Physical Medicine and Rehabilitation Physicians diligently work to improve the quality of life for their patients and through groundbreaking research, innovative care, public service, and volunteerism. From the individual physiatrists in practice to the collaborative work of thousands of members within the Academy, physiatrists have risen to the occasion. The American Academy of Physical Medicine and Rehabilitation and the Foundation for Physical Medicine and Rehabilitation, PM&R, offer our deepest gratitude to those with exceptional commitment to excellence and advancement in physiatry. Here are the 2021 recipients of distinct recognition. The Foundation for Physical Medicine and Rehabilitation's mission is investing in the future of physiatry through research. Over the past two decades, the number of grant applications we receive has greatly increased, as has the level of scientific sophistication. Congratulations to the following Foundation for Physical Medicine and Rehabilitation grant recipients. Dr. Daniel Daneshver, Assistant Professor at Harvard Medical School, awarded for his research on neuroinflammation and neurodegenerative disease following traumatic brain injury. Dr. Allison Bean, Assistant Professor at the University of Pittsburgh, awarded for her research on extracellular vesicles for tendon regeneration. Does donor age matter? Dr. Ishan Roy, a resident at Northwestern University, awarded for his research on serum markers for predicting functional decline in lymphoma. And Dr. Dmitri Esterov, Medical Director of Mayo Clinic's TBI Model System Program, awarded for his research on impact of adverse childhood events on long-term psychiatric outcomes after childhood traumatic brain injury. Dr. Jessica Jarvis, Assistant Professor at the University of Pittsburgh, is awarded the Gabriela Molnar Pediatric PM&R Research Grant for her research on equity in rehabilitation therapy use during pediatric critical care among children with traumatic brain injury. Dr. Eric Ryzadski, Chief of the Division of Rehabilitation Medicine and Director of Cancer Rehabilitation at MedStar National Rehab Hospital, is the recipient of the 2021 Scott F. Nadler Assore Musculoskeletal Research Grant. Dr. Ryzadski will be working on improving adherence to aromatase inhibitor therapy in early-stage breast cancer by early physiatry referral to decrease musculoskeletal symptoms. Dr. Linda Kroc is this year's recipient of the prestigious Gabriela Molnar Pediatric PM&R Lifetime Achievement Award. Dr. Kroc is a pioneer in pediatric rehabilitation medicine as a clinician, educator, and researcher. With an extensive list of published papers and book chapters, she has contributed to the treatment of pediatric acquired brain injury and spasticity in children with cerebral palsy. Dr. Kroc served as Treasurer on the Foundation's Board of Directors and was awarded AAPM&R's Distinguished Clinician Award in 2012. The Foundation for PM&R Research Grants are made possible by the generosity of donors like you. Your support is deeply appreciated by these physiatric grant recipients and awardees who are greatly contributing to the future of our field. Again, congratulations Foundation for PM&R grant recipients. The American Academy of Physical Medicine and Rehabilitation leads the advancement of physiatry's impact through healthcare across all clinical areas and practice settings through stewardship, leadership, collaboration, innovation, respect for human dignity, and the success of every member. Thank you to this year's awards committee for their time and diligence in selecting the following AAPM&R Award recipients. Dr. Stanley A. Herring, Frank H. Kruzan Lifetime Achievement Award. Dr. Herring is awarded the Academy's highest honor for his distinguished career of outstanding and unique contributions to the specialty of PM&R in the areas of patient care, research, education, literary contributions, community service, and involvement in Academy activities. Dr. Herring is a board certified physiatrist who has been in practice for more than 38 years. He is a clinical professor in the Departments of Rehabilitation Medicine, Orthopedics and Sports Medicine, and Neurological Surgery at the University of Washington in Seattle. Dr. Herring holds the Zachary Lystedt Sports Concussion Endowed Chair. He is a co-founder of the Sports Institute at University of Washington Medicine, where he serves as senior medical advisor and co-medical director of the UW Medical Sports Concussion Program. He is also one of the team physicians for the Seattle Seahawks and Seattle Mariners. Dr. Herring has held many leadership positions and authored more than 97 peer-reviewed journal articles and 55 textbook chapters. He was a major contributor to the successful passage of the Zachary Lystedt Law in Washington State, and his continued work helped to pass similar youth concussion legislations in all 50 states and the District of Columbia. Dr. Herring's countless achievements have been vital in evolving the specialty to where it is today, and it is with great honor that we recognize his extraordinary contribution and impact on physical medicine and rehabilitation. The Distinguished Member Award was established to honor AA PM&R members who have provided invaluable service to the specialty of PM&R. Dr. Susan Lee Hubbell, Distinguished Member Award. Dr. Hubbell has been the medical director of the Outpatient Rehabilitation Department of Physical Medicine at St. Rita's Medical Center in Lima, Ohio, for more than 30 years, and is a clinical assistant professor at The Ohio State University Department of Physical Medicine in Columbus, Ohio. She has been in private practice in Lima since 1986, including starting Physical Medicine Associates of Northwest Ohio Gang. Dr. Hubbell has been involved with the Academy since her residency and has held several committee appointments. She is currently the Academy's Delegation Chair at the House of Delegates of the American Medical Association. Dr. Hubbell's research interests include single-fiber electromyography, prosthetics, electromyography, and polio. Dr. Kevin Michael Means, Distinguished Member Award. Dr. Means currently serves as Professor, Chairman, and Associate Residency Program Director of the Department of PM&R at the University of Arkansas for Medical Sciences College of Medicine in Little Rock. Working as an academician for more than 35 years, Dr. Means has skillfully cared for his patients and research participants. Dr. Means has provided decades of service to professional PM&R-related organizations, including membership and leadership roles on several AA PM&R committees, including the Membership Committee, the Nominating Committee, and Program Planning Committee. He has received numerous national and local awards, honors, and recognition for his work as a clinician, educator, and researcher, with pioneering research and clinical work on the prevention of falls and rehabilitation of balance disorders in elderly persons. Dr. Monica Badusco Gutierrez, Distinguished Member Award. Dr. Gutierrez is an accomplished academic psychiatrist and professor and chair of the Department of Rehabilitation Medicine at the Joe R. and Teresa Lozano Lohn School of Medicine at University of Texas Health in San Antonio, Texas. She is currently the Clinical Chief of PM&R at the University