Hi. First off, I want to say how surprised and honored I was when the Academy Awards Committee reached out to notify me of this award. I certainly thank them for this recognition, but when I look at the list of past recipients of this award, I'm absolutely humbled that I have the opportunity to join these distinguished physiatrists whom I have looked up to my whole career. So today, I decided to talk to you all about the Passor legacy in 2020. So I have no disclosures, except for this. For the next 20 or 30 minutes, I wanted to take you through my lens of what the legacy of Passor means to me in 2020. To provide you some context of where I'm coming from, I was actually at the first ever Passor Legacy Award Lectureship given by Dr. Jay Smith. It was actually the very first annual assembly I ever attended when I was a resident 12 years ago. And it was an awe-inspiring talk about the history of musculoskeletal ultrasound in our field and the possibilities that it could bring to our future. And I remember very vividly because it made me so excited about the specialty and the future. I knew that I was listening to a pioneer talk about his experience, and his words made me feel like I could do something like that, too. So when I was given this opportunity to give the same lectureship, I realized that I wanted to speak directly to the younger generation of physiatrists out there, many of whom actually have very strong career interests in sports medicine and spine medicine and overall musculoskeletal medicine. But maybe surprising to many people, many of them have actually not heard of Passor before. And I believe it's important to know where we have been before we decide where we're going to go next. So here is my view and my take on the Passor legacy in 2020. So what is legacy? Well, the Webster dictionary actually defines it as a gift by will, especially of money or other personal property, or something transmitted by or received from a predecessor or from the past. So when I think about the Passor legacy, there are many wonderful things that I feel have been gifted to me by my predecessors that I'd like to discuss. And I really want to center this conversation around these three legacy items. The innovative spirit, musculoskeletal medical education, and sports medicine. But by no means is this an exhaustive list of what Passor has created for us all. I picked these three because all three have been very integral to my career. And when I really think about it, without the groundwork that was laid out before I started my career, without these three things, I would not be able to do the job that I love so much today. So I wanted to delve into these topics. The field of PM&R is really about pioneers, after all. So when you talk about the innovative spirit, it's not exclusive to Passor. When you think about what Dr. Frank Cruzen or Dr. Howard Rusk or Dr. Henry Betts did during their time, they really reinvented the way that the medical community interacted with patients with a disability. Our field has continued that pioneering spirit to improve the function of our patients. Like for the first time a physiatrist injected botulinum toxin into a muscle to treat spasticity. Or the first time a physiatrist admitted a patient with an LVAD to a rehabilitation unit. Or most recently, the first time physiatrists answered the call to take care of post-COVID patients on a rehabilitation floor during a global pandemic. The notion of Passor was also a very transformative pioneering moment in our field's history. And as many of you know, prior to the 1990s, physiatrists were primarily based in neurorehabilitation. There were no pain physiatrists, interventionalists, or sports physiatrists. Musculoskeletal issues were being addressed, but in the context of a neurorehabilitation patient. Soon after I was notified of this award, I actually called my dear mentor and friend, Joel Press, to talk a little bit more about what it was like for him to be a part of Passor's formation. I had heard various stories over the years working with him, but this time I actually heard the story all the way through from the beginning to the end. And for those of you who are not familiar with it, he actually recently recorded a podcast, The Road to Chair, that also nicely details some of that story as well. And Passor, for those of you who don't know, started in the 1990s with a meeting in San Francisco hosted by Jeff and Joe Saul and about five to six others around the table, and they're all pictured here. They saw a growth opportunity at that time for a field to extend the ability of physiatrists to be a relevant influence to a larger audience of patients who needed help with their return to function. They grew the definition of what a PM&R patient looks like by encouraging the expansion of physiatrists' knowledge base and skillset. And it's really important to talk about this because I meet a lot of individuals in our field who have always just assumed that things were the way that they are right now, and that spine sports and musculoskeletal medicine were always a large part of PM&R from its inception. In under 30 years, we went from seven to eight guys around sitting around the table talking about the concepts to having over half the membership of the academy identifying themselves as musculoskeletal providers. We grew at an explosive rate. And from talking to Dr. Press, who