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Dec 19, 2019

What do making sauerkraut and physical therapy treatment have in common?


They both rely on the cultivation of healthy CULTURES in order to optimize OUTCOMES...


Let me explain...



I am a food nerd and I have a specific fascination with making foods that rely on the process of fermentation. Many fermented foods begin with rather ordinary ingredients, but it is the careful cultivation of the right types of microbial life (cultures) that transforms the food that you start with into an entirely different, magical end product. Think of starting with raw cabbage and salt and ending up with sauerkraut or fermenting milk to make yogurt. 


Similarly, there is a beautiful alchemy at work in physical therapy practices that thrive due to the positive culture at work. Think of the clinic where patients look forward to attending therapy sessions, where the office staff greets patients by name and by asking about their children or hobbies, where physical therapists and physical therapy assistants are fully engaged in patient care, and where a growth mindset is the norm... 


This beautiful environment of cultures is discussed by the writer Sandor Katz, a celebrity in the fermentation world, who proposes that the best “ferments” or cultured foods come about due to an elegant balance between environmental controls and relinquishing control of the fermentation processes to “expert” microbes who perform the REAL transformation3


This looks like:


Healthy Food Culture (e.g., Cheese) = Proper Environment + Key MICROBES (bacteria, yeast...) 


The concept of cultivating positive cultures in the clinic is also discussed in The Level Up mentorship, and many of the seasoned clinicians that are involved embody just that in their clinics. We review some of the literature that supports such clinical environments, including this paper7 by Rossettini that investigates the “contextual factors” affecting clinic culture. These factors serve as a parallel to the “microbes” that affect the best ferments that Katz refers to. 


Therefore, the above formula applies when trying to “cultivate” the best culture in physical therapy clinics:


Healthy Clinic Culture = Proper Environment + Key HUMAN BEINGS (PTs, PTAs,  office staff…)


This is why the Level Up Initiative is more than a mentorship: we are interested in cultivating quality HUMAN characteristics and cultures. Your work environment is all about nurturing positive experiences: for your patients, clinicians, and support staff. The Level Up Initiative understands and supports those efforts. Being exposed to these concepts made me think about what I was learning from fermentation, and led me to think a bit more deeply about cultures. Here are my big takeaways…


The top 5 ways that I think this analogy of food cultures to PT clinic cultures is useful: 


1. Just like food cultures, human cultures thrive when the people involved function in a “symbiotic” way (as a TEAM) and celebrate team members’ diversity 



You can’t have a healthy culture (food or people) if the key players are looking to stomp out everyone around them. The stress that is created is bad for the whole ecosystem. Also, it is important to have individuals (or microbes) in your culture with complementary skill sets. Just like food cultures, the diversity of individuals that belong to your team or clinic can bolster its effectiveness and resilience! Those who like the fermented tea drink “kombucha” may be familiar with the name of the  microbial culture fueling the fermentation process for this drink. It is called a “SCOBY”, which is actually an acronym that stands for: “Symbiotic Culture Of Bacteria and YeastThis ferment would not work without this “symbiosis” and diversity of microbes! We need a similar diversity in personalities, backgrounds, and strengths for our human cultures (and clinic cultures) to thrive!  


2. Just like food cultures, human cultures thrive when people are allowed to work to their strengths or preferred “niches”.



Some microbes like more oxygen, some like less sunlight, and some prefer to grow in the presence of salty conditions. Just like microbes fill certain “Niches” in their preferred environments, people tend to have preferences and natural environments in which they THRIVE. Let people fill their preferred “Niche” in your clinic environment!  Allow the extrovert to participate in physician marketing outreach and community based programming. Ask your physical therapist with interests in strength and conditioning equipment to be involved in equipment ordering. Utilize your front office staff member’s prior experience in website design to make your company’s website more “user friendly” and accessible to patients.  


BONUS: You can also create extra opportunities for people to share their passions. For example, think about blocking off 30 min “lunch and learn” sessions for informal presentations from different therapists or guest speakers about topics of interest: did someone just take a course they are excited about? attend a health and wellness nutrition seminar? obtain a board certification? Have them share this expertise with everyone! 


3. Just like food cultures, human cultures thrive when they are exposed to small stresses that force adaptation and growth.