Hospital System and the Medical Director of Critical Illness Recovery and Neurorehabilitation at Warm Spring Rehabilitation Hospital in San Antonio, Texas. She is a current member of the AA PM&R's Inclusion and Engagement Committee. She is directing a COVID-19 Recovery Clinic, which aligns with her mission to increase access to interdisciplinary care, optimize function, and improve quality of life for patients with Long COVID. She is a leader in the national dialogue around Long COVID and in support of the Academy's Call to Action and Multidisciplinary Collaborative. Distinguished Public Service Awards honors individuals who have made significant contributions to public service activities to enhance the quality of life for most vulnerable populations and individuals with disabilities. Dr. Maurice Sholas, Distinguished Public Service Award. Dr. Sholas is the founder and principal for Sholas Medical Consulting LLC in New Orleans, Louisiana, where he solves operational challenges for individual practitioners, hospitals, and health care agencies. He previously served as a Senior Medical Director for Multiple Children's Hospital and has founded multiple programs in pediatric rehabilitation medicine. His work is focused on optimizing function and advocating for the marginalized. Dr. Sholas' pursuit of intellectual achievements is matched only by his pursuit of advocacy and inclusion. He feels strongly that every segment of the population has a contribution to make and that only through advocacy and inclusion can the many voices be heard, consensus reached, and true democracy flourish. Dr. Kate Sully, Distinguished Public Service Award. Dr. Sully serves as the Director of Pain Medicine at Veterans Administration Texas Valley Coastal Bend Health Care System in Hollingen, Texas. Prior to her current position, she was a medical consultant for the Florida Department of Health in Pensacola, Florida and interventional physiatrist at the Battle Creek Veterans Affair Medical Center in Battle Creek, Michigan. She completed her medical training at the University of Missouri-Kansas City and is an MBA candidate in health care administration at Johns Hopkins University Carey School of Business. Dr. Sully addresses musculoskeletal pain across multiple platforms, teaching MSK ultrasound on both local and national levels, and has elevated the field of PM&R as the recipient of the International Young Investigators Award in 2017 for her research in the area. The Patient-Led Research Collaborative Distinguished Public Service Award. The Patient-Led Research Collaborative's mission is to facilitate patient-led and patient-involved research by incorporating participatory design, multidisciplinary collaborations, and rigorous research methodology. A self-organized group of Long COVID patients formed out of the BodyPolitik COVID-19 Support Group. They were the first to conduct research on Long COVID in April 2020 and have continued to focus on disseminating timely research guided by the collective interests and needs of patients. Their most recent research was published in the Lancet's eClinical Medicine and documented 205 symptoms over seven months in people with Long COVID. Their work has led to invitations to present to the World Health Organization, the United States House of Representatives, and the President of the United States COVID-19 Health Equity Task Force, and has informed clinical guidance for the CDC, World Health Organization, and the National Institute for Clinical Excellence. Pastoral Legacy Award and Lectureship. This award is meant to recognize an individual in mid-career who has advanced musculoskeletal physiatry through clinical care, education, service, or scholarship, like the Jonathan Finoth Pastoral Legacy Award and Lectureship. Dr. Finoth is the Chief Medical Officer for the United States Olympic and Paralympic Committee and a professor in the Department of Physical Medicine and Rehabilitation at the Mayo Clinic College of Medicine and Science in Rochester, Minnesota. Dr. Finoth has published more than 100 articles in peer-reviewed journals, authored multiple book chapters, and co-edited a book with Nora Paris, MD, Fellow of the American Academy of Physical Medicine and Rehabilitation, titled Sports Medicine, Study Guide, and Review for Boards. He has been a faculty member and course director for numerous international and national conferences and previously served on the boards for the AAPMNR and the American Medical Society for Sports Medicine. He has provided medical coverage at the Olympic Winter Games, Paralympic Winter Games, World Cup, and World Championships. Thank you to the 2021 award recipients for advancing our specialty and the work we do on behalf of our patients. Please join us in congratulating all of the distinguished AAPMNR and Foundation for PMNR 2021 award winners. Good afternoon, everybody, and welcome to the 53rd Annual Walter J. Zeider Lecture and Awards Video Presentation. Congratulations to all of our award winners. It's inspiring to see all of the amazing work you've accomplished. As chair of AAPMNR's awards committee, I'm honored to be introducing the recipient of the 2021 Frank H. Krusen, MD Lifetime Achievement Award, Dr. Stanley Herring. Dr. Herring is a clinical professor in the departments of rehabilitation medicine, orthopedics and sports medicine, and neurological surgery at the University of Washington in Seattle. He has been in practice for more than 38 years and holds the Zachary Lightstead Sports Concussion Endowed Chair. Dr. Herring's practice focuses on the diagnosis and management of neurological and musculoskeletal injuries, particularly spinal disorders, in active people and athletes, as well as sports related concussions. He is co-medical director of UW Medicine Orthopedic Health and Sports Medicine and one of the team physicians for the Seattle Seahawks and Seattle Mariners. Dr. Herring has held many national leadership positions, is on the editorial board of professional journals, and has been an editor of a variety of textbooks, peer-reviewed journal articles, and textbook chapters. He was a major contributor to the successful passage of the Zachary Lightstead Law in Washington State, and his continued work helped pass similar youth concussion legislations in all 50 states and the District of Columbia. In addition, Dr. Herring is a frequent national and international speaker on a variety of physiatric and sports medicine topics. I'll now turn it over to Dr. Herring, who would like to give a few remarks. Thank you, Dr. Flanagan, for that kind introduction. I so very much wish we could be meeting in person so I could directly congratulate the other award winners and express, in person, my profound gratitude for receiving the Frank H. Kruzan MD Lifetime Achievement Award. My brief comments will be more words of thanks. First, thank you to Dr. Flanagan, the awards committee, and the Academy. While I have been privileged to be recognized over the years, this is the highest and most unexpected award of my career. Frankly, I was stunned. Once I accepted that I was the 2021 recipient, I immediately wondered why. Then I recalled some comments from an extraordinary physician from the University of Michigan, Dr. Oh, Dr. Okunlami. I heard him speak of his accomplishments, and let me take what he said and