was essentially in the room where it happened, they really got organized back then. They were passionate about what they were doing. They were driven. They were relentless in promoting themselves to patients and other health care providers to demonstrate the value a physiatrist has in musculoskeletal care. They were bold, and they really believed in what they did. They worked very hard to establish a presence in musculoskeletal medicine so that it would be easier for people who grew up behind them to step in and continue to carry the torch forward. They lit the match and opened the door to stoke the fires of performing spinal procedures and covering sports events. This eventually led to the institution of ACGME accredited pain fellowships in 2007 and sports medicine fellowships in 2009. And most recently, NASA accredited spine fellowships for a physiatrist. They set the tone for a culture of continually redefining what a physiatrist can do. And I have to tell you, it is so powerful to have had a mentor who did this and would talk about this because what this ingrained in me is that we are a specialty born out of creativity. And I am not meant to just take what I'm given and leave it alone. We are all meant to take what we are given, improve it, and pass it along. That's the legacy of Passor. And when we see a gap in our field or in the care of our patients, we should not just complain about the gap. We should fill it. We need to be bold because that's what others before us did, and they were all ordinary humans too. We are all capable of being creative, and we're all in a specialty that thrives on creativity. Part of that creativity in the late 2000s led Passor to rebrand themselves as the Musculoskeletal Council of the AAPMNR and reshaped the look of its members. So this is how we see it today. We see the innovative spirit very much alive and well today. The areas of growth right now are really in funded musculoskeletal research. We see more MD, PhDs interested in musculoskeletal medicine than ever before in our specialty's history, and they are vying for NIH support aimed to improve clinical outcomes for musculoskeletal patients. We are seeing the importance and emergence of MSK wellness programs. Dr. Heidi Prather spoke on this topic a few years ago during her Passor Legacy Award lectureship, and how weight and mood and stress and sleep all have significant impacts on the rehabilitation of the musculoskeletal patient, and we have to help our patients address issues outside of just the musculoskeletal system and think about them as a physiatrist where we look at the holistic care of that individual. Wearable technology is going to change the way we track compliance and we measure patient outcomes. We will have real data points rather than just relying on our patient self-report. We are at the infancy of understanding regenerative medicine and where it fits in the treatment plans of our patients and how to understand and unlock its true potential. We have peers amongst us who are pioneering ways to perform surgical procedures in a minimally invasive way under ultrasound, and if you're listening at home and wondering what's next, I'm going to throw it back at you, particularly the young generation who I am so eager to speak to today, because all of you determine what's next. Passor's legacy to us is weaving an innovative spirit into our fabric. How are we all going to make an impact and take it to the next level? That is what we're asked of at this point in time. So the next topic I want to talk about is musculoskeletal medical education, and I'll tell you, we have a problem, folks, and when I say we, I'm talking about all of medical education. Musculoskeletal sources of pain is actually the most common reason to go to the doctor's office, and musculoskeletal issues actually cross over to so many different specialties. However, it has been proven over and over again in the literature that medical schools do a poor job at teaching musculoskeletal issues, and it's not just us. The UK actually has this issue too. Speaking from my own personal experience, I actually sat on the musculoskeletal anatomy curriculum committee for my medical school a few years ago, and we actually had a very real conversation about whether or not it was necessary for a medical student to know the muscles of a hamstring and be able to identify them by name. There were legitimately people thinking that that was not a necessity for a medical student to learn because you could always look it up online, and so we have a gap, and in understanding that gap that is happening at the medical school level, PASOR actually made a very specific goal about improving musculoskeletal medical education. By the year 2000, PASOR made a strategic plan with the goal of enhancing resident education in musculoskeletal medicine. They knew that if they wanted to grow musculoskeletal physiatrists in our field, they had to come up with a standard way to educate, and in 2001, PASOR published a physical exam core competency list, which really became the standard of musculoskeletal physical education for a lot of physiatrists. I do remember when I was a resident going through the PASOR physical exam core competencies. The formation of PASOR in the 1990s undoubtedly led to the fact that more than half of the practicing physiatrists in this country today identify themselves as musculoskeletal