs, if you type in kind of like my earlier Google search there, mike, where I was trying to type in how to make money I think I actually went the opposite extreme, because I was buying it for a company where I was like evidence-based FCE testing that costs less, or something like that. So I went the other extreme, though, because I had to look out for a budget, and I still think I got 30 different software companies or training companies out there that do FC training and, as we know with marketing, does any of them say we got the fifth best results or the 18th best?
Speaker 4:evidence they're all the best. They're all the gold standard right, even though there is no gold standard. I got 30 different gold standards out there because some doctor recommended it. It's all the best. So, with that said, what I usually tell people is a couple of things to look for for an FC. You know, these are just some basic questions. Number one how long has the FC evaluator been doing it? Because it ultimately comes down to not only the technology but the evaluator.
Speaker 4:If somebody has only been doing I mean, everybody's got to. You know, learn the hard way, and I'm not saying there's anything wrong with somebody that's only been doing a couple months. But, however, if you're looking for somebody to really get that challenging patient case where nobody knows what's going on, I'd recommend something that's been doing it a while, because you ultimately want what's called a thinking evaluator. They're not just relying on the data but they're also relying on thinking it through, looking at what they see, because there's so many different things to take into account here. So, somebody that's done multiple trainings too they just didn't go to one of those 30, but they actually probably did a few different trainings to learn kind of what's best from each one. Because if you see a good training course, we'll say, hey, we're not the end, all be all. I'd recommend also going to so-and-so and so-and-so and learning from them and combining these techniques.
Speaker 4:So, overall, the other thing I would say is time too, because, mike, to go back to it, there are people out there because I know there's certain ones that it's just a diagnostic code for them, so they will literally bill like they're doing the full FCE and they only spend in 45 minutes. Cause I've had to do a lot of redos for people around my area and I'll see the injured worker. I'm like you had one of these before and they'll be like my interview takes longer than their whole eval. Like you spend an hour and a half talking to me. My last eval only lasted 45 minutes and I'm like whoa. So I mean I would say time experience of the evaluator, their training would be a lot of things coming into play there.
Speaker 2:Great points, Great points. So, as we kind of wrap things up, looking at one of the questions and I feel like there's often confusion about this is the difference between work hardening?
Speaker 1:and work conditioning.
Speaker 2:And I'm not sure that I could, even today, in this moment, tell you the difference.
Speaker 4:I don't know.
Speaker 3:Greg, can you tell us the difference?
Speaker 2:No, that's not what I want to ask this question so it's been explained to me before. I know there's a difference, but I don't want to lead us down the wrong path. Josh, I'm hoping you can tell us the difference between these two things.
Speaker 4:I'm hoping I'm giving the right answer. Maybe somebody will send us an update after I'm done and be like dude Josh is way off. I did go to the American Physical Therapy Association website. What's interesting is, I know in the state of Florida, I know when we're billing it's basically the same billing code for work conditioning and work hardening, which, I mean, also makes things a little bit more nebulous, a little bit more confusing. But the definition of work conditioning you're almost looking for, you're looking for the similar outcome, right, you're looking to.
Speaker 4:I always tell people you got general physical therapy, you got general occupational therapy. You know, or you're getting it. You know. One hour a day, three, you know, three times a week. I look at work conditioning. Work hardening is like therapy on steroids. You're now seeing that patient every day for multiple hours per day. Cause cause again, it goes back to that time equation I was saying about earlier.
Speaker 4:It's very difficult for us to extrapolate. Oh man, I got this patient who's supposed to be a railway worker. He's got to lift a train knuckle that weighs 83 pounds. I got this. Any kind of hard labor job where somebody needs to be able to do a very heavy physical demand level. It's very tough to extrapolate in that one hour a day, three days a week, after they come off a shoulder surgery to go. Hey, I think this guy's ready to go back to work full duty. How would you know? I mean, they may do really well Going back to your point there, mike, about the shorter exam may do really well like kind of like a highlight reel for that first hour, but who knows that they start really just kind of their endurance is weak and they just really look bad four hours into it.