apply it to my situation. So, why the Kruzan Award for me? Well, I've been active as a team physician for many years, trying to show that we have a seat at that table, but I was not the first. Dr. Kruzan himself served as a team physician at Temple University in 1915. I've tried to demonstrate the value of a physiatric approach to sports medicine, but I'm not the only one to do so. There have been many physiatrists who have shown the world what we have to offer. So, I am not the first, and I am not the only, and I am certainly not the best. I have been surrounded by talent and support my whole career, and I have benefited greatly from it. So, I am grateful that the Academy has decided that the sum total of my life's work merits this recognition. And for that honor, I need to thank Dr. Kruzan and all the Titans who built a specialty of physiatry, a specialty that focuses on helping each individual live their fullest and best life, an approach that works wonderfully, effectively, and uniquely in the world of sports medicine. The next set of thanks goes to the mentors, friends, and health care professionals who have shaped me. And please excuse me as time does not allow for nearly a complete listing, but just a few. Carl Klein, Fela Helm, the faculty of the Rehabilitation Medicine Department during my residency, Michael Dillingham, Joel Press, Ben Kibler, Margo Patoukian, David Koppel, Stu Weinstein, Sandy Thompson, the Leistetts, and Richard Adler. Even more important to thank are the patients who have entrusted their care in me, who let me in and amazed me with their resilience, courage, and life stories. You have taught me so much, and I am humbled. And most importantly, thanks to my family who have lived with someone who has been blessed with a burden. I have had the privilege of following my passion, of heeding my calling in a profession which is not always easy and, for me, frequently distracting and consumptive. My wife Betsy, children Tracy and Nathan, my sister Joyce, and my brother Ralph have understood, supported, and indulged me. I thank them for their endless affection, tolerance, and acceptance. And I thank the Academy once again for this most meaningful award. Thank you so much for those wonderful remarks, Dr. Haring. And also, while I have the stage, thank you for your very heartfelt introduction to our president, Dr. Stu Weinstein, during the opening plenary session. We are so glad that you've been Stu's mentor and friend over the past 30 years. Super, super congratulations to you, Dr. Haring, and to all of our award winners. We are all so very proud of you, and we could do a virtual applaud. It's very difficult to do virtually, but we'll try. As the AAPMNR's president-elect, I am truly honored to introduce the recipient of the Walter J. Zeider Lecture, Dr. Julie Silver. The Walter J. Zeider Lectureship honors a physiatrist who has made consistent contributions to our specialty and who has earned the respect and admiration of peers for outstanding accomplishment in the field of PMNR, much like Dr. Zeider, one of PMNR's founders. In fact, Dr. Zeider also worked at the Cleveland Clinic, where I am employed. In fact, he joined the staff at the Cleveland Clinic in 1937, just a tad before my time. And he was head of the Department of PMNR from 1937 until 1954. This year's honored recipient, Dr. Julie Silver, is an associate professor and associate chair in the Department of Physical Medicine and Rehabilitation at Harvard Medical School. Julie has held numerous leadership positions, and she is a former startup company founder. Dr. Silver also has a Wikipedia page, which is pretty cool. Dr. Silver's research and clinical work has focused on improving gaps in the delivery of healthcare services. She has published many scientific reports, and she is well known for her groundbreaking work on impairment-driven cancer rehabilitation. She has developed a best practices model for cancer rehabilitation care that hundreds of US hospitals have adopted. Last year, in 2020, Dr. Silver received the AAPMNR's Distinguished Public Service Award for her cross-cutting work on workforce and patient care disparities, with an emphasis on diversity, equity, and inclusion. Julie has authored and edited many books, and she has led numerous high-impact national strategic initiatives, such as the Her Time Is Now campaign, the Be Ethical campaign, Need Her Science campaign, and the Walls Do Talk challenge. Dr. Silver has graciously agreed to address a few questions at the end of her presentation. So, throughout the presentation, we hope that you'll engage with us. To the right side of the video window, you will see a green tab that says Q&A. If you click on the option, on the icon, a panel will open, and there'll be an option where you can enter a question into the Q&A, or you can leave a message or a comment. If you have a question related to the presentation, please use the Q&A feature to send it to our honored lecturer. If you have a comment about the presentation or just want to say hi, we'd love to hear from you via the message feature. So I have been so looking forward to listening to Dr. Silver's presentation on a subject that is close to her heart, addressing patient care and workforce disparities. I will now turn the microphone over to Dr. Julie Silver. Thank you so much, Dr. Vennessy, and thank you, Dr. Weinstein, for your sponsorship and giving this lecture. I appreciate it and I'm really excited about it. I'm going to start with just saying that I don't have any disclosures related to this talk and I want to make sure and highlight the objectives, which really are about patient care versus workforce disparities. And I kind of break these up into two different categories, and that's how I often think about them, but they really do overlap a lot. And in fact, this was the first review to examine these relationships. And we did this review specifically because there is some overlap, even if we don't understand all the reasons for it, or all the ways that workforce disparities do impact patient care, we know that there are relationships. This is a slide that I made for ACGME, and ACGME has a new initiative called Equity Matters. And I want to highlight that there's a lot of different underrepresented groups and many of the individuals have multiple identities or intersectional identities. And so I just want to highlight that throughout this talk. I will be focusing a lot on academic medicine because that's where a lot of the research lives. And I want to be sure and include the clinicians that are not in academic medicine and the physiatrists that are not in academic medicine, but just highlight that in a short talk, I can't cover everything. So I'm going to give examples, but all of these different identities are important for sure. And I also want to just say that it is really hard to give a lecture on diversity, equity, and inclusion for a large audience, because people bring a lot of ideas and opinions. I'm strongly held, deeply held, and not necessarily based in science. And so one of the things I'm going to just ask is for grace to give this talk and to be receptive to the science. I think that it's really important. This is not about politics, and it's not about personal opinions, it's really about science. So let's take a look at the science. And