The Path to Pain Management Expertise: Nick Rainey's Roadmap

MPP 156 Nick Rainey

[00:01:34] Mark Kargela: Welcome back to another episode of the Modern Pain Podcast. This week, we sat down in Las Vegas at the Pain Science in Motion Conference with a friend and colleague, Nick Rainey. Nick is an accomplished physical therapist and clinic owner who has really developed a practice where expertise and excellence are the rule.

We discussed the necessity of mentorship to really boost your journey to expertise. 

[00:01:54] Nick Rainey: And I, I think it's important that people go through residency and fellowship training or some type of long track training. They need mentorship. That's really what they need. And they need structured mentorship. If you don't get structured mentorship, it's difficult to become an expert quickly.

And I need these people to become experts. We can't wait, wait a few years. 

[00:02:11] Mark Kargela: Nick and I discussed how he searched out expertise actively to improve his own practice. So, this was after fellowship where you decided like, hey, I need to kind of, this is somewhere I need to like up my game, so you decided I'm going to find somebody who's like, who's doing it, who's been, like you said, doing it longer than you've been alive, um, those are the people you search out.

We discussed our experience and how there is a broader understanding of what it [00:02:34] means to have good hands with patients. 

[00:02:36] Nick Rainey: When the patient believes that you're good, they get better faster. And so when you're better with your hands, is that because you're a ninja or is that because then they believe you more?

[00:02:45] Mark Kargela: We talked about this and much more in this week's episode. If you can do me one favor this week, I'd love it if you could share this episode with somebody who may be early in their journey and trying to find their way in their own journey to expertise. If you aren't subscribed yet, please do so. And if you're really getting value out of the podcast, I'd love it if you could just give a review so this information gets to more people who really need it.

Now, on to the episode. 

[00:03:07] Announcer: This is the Modern Pain Podcast with Mark Kardula. Nick Rainey, welcome to the podcast. 

[00:03:14] Nick Rainey: Thank you very much, Mark. 

[00:03:15] Mark Kargela: We're in Pain Science in Motion here in Las Vegas. It's a live podcast, first time we've done this. This is episode two here while we're in Las Vegas. You and I have both been through fellowship and I thought it'd be a good opportunity for us to discuss kind of the whole fellowship process because manual therapy, as you know, has had an assault on social media.

And I think in some ways, [00:03:34] good, there's been a lot to criticize about traditional manual therapy, right? Some of the stuff that we see online and some of the crazy stuff we see online with like bruising people and all this stuff, but that's not what we're talking about. And this kind of follows up with the episode we had with Jason Silver.

Now, you know, we're. Talking about that before we went on air, but before we get into kind of the nuts and bolts of that, can you kind of introduce yourself to the folks as far as kind of where you're at, what you're up to and kind of your journey with kind of manual therapy? 

[00:03:57] Nick Rainey: Oh, sure. I'm in Sierra Vista, Arizona, which no one knows where that is.

Um, it's the bottom of the U S our County borders, New Mexico and Mexico. It's a decent area though. There's about 75, 000 metro people. Um, it's Southeast of Tucson. We're in the mountains, so it's not as hot as most of Arizona. So we, we, we appreciate that particularly here in the coming months. Uh, so I have my primary practice rainy pain and performance.

Uh, there's, uh, we have several clinicians there and everybody that. Practices with us has to do some long track training, residency or fellowship training. And then I [00:04:34] have a sub practice. It's Sierra Vista headache and TMJ specialists. Uh, that's basically, it's basically a marketing gimmick, if you will.

You know, I mean, we, there's a separate page for it. It's a separate business line for it. So when people call and everything, I have a separate room for it. Um, but it's run as a sub practice in the same, in the same building that way I can market and then specifically look at how I'm doing with that population scheduled a little bit differently and whatnot.

Uh, so I, I enjoy doing that. Uh, and then I also have, I partnered with somebody to do a Tony rich to do a Medicaid practice. So in Arizona, the acronym for act for Medicaid is access. And so this is access therapy. It's accessible people, accessible care for people on access. Uh, so that's. That's where I spend a lot of my time.

Uh, we also have our own in house residency program. And so I do a lot of teaching with that cause I lead most of that. I don't do all the teaching we have. [00:05:34] Like I said, all of our clinicians have done some type of long track training. So we can bring a lot of expertise with areas that other people are better at than me.

Um, 

[00:05:44] Mark Kargela: Your journey, like with manual therapy yourself, I'm curious, like where you, cause we all have our stories, right? With manual therapy. And, and as far as our training, um, I thought in school, you've, I know we've, you've listened to the podcast and you've probably heard my stick with the whole thing as far as like, that was my pursuit.

