Well, I'll start off by just saying it is great to be on this call with all of you exceptional future leaders. Really great. I see some people I recognize, so shout out to Dr. Shapiro, nice to see you, and lots of others that I see on the screen. So Dr. Wortswitz and I, I think I speak, Greg, do you agree it was a lot of fun doing that recording? You should unmute if we're going to have a chitchat. Is it working? You did say you wanted me to talk most of the time, so that's an easy out. There you go. I apologize. I'm sitting in Wichita. My computer was going down, so I'm speaking via phone, so I'm really trying to be techno, but David, I agree with you. It was a great time, and I think the best thing I would do, I learned a lot from you. So that's my one recommendation to everybody out there. You have a lot of questions for us, but most of the answers are not black and white. There's a lot of gray in there, and so by meeting with other medical directors and talking to people, reaching out even to my past mentors and mentors of mine like Kathy Bell, who's on the line with us, don't ever hesitate. We're in this together. So I don't know if Kathy has any opening remarks. Yeah, I would just say that Greg and I were more colleagues than me being a mentor, and we actually did indeed, in addition to betting on sporting events, frequently also would pass along a lot of information back and forth. And I agree that much of what I learned about all of the things to do with this were either, unfortunately, by the seat of my pants or were by getting my fellow physiatrists on the phone, on email, and saying, what should I do about this? What do you do about this? So there's no other way to learn this at this point except for this course right now, which we're hoping is going to short-circuit some of the seat of the pants learning. I agree. We had a few questions that were offered by the group, but I was first going to just offer a little bit of perspective. I'm sitting here now close to the age of 60. I've been a PM&R doc for a long time, maybe not as long as some of my colleagues, but feels like a long time. So I came out of my residency in 1995, and I, at the time, never had occurred to me that I'd go into a leadership role, like hospital leadership or medical directorship. It wasn't even on my radar. I just wanted to be a doc, join a good group, and kind of learn the ropes. Five years into that journey as a member of the team, so I was doing inpatient, outpatient rehab, I was in a single specialty private practice group, and I was the most junior one in the group. And then I'm going to share some, you know, some challenging situations that occurred. I think a lot of it because of the difference between a formal organizational structure as an informal. I got called by my most senior partner, who was the medical director, and he said, I was just fired. As of this moment, you are now the interim medical director. And I said, what? What are you talking about? He said, well, you'll learn more about it. It was July 4th weekend, 2000. He said, you'll learn more about it tomorrow, you know, when you come into work. And my head was spinning. I was like, what, what is going on here? And it was very complex, some things I can't really share. But the bottom line is that as a contracted medical director, the institution had the ability to fire him. He served at the will of the hospital CEO. And they decided they want to go in a different direction because of some, you know, complexity related to compliance and other issues. They saw things maybe different ways, but they went sideways in their relationship. And they had been trying to work that out for some time. And they went to the head nurse and said, who do you want to be the medical director? And they chose the young guy. I think because I just got along well with them and I kind of, I had earned trust with the nursing staff and leadership. So, but that's when my journey in leadership started in 2000. So fast forward to 23 years later, now it's evolved over a lot, a lot of time. But I will tell you that even though the formal org chart said that I was in charge starting July 4th of 2000, my senior partner never viewed me as being in charge. He didn't care about the org chart because I had influence as a medical director, but he didn't report to me in the practice group. So I couldn't actually influence, I could influence his behavior somewhat, but I couldn't tell him what to do as a medical director. Greg, have you had similar circumstances where you're sort of have that kind of tension about the formal reporting structure versus where you had influence versus power? Sure. I think you went over very well in your talk, but a little background on me. After training, I went into an academic position for a year, private practice for four years, back to an academic position, got kind of, I'm kind of a, oh, jack of all master of none trades of PML. And I realized we have some experts in different areas, went back and got a business degree because my work paid for it. And if anybody goes back for degrees and your work pays for it, make you get, try and get CME or some other credit, then you don't pay taxes on it. Kind of a word on the living wise. But then I was either after getting the MBA was, do I go be, use it as kind of a leadership role or do I use it as, you know, going to industry and really being a chair at a program. I went, and so I did that, but I kind of interesting, I, when I was at University of Missouri, 19 years, I also ran the practice plan and this