if you're interested in more of the science, I direct you to the Her Time Is Now campaign report in which I cited many, many, many studies. And I can only show you just a tiny smattering of studies today. But what I really want to highlight actually is the strategy that I use to develop tipping points and things that will drive big change, even when it's just a small number of people that are doing this work. Because that is really how change happens, or at least a lot of times that's how change happens. I'm again focusing on the relationships with workforce and patient care. And I also want to just give some suggestions about moving beyond what we've done already into things that could potentially make a difference. So as we think about patient care disparities and workforce disparities, these are tipping points that I focus on in my work, and I'm going to explain each of them as we move along. In clinical trials, there is no doubt that we need to be inclusive in clinical trials. We have these mandates and guidance statements and so on from NIH and from other agencies that are really saying, look, we need to be inclusive in clinical trials. We need to understand, for example, sex-related differences. We need to understand what happens if, you know, between people who are XX and people who are XY and how that works. For example, people who are XX can get pregnant. And how does pregnancy affect the kinds of treatments that we offer? And clinical practice guidelines are also super important, and I want to focus on those as well. So these are really tipping points. And we know that in our literature, in our own literature, we have gaps. We have some places where we've really done a good job and we've looked at things, but we've also, we also have quite a few gaps. And so one of the studies that I did with colleagues is that we looked at all of the clinical trials that were registered on clinicaltrials.gov and had reported results. And remember that people are supposed to report their results on clinicaltrials.gov. And so we saw that there are disparities, and we looked at three different groups. We looked at women, older individuals, and racial and ethnic minorities in these trials. And if you just look over on that far left side with spinal cord injury, you'll see that we're not including very many women in our spinal cord injury trials, and there were no trials that were including older people, two huge gaps that potentially we could fill and really look at. And there's a number of other gaps. I'm just showing this mostly to say that there's opportunities for us to really look at things. This is a burn model system. And what we were looking at here is we were looking at as we consent people, as we invite them to participate in the model systems, are there differences about who agrees to and who doesn't? Now, finding these disparities is really helpful. It's not about blaming the patients who don't enroll, and it's not about blaming the people who are doing the consent and explaining things. It's really about understanding, oh, some people are more likely to join than others. Why is that? And are there things that we could do to make it more equitable? So, again, just trying to understand how these differences occur and how these disparities occur so that we can have equity in participation amongst our clinical trials or in the model systems and such. So now, as we think about, okay, action steps, what could we actually do? Well, if you're a researcher, you can focus on recruiting an appropriately diverse patient population or participant population in your studies. Make sure and report that on clinicaltrials.gov as you're supposed to. And then consider studying things like the social determinants of health. And I'm showing you this PhenX toolkit. This is one of a number of different ways that you can look at it, but people often ask me, what do you mean by social determinants of health, and where can I find more information, and how do you incorporate that into a study? And so I want to just highlight this opportunity to do that. So let's talk now about clinical practice guidelines. A lot of my work focuses on financial issues because finances drive the world. You probably know that already. I probably don't even need to say that, but finances are really top of mind. And there's nowhere, probably, that there's bigger money than in clinical practice guidelines, and that is because these guidelines drive care in entire countries. So, you know, people look at what we do in the United States, and other countries will use our guidelines and literally spend billions of dollars to change the way they're delivering care and what they do for the people in their country based on what we say. So in 2018, there was a really important study that came out in The Lancet, and it showed that women were not equitably included as CPG authors, women physicians and scientists, but more specifically, when they looked just at physicians, that percent dropped even lower. And we see that frequently in our studies. We see that women overall are underrepresented, and then when you go into the category of just physicians, you see even a further drop. And that's an opportunity for physiatrists to think about including women physiatrists in their studies and clinical practice guidelines and so on. We looked at this with regard to the Paralyzed Veterans of America clinical practice guidelines and found similar things. And then we did another study that we're presenting here at the AAPMNR meeting this year that focuses on a downstream effect. So this poster that you see on the bottom right, and I know you can't see that well, but you can go to the poster section, is really looking at this consensus group that looked at concussion and mild TBI guidelines and came out with a new statement about them, but they were using guidelines that didn't equitably represent women physicians or women in general and women physicians specifically. So very important to just consider that. So as my work kind of evolved on this topic and I worked with various colleagues and so on, I really started thinking about this. We have to explain this issue more because it's really important. It crosses over into patient care. It's a workforce disparity that really crosses over into patient care. And so you can see the findings here. And we looked at not only gender, but we also looked at race and ethnicity in this study that was just accepted. We also did a secondary analysis of the content and we were trying to see, you know, are there gaps in content? And I think one of the easiest ones to just highlight is this issue of not making recommendations or even mentioning things, for example, women who are pregnant and women who are lactating and women who are going through menopause and things that may actually drive or change the way that we implement the things that we do. So as I've worked on this and thought about this a lot, I'm working now on the PASC guidance statements, and we have a number of people working on this. Dr. Verduzco Gutierrez and Dr. Fleming and I are focused on DEI content. And we really approach this from, you know, five different points of view. One is to just acknowledge the importance of DEI from the get-go. And two is to comment on the diversity of the authorship team. And