Like I thought it had to be like this amazingly nuanced, you know, millimeter detection skills with my hands. And obviously that, that shifted for me. How has been your, your journey with manual therapy as far as you've kind of come up with it over the years? 

[00:06:14] Nick Rainey: Yeah, that's, uh, as I listened to your journey, I, mine is different than yours.

Um, I, when I, I, mine's a little bit more opposite. I, I probably started off more, I think it was at Seth's podcast. When you talked about like some people just turn off their brain with it. That's more where I was earlier in my career. [00:06:34] And. And then I've become more nuanced as I've progressed in my career.

And we all think we're right wherever we're at at that point in time. Right. So I'm, I'm not, I'm not, uh, oblivious to that, but, uh, early in my career, I, as a student, I was given a more of a psychosocial point of view of this. Um, and then, so I was with, uh, Tim Flynn was at our, was our ortho professor. And so we had some association with evidence in motion.

So 45 weeks as a student, I was, we had a long clinical under fellows. And so we had, it was kind of like a residency program. We had posts that we had to do online. We had rounds and whatnot. And then I went right into residency and fellowship training. And I've become a little bit more detailed few years into my career.

And so I feel like I have a healthy appreciation for the limitations, uh, but also for the value that it can provide for people. 

[00:07:29] Mark Kargela: I mean, it's nice to have that kind of experience, right? I wish I would've had like that more residency cause it kind of [00:07:34] instills this clinical thinking, critical reasoning that if y'all read the OMPT paper, that Jason Silvernail's episode refers to, we'll link it in the show notes, but that there's unfortunately manual therapy gets lumped in with this, like, you know, turn your brain off and just rub or poke or, or, you know, jab a needle or whatever it may be into that where.

There's a lot more nuance and thought, like you're not definitely turning your brain off when you're doing manual therapy, obviously, if you're going to make it through a residency and fellowship, what's been your experience with kind of seeing what gets portrayed out there online with manual therapy and then what your experience has been with, you know, learning and the thinking that goes behind it.

[00:08:10] Nick Rainey: Yeah, so I, I guess I don't see as much stuff online. I listened to a lot of podcasts, so I, I hear what is said and I. I feel like I do have a little bit limited view of what is predominantly out there. Cause we all, we run around with people that are typically think like us, you know, and so, and there are times when I'm teaching to a group, particularly like oral facial pain is where I teach the [00:08:34] most.

And it's typically, um, Not the people that I've typically been associated with. And so they have more varied backgrounds and I quite enjoy, but then it is tougher to know where they come in from, you know, so if I ever, you know, like if I was at an evidence of motion weekend or whatnot, I have an idea of where, you know, where their education has been at before this.

But as I teach TMD with evidence in motion, it's not people that have been through their management programs and whatnot. And so it's a more varied. So I have a tougher time, you know, then I realized of seeing what, where's most people at. I know where most people are at that I listened to, you know, that I talked to the residencies that we've had people with fellowships and residencies and people that are programmer and are in our practice, you know, where theirs are.

But I also advocated they go to ones that, you know, coincide with, you know, more of my beliefs with it as well. So I know there's still gurus out there, but I don't, I don't really associate with them that much. [00:09:34] 

[00:09:34] Mark Kargela: And I think our profession is generally moving away from the whole guruism approach where there's this one gray haired individual on stage who, you know, you were kind of bowing at their feet and I know that's an extreme take on it, but yeah, and it sounds like you've created a setting where and founded on good clinical reasoning, good critical thinking and having, and it makes sense, right?

If you're a business, you, you all probably need to be discussing things and working with things in a somewhat similar fashion. If you have somebody. Who's in your practice, who's going way off in the left field. I I've seen this with students I've mentored and talked to where they're in clinics where they're very traditional, maybe guru based manual therapy and they're trying to do a very different approach that doesn't necessarily work well when you're the lone wolf in that setting.

What have you found the strengths of like getting into that residency and fellowship training when you're looking at maybe yourself, but also your employees to kind of. Provide a standard of care, I guess you would say to to deliver a product that you're you're as a company proud of 

[00:10:27] Nick Rainey: yeah, there's probably multiple aspects.

I could answer with that when uh when I started it wasn't a business [00:10:34] decision. It was a I don't want, I don't want everybody that comes to the practice to want to have to see me, you know, that's, that does me no good if I'm working 60 hours a week seeing patients and everybody else is sitting around there because if, and then, because when you're practicing on a day to day basis and they know you're there, if everybody says, Oh, can I see Dr.

