Exercise Your “Caring Muscle” - Dr. Larry Benz, President and CEO of Confluent Health

SHIV GAGLANI: Hi, I'm Shiv Gaglani. Today, on Raise the Line, I'm happy to be joined by Dr. Larry Benz, President and CEO of Confluent Health, which owns and operates over 230 physical therapy practices around the U.S. 

Dr. Benz is nationally recognized for his expertise in private practice, physical therapy, and occupational medicine. His current areas of interest include conducting research and integrating empathy, compassion, and positive psychology interventions within physical therapy. I'm really excited to have him on because, actually, my mother is a physical therapist in Florida with her private practice, and my best friend since 7th grade is a physical therapist in Charleston, South Carolina. I think Dr. Benz is our first physical therapist on the podcast, so welcome.

DR. LARRY BENZ: Well, thank you. It's great to be here. It's always good to be first.

SHIV GAGLANI: Can you tell us a bit more about your background and what led you to even get into a career in medicine, specifically physical therapy and occupational medicine?

DR. LARRY BENZ: Yes, sure. I was one of the oddballs, and when I was a young kid, I knew I wanted to become a physical therapist. I was involved in sports and athletics and had my fair share of injuries, and I was exposed to athletic trainers and physical therapists, so around middle school age, sixth grade, probably, I thought, “Man, that'd be a great profession to go in, keep me close to athletics, keep me close to caring for people, a very service-oriented business.” I decided early on, so I stayed on that pathway the entire time. When I got to college as an undergraduate, the education, physical therapists tended to migrate from bachelor's degrees to master's and then a doctorate. I was in that phase where it was a master's degree. 

After finishing undergraduate and applying to different PT schools, I had some problems in the sense that I ran out of money, so I went to the U.S. Army Baylor University Physical Therapy School, which involved graduating from school and then serving in the military, in my case for about five years of active duty and many years in the reserves. The Army was a big sports medicine center for me, so it was a tremendous experience, and I just loved all parts of being a physical therapist.  But one of the things I noticed in my clinical practice was there were things that mattered other than my physical exam --  how patients responded your so-called "bedside manner," if you will -- and it occurred to me that we need to have some evidence and research that supports sort of these nonclinical factors of clinical success, whether it be empathy, compassion, high quality listening, peak-end effect, goal setting, how do these things really influence outcomes?

As it turns out, they have a tremendous influence. During my career that stayed with me. like when I was active duty army, I would be floored to see that if you just told patients, “yes, your X-rays were normal, all is good” a certain percentage of them were just miraculously sort of cured. There had been a study by Boeing that basically said that if you were an injured worker, if they just called you within 72 hours after your injury and said, “look, we care about you. We want you to know we want you to get better and we want you to be back at work as fast as possible,” there was a statistical difference between those who were called and heard  just those very simple phrases and how somebody got better. 

These sort of nonclinical factors of clinical success eventually led me to the University of Pennsylvania and their program called Masters of Applied Positive Psychology, where I extensively studied to see what kind of empirical evidence there was that suggested that emotional intelligence and the so-called soft skills, do they really make any difference? And if so, how do they? That's sort of my journey that eventually culminated with Called to Care and the program and the book that went with it. 

SHIV GAGLANI: That's fascinating. We have a pretty solid relationship with Penn and Osmosis, and I had the opportunity to once have dinner with Martin Seligman, who I’m sure you know well is the father of positive psychology. Can you tell us a bit more about that program before we dive into your book Called to Care?

DR. LARRY BENZ: Yes, it’s a great question. Dr. Seligman started the program called Masters of Applied Positive Psychology, and he's obviously a co-founder of the whole movement of positive psychology, which basically tends to look at things and says “what went right, what and how could we better reproduce it” rather than “what is wrong” and have a negative side of it. He really founded it when he was the president American Psychology Association. This was one of his gems, to educate those who are in education fields, medicine, coaching of all types to say how we could integrate positive psychology. 

Research has been, you know, just studies after studies after studies...how could we integrate it into their profession? And that's what really happened for me because you had all this research, but nobody bothered to transport it or integrate it within healthcare, so that was the quest that I was on very early. That program is a master's degree program. It takes about a year. It results in a thesis, a capstone if you will. My capstone was Called to Care, how to integrate those concepts within the field of physical therapy and generally in healthcare as well.