three is to mention issues that are relevant. So, for example, if you're not going to get a CT scan on a woman who's nine months pregnant because she's having increasing pulmonary issues, that's an important exclusion. And so what would you do if she had increasing pulmonary issues or more shortness of breath or whatever? And then also to add a table to give examples. And finally, to develop a DEI statement that was primarily, or at least a lot of it was from the content that was already on the AAPMNR website that was developed by folks that were, you know, focused on DEI previously. So taking that content and just bringing it forward is what we've been doing. And we've had really great support for this approach and great support in the meetings and great discussions in the meetings, which is really, really nice. So as you look around the table and you think about, okay, who's sitting here at the table with us? I hope that you see diversity. And if you don't see diversity, especially for women physiatrists, I hope that you really say, you know, we really need to bring those smart women physiatrists in as well as our scientists, et cetera, never leaving anyone out and certainly people with intersectional identities. So moving forward, workforce disparities, looking at, I'm going to switch gears here. And I really want to think about these workforce disparities. And again, money drives everything. So I spend a lot of time on compensation studies and I spend a lot of time on recognition award studies, not because I want to be a recognition award researcher, but because it's a tipping point and also on editors. And I'll explain why, because that's a tipping point too. So for compensation, one of the things to know about compensation is this is probably the biggest body of literature of almost anything that there is, because it involves every single field, whether people are teachers or office workers or lawyers or accountants or anything, there's disparities in pay for women primarily. And the other thing to know is that a lot of times that the pay gap research gets a little convoluted because of decisions that women do make, which is to work part-time, some women, not all, but some women make decisions to work part-time or to take time off from work or things like that. Nevertheless, there are a lot of studies that focus on comparing apples to apples and they take into account covariates. They take into account part-time work. They take into account all these things and still there's pay gaps. And so in this study, what I did with other researchers was I showed that women are primarily doing these studies and they're primarily disseminating these studies. And so probably they know more about these pay gaps and yet men are primarily responsible for pay and compensation. Really important because when I hear a disconnect between what somebody's saying about the literature, I often think, oh, they don't know the literature. They haven't seen it. That's really interesting. And most of this research, by the way, is not funded. So very important to know that. Also, just because you have pay that is equitable at a certain level does not mean that it's fair. And this is just an example of a study looking at RVUs because I get comments a lot that say, well, you know, we do it by RVU. So it's totally fair. Well, actually it's not because baked into the RVU system are disparities. And you can see that these two biopsies are relatively similar, but that the biopsies on men are generally done by men who are urologists and the biopsies for women are generally done by gynecologists who are women. And so therein lies another reason for pay gaps. And there's a lot of things that are just baked in. And you see that a lot with structural issues. So now let's talk about sort of this financial stress equation. And that is where you have high educational debt combined with unfair compensation. And that's been something that we've been really thinking about a lot and looking at and trying to understand, well, if you do have high educational debt and maybe you're not paid fairly, then how does that drive your decision-making? And in this study, you know, we really went beyond what had been done before, which was showing that it may affect your specialty choice and so on. But in this study, we basically said it might affect whether you join a professional society or not and actively participate. It might affect whether you work in a setting, a role that offers lower compensation, whether you go on vacation and how that affects your burnout and so on. So a lot of things that this study actually showed. And we went on to study it in women physiatrists specifically. And this study looked at it in women physiatrists perceptions of financial stress. We found that greater education debt was associated with personal life dissatisfaction, career regret and burnout. And just think that through because we don't want physiatrists to to have career regret. Of course, we don't want that. We need the strongest possible workforce. And these issues are really top of mind. So in 2017, there was an important study that came out that said that women hadn't been invited equitably to give Grand Rounds. And so thankfully, a lot of invitations were extended to women. But what happened was they still didn't necessarily get the most prestigious invitations. And some of those invitations are associated with compensation. And so this is an action step that anyone can do in a leadership position. You can conduct an analysis over the past five years and you can just look at overall, are women underrepresented for these prestigious invitations in your in your department or in your hospital or in your institution? And in the total sample and also doing a sub analysis among physicians only, how much money did people get? And if there are gaps, can you work to close them in 2022 and beyond? So that's just an action step. Now, we have these four gatekeepers in academic medicine. And remember, we all trained in academic medicine. That's where we all came from. So if we can't get it right in academic medicine, that goes out and informs what we do in in the community and in non-academic settings. So we have got to get it right. And there's four main gatekeepers, two of which I really want to focus on today, which is where a lot of my research is and which is why they're tipping points, which is why my research is focused there. In 2020, this was probably the most discouraging study that came out for women, which is which showed that, you know, there was no apparent narrowing of the gap for more than 35 years. And I think, you know, I often think about this study because if we ever had like, let's say it's a vaccine or some other treatment, and we said we've been doing this for 35 years and it hasn't worked, like people would be like, are you kidding? What are you doing? Like, why would you do that for 35 years? That's crazy to be doing something that doesn't work. And so we have that we were really at an inflection point to say, what we've been doing has not worked. It has not worked very well. It doesn't mean you can't find examples where things have worked, but we clearly, clearly are not doing the right thing. And when we look at, for example, our women who identify as black or African-American or Hispanic