Rainey? That's, uh, that's not a good business model. That's not good. That's not good for me personally. Uh, and so, and I think it's important that people go through residency and fellowship training or some type of long track training. They need mentorship. That's really what they need. And they need structured mentorship.

If you don't get structured mentorship, it's difficult to become an expert quickly. And I need these people to become experts. We can't wait, wait a few years. And so it was mostly based off of my principles that I think that it's important originally, and it's turned into a very good business decision.

Every place else in our county has struggles to recruit and hire. And, I mean, I don't want to say we don't snap our fingers and somebody's there, but always within a few months or within the year. We've had people and we've [00:11:34] just We've been able to recruit quite well from it because if you're just looking for jobs out there, there's a ton of jobs out there and if you're just going to base it off of pay and location, you know, and hours and benefits, there's going to be a lot of competition.

If you're based off somewhere where they'll pay completely for your education, you know, and you're going to get structured mentorship and you align with that person. Some people go into residency and fellowship programs where they don't align with the person, you know, that they're learning from. Then, uh, it's been a, it's been a great recruiting tool for us.

[00:12:03] Mark Kargela: Yeah. And it makes sense, right? As a student, I don't see how you look at that. I mean, it's tough though. I think there's probably some students out there who see, cause I think some settings will dangle maybe higher salaries at you because they can, they're going to throw high volume at you, high productivity.

And it's, I mean, I honestly reflect back, I don't know if I'd survive in those practices, but you, you get in other settings where you see a progression, you see like this movement towards expertise, like you spoke of bringing it back to mentorship that you spoke about, because I think that's been one of the keys that I think it's overlooked sometimes where [00:12:34] Everybody envisions, I think at least some of my discussions that manual therapy training is just this like learning how to perfect, like just some of these dated, maybe theoretical models of, you know, very high, highly specific segmental assessments and stuff like that.

And I'm not saying there might be not times where we can kind of figure out some specifics, of course, but. Where has, you know, it sounds like mentorship for you started pretty much right in, in, in school, like in, which is a, I'm jealous because I didn't really have that. I had great faculty, but it wasn't that kind of setup that you had at Rocky Mountain there where you have Tim Flynn and obviously somebody who's a, you know, kind of a legend in the profession of manual therapy as far as really kind of pushing us to, to think a little deeply.

What's, what have, what's your personal experience been with mentorship? Has it, have you had the experience that I think most, many of us have where you got knocked on a few pegs coming into things thinking, uh, we just had a discussion last night at, uh, uh, dinner before dinner. And it was, um, about how like we kind of come into these situations thinking like, we got some [00:13:34] things figured out, man.

I like, I think I got this. I think I'm. I'm good. Did you have any of those experiences with your mentorship where it kind of, you had to kind of get set down a little bit in a professional way. Right. And most of the, my experiences with mentorship have been great, but what's been your experience? 

[00:13:47] Nick Rainey: Yeah. So the thought, the experience that I thought last night was, uh, it was the early on in, It was early on one of the courses that was a bit later in fellowship.

And I thought, you know, I've done the 45 week clinical, you know, under with fellows and it was really quality education that I had residency. I'd been through half a fellowship. I was feeling pretty good about myself. And I submitted a video. I was like, man, they're gonna be like, wow, who's this guy? That was not what it was like, as you could, uh, as you could imagine.

And I was like, they just don't know. Well, that person. You know, I, I really blew it on Neva. Like she, I totally misgaged where she was at. You know, I thought it was like an acute on a subacute. Well, I didn't ask enough questions and it was acute on subacute on chronic. She was in our clinic for like a hundred [00:14:34] visits.

I mean, it was a worker's comp, so they kept approving more. And so you can't not, you know, it wasn't like this isn't medically necessary. Like they said, well, just keep seeing her. And so like I kept trying, I mean, I kept trying new thing after new thing. I would, I was searching and, um, And so, and I was like, that was a very good lesson on that video that I really, I didn't do a good job, but they were exactly right in the feedback they gave me, but also don't make that mistake anymore.

[00:15:02] Mark Kargela: Yeah, a hundred percent. Like I think some of those learning experiences are the ones that get seared into your memory that when you see that presentation come into like not going to happen again, especially when you've had. Um, some criticisms, uh, and some good again, professional mentorship is all about not just patting you on the back of like, Oh my God, you're so good of a therapist.