SHIV GAGLANI: That's fantastic. We're a very culturally-driven organization at Osmosis, and our first of six core values is Start with the Heart. In fact, our vision is to create a more caring world by developing the most caring people, which is why we train healthcare professionals. I would love to hear more about Called to Care. I haven't had a chance to read it yet, but I know it just came out on the shelves last month. Can you tell us a bit more about the book and any practical advice that you put in the book about how healthcare professionals can put humanity back in healthcare as you describe it?

DR. LARRY BENZ: That's a great question. It really was the motivation. I was interested in sort of three ways that rehumanizing could help you. One is, does it have any effect on the outcome of clinical care? Does it make patients better faster? Does it add nothing to it? Secondly, does it have an effect on the provider? You read a lot about burnout in the profession. As it turns out, burnout in healthcare is abundant and almost proliferating at record-setting paces, and COVID has been no exception. Can it help you? Is there a true antidote to burnout? Lastly, can it make your organization better?  Can you make money from it and does it help me differentiate my product and just give me a competitive advantage in the marketplace? 

As it turns out on all three levels, you can. You can decrease burnout, give patients a better clinical outcome, and help your organization flourish. That was the primary motivation. The answers to all those things are, “Absolutely yes.”  So what do empathy and compassion truly say? There's a lot of emphasis these days on compassion versus empathy, and sometimes empathy gets shortchanged, but the reality is these are multidimensional constructs, and you have to be intentional about them. They’re muscles if you will, so you have to train for them. 

We, as physical therapists, oftentimes get trained in our hands-on care, manual therapy, and exercise. Those are relatively straight forward.  But the cognitive skills -- emotional intelligence, how you manage yourself and others, what truly motivates you from a compassion standpoint -- those are a little bit harder to train. They're harder to get deliberate feedback on, but they're as important, and in many cases, the research shows they’re more important than your clinical skills.

SHIV GAGLANI: Yes, totally. One reason I think we are so interested in that area is that I think over the next 5-10 years as the use of artificial intelligence accelerates, one of the last things that maybe the machines or AI will be able to take from healthcare professionals is genuine care. So can you tell us a bit more about how do you select for that? How do you build that caring muscle? What are some of the strategies that you've incorporated yourself and also in the book from your studies of positive psychology?

DR. LARRY BENZ: Yes, absolutely. In the book, we describe 12 to 14 of these so-called “soft skills.” We objectify them, if you will, and then give the underlying support and research for them.  But at the end of the day, how you train for them is the real, real important factor. When it comes to the area of empathy, for example, what you find out is that empathy doesn't have one definition. It has four, and it's a multidimensional construct, so you have to train in it, and you have to get folks to exercise those muscles. 

We did an interesting study with Northern Arizona University, where we train physical therapists prior to going out on their last internships, clinicals if you will, and it said, “Here's what empathy is. Here's how you train for it.” We compared that to a base group where we just tested them for empathy. By the way, all the studies indicate, whether it's physician studies or anything else, that you start out in medical school with a lot of empathy and by the time you graduate, you've had it drastically reduced. So how do you maintain it? 

As it turns out, the group that continued to get reminders of empathy -- such as a short snippet of video --  coupled with underlying base training and empathy outperformed everybody else. You really do have to have what we call in our company, a “re-mind” about empathy because it’s like willpower, if you do not exercise it, it'll slowly disintegrate.  

The other part of empathy that is critical is that as healthcare providers, we rush to prosocial concern. We rush to want to do something, create action plans around helping. Well, that's only one aspect of empathy. If you're grading somebody on empathy and you're only scoring them on prosocial concern, healthcare providers generally rate high. But the other sorts of empathy --  perspective-taking, literally taking the long walk around, seeing it from all angles; emotionally sharing; experience sharing with your patient -- healthcare providers don't necessarily do too well. 