kind of will go into the medical directorships, but I was the chair of the plan of 650 docs because, oh, they thought I knew something, which I didn't, but you learn as you go. And everybody thought I had the power to move money, but I didn't, or the Dean would come to me. I had a lot of responsibility to, but no authority. So I had to almost get coalitions to move things forward among chairs of a medical school. And you try and do that boy, that's a, but it's very similar to what you face as you know, and we, I faced as a medical director is someone, we have a couple of questions we're going to go over here. And I think I was talking with Mike Lupinacci and Kathy Bell who put together this course. There's a lot of hard data we can have, but it's a soft science of management and doing things that drives us all crazy because there's not a yes or no to it. So, and yes, sometimes you're put into positions and you feel like you might be an authority, but authority sometimes is earned rather than given. Thanks. I think what you're, you're getting at Greg is a lot. Our very first question was about how do you manage resistance? When other leaders are resistant, it can be challenging. How do you, how do you navigate through that to bring about change in the institution when not everybody's on board with that? And a good example is with a senior partner who wanted to, you know, keep its status quo the way it was. And I had some decision ability, but otherwise I needed to kind of use some influence. I'd be interested to hear other people's perspective about that. Maybe Kathy, I know you have to leave after a short amount of time. So how do you, how do you navigate through that when you run into other leaders who are maybe not on board with your vision of change? Well, you know, I would say two things. One time when I was basically in a situation where I was in a leadership position, but basically locked out of the financial decision making and that planning, I have to say that what I finally did was leave the institution because, you know, you can bang your head against the wall for so long, but if you're working with, you know, your next, your leader and they're not allowing you to, to lead and to do that, you know, at a certain point, that's hard to affect the leadership of the leadership on FUDGE. I think that working with resistance downstream, there's a number of different things that one can do and much of that involves really transparent communication and, you know, working with a group so that there's a certain amount of group pressure because if the group is all on board and there's one person that's sticking out, it becomes more and more obvious as time goes along, if there's resistance to change or to things like that. So I think that that, you know, has proven very helpful over the years, but honestly, I think that there are occasions when you just have to decide, is this, is this where I'm going to be successful in the long run for what I want to do in terms of moving into leadership positions, directorship positions, is this going to work or not? You have to be seen as a director, you have to be seen as that person, you have to have some level of whatever you feel comfortable with. I feel very badly when I see people get in positions as medical directors where they're rubber stamping because, you know, and I think that happens sometimes particularly to our younger colleagues, they get into positions that end up really being kind of manipulated and not knowing what to do. And I think it's bad for your head in the long run, it's bad for your professional growth. It's, you know, it's bad for you developing those skills. So and I do think that, you know, talking, every situation is different, right? Every family, every unhappy family is a unique family, right? So and it's the same really with workplaces, even though there's a lot in common with say, you know, for profit companies or for not-for-profit companies or for academic institutions, everyone is their own, has their own pathology. And I think the only way that you can navigate that sometimes is really by getting counsel from people and talking it over and trying to get some ideas on how to cope with those things and decide, you know, what your goals are and what your limits are. Yeah. Oh, can you hear me, David? I can, yeah. Yeah, I think Kathy brings up a good point. There are certain changes, some as you as a leader are going to bring that you want to change. Those things, you got to get some allies, early adopters, and the early adopters are going to help push that agenda forward and make that change. And then you will have some slow adopters and they're going to be, or outliers, even like Kathy said, there's also going to be change where, wow, maybe an institutional change that says, and people don't like it, but you as a leader are going to have to push it forward. Once again, you're going to have to adopt that. Then there are some changes Kathy mentioned as a medical director where, wow, if your IRF or your system or your hospital wants to maybe admit people right from the ER that you don't want to, you think are appropriate, you're going to have to stop that change and dig in and say no, but you have to do it on good grounds of medical decision-making and have data to back up when you do say no. I think that's where it's hard sometimes as a new med director or any medical director is boy, drawing kind of, no, I had an interesting setup. I worked at a joint venture with a for-profit company, nothing wrong, that's not bad. It's what