This may be the HARDEST, but most important factor for really encouraging growth and resilience of positive cultures! None of us inherently like to “fail”, but experiencing many small failures on a consistent basis is the ONLY way that we are forced to adapt and change for the better and avoid making the same errors in the future. A nice parallel with microbial systems is that microbes that are tolerant of diverse conditions are able to grow more effectively and robustly. As it applies to humans and human systems, this idea has been talked about by many people smarter than me and within various contexts and paradigms, from the success habits of professional athletes and musicians1, to success in the workplace2, to the avoidance of catastrophic system errors (natural or man-made)4.  


I like to think of this idea as:

 "Fail small (over and over), to Succeed BIG 


The importance of this is to reinforce in your clinic that it is okay to make mistakes and learn from them. In fact, each of the above named authors cites examples of leaders, coaches, and teachers whose students succeed because they ENCOURAGE these small errors and the learning that can be leveraged from them. This is the epitome of a growth mindset, which also happens to be a core value of The Level Up Initiative.


4. Just like food cultures, human cultures thrive when there is flexibility and CHOICE of how/when/where to grow…



Making the same sauerkraut recipe over and over again could admittedly get tiresome. When I have made sauerkraut (or yogurt, or kombucha) in the past, part of the enjoyment for me is having the freedom of choice to try a new recipe or adapt a recipe that someone passed along to me. 


People like to be autonomous, even in a work environment, and successful cultures leverage this by creating “pro-choice” opportunities. You can do this without sacrificing clinic goals or values by creating opportunities for choice that fall within the parameters of what is necessary to provide the best services possible to your clients. This has been termed “Choice Architecture”:


For example, in order to cater to clients’ work schedules it is often necessary to have clinic hours that begin early or end later than a “traditional” 9am-5pm work-day. This could be a stressor for employees with families or even just preferences for certain working hours. Why not try to collaborate with employees to let them choose an “early” vs. “late” schedule preference? As long as you can attain enough staffing, this may keep your “night” people happier and your “morning” people more productive. When people feel like they have a choice they are much more likely to feel content in the parameters of that choice! You can’t complain about your early schedule if you were the one who chose it! 


5. Just like food cultures, human cultures thrive when they are not overly restrictive or “sterile”.


The key way that I see this applying to physical therapy clinic culture is in the amount of vulnerability and “realness” that is allowed between human interactions. While it is important to interact in a professional way, if we interact with too much detachment not only do our clinician-patient interactions suffer, but our co-worker interactions suffer too! An example of this is the importance of humor in the workplace5,6. If microbial environments are too “sterile” this sets the stage for ‘opportunistic pathogens’ to grow and out-compete healthy microbes. Additionally, if our interactions at work are too superficial and guarded, we never get a chance to get to know patients and co-workers as HUMAN BEINGS- with likes, dislikes, fears, weaknesses, and eccentricities...that is the mess and the joy of being human! “Humaning” as it is referred to in The Level Up community, is at the forefront of much of what we talk about and place value on- if you cannot connect with people, if you are too “sterile,” interactions with others will suffer, including those you have with your patients.


So, a quick recap: in order to grow an optimal physical therapy clinic culture: 


Celebrate diversity, allow people to work within their strengths, encourage situations in which small failures can be seen as learning opportunities, provide choice to employees, and allow vulnerability in the human interactions that take place in your clinic.


Don’t like your current work “culture”? Don’t get discouraged! I like to think of culture as dynamic and evolving based on ever changing inputs. Try to take a few of these ideas and go create the culture that you want to be a part of!   


Thank you to the referenced authors and to my nerd interest in fermentation for sparking this idea, and thank you to The Level Up Initiative for, again, being more than a mentorship for myself and others to “cultivate” their own passion an humaning skills.


Written by Leda McDaniel 



  1. Coyle, D. The Talent Code: Greatness Isn’t Born. It’s Grown. Here’s How. Bantam: 2009. 
  2. Friedman, R. The Best Place to Work: The Art and Science of Creating an Extraordinary Workplace. TarcherPerigree: 2015. 
  3. Katz, SE. Wild Fermentation: The Flavor, Nutrition, and Craft of Live-Culture Foods. Chelsea Green Publishing: 2003. 
  4. Taleb, NN. Antifragile: Things That Gain From Disorder. Random House: 2012. 
  5. Tarvin, A. The Skill of Humor: YouTube: June 13, 2017 (TedX TAMU):
  6. Tarvin, A. Humor At Work: YouTube: June 30th, 2014 (TedXOhioStateUniversity):
  7. Rossettini G, Carlino E, Testa M. Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain. BMC Musculoskelet Disord. 2018 Jan 22;19(1):27. doi: 10.1186/s12891-018-1943-8. Review. PubMed PMID: 29357856; PubMed Central PMCID: PMC5778801.

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