providers. So what's the issue then? You know, if PASOR has done a really good job, where are we having issues with musculoskeletal education? And I'll tell you, I want to speak a little bit about my experience as a residency program director. So I actually have the great pleasure to interview hundreds of applicants for residency over the years, and I've definitely noticed, as many of you may have also noticed, a trend of more applicants entering our field of medicine with interest in musculoskeletal, sports medicine, or pain medicine. I've also had to field a lot of questions about the musculoskeletal aspects of our residency program, and I just want to share with you the top three musculoskeletal questions that I get asked by medical student applicants, okay? So these are the top three. Obviously, this is not evidence-based medicine. This is my own anecdotal experience, but these are the questions I most commonly get asked. What is the ultrasound training program here? Do you do PRP, stem cell, or any regenerative medicine? And are there opportunities to cover high school football? So why are these three questions a problem? Well, I don't know that they're exactly a problem, but it is a reflection on how our field is being represented to the outside world. And when you think about it, going back to the basics of why a physiatrist is very well-suited to be a musculoskeletal physician, I would argue that none of these three things are at the core of what is important in a training program to build a very strong musculoskeletal physiatrist. In fact, what I really think PASOR was on to something when they put together that physical exam core competency list, because it is really about how you talk to people, and then your physical exam that gives you really 100% of the diagnosis and your skill set as a physiatrist. And the questions that I'm missing are really, you know, the students don't really ask how they're going to be taught the musculoskeletal physical exam, how faculty are going to engage with you in talking about discussions over differential diagnoses of musculoskeletal issues. These are the things that are being lost, and really the trends of the time, which are very exciting. So certainly I love doing ultrasound myself. I find it a very exciting topic. The area of regenerative medicine is certainly very exciting. And, you know, being a sports medicine physician, such as myself, sidelining coverage to me also sounds very exciting. But when you think about what the core of musculoskeletal physiatry is, you know, someone who is interested in making sure that they are being trained at a top-notch place that gives them support in musculoskeletal education should really be focused on how are they going to be taught deductive reasoning, how are they going to be taught diagnostic skills, is there some system in place, or is it see one, do one, teach one, or is it learn on your own, you know, and these are the things that become more important. And PASOR recognized this. So PASOR supported studies that actually looked to characterize musculoskeletal educational experiences in PM&R residency programs. So in 2004, they actually published this one study that determined that there was a strong interest by program directors to expand their musculoskeletal education, but really there were barriers to that expansion, and that was really the lack of direction regarding implementation. And then, you know, PASOR sponsored another study a few years later where they didn't just look at the, they didn't, they shifted their focus to looking at graduating PM&R residents regarding their musculoskeletal training, and really to assess whether or not these residents felt like their musculoskeletal training was adequate, and to assess what perceived barriers there were. And the perceived barriers were that there was a issue with having enough staff to teach, having enough money to bring in visiting lecturers if you did not have musculoskeletal providers at your institution, and having the appropriate time dedicated to this. And so when we think about these barriers, some of the interesting things is, have we changed that much from over 10 years ago? Do some of these barriers still exist? Now, I would like to think we have a lot more staff that are, that can appropriately teach, but at some look, at some residency programs, there may not be an abundance of musculoskeletal providers who can all teach. There may be one person, and that, or two people, and those two people get, can get overwhelmed fairly easily with all the burden of musculoskeletal education, which, you know, it is a wide topic, and there's certainly a lot to learn. And so the question with musculoskeletal medical education is, you know, do we need to move forward, or do we need to go back to the basics? And, you know, my answer to that is yes. And what I mean by that is, we need to move forward in the ways in which we teach the basics. And we are moving further and further away as a specialty from the basics and the important things that make us inherently physiatrists, such as the musculoskeletal physical exam, such as deductive reasoning and differential diagnosis formation. These are the skills that we should expect every resident in the country to be a master level, at master level by the time they complete their residency program. And certainly, if someone has the opportunity