And that's kind of how I thought I was going to be like, I say, Oh yeah, same thing. Like, here's my video. Let's we'll watch it. We'll have them watch this and they're going to be like, man, this guy's got it figured out. And it was the exact opposite of that. I remember I went through it with my buddy, Jason Steer, uh, and we both were [00:15:34] texting.

I was texting him while he was doing his, I was like, man, I got your back. This is rough. And we're both like acting as support systems because it's that critical thinking, clinical reasoning piece that I think it's so overlooked. And it's not just with how you're going to use your hands, but how you're going to stage a patient, where's pain science education going to fit in is even hands on care, uh, you know, indicated for a patient.

Um, so I think sometimes, you know, again, these programs get kind of perceived as it's just a bunch of like sitting around tables and, you know, everybody's watching somebody manipulate and there's some technical skill. I mean, obviously you have to have some technical skill in delivering some of these things.

Is that been your experience too, or it's been, you know, it's been much more about like the thinking and reasoning piece versus like, there's some technical pieces. We both went through a similar journey with it. I mean, there's courses where you have to like show proficiency in that. But to me, that was like about 10 to 20 percent of the journey.

How was it with you? 

[00:16:27] Nick Rainey: Yeah. I often think about how much is it the technical component versus everything else. And I don't know [00:16:34] that it's hard to separate that out. You know, I mean, I, I know there's research, I can't spout it off, but that when the patient believes that you're good, they get better faster.

And so when you're better with your hands, is that because you're a ninja or is that because then they believe you more, you know, and I, I don't think we can separate that out. 

That's a, that's a good point. I think there is like this nonverbal communication of just skilled handling of a patient, right? It probably isn't the minutia of like you, like you said, like ninja type stuff, or is it just like, You can command like an intervention interaction and show supportive, you know, handling of a patient to where they almost like, man, this guy really can use his hands.

Well, it makes me feel comfortable, makes me feel supported, makes me feel like I can kind of move on my journey. Yeah. I think that's a good point because it is more than, than the, the, the ninja skills for sure.

[00:17:24] Mark Kargela: I'm wondering with, cause I'd love, this is a selfish thing cause I don't see a ton of TMJ, orophacial pain, but, and we're at a pain science conference.

So, and that. Population seems to [00:17:34] fit well with, with pain science things. Cause there's often, you know, stressors and psychosocial things. I'm wondering where that came from in your price. It just something that you had a special interest in that you kind of just dovetailed into, or did you see a need in your community that needed to be filled or how did that kind of show up for you?

[00:17:50] Nick Rainey: Yeah. So it was near the end of fellowship training and we had very little in fellowship training and that's not a criticism of it. You can't do, can't do everything. And I, um, I realized one, there was a hole in the community. Two, I realized that I treated some of those people and they got better, but I don't really know why.

You know, I mean, I basically do some manual therapy and exercise and you know, and words that heal and not harm. And they did pretty well, but I was like, I think I could do this better. And now that I have the clinical reasoning aspect, I felt pretty nailed down. And I'm skilled with a lot of elsewhere. If I could just add this, it would really help.

And I thought it would help me be able to teach more as well. And so, I, um, I flew out to New Jersey, Jeff Manheimer. [00:18:34] I'd looked at his, he'd been treating only oral facial pain longer than I'd been alive. And I was like, well, I have, you know, most of the rest of the body. I'm doing pretty well with, I should be able to learn something from him.

And I did, it was some, it was some rough red eye flights there. I wouldn't go to bed that night. I'd eat dinner in Sierra Vista. I'd hop on a flight. I'd walk into the clinic the next morning. And it's tough to stay awake during those some, but, um, instead that's really why I nailed, why I went into. 

[00:19:03] Mark Kargela: So this was after a fellowship where you decided like, Hey, I need to kind of, this is somewhere I need to like up my game.

So you decided I'm going to find somebody who's like, who's doing it. Who's been, like you said, doing it longer than you've been alive. Um, those are the people you search out. I think that's a good example of like a clinician who's striving for expertise, right? And that whole mentorship piece, right? And I'd recommend anybody and it doesn't, I mean, this is just something that sounds like you arranged with, with him to say, Hey, can I come hang out with you?

Or did he have more of a formal program? 

[00:19:31] Nick Rainey: It was a small formal program. There were six [00:19:34] of us, so it was three separate weekends. We went out there. And, uh, my wife said, go for it, which when you have how many kids we have at that point, we had three, I think we had three, maybe it was four kids by then. So it was, uh, quite supportive of her.