Then there's the third aspect of it, which is the emotional side. You've got the cognitive side, perspective-taking. You have the affective, which is “how can I emotionally share? What do I have in common with this particular individual?” And then the last part of it is non-judgment, “How can I exhibit under an environment of non-judgment?” Judgment is the most addictive drug we have, but in the context of patient care, we have to recognize that somebody's truth is their truth, regardless of my bias and where my brain is taking me. Who could think of a better time than right now with all of the conversation about racial justice, diversity, equity, and inclusion, to really start to embrace empathy, but to really understand it on all four of those levels, because if you don't, you're really going to shortchange it somewhere along the way.

SHIV GAGLANI: Those are some really fascinating examples. Thanks for being that specific. Now it's one thing to read a book and have some really interesting insights and takeaways. It's another thing to change curricula of how we train medical students, physical therapists, or residents.  In your ideal world, how would somebody go from just taking a reading of the book and actually applying it? Is there a course? Are there some other strategies that can be incorporated?

DR. LARRY BENZ: It's interesting that many med schools now have added coursework in empathy. We've had our curriculum called Called to Care adopted by many PT schools around the country and a few medical schools as well. What we have found, what our research really shows is that if you hold somebody accountable for empathy, they will be empathetic. So in our organizations, we use a third party validated instrument called the Compassion and Relational Empathy questionnaire. 

It was developed out of Scotland. It's got a database of about 15,000 practitioners. It’s 10 questions on a Likert scale about goal setting, about listening to patients, about giving them a say so in their care and very simple, very intuitive type questions, and it can be scored and graded. We grade all of our therapists on empathy every month through this care questionnaire. What you find is if they realize they're going to be held accountable for it, they listen a little better. All of a sudden, they start to demonstrate a little bit more perspective-taking. They put more emphasis on a higher quality connection, mutuality, vitality, all of those kinds of things.

Coupled with that, we do have to provide the underpinning, so the attitude we've taken as an organization is, we don't care which of the 250 physical therapy schools you trained at. When you come to our organization, we're going to give you an underpinning in empathy, compassion, emotional intelligence -- soft skills -- because we don't feel like those are honed in a traditional academic environment, so we think it's our responsibility to help facilitate and make it a contagion within our own organization.

SHIV GAGLANI: That's awesome.  I would love to have a look at that instrument out of Scotland.  It reminds me of the quote “If you can't measure it, you can't manage it.” It also reminds me of a guest we had on Raise the Line a couple of weeks back, Mel Hall, who is the CEO of Press Ganey. One of the anecdotes he shared with me was when he became the CEO of Press Ganey, I think it was less than 10% of the health system and hospital CEOs were measured on patient satisfaction as part of their compensation review, but by the time he left Press Ganey, over 90% of health system CEOs were graded in part on patient satisfaction and giving voice back to patients. It sounds very similar to you guys. How long have you used this instrument to measure your staff, and what are some actual outcomes that you may be able to share on how patients have responded and how outcomes may or may not have changed?

DR. LARRY BENZ: We've been using the care surveys since 2013. We also have developed and validated an additional instrument that we call patient loyalty because we really believe patient loyalty is the next level of patient satisfaction. You could have a patient that's very satisfied. In fact, the healthcare literature is full of the fact that we have satisfied patients, but do those satisfied patients truly recommend their friend, family member, or if they get an additional injury, will they come back and see you? What we're really trying to impart is patient loyalty, so we couple all of those things together, and we score them like crazy. 

We have this report card that we give to physicians, to payers and employers, by location, by therapist -- complete transparency on this -- and it is their compassionate, relational empathy score, their patient loyalty score. It's all done essentially by a third party because we really believe that it's made us a better organization. We have 230 PT clinics. There's a lot of data I can look at and the number one piece of data I look at every month is how many current patients are former patients, friends, and family members. We know we can get that number to about 30%, and that's a lag indicator of the lead indicator, which is training in empathy, compassion, and having a culture built around that.  So it's very, very important to our company. 

As I said, I mean, look, I'm a capitalist. I love academia. I love being a physical therapist. I love empathy and compassion, but we're an entrepreneurial organization at the end of the day, and we want to be successful. Part of that success is all the stuff that comes after you do all of these things, and part of that is frankly financial, so that's very good. The other quote that we say a lot in our company is not only about measuring it, but “you get what you emphasize.” You really do. So by emphasizing an environment where patients are really going to come in and have an unbelievable experience, that can lead to success. We really believe in it and emphasize it and train for it, teach it, monitor it, reward it, re-engineer it --  and all the things that go in a learning organization.