they do. Also a university setting where the land grant, where we serviced a lot of Medicaid patients and underserved populations that didn't have resources. Boy, we had some very interesting discussions at times on, boy, do we admit, do we not? Would it make money or not make money or is that my mission? Again, we can talk, I have something later on our talk of one of the questions. You just have to know, it's like anything, what's the structure? Almost like Dun & Bedian, who's in charge of what? What's the process for getting things done? Every institution or every family has a different process and what outcome do you desire? You have to almost, I used to be very quick to jump at things. I had the answer for everything. The whiter my hair got, the less answers I had right away. Thanks. Thanks. I think some of my most stressful moments that I was thinking about related to resistance and disagreements with other leaders, two in particular. One went not well, another went, I think, pretty well. It's kind of an active issue here where I am. The one that didn't go well was there was a relatively new director of case management. We had a rehab unit within the acute care hospital, 40-bed unit. We had, for those 40 beds, we had four, if I'm remembering correctly, three or four case managers and two social workers. The director of case management just unilaterally decided that we only needed one social worker. My partners came to me and said, this is unbelievable. You have to stand up and tell them they can't do that. That's just bad. That's not an appropriate staffing model. I went to that individual, I was really thoughts racing, how am I going to approach this? It was already announced that this was going to happen without my any input. I'm like, I'm the medical director for this rehab unit. How can someone make a decision like that without having a conversation? That's a lack of respect. Right away, I was angry. I went into that meeting kind of hot. I never get angry. The bottom line is that I kind of tried to keep my cool as much as I can and have a reasonable conversation. This person looked at me and said, look, I've been in healthcare management for a long time. The one thing I am proud of is making my budgets when I'm told to make a budget. I'm making a budget. It's your job to make it work. But that's the staffing model. We're done. I was absolutely dumbfounded. So then I went to my, you know, after I was, I went to my department chair, I went to the chief of staff, I ended up having a meeting with the CEO of the hospital and kind of explaining that this was going to lead to poor outcomes and bad care and that ultimately this person's leadership style was not in sync with the culture of our institution. And I ran into it. I was like, that's not how we do things around here. You know, I've never encountered this before. And that struck me as an ethical type of an issue that you're going to make a budget despite the consequences. That to me was not in line with everything we talked about in our mission, vision and values. And I escalated through the chain of command in an effective way. And ultimately over a period of time, there was a reorganization and we had it, we, you know, but I had to be patient about it. So that's one example. More recently, you know, I'm part of a big university and we have a prominent rehab program, but our nursing team reports to the chief nursing officer. So rehab nursing has some, you know, I have a director of nursing locally, but the bottom line is that they are changing the nurse to patient care ratios as an institution. And they're pushing through ratios onto rehab that are acute care ratios. For our PCAs, it's a, I think it's a eight to one ratio. And I'm just like flabbergasted again, it's that same feeling I had 15 years ago. How can you do that? You don't understand rehab. But I'm going about it in a very collegial way. Having lots of conversations about it and ultimately supporting my nursing director to get benchmarks from other programs that, and backing it up with data about why those are inappropriate ratios in a rehab environment with a high case mix index. So I think it's what you're talking about, Greg and others, which is get some data. Have some control of your emotions when you're going into this conflict situation and have your values straight about it. It's about what's best for our patients. And sometimes that's not what's best for the budget. In the long run it is, right? Because if you shortchange care and quality, it's going to hurt the institution. And your job is to protect your patients, protect your unit, and advocate for what you think is right in the long run. I bet some of you have similar circumstances and experiences. Go ahead, Greg. Sorry. No, I think you're spot on. We did the same thing where I was. Our nursing ratios, and we were concerned with the acuity of the patients we were bringing. As a physician group, and I being the leader, we said we're going to cap admissions at this number. We just can't handle it. It's not safe for our patients. Now, boy, you don't think I got calls from the acute hospital where I worked and did most of my work, and from the CEO of our system. But you know what? I had built enough chips that with my own system they supported me, whereas the IRF who worked for a different company was not real happy, but he had to support me based on where my patients came from. So I think it's almost like you said, you built up some equity. So when you went and made these arguments and you went with data and