[00:19:51] Mark Kargela: Yeah, no, happy wife, happy life. And that's awesome. When we have spouses that you just support us on our journey. For sure. I'm fortunate in the same, uh, with my wife. But that's still like, again, that mentorship piece of like, you can, there's only so much you can do. It sounds like it was very much like we're going to be treating patients and you're going to be seeing, you know, kind of how we do it.

Is that the, been the structure of that program? 

[00:20:11] Nick Rainey: Yeah, he, um, we did have a live patient come in there, you know, and it was, I mean, there was a decent amount of lecture with it, but when there's one versus, you know, one on six, you get a lot of like, this is what I'm seeing on here. It was a lot of questions, you know, that he could say, this is, you know, How I attribute, you know, this is when I do this and I knew that I wanted to teach.

So I had already, you know, I was taking notes like, okay, [00:20:34] that's when I add this in here. Cause I'd done a little bit of it and that's when I add this in here. And it was just very helpful to, it wasn't my, it wasn't early on in my career. So it wasn't an intro piece. And so it just helped finish it off for me.

[00:20:48] Mark Kargela: Sure. Sure. As you've. You've been exposed to pain science. That's obviously been a big explosive topic in the last 30 years. Where have you seen that fit into that oral facial population? Like is, are there kind of some common themes you see that come out with that are common issues or, or things that you feel like with pain science, you've really maybe looking, taking a little bit deeper look with people to see some different factors that you may not have considered in the past.

[00:21:12] Nick Rainey: Yeah. So, So with it, I see oral facial pain, which encompasses headaches and TMJ issues. And obviously with headaches, you know, migraines. If you look at the central sensitization inventory B. Um, so the A is the 25 questions. The B is the, have you been diagnosed with any of these conditions? Uh, TMJ is on [00:21:34] there, and so is migraine on there, uh, I think whiplash is on there, you know, all things that are correlated with that.

Um, so when we talk about chronic overlapping pain conditions, that's where, so I've also done some pelvic health training as well, and a lot of people say there's, between there. And so I really like pain and ortho and which is why I've expanded into both of those. It's not a new niche. It's expanding on the niche that I'm already in.

And so when one thing that I've focused on with them, I have them all do the CSI B or CSI a So if they have a 40 or over on there, I know that person isn't going to get as better as quickly as I think they may. Um, and I remember one person, I was like, Oh, maybe this one doesn't line up. I think this person will get better faster.

Nope. I was, I was wrong. You know, if it's comes in with like a 23 on there, a little bit of jaw popping or clicking a little bit of an egg, that's like a three or four visit person. If it's achy, it's, and it's 70 on the CSI, that person has taken longer. I've really got to, I've got to make sure that [00:22:34] I don't treat them as just nociceptive pain.

We've got to work on that some, but I'm really hitting the lifestyle factors and beliefs and identifying where's the limitation, where's the hang up here? 

[00:22:43] Mark Kargela: Yeah. Yeah. I mean, a lot of that to having worked again, a little bit limited with that. There can be, you know, if somebody has got a massively stressful situation that they're not addressing or they're struggling to cope with, then, you know, incorporating, um, you know, maybe some other professionals or, or doing a, do you have the access to that in your setting to where you can kind of like somebody's You see like a psychosocially, there's some things going on outside of your clinic that are maybe driving that condition.

I mean, what's, how do I, how do you handle that? 

[00:23:10] Nick Rainey: Yeah. So, you know, the easy answer is it depends. I've worked to develop relationships with individuals in town. Uh, Most aren't great at talking to them about pain as, as you know, you know, there's some that are really good with pain, but some are going to be doing just other things.

There's also limited access. Sometimes it's hard to get people to go see somebody else. And it's like, Hey, you need to go here. We [00:23:34] even with one of the, I forget what exactly your degree is, but she was a counselor therapist, some kind. And, uh, we put on the paper, this is what she'll do. This is what we'll do.

And we give it out to people. And it, it didn't work magically either. Uh, some people are already seeing something, somebody it has helped. I don't know how many of my people see better help, but there's more online avenues with this. So that has helped access a lot of people that I bring this up with like, Hey.

This is looking like high anxiety here. How have you been dealing with that? Easy question. Like they marked it. I'm not like trying to probe on something that I'm reading between the lines. They marked it there for me. You know, how are we dealing with that? That's an easy question. And a lot of times they're already doing something.

And so I'm saying, okay, you keep that up. I want you to know how important I think that is, because I want them to know I'm not glossing over that, but I'm not, if they're seeing another professional for it, I don't need to delve into that, you know, extremely, we're going to work on the pain aspects, I'm going to work on their fitness, you know, I'm going to work on helping them [00:24:34] understand it, not be so worried about it, give them some other day to day management strategies.