or Latina, what we can see actually are these inexorable zeros. Inexorable zero is a something that I learned from a biostatistician working on a paper with us, which is really something that the courts, including the US courts have used as a telling symptom of hidden attitudes or hiring practices that exclude entire groups of people from those jobs. And it can be a true zero and near zero number. But when people see zeros, when you see zero or almost zero number, you can pretty much say there's something wrong here. There just have to be more than zero or near zero numbers. And when you think about medical societies and you think about, okay, we have these gaps for associate professor and professor hasn't changed in 35 years. What role do medical societies have? Well, what I saw in our department is that we work really hard on diversity, equity, and inclusion. We work really hard to support our faculty, but what we have to do to get them promoted is we have to send them to the medical society and they need to put all these things on their CV. And if they don't get these things on their CV, it is very hard to get them promoted. So the medical societies are a big gatekeeper, no matter how equitable we are at our institution, we can't get them promoted unless they get these things on their CV. So I started thinking about that and realized, wait a second, the money flows a different way. That's a tipping point because if the money flows from employers into people's bank accounts, from NIH and funders into people's bank accounts, but the only way the money flows out is to medical societies. That's the only way it flows out of our department and it flows out of individual faculty's bank accounts. And keep in mind that I'm one of the leaders in our department that's telling our faculty to join medical societies, which by the way, I think is a very good idea. I do think medical societies are wonderful, including the AAPMNR, but I also think they have to treat people fairly. They must treat people fairly. So that's critically important. Now, this is actually a snapshot that one of my mentees took at a meeting where she was sitting and you can see she is somebody who has an intersectional identity and she's taking this picture and just showing me, I'm sitting in this audience and I'm paying to go to this medical society and this is what I'm seeing. I'm not seeing anyone who looks like me. And so that became a bit of a moral crisis, if you will, for me to basically tell people who I knew were under incredible financial stress with high education debt, that they needed to go to these medical societies and pay this money and leave their families, leave their little kids and so on. And that someday they'd get promoted and not to worry because the data didn't say that. In fact, the data said just the opposite that actually they wouldn't get promoted all the way up and that they really weren't being treated fairly. So I started really looking at this doing studies using recognition awards as a tipping point. And this is from the Association of Academic Physiatrists. And I know this data doesn't look good, but keep in mind, I mean, this is data on the website. This was data that people, thousands of people sat in a room and watched only men get awards for four years in a row, the most recent four years of which we did this study. And so this was a really, really a turning point. I think everybody was a little bit surprised at this, but it was what people in the audience were seeing and what our early career and trainees were seeing. As the AAP to their credit said, well, we need to develop a task force. We need to look at this. And Dr. Sarah Cuccarullo and I co-chaired that task force. And we started to look a little deeper. And what we saw in terms of the nominations, remember when you find a disparity, you don't necessarily know causality, but we dug a little deeper and we actually looked at nominations. And what we heard from a lot of people was women should nominate more women, which is actually not, you don't really have the oppressed group doing the work to fix the oppression, but that's beside the point. What we really wanna show you here is that that didn't really work anyway, because in the mid and senior career category, no women were nominated at all, which was really interesting. So no one, no men nominated women, no women nominated women, no women were nominated in the mid and senior career. In the early career, women were nominated, but they never made it out of committee. They never actually received the awards. So different reasons, and they require different strategies to fix them. And as the Harvard Business Review recently put this out, and this was something that has really resonated with a lot of people. And that is because a lot of women have sort of absorbed this feeling of not being good enough, and not just women, but anyone who is from an underrepresented group of not being good enough, and smart enough, and accomplished enough, and all these things. But in this imposter syndrome, really didn't account for being in a room where you don't see any women receive awards at all, or other types of things. So important to really say that it's not you, it's the system we have to change, and together we have to change this system. So I went on, Dr. Weinstein was really gracious, has sponsored me many times throughout my career. And this is one of the ways he invited me to write this perspective, because I wanted to show it's not just PM&R. This is in lots of medical societies around the country, people are sitting in rooms and not seeing anyone who looks like them, or hardly anyone who looks like them receiving awards. This paper has been cited more than 130 times, and is the second most distributed or disseminated paper in the journal PM&R. So really has gotten a tremendous amount of traction, and you probably can see why. And I think that this researcher and contributor to Forbes was looking at my work, and summarized it nicely in terms of the interview that I did with him. But really, there's so many talented women, and we have so many physiatrists who are so deserving, that the zeros just don't make sense. So we have to look at that and think about that. And of course, we see these wonderful award winners in a very diverse group, and a diverse committee making these decisions. And also just really recognizing that the work to publish these studies and bring this out was very challenging. It was very hard. We went through a very rigorous review process, and some people were really not that happy about showing that information, even though it was in the big room and on the big stage, and even though it was on the website, and even though this was all public information, it still made people uncomfortable. And so again, the AAP, they decided to convene this task force. What they did is we actually used a set of metrics that we had published in the paper, Where Are the Women, that was published in the journal PM&R. And again, Dr. Weinstein was really responsible for allowing that to happen, and for us to be able to get the word out about that, which was really fantastic. And the journal PM&R has really done a lot to move the bar for the entire specialty. And this is the first medical report that's ever been published, where we looked at a