Speaker 4:So work conditioning, when I looked it up in the American Physical Therapy Association, it's basically, first of all, it's one discipline, so it's usually just like physical therapy and it's four hours. It can go up to four hours a day, up to five days a week still working on work related activities trying to get that injured worker back to their job. Now, work hardening can go up five days a week but go up to eight hours a day, okay, and typically it's more than one discipline in nature, which means you know they're getting physical therapy and occupational therapy. I remember with one of the programs I used to have would be physical therapy and they also get psychology too, because the question was like things about fear avoidance and trying to get that you know that injured worker over the psychological part, over that hump of hey, you're going to have to lift more, You're going to have to get used to this, we've got to talk you through it.
Speaker 4:So a lot of those fear avoidance. So typically the main difference is, from what I've seen, the max time per day goes longer, with work hardening versus work conditioning, and then also it's usually multidisciplinary in nature. So more than just PT, they're also getting another discipline Perfect.
Speaker 2:Perfect, perfect, perfect. I'm going to whenever I have this question, I'm going to come back and I'm going to listen to this little segment right here.
Speaker 4:I just hope nobody shoots me down there for you, Greg, I feel bad. So I'm glad that guy was way off. So like find a new guy to interview next Monday. Oh, you did great.
Speaker 2:Well, one of the things I'm doing this season as I wrap up this year is you know, last year we we talked about people's happiest moments. This season, I wanted to focus on what's your favorite part of what you do every day. Obviously, there's large parts of people's days that have to happen, but they might not be the moment. So what gets you up in the morning with what you do every day, Josh?
Speaker 4:I love it and I hope you guys don't mind, I want to hear a little bit from you too to get me fired up for the day. But I'll go ahead and start here. But the biggest thing for me is I get to do a couple different things with my job. I get to sometimes treat, do the functional capacity evaluations as a physical therapist. I do the sales role which you know again, helping come in. And then also I also get help out program development, creating new programs. But then I also get to help out sometimes a case management as an injured worker goes through different settings. I sometimes help out with the touch points there, getting them set up from inpatient to another clinic, so maybe setting up work conditioning. So I'll actually use this one that has everything involved. So my happy moment generally is this to be able to see an injured worker that I mean sometimes could literally be on death's door when I first get the call and we're not even sure if we can get them to the hospital because we're not even sure if that injured worker is going to live. But they stabilize, we get them into our hospital and then seeing them six months, a year later I do the FCE on them and they return to work. And that is probably the thing, because it's like that's why we do what we do. So real quick one, if you guys don't mind, just for about one minute here.
Speaker 4:One time I did get a call. I was doing an FC on another injured worker at another clinic and they called me and they go. We got a guy he literally had like a tree fall on him. We're not even sure if he's going to live. I mean, this is how bad it was. And they go. If you bring him in, do you think you could handle this? So I make a bunch of calls, go back in see my injured worker, hear about it. A week later we bring him in and he finishes up and it's three months of intensive rehab. This guy's got to get, but by the time he, after the tree falling on him, everything's kind of shattered for him to get up and move again. This guy was so the endurance just wasn't there. So he started off with basic therapy and he was having trouble with that.
Speaker 4:And then they go Josh, can you train us at this other clinic how to do work conditioning? So I showed him how to do work conditioning and I kind of forgot about things. But then about three months after we started the work conditioning, or probably two months they go Josh, can you see him for his FCE? And I'm like all right, I didn't know what, in months I think it was basically almost six, seven months to the day from the time I got that call to doing the FCE the guy did the FCE and he actually aced it. He could return to full duty work.
Speaker 4:So I mean it was amazing and I told him that. I said I said I, you know cause I'm pretty much uh, just talk the way I talk. I was like brother, you know cause I'm here, I'm sounding you did, man. I was like I remember you barely lived seven months ago talking to your wife and family and weren't sure if you're going to make it, and you just did everything to return to work. This is amazing. He goes. Yeah, man, I was like he goes. It's kind of set in with me too. So I think that is like one of the highlights. It's like why we do what we do, cause to be able to see that that comeback. That's what you want to see, that's what gets you up in the morning. That's why I feel like WWE wrestling, where I have to throw my laptop off here, but anyone hear me finish, guys. So that one and I had another guy recently who I saw for his FCE.
Speaker 4:No, it's actually a couple of years ago I saw for his FCE. But he decided to switch careers and he got so inspired by the therapy he got. He's actually he. I mean talk about a leap of faith. He didn't have the money, didn't have the resources, because he hadn't settled yet. He put everything on his credit card and had to actually even take food from his food bank at his church. He is now a therapist with us. He's totally switched careers and he's now helping out. Other people started working with us two months ago. So that's why I do. What I do is awesome comebacks like that.