And then if there's still problems, then we can look for other for other avenues for it. So. 

[00:24:42] Mark Kargela: Yeah, it sounds like a reasonable approach. I think, you know, it's always interesting like service, uh, smaller community, I think, right? It's not, not a big one. And it's, it's tough to find pain psychologists and things.

And you're right. Like patients, some just don't see one. It's like, I'm here for my pain. Where's the psychology thing? And then it becomes this, and you're, you're telling me it's all in my head thing. Is that something you've had to be tread lightly with as far as with patients to say, Hey, okay. Yeah. I need you to see this person, but you have, there's obviously a nuance to that pride discussion to make sure you, they understand the why and how it fits into what you're doing.

How do you handle it? 

[00:25:15] Nick Rainey: Yeah. Better than I used to. You know, I, it feels like I used to have the, you think it's all in my head type of things, you know, and I'd be like scrambling back. No, that's not what I said. I haven't had that experience in a while, so I don't know if I'm just doing it better or if I'm just, Not having the discussion as much.

Maybe I think that I am, [00:25:34] um, things that I've done to work on that is, you know, one thing I'll often say is nobody ever told me that their stress made their pain better. You know, it's an easy, everybody nods to that. And as a salesman, you want people nodding and I'm trying to sell them on what's going on with this.

Right. And so no one's ever said, yeah, I've been more stressed. My pain all went away, you know? And so then it just opens that up. And I'll also tell, Say, hey, I realize that if I just say, well, don't be stressed, and I will say that jokingly so they know it. I'm like, I know some people will say that, like, that's not, that's not helpful.

I'm here. Let's work on this because that's going to be an aspect of it. I also want, I also always let them know that if I'm telling them something, they're going to be skeptical about. I emphasize, I bring that up before they have to. Like, I don't think just by not having stress, all your pain is going to go away.

But I think it's a component of it. And so that's something that I really focus on. If I ever say, if I want them to do some aerobic exercise, I don't think going on a walk is going to take all their jaw pain away. But it's [00:26:34] a component of it. If they're not doing, if they're sedentary, being more physically active is going to help their health and just everything.

And so I emphasize, I bring out the skepticism before they have to bring it to me. So I head it up front there. 

[00:26:46] Mark Kargela: Yeah, that's a great approach. I think sometimes, and once you've been doing it enough, you know, where the skepticism is probably going to come back at you. So you can kind of head it off at the past before you allow, like, you know, the immediate kind of like, you know, the blank stares that come back at you and the kind of folding the arms and just, you can just see the skepticism in them.

But yeah, that's a great thought process to kind of. Hit it before it comes back at you because same thing I do and it's like, you know This is not to say I always will just like first off Don't ever hear that I'm telling you this is all in your head. Like that is the last thing This is or this is in your life.

Part of it is your head I mean, like you said, it's a component and it's all of our heads when we're experiencing Pain and it's disrupting life. And then, you know, you just list off the things that they're talking to you about all the things, how it's changed your life and really move them maybe in a negative direction.

But yeah, I think that nuance to it, it sounds like you've honed your [00:27:34] discussion with patients to where, you know, likely the, those like immediate, like, Whoa, like reactions coming back at you have probably decreased just from, you know, maybe taking your lumps in those conversations, which many buttons.

Yeah. I think we've all done it, man. We've all had, had those lumps for sure. I want to bring it back because I love what you do. And some people get so uncomfortable when this word is even uttered in, in healthcare sales. Right. And I, I think, and I, one of the things I've looked at as sales training, cause it's just, you know, you're trying to sell somebody on what you're offering.

Right. And I think for most of us, we, if we're evidence based, we're science based, we're using the best interest of our patient's hand. It's our duty to try to sell it well. Right. And I just think that is such a, a skill that one, it doesn't get taught in school. Right. I mean, I think we do it kind of implicitly without any explicit understandings of like the Metro, the whole, how much, and some folks don't really maybe take too much of like a specific, like sales training approach type thing, but yeah.

How often do you think of that as like [00:28:34] a sales, you know, situation as a business owner? I think it's smart to do that. Um, to, to, and it's not in a way that I'm, well, let me see if I can empty this person's wallet as much as possible. I'm sure there's some horrible examples of that out there in healthcare, but like I have something that I know can help this person.

The research tells me I can help this person. Um, But there's a lot of competing narratives out there. How do I position my product or what I'm offering this patient in a way that can move them towards, you know, this, this journey with me, do you look at sales kind of specifically as, do you look at those encounters again, not like in a generic, like, you know, QVC trying to sell you on a bag of goods type thing, but what's, what's been your approach or thought process around like the whole sales process?