SHIV GAGLANI: That's fantastic. Going into Confluent Health, the scale that you guys have achieved is tremendous, over 230 physical therapy practices. Do you mind giving us a bit of backstory on how you joined, what that ramp up was, how many therapists you employ, and then also how many patients you see every year? 

DR. LARRY BENZ: I've been a physical therapist for well over 30 years. I was an army physical therapist where ironically enough, it is actually a fantastic environment to be an entrepreneur because you have no money at risk, but yet they want you to do it. The more you do, the more they want you to do, so I cut my teeth in the military. As soon as I transitioned out, I went right away into private practice, which is very counterintuitive because I knew nothing about reimbursement and healthcare systems, Medicare and billing patients and any of those kinds of things.

The good news about that is I didn't have any of the biases either, so it allowed us to propel our practice in that manner. Over the years, we've just really developed good clinical operating models around training and a human capital, talent management approach which allowed us to grow very rapidly. I'm a co-founder of Confluent Health. All of our brands are partnerships with other private practices, PTs that join our group, or we partner with them in kind of a merger acquisition standpoint, and that's allowed us to have great scale. We're in about 14 States in 235 locations.

Once COVID goes through the paycheck protection program, we've got about another 100 clinics that are joining with us. We have an education company called Evidence in Motion because we believe education truly is the great equalizer, so all of these things around our customer service value proposition, Called to Care, really culminated in an education company that trains PTs.  We're the only group I know that actually trains our competitors, and we're happy to do so. We have orthopedic sports medicine, manual therapy, neurology, women's health, occupational medicine, residents and fellowships for the largest provider of that in the U.S.

Then the third leg of our stool is a company called Fit for Work. Fit for Work provides onsite work injury management through athletic trainers, occupational therapists, and PTs around the country. We're in about 800 sites -- lots of companies that have material handling, very heavy manufacturing, repetitive use injury jobs. We stage them with our PTs, OTs, and trainers. It's a very, very fun company and lots going on. Obviously, we were impacted by COVID, as you would think, but we've been able to bounce back pretty well. We think one of the reasons why we're able to bounce back is really our motivation around compassion and empathy. It's been very, very helpful in that sense as well.

SHIV GAGLANI: That's tremendous. You mentioned how COVID has slightly affected Confluent Health. Do you mind walking us through the process of dealing with COVID across 14 states and 230 locations? How has COVID affected everything from back in March, when it started getting big in the U.S. to today, and then where do you see it going in the next year, especially as it relates to your practices?

DR. LARRY BENZ: It's very interesting. We have clinics in Seattle, Washington which some would argue is one of the ground zeros of where things in the U.S. started to come into place. In early March we were faced with it very, very quickly. There was so much variance from state to state, and how quickly things shut down and what were the measures taken. All that I can tell you is that eventually, everybody adopted the similar patterns of PPE, 6 feet distancing, and everything else. Physical therapy was always deemed an essential service, but that didn't mean you had to attend, so our business went down to about 30% of its level by the end of March and early April. Since then, we bounced back. We're literally back to almost 100%, which is a real tribute to what we've had, but we developed a strategy that says that we have to take care of our own first.

We have to make sure our employees and their families are safe and secure. We did that. We did that very thoughtfully and measurably. All of our therapists could test it every two weeks. I think we're the only organization in our profession that does that because it puts a level of accountability on it. We have 3,500 employees, and a lot of our therapists are young, and they're in that demographic that's really, really raising a high number of cases. We've only had 10 cases. We haven't had any case in the last nine weeks, which we're really incredibly proud of. We took care of our employees first, and then we did branding and messaging around confidently safe, reliable, and accessible.

We had to do some pivoting into telehealth. Lots and lots of dollars were spent on getting the standardization, the temperature checks, and all the other things that you have to do in a clinic. And then we let everybody know virally through text messaging and videos and cartoons and everything else that we're open for business, that these are the precautions that we've taken. Then, not surprisingly because we love data, we started surveying our patients. Did they feel safe? Did they feel confident? And they did and then had a high sense of urgency around getting patients in the door. Now having said all of this, we still have some of our most vulnerable patients oftentimes that need care,  like our elderly, like those who have diabetes or breathing disorders, respiratory issues. 