to sit sideline at a football game, that is the frosting on the top. If someone has the ability to learn a little bit about regenerative medicine, that's the cherry on the top of that. But the core truly should be, how do we teach our residents and our medical students and our fellows the basics of musculoskeletal medical education? We have lost a little bit about that. But what we need to do is we actually have to move forward in our learning theories about that and our teaching theories about that. And I think one of the big things in medical education right now is that the see one, do one, teach one model is an antiquated model. And we all have been in that realm where we saw one, then we did one, and then all of a sudden you're expected to teach it. But the main thing we're missing when we've used that algorithm is that we are missing the inherent practice. Where and when do people have time for guided practice? And so when you think about the last time, if you're a trainee, think about the last time a faculty member sat with you and taught you the physical exam. If you're a faculty member, think about the last time you sat with a resident or a fellow or a medical student and taught the physical exam. Did you practice it on each other? Did you give them feedback? Did you feel how much pressure they were putting when they were doing each physical exam maneuver? We are losing these aspects and it is making it harder for people to become great diagnosticians because we aren't doing this hands-on piece. There is a learning theory called mastery learning. Northwestern University is actually a big proponent of mastery learning. They use it in a lot of their education for spinal taps or for chest tube placements, for certain procedural things. But there is a movement in medical education where we are no longer going to provide a competency based off of the time that you spent on a rotation. Rather, we should really look at people's skill sets and assess if someone has become a master in that skill set. And what they mean by that is essentially you can do something two times and be a complete master at it, or you can do something 200 times and you still need some practice. So everyone learns at different rates and we need to adjust for our learners when we think about musculoskeletal education. The other really exciting direction that musculoskeletal medical education is taking is using the tools of the future and incorporating that into teaching us the skills that we need as part of a basic set of being a musculoskeletal physiatrist. So I think the most exciting area for me when it comes to that is actually the utilization of musculoskeletal ultrasound in teaching physical exam maneuvers, in teaching anatomic landmarks, in teaching dynamic motion. And so there's a lot of papers that have been published over the last 10 years that have looked at how accurate we are in palpating the biceps tendon or the medial joint line or the AC joint. How accurate are we when we're just taught by the see one, do one, teach one method versus when we're taught with direct feedback utilizing musculoskeletal ultrasound. There have also been some studies that have shown that musculoskeletal ultrasound can be extraordinarily useful when it comes to retention of knowledge in EMG placements and understanding placements for nerve conduction studies and also for the needle EMG portion as well. So we have to start continuing to innovate ways to teach the basics better. So we are moving forward while going back to the basics and that's the legacy of PASSER in 2020 when it comes to musculoskeletal education. So the last topic I'm going to talk about here is sports medicine. So of course sports medicine is near and dear to my heart. When I entered physical medicine rehabilitation I think there were a small handful of really special physiatrists out there who got the opportunity to do sports medicine on a very large scale. And so it seemed that the canvas was open and the slate was pretty clear for various different possibilities. And I'll tell you there is no greater specialty that I think is suited to be a sports medicine physician than physiatrists. We are naturally gifted to be a team physician or a sports medicine physician because as physiatrists we are taught how to work in a team. We're taught how to address people's goals and we're taught how to go about achieving functional recovery based off of these goals in a team-like environment. And I will tell you as a head team physician for a sport, a major sports team, that is the number, these are the characteristics that the head team physician truly needs. And I really do think that the original founders of PASSER who thought that we can do this, we can do sports medicine, they really had great foresight and they knew that it was going to be a good fit. And obviously I'm very personally affected by their willingness to kind of start the field down this path because what had happened in my personal career is that I was actually in a sports medicine fellowship when it officially became accredited by the ACGME. And so I feel like I benefited from the work that was done before and it allowed me to end up here. And so sometimes I wonder how I ended up here. This was obviously the 2019 Women's World Cup. I was on the field when the women won. I've been the head team physician for this team for the last three