group of metrics, not just in our specialty, but ever, looked at a group of metrics, figured out a plan to try to close gaps, and then published a follow-up report. And to the people who have done this work, and you can see their names that I've included here, I'm a huge thanks to you, because this was a ton of work and really made a difference. And you may not know this, even the people who worked on the committee, you may not know this, but what happened is other researchers and other physicians in other countries have been following what we've been doing, and they are now publishing the same kind of work. And these are two researchers in Canada who connected with me and said, I love the work that you're doing with your colleagues in the United States, we're going to do that in Canada, and we're going to just follow along and publish the same types of studies that you're publishing, and that makes a huge difference. So now I wanna really talk about this issue of editors, because again, this is a tipping point too. This is probably the only study, I mean, sorry, the only problem that we have that's really easy to solve, pretty inexpensive to solve, and has more than 20 years of studies and reports in the medical literature that says it still needs to be solved. So it really speaks to this issue of if we can't solve the easy problems that are relatively inexpensive, how well are we going to solve harder problems that cost a lot of money? And so the research really started, or the literature really started in 1998 with is there a sex bias in choosing editors? And I have this going all the way up into the pandemic, so the pandemic started. And then I wanna show you what happened next, is I'd been publishing on this issue and saying, we have got to fix this problem. I mean, there's really not an easier problem to fix, and so many editors have already fixed it. And also, we can't say that medical societies and journals have a firewall. They have a firewall when it comes to content, but they don't have a firewall when it comes to their personnel. There's no firewall there. And in fact, the International Committee of Medical Journal Editors has codified owner obligations. Keep in mind that a lot of journals are owned by medical societies, or at least affiliated with medical societies. And this means that the editors have to act in a manner that's compatible with trust. And acting in a manner compatible with trust means gender equity, and it means diversity, equity, and inclusion for people who identify as racial and ethnic minorities, and people with disability, and LGBTQ individuals, et cetera. So I kind of went through, and I explained this on social media, all the work that I had been doing on this topic and so on. And what happened, interestingly, was this physician, Dr. Givens, he decided to just publish his own analysis. So this is just a self-published analysis of people who are racial or ethnic minorities as editors on journals. And that created a huge amount of looking at things and so on, and what happened next is there was this podcast that probably made every newspaper and was on every TV show and whatever. So I assume that almost everyone who's listening to me now heard about this racist podcast, and the New York Times covered it, et cetera, but it didn't start just recently in 2021. It started way back in 1998, where they had opportunities to correct things and they didn't do it. So the representation of women on journal editorial boards, super important, we've been doing research on this, showing that we have to get the AAMC to hold the medical societies that it works with accountable for these things. And this is just an example of a talk that I gave where someone said, I am going to make a change. I wanna be one of those early majority that makes a change that really says, yes, the data's convincing, et cetera. I don't wanna be on the tail end of no change, et cetera. And so I basically say, conduct an audit of your own publishing metrics. Consider this your body of work. And remember that the web of science and other places where there's metrics, they list all of your co-authors. This is public information. You can literally go on web of science and look at anyone on there and see all of the people they work with. So this is public information and we should all be looking at like what we're doing and how inclusive we are, because this is super important. And this is part of our legacy as leaders. Whether we like it or not, we don't get to write our own legacy. Other people decide what our legacy is. And part of our legacy is, did we step up at a time when there was such a need for more diversity, equity, and inclusion? Did we step up and did we lead the way? And how was our own track record on this? Because of course we can't just say that other people should do this. We have to do it ourselves. And so I think about this a lot and I know I always have room to improve. The world really wasn't made for women. We know that there's a lot of data to suggest that this is an example. This is women queuing to go to the bathroom. Now we know from a scientific point of view, it takes women longer to go to the bathroom than it takes men to go. And we can basically fix the women, meaning we can put them into premature menopause or do all kinds of things, or we could fix the structure. And if we fix the structure, it's really a lot easier. We don't need to change women. We don't need to change other people. We just need to fix the structure sometimes. So this is one of the easiest problems to fix. And I can always tell leaders when they're really savvy because they start sentences with leaders should. And people who really are still not fixing problems start with women should. So women should go to the bathroom faster or whatever versus leaders should just make bigger bathrooms. And this also happens in terms of women literally are physically working harder. This is a study looking at surgical equipment and the amount of muscle strength and such that it's taking during this surgery. And just recognizing again, the world wasn't really built for women. Citizenship tasks are something that I've studied and really been thinking about a lot. And that is, whose job is it to change all of these things? Well, ultimately it's going to be a grassroots effort. It's going to be top down and bottom up. It's going to take all of us. But I think that one of the things we have to be very careful of is to not ask people who are already very burdened to do even more. And this is a study that had an accompanying editorial that I didn't have anything to do with, but just kind of highlights this gender tax and minority tax that is really important. This is a true story. A group of women physicians told me that they needed a lactation room at their medical society. And they spent weeks and weeks and weeks working on this and getting it done. And they were so proud of this. And I thought, my goodness, why didn't they just go to a dean or chair, call the executive director of the society and say, this needs to be done. Our department is paying for these individuals to go to this meeting and they're paying out of pocket as well. And it just needs to be done. So some of these problems really are pretty easy to fix. And I often say, just solve the problem. We know no