Speaker 3:But guys, tell me what gets you up in the morning.
Speaker 2:Please, mike, greg, fire me up right now. Greg, you first man, I'm not following that. Well, I'll tell you for me, I love feeling like I'm making a difference and so when it comes to workers' compensation, when I know that one, we're doing the right thing for people and we're helping people get back to work and we're helping businesses be able to stay in business that and then watching my own staff grow from when I came to where I am now. You know those little steps and then watching their lives change, people that are recruited and brought in that did not have workers' compensation backgrounds. One instance was customer service working at a Publix and he made the transition to workers' comp. Watching him get his insurance license, watching him develop and then seeing him be able to have the freedom because of working more normal hours to be able to do what he loves.
Speaker 2:He's leading praise sessions at his church. It's great that he's able to give back to other people because he has freedom, a little bit more freedom in his work schedule to do what he does. So those things and then, of course, seeing our injured workers succeed for me is what it's all about, and you know I want to when I'm done here and hang it up, feel like not only did we do the right things, but we also changed the way people think about workers' comp, and so hopefully, between the podcast and the other things that we're trying out with our empathetic resolution model, we get to a point where we help people see workers' comp a little different, and if I can achieve that at the end of all this, it'll be worth it. I definitely think you could, greg. All this. It'll be worth it. So there's, I definitely think you could.
Speaker 4:Greg, I definitely think you guys will help change. Just a quick shout out to you I had a call with some of your teammates there recently and it was definitely a breath of fresh air. I mean, they were trying to go above and beyond to help out one injured worker. Just from every which way biopsychosocial they are truly living the model and they didn't have to do that and it was just amazing because ultimately, we're about we're in the business of people helping people, and it was just a breath of fresh air. So I definitely feel like you guys are on the right track and can definitely. You know, that's how we make a change one person at a time. So I really appreciate your vibe. But of course, mike, you got to follow that up, brother, you got to take it. You got to finish us up strong man. I got faith in you.
Speaker 3:Look, I'm going to go a completely different direction because you guys have basically taken all the work stuff. I could have said I'm going to go completely outside of work. I'll be 100% honest. I think my biggest thing that gets me up every day, that makes me feel maybe accomplished. I don't watching.
Speaker 3:I have a very young daughter. She's four years old. Watching her develop, like every day she learns something new Every day she says something different Every day. She's like she'll say something You're like where did you, how do you know that? I think I say how do you know that? Like 17 times a day. And so I mean it goes back to all the stuff you guys are talking about have been the same as your guys. Honestly, I'm like Greg. Watching people develop, working with newer people, figuring out what makes them tick, figuring out what's going to make them grow and their work is big for me. But I think that probably takes the cake is watching such a young person figure out how to live life is kind of wild, and it's it's what keeps me going every day for sure. That's awesome, is that your only? Yeah, we got one four years old. Her name is ellie, so good deal, congratulations there, my, that's awesome thank you, I appreciate it.
Speaker 4:I don't have six like greg so you got, you got multiple kids, right I do I do?
Speaker 2:we just wrapped up homecoming and I had three in high school and they all went together as siblings with their date, which is really cool. Awesome, bro. Yeah, so life is good, life is good.
Speaker 4:I'm very fortunate too. I got, uh, my son's gonna turn 13 this week and, um, yeah, we, uh it's like I said, this past weekend we all went out, ran with the kids together and it was just great vibes, so I'm in total agreement with you too. I I realized the question initially is works? I don't sound shallow and I was just yeah it's a combo package.
Speaker 4:I mean you got to love what you do, but definitely family, you know, I mean without that dude, I mean. So it's definitely what helps get me up in the morning. But, guys, I really appreciate the opportunity. You guys are both awesome and the whole team on here. But I know we got some people, you know, riding out back there, you know, just helping us out. So thanks, so much.
Speaker 2:Thank you, josh. It was great chatting with you. It's always good to see you. I know our paths will cross again, different conferences and hopefully with some recovery of some patients down the road. And I just remind all our listeners our motto to do right, think differently and don't forget to care. And catch us every other week as we release on Monday as a reminder that on the off weeks we do have a blog, so if you prefer to read your media rather than listen, that's an option as well. So thanks again to everybody and we'll see you next week. Thanks guys, thank you.