years. And I feel very fortunate that the field of sports medicine within PM&R has grown immensely. And it's not just obviously unique individuals anymore. There's actually been a very strong national movement of physiatrists in sports medicine. And so, you know, this is just a smattering of physiatrists involved in sports medicine nationally. I'm missing a lot of teams and I'm missing a lot of people, but we've actually, so I apologize if your team's not up there, but I have to say we've had a good run for the last 10 years. You know, Stan Herring won the Superbowl with the Seahawks. Kelly McGinnis won a Superbowl with the Patriots and a World Series with the Red Sox. Sherry Blowup became the first, I'm sorry, the chair of the International Paralympic Medical Committee and then moved on to take a seat at the Board of Directors for the USOC, where she immediately became instrumental and impactful by bringing about a name change to the US Olympic and Paralympic Committee. And speaking of the USOPC, Dr. John Finhoff became the chief medical officer this past year of the USOPC. And then you've got people like Dr. Ellen Casey, who took over a devastated US women's gymnastics medical program and started to build back trust in the medical system for those gymnasts. So physiatrists have had a very long reaching effect in sports medicine and really the growth of it has just boomed recently. It's been really amazing to watch. And, you know, one of the things that I kind of see that's a common thread amongst all the sports medicine physicians or physiatrists that are practicing out there is that we are physiatrists first. And I think a lot of us value the physiatric principles that were instilled in us. One of the things I like to tell my residents very often, particularly during their early years in our residency program is I actually became the head team physician for the women's national soccer team, not because I was the smartest sports medicine physician, not because I could do the best PRP injection, not because I was the quickest and most adept at doing the musculoskeletal ultrasound. I'll tell you, I was given that opportunity because of things that I learned on inpatient PM&R rotations. And so the things I learned that on inpatient PM&R rotations was how to lead a medical team, how to respect interdisciplinary people on your team, and how to incorporate the expertise of all the different people on your team in order to provide the best level of care for the individual. I learned how to coordinate care. I learned how to utilize the expertise of a lot of different people and coordinate the care of someone effectively to get them from point A to point B. This is how I got that job, because when the chief medical officer of U.S. soccer called me up and asked me to be the head team physician for the women's national soccer team, he did it because he saw me doing this at a different level within the organization and saw how the holistic care of the athletes elevated the program. And I'll tell you again, and I can't say this, I can't stress this enough, it was because I was a physiatrist first that I got that job. It was always because I was a physiatrist first. I think it's really important for the new generation of physiatrists who are interested in sports medicine and the ones who are interested in pain that when you put the principles of physiatry first, it really can take you to further places, further than you would have ever imagined that you could go yourself. And so that is, to me, the fact that sports medicine and PM&R, they all stayed within the same specialty, and my training was tied to the training of what all physiatrists in this country do. That is what makes me unique and special as a sports medicine physician, and to me, that is the legacy of Passor in 2020. So to sum it up here, these are my lessons learned when I reflected on the Passor legacy in 2020. The first lesson is, if you want to see it change, become a part of the change. Stop waiting for it, right? Our predecessors before us, they were bold, and then they backed it up. They worked with hard work. They made bold statements. They wanted bold change. If you want that too, you've got to back it up as well. Creativity and innovation sits at the core of what we do, so you should always be thinking creatively and what's best for the patient and what we want to do next. The next thing is on the horizon. The next thing is out there, and someone's thinking about it right now, and I encourage you to pursue it and put in the hard work because when we do that, we overall can transform our field, and we are unique in this space because we are physiatrists first, and that is really important to remember, and certainly I think it's very important for all of us to embrace the core principles of function, patient care, and the holistic care of the patients that we take care of. So I wanted to thank you all for your time. I wanted to thank you all for the opportunity to give this lectureship, and it's a great honor, and I hope some of my musings and anecdotal stories help you think a little bit about what you want to do moving forward and how we can continue to make this field some of the most exciting areas of medicine for years to come. Thanks a lot.

Dr. Kruse

Passor Legacy Award

legacy of Passor

innovative spirit

musculoskeletal medical education

sports medicine

patient care