talk could be complete without talking about COVID. The second shift has often been described as home responsibilities. The third shift is gender equity work or other advocacy work that people are doing. And then also there's this other shift with unpaid pandemic work. And that's a lot of shifts for women in medicine or for anyone who comes from an underrepresented group in medicine. And I just wanna like close with really saying that we have to treat this similar to the way that we treat patient issues, which is we have to solve all these problems simultaneously. If we don't solve them all simultaneously, we continue to have big disparities. And so we thought that if we got enough women or if we got enough of any group to get to be in the system and so on, that it would just change on its own. And especially for women in medicine, that's been proven not to be true. And that's been proven not to work. And so we have to be very intentional. And that's why I say I'm committing my time and resources to making the specialty of PM&R more equitable and inclusion. I know I'm a better ally today than I was yesterday. And I have a strategy to be a better ally tomorrow than I am today. And I wanna just thank all the people who have supported my work and diversity, equity, and inclusion, from the chair of my department to my colleagues in my department, the journal editors at the journal PM&R and American Journal of Physical Medicine and Rehabilitation including Dr. Frontera and Dr. Weinstein and Dr. Friedli. They've just been fantastic in supporting this work. We've undergone very rigorous peer review on all of our studies. And it's just been a pleasure to have the opportunity to present them here today. And especially a thank you to the medical students and PM&R trainees. I just wanna tell you, you're smart, resilient, kind, worthy, and don't let anyone convince you otherwise. Believe science. And science tells us that there are disparities and we have to work to close those. And we really value you. So thanks so much for having me talk today. Yay. Thank you so much, Julie. Wow, you have, we have several questions, but I'm not sure that we have time for all of them, but maybe one. You presented a lot of compelling data, but I wonder if you can share a little bit more about mentoring and how that plays into supporting or reducing workforce disparities. If we have time to do at least one. Yeah, absolutely. And I know there's a lot of questions on this. The mentoring, mentoring is super important and try to look at the people that you're mentoring and think about, can you get something on their CV? Can you help them specifically with something? Also think about mentoring compacts, C-O-M-P-A-C-T-S, and really formalizing a relationship to the extent that you need to, depends on what it is. But remember that it's super important to not have homophily with all your mentor, with your mentees, that you really want to mentor a diverse group and make sure that they have specific opportunities that they can put things on their CVs. Awesome. Maybe, maybe one more. Okay. I think it's an easy, some of them are very deep. So I was trying to see if we could answer them someplace else, but can you speak to the role of virtual Grand Rounds meetings, or virtual Grand Rounds and virtual meetings as it relates to advancement of women who have more primary childcare responsibilities and may represent or experience challenges traveling to all of those? Absolutely. The virtual world has opened up a lot of opportunities for women to build their CVs and things, but they still need the invitations. And more specifically, they need the invitations for the high level lectures. So if somebody is, it should be appropriate for that individual. So if somebody is early career, they probably need to give a lot more Grand Rounds. If they're more mid-career or senior, they probably need those lectureships and so on. And so I've been really watching sort of how the gospel of diversity, equity and inclusion has been spreading in our department. And I can tell you that, I do think we need to do more data analysis and look at things, especially the compensation, but that we've been finding these really talented women physicians and scientists to come into our department and speak. And those invitations have not all come from me at all. Those have come from our chair and from other leaders in our department who are really trying to make sure that we recognize that great science comes from all of us. That's great. I have word from above that we're allowed to go a few minutes over. One more, one or two more. This is, they're all very good questions. So thank you so much for sending them in. One question is the greatest disparity of inclusion irrespective of ethnicity or gender are the emerging real clinical evidence of private clinical practitioners. Do you think there'll be a study of the clinical private practice folks? Yeah, so, you know, it's a really good question. And I was talking, you know, my talk was a bit more on conventionally socially or historically marginalized individuals. And that question is a little bit different. So it moves a little bit out of my work, but I love that question. And I hope that we do study those types of issues because I agree, you know, it's easy to get marginalized in lots of different ways. And so, you know, my work's been very much focused on historically and socially marginalized individuals, disparities in the patients and in the workforce. Exactly. And how do we address historical, historically, it should be historical inequities, contributing to the huge gaps of black, indigenous and people of color physicians of all genders? That's a biggie. Yeah, so I've been thinking about that so much and I don't have all the answers, but I can tell you the clinical practice guideline study is one where we used really interesting methodology to study the, you're talking about BIPOC individuals, to study people who we identified, we coded as coming from a racial or minority ethnic group. And those studies have been super hard to do. And it took me a couple of years to figure out how we could do that well. And part of the reason it took so long is because I had to dig really deep into the literature and really work on refining the methodology and really work on getting it through, you know, talk to Dr. Frontera and say, this is really important. We have to move this research forward. It's a limitation that we don't know people's true race or ethnicity, et cetera. But we're making progress in that way. I mean, that's such a huge issue though. And I don't have all of the answers, but I can tell you that it has been very top of mind for researchers in this space to find better ways to code and do these studies. Yeah, exactly. Well, thank you so much, Dr. Silver. I am so appreciative of you and your time and your research. And I wanted to thank everyone that has participated and with all the questions that are coming, I wish we could answer them all. And I wish everybody, oh, congratulations to all the award winners and have a wonderful day. Thank you so much for your time. ♪♪

disparities

underrepresented groups

women in medicine

clinical trial diversity

compensation gaps

inclusive mentoring

diverse participants

structural issues

inclusive environments

equity