[00:29:15] Nick Rainey: Yeah, I definitely think about that a lot. Um, and again, like you said, not in a, not in a financial way. Um, you know, I tell people that you have two, if everything else fails on the first visit, you got two responses. One, rule out emergent, you know, urgent red flags. If they need to be to the emergency room before they come in again, [00:29:34] you better not miss that.

You know, we can miss a red flag that's slow growing, you know, that we're not sure. This is concerning. Let's see how they do by visit two. We can't miss the urgent ones. That's a hard pass. Second one is get them to come back for visit two. The chances of helping somebody completely in visit one is pretty low.

It's not never, but it's pretty low. So vast majority of the time. Whatever mistakes you make, if they come back for visit two, you get a chance to come up to bat again and see what you can do. Um, and we will, and to emphasize with people that the focus is not on the financial aspect of it for, for our clinicians is that we'll bonus them as long as they and the patient know it's their last day.

I don't care if it's visit one, two or 20. You know, we'll bonus them. And even though that's not the best financial decision, the focus I always want is to make sure that they and the patient know that care is concluded for that episode. If it's going to be concluded, some people need booster session and to go on for sure.

Um, so again, yeah, not that it's not a financial thing. It's to sell them on what they need. And sometimes I'm selling [00:30:34] them. I'm going to somebody else, you know, like, you know, maybe they need an x ray. Maybe that I'm concerned that it's a fracture. Maybe they, maybe they need a surgery. You know, I'm Sometimes people need a surgery so they don't have permanent nerve damage, you know, and if they don't have, if we don't have good shared decision making, they've got to, they've got to be able to see what it, what decision are they making there.

And so something I've, uh, specifically done some training with recently, some reading and worked with our people on, is not using the question why. So why brings out defensive measures? How and what? And so if you look at motivational interview training, um, it talks about rolling with resistance. Why brings out resistance?

We don't want to bring out resistance. We want to be able to roll with it and ideally have less resistance. So we can ask a lot of the same question, but without bringing out why, and again, that's the sales aspect. If you're trying to sell somebody a car, you don't want resistance. You want everybody happy and nodding and you want to have low tension.

With higher attention, people [00:31:34] don't give as good of answers. They don't think as clearly. And so I don't ask, I'd rarely ask why questions. 

[00:31:40] Mark Kargela: Yeah, that makes a lot of sense. I, it sounds like you're very purposeful and your consideration in yourself and in of your employees as well of like their communication, right?

To where you're, you're being very mindful of that. Has that been something that you prioritized immediately, like coming out of school? Like I need to be like the most amazing communicator. I mean, for me, I'm just, I, I've prioritized more my hands on technical skills. And then it became utterly apparent that, you know, your, your hands, that can be part of it, of course, the skills there, but your communication allows you to not be as good, that gets you another, like you said, at bat visit too, even if it didn't go as well as you wanted.

But if you can. Communicate, sell a patient on what you're doing, how it's going to help them. And they buy into where they're going to give you a little bit of leeway versus. And, and our friend Jared Hall just put a post on social media about like how he'd take the most, the choice of like the best communicator person centered person versus the most highly skilled [00:32:34] technical evidence based person.

He probably take the communicator on the first and cause he can move them and train them into a better evidence based, you know, a skilled practitioner. What's been your, your journey with, um, communication, like as far as how's that kind of fit into your practice and in your being purposeful with the thought process around it?

[00:32:49] Nick Rainey: Yeah. So. I guess different and similar, uh, different in the fact that before I was a, before I went to physical therapy school, I did a decent amount of sales. Um, and I did, I was also a missionary for our church for two years. So I was talking to new people all throughout the day, every day. And I was thinking, how do I, you know, head off resistance as far as my focusing on it in a clinical aspect, you know, researching, figuring out trainings for it has been later in my career, which is what happens to most people.

And I don't know, you know, Rarely do we get one or the other with people, right? A lot of times we, you know, in school, we have to be, we have to make sure that we don't miss red flags. You know, I'd rather somebody that doesn't miss red flags and be a good communicator, you know, if they need to be the emergency room.

And so we're hitting those things in [00:33:34] school. And then like most people, as they start to become better, they're realizing where the holes are and it's communication. Rarely do we ever see somebody becomes a really good communicator and then they get more skilled. 

Is that, is that a limitation? Is that just a feature of what's normal human tendencies? I'm not sure. 