They're still having a little bit harder time coming into therapy because they're scared, but what we've done is we've created a safe place for them. We've set hours aside to where there are very few folks in the clinic and allowed them to come in and be very comfortable with that. All that has allowed us to bounce back pretty aggressively. 

We're very, very thankful for that, but what we're really concerned about is the impact of COVID on our healthcare system. Healthcare disparity and educational disparity have never been greater. They're only going to get greater because of COVID. The second part of that is that patients are out of shape. We've had patients that have had the weight gain that you hear about or read about.  That has a musculoskeletal impact, more aches and pains, sprains, and strains. You have what I call the pandemic behind the pandemic, which is the opioid crisis has been renewed. It's just not talked about as much, but we have lots of chronic pain. There are 50 to 60 million Americans with chronic pain in the U.S. That's a particular specialty of ours, and COVID is accelerating that to maybe 65 to 70 million, so very, very concerning. 

Then the last piece of it, which is the most interesting piece, is recently a lot of sports have started back again, whether it be professional, amateur, school. The injury rates are statistically higher than at any time ever. You've seen it in the NFL, the number of pro athletes who have access to the best resources. But think of the non-pro athletes that don't have resources to train and stuff whether they are sheltered at home. You literally are seeing some impact from that. So all that said, in a post-COVID world whenever that is, there'll be continued implications from COVID. 

The first patients that I treated when I was a young therapist were post-polio patients. Think about that, a virus that impacted many, many moons ago. We are going to be seeing post-COVID patients for a long time. There are definitely latent effects on the respiratory system. We're definitely seeing whether it's the metabolic changes that are causing more obesity or more injuries. The effects of COVID on the healthcare side of things is not going to go anytime soon.

SHIV GAGLANI: That's fascinating. I definitely had heard the term pandemic behind the pandemic and in regard to opioids as well as people not utilizing care as much, not doing the preventative screenings or not going to the ER because they're worried, and maybe we're missing heart attacks and not doing mammograms, for example. I've definitely heard about that, but I didn't know about the athlete injury levels going up. That's fascinating. PT has always been, I think, a very technological field just given the nature of the work. 

As I mentioned, my mother is a physical therapist. She specializes in urinary incontinence and other issues and runs her own practice in Florida. She's published a couple of books on post-prostatectomy and how you regain continence. Seeing her practice going through the COVID wave in Florida has been very interesting. She does a lot of tele-PT at this point and biofeedback, and things like that. What is your view on tele-PT or other technologies that are impacting the practice of physical therapy?

DR. LARRY BENZ: I'll compare in contrast to a couple of different ways. One of the things that we've had in this country is an explosion in behavioral health for all the right reasons. People have higher levels of anxiety and depression, and behavioral health, adaptation, and ability in telehealth are amazing. It's essentially equivalent developed, done properly through telehealth, and physical therapy is not a replacement for PT. It's really more of something that augments it or adds value to it. We look at telehealth as a delivery system. Just like we use virtual reality, we look at it as a delivery system. We had an amazing influx in the number of telehealth visits early in COVID that is now dwindled quite a bit. We're still doing some, but we're using it to screen patients, to monitor patients, but not to replace hands-on clinical skills. 

You mentioned pelvic health and the techniques of the intervention that you have. Just some of them cannot physically be done over telehealth, but biofeedback and some of these things that are a little bit more behavioral health-oriented certainly can be. We're very, very excited about it. We also like virtualizing other practitioners. For example, in our chronic pain program, we may have a patient and then we bring in through telehealth a behavioral health specialist, a nurse psychologist, for example, or a neurosurgeon or an orthopedic surgeon so you see that used in a multitude of ways. We also believe that patients do want to be able to communicate with their providers. They want access. They don't like waiting room times, so you see more virtual waiting rooms. 