[00:33:50] Mark Kargela: Yeah, no, I think it's a fair thought. I, it, I do think sometimes in the health profession and I, I may be a little bit of a, you know, symptom of the biomedical ism where it's more like I'm going to find the pathology and fix it where I don't want to say it's de emphasized.

I think, you know, in our program and what we see in our university, I think we're getting more, much more conscious of how we communicate and how we involve the patient and all those things. I just think maybe there's a little bit of that sometimes where. We, you know, in our early training, we're so focused on maybe the technical and the pathoanatomy and kinesiology and biomechanics and all the things that, again, have their place, but just maybe not, you know, prioritize as much as they do, especially when you come on the clinic floor, when you're coming out of school and those power [00:34:34] points aren't lining up with the patients in front of you.

And you got to form some sort of a coherent narrative with the patient. And that's just where I think folks that have that sales background and, and like you, I think have a leg up to be able to, cause you've, you've rolled resistance already. You've been in those uncomfortable conversations where resistance is coming back and you've been able to defuse situations and then move somebody forward.

Dad, did you find that something that just kind of came a little bit naturally with your background? 

[00:35:02] Nick Rainey: Yeah, I didn't, I never thought about it too much until I was talking to, we got a lot of students and one of the students like, how did you do that? And I was like, and I hadn't thought of it. I hadn't thought of it specifically.

And so then I'd started paying attention. Like, Hey, I said that really well in that, you know, in that situation. And I'm like, I think that's where some other people will struggle is what do I say in that situation? And it's still hard. Like there's times I do manual therapy so I can think, you know, it's hard if I'm just staring at you and I don't know what to say.

I can get awkward kind of quick. But if I'm [00:35:34] like working on your shoulder, your back, well, I'm thinking sometimes I just need to think. And I'm like, I don't know what to say to you right now. And so I'm doing manual therapy so I can think, and it's not awkward. 

[00:35:43] Mark Kargela: Yeah. Hey, you know, we got to sometimes buy us some headspace to, to, to, to kind of navigate some of those situations.

I think we've all probably been there to where, okay, I need to, I need some time to kind of collect my thoughts and kind of, well, yeah, cause you're right. If you're just sitting there and with blank stares, looking at each other, it gets awkward, awkward, real quick. Um, I want to respect your time and we got a conference to go ahead out to here in a little bit, but um, I'm wondering like the online, where can folks find your clinic?

I know, you know, we sometimes get patients of course, listening, but also clinicians who might be interested, like, Hey man, I want to go learn from Nick. And especially if any of y'all are looking at oral facial pain, obviously Nick's got an amazing practice and really look, you know, teaching and deliver and walking the talk daily in his practice.

Where can folks find you online? 

[00:36:28] Nick Rainey: If you Google my name, I think the, our practice will come up on our main page. I [00:36:34] think we have a page of different areas where I'm teaching and whatnot. Um, we're overhauling our website right now. So I, I think that's accurate still. If not, we'll get that changed. Um, I have a decent number of low back courses on physio plus, um, physiopedia is this con ed platform.

Um, where I really go through a lot of, um, the way I evaluate low back pain, the Thoughts that I have to it. There's videos and some readings and whatnot. Um, so that's low back there. Yeah, I am. I do TMD courses with, I don't think we have any scheduled right now, but if you reach out to them, we do have one.

I'm going to be teaching one in Utah with Rocky mountain, um, in November. And so that link should be coming up. We just set it up a couple of days ago. So that link should be up there pretty soon. We also have an online one in the summer. That one is on Rocky mountains page. Um, there's always different things coming up.

So if they find, you know. Google it and they can email me or I can give you my email. You can put it in the show notes. That'd be totally cool. 

[00:37:27] Mark Kargela: Yeah. We'll drop a lot of that in the show notes. And I wish you would just get busy with some things. It sounds like you're just bored with your life. It's [00:37:34] I always, I, whenever I see what you're up to, I'm like, dang, dude, that the guy is up to something.

He's always got some good things going in and kudos to you for doing that, man. You give back a lot to the profession and really pay it forward. So thanks for your time today, man. 

[00:37:45] Nick Rainey: Appreciate it. Thank you, Mark. I love your podcast. I've listened to, I think, well, over 75 percent of the episode since it started.

So I appreciate being on here. Well, we appreciate 

[00:37:53] Mark Kargela: you listening. We appreciate you all who are listening or watching on YouTube. If you can just subscribe on YouTube, we'd love that. Or if you can subscribe on your podcast vendor, we'd love that as well. We'll leave that there this week. We'll talk to y'all next week.