You're going to be sitting in your car, waiting for your appointments a lot more in healthcare, I think, than ever. People don't want to be in a waiting room. I think those changes are going to be helpful. I think we're going to be screening using temperature and probably PPE for a long time. I think it's very effective, especially during the flu season when you're gonna get a resurgence, at least if nothing else, of the common flu. I think a lot of those changes are going to be around for a long time, but telehealth is definitely a game-changer for many in healthcare. It has an impact on PT, but not like it's having on behavioral health.

SHIV GAGLANI: Those are definitely astute observations. I know we're coming up on time, but the last two questions I had are, one, given that so many of our audience at Osmosis are current and future health care professionals, people who are maybe even considering careers in the health professions, what advice would you give to them about meeting the challenges of the COVID pandemic and beyond?

DR. LARRY BENZ: Given the data on the numbers that we'll be accessing healthcare post-COVID, I would tell them that the world is their oyster right now. Healthcare heroes are a very real phenomenon. I think you've seen great highlighting of the impact of healthcare, whether it be nursing or any type of caregiver, physicians, and everything that we're working in the ICU. We saw very heartwarming stories about being able to FaceTime a patient in real-time that a nurse was doing with their families because they weren't able to visit them during COVID times. I think for a very, very good reason, be excited about healthcare. Lots of positions, whether it's an ancillary provider, any type of health caregiver is going to be a good occupation to go in for sure. I'm very, very excited, and I hope we can continue to emphasize it as a career pathway for our young folks because there had been this phenomenon prior to COVID, particularly in the physician data, that showed they were not recommending the career to their loved ones, including their kids. So what I'm hoping COVID has done is say, “Look, there are definitely some regulatory issues. There are definitely some challenges, but it's still a great field. If you care about people, you’ll love being in the healthcare world.”

SHIV GAGLANI: I'm sure this is the case in PT schools as well and across the health professions. We had the president of the AAMC on Raise the Line, and one statistic that's really remarkable is there's a 17% increase in applications to medical school so far this year. We'll see if that trend continues as people want to meet the moment and maybe also go into professions in which, as you've said, there'll be demand for years to come. My last question for you is, is there anything else you want to be able to talk about to share with our audience while we have you on Raise the Line?

DR. LARRY BENZ: I usually like to give the whole empathy definition in training on that, but I think the other one that's very, very important is the difference between dehumanization and burnout. If you are burned out in your profession, whether you're in healthcare or not healthcare, what that really means is you've lost your zest. You don't feel like you're having any impact and that what you do doesn't matter anymore. It's almost a clinical diagnosis. It's not depression, but it's kind of like depression. That has a variety of interventions that are necessary for it. That's much different than dehumanization. If I'm a physical therapist, I've had a very busy day, and I'm on my 11th patient without any break. At some point, I am going to do what the call center research calls “calcification.”

I'm going to calcify, meaning I'm going to get a little bit tired, and I'm going to take a human being that's normally a three-dimensional character. I'm going to make them a two-dimensional character. That's a very natural human behavior to happen. When you calcify, you're essentially dehumanizing, but the antidotes to dehumanization are empathy and mindfulness breaks and doing whatever it is that hacks you back into normality. For some, it's taking a five-minute break. For some it’s having a cup of coffee. For some, it's meditating. Whatever your thing is, listen to music, do whatever it takes to rehumanize you at the moment, but that doesn't mean you're burned out. That means you’re normal.

Burnout, on the other hand, the real antidote is rediscovering your profession as your calling. It's re-engaging the whole definition behind empathy and why you were called there to begin with. Looking at the thank you notes, looking at your old application for medical school, why you wanted to become a doctor. Those are the ways you can hack your way out of burnout. But burnout is much more of a diagnosis, where dehumanization is much more of a symptom that can be dealt with in real-time.

SHIV GAGLANI: That is fascinating. Thanks for explaining that. That's the first time I heard that distinction. Dr. Benz, I'd feel like I made a 30-minute podcast with you for a couple of hours. I really appreciate you taking the time to be with us today. 

DR. LARRY BENZ: I thoroughly enjoy it. I love the work that you're all doing, and I know you'll have continued success with it.

SHIV GAGLANI: Appreciate it. Likewise. With that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show and remember to do your part to flatten the curve and raise the line since we're all in this together.