facts, that could help. And I think that kind of led to a second question, David, we had from the group, which is, wow, I'm a new medical director. I feel like we're not getting what we need. Our ratios are way out of whack, because nurses are expensive and we're an eight to one or six to one. And you have patients that are on spinal cord units or brain injury units that need nursing as a critical component of the rehab team, not just to pass meds, but to teach, cathing schedules, bowel and bladder programs, other things. How have you found some of the, I love the idea of going and talking, how are you going about finding industry standards or have you found some for those sorts of ratios? Here's how I would answer that. First off, none of us are alone. We're all part of the AAPMNR. We have a wonderful inpatient rehab community, Lauren Shapiro, thank you. Now to you and we have colleagues that we can reach out to and get on calls with them, reach out to, I think we have a email chain, right? Where you can post questions and get responses. We also have other sources of benchmarks. Some of it is colleagues, right? So I worked with my nursing leader to say she was upset. She's like every place I've worked for before, we've never had ratios like that. We have high acuity. So I said, reach out to your colleagues and these other institutions and gather data so that we can come to the meeting with the right type of benchmark. So she reached out to the nursing leader at her prior institution and a few other prominent places, but it had to be places that were like ours, that had similar phenotypes. So academic hospitals that were organized with diagnostic floors and certain case mix index so that we're comparing apples to apples. Also AMRPA is a great source and they also have listservs and forums to pose those questions to ask about benchmarks. We also have within, we have a group of department chairs and academic leaders. You can reach out to them and ask them information through listservs and other ways like that. I sometimes will just do a quick old Google search. Say, what can I find about in the literature about posted ratios or other types of models? So you try to gather that data, but reach out to each other. So I'd pick up the phone and talk to Greg Warshawitz. Greg, you have a lot of experience. What do you think I ought to do in this circumstance? Yeah, and David, you're spot on with the answer of what I've done is going to getting that data, talking to each other and it has to be like type of facilities. All are sure not the same. Doesn't mean they're all different or good. You and I have had experience in academic ones. I had also experienced in a community-based one and it is a little bit of different mix of populations based on the acute hospitals that you serve and what they have, so. Greg, can I interrupt you? I'm not trying to be disrespectful, but there's a question for Dr. Bell and she's got to leave. And I do have to leave. Yes, I was looking at that and just asked a question. Great. Yeah. So that's very interesting. And yes, I do think that there's still some issues with gender and professional relationships. I do think that's an issue still. And I think that, you know, I mean, I think, you know, we see this on the national stage, right? And again, I'm not going to get into national politics, but there are certain people who don't accept the concept of women leader, a woman as a leader. And don't think that people in medical school and don't think that people in medical settings are any different than people anywhere else in terms of, you know, the way they might work with this. So I do think there's some issues. I do think you need to know who your allies are. I definitely have had some really interesting experiences, say with, for instance, other chairs who tried very hard to make end runs around the lady. And I, you know, really had to be extremely direct and bring this up to, for instance, the dean in this case and actually, you know, have a meeting where it was very interesting meeting. I definitely ended up on the upper hand of that one with the dean, but it was very difficult meeting and it was a difficult relationship with this person for the next few years because there was big grudge being held. So there, I think it's different. I think you need to know who your allies are. I think you will have different experiences with non-physician, middle managers, and things like that as well. Some of whom, again, kind of assume they can make an end run for some reason that they would never try to do with Dr. Steinberg or Dr. Worsowitz, but they would try to do with Dr. Bell. And so, you know, and is it always a male-female thing? It is not. So it is definitely not. So I think that, you know, really taking the time when you get into a directorship or leadership position to really scout around and know who your allies are. And I mean, your allies at every level, your allies in nursing, your allies in administration, your allies in the academic administration, because there are times when you're going to have to call on them to help you, to also help you dig out of a situation where you're having an issue. But like I said, it's not always, it's not always who you think it's going to be. I mean, some of, I think my biggest problems were with a female colleague, who I think it was a combination of being a woman and being in PM&R. So those two things together, I think were like, you know, first of all, you have less seniority than I hear, and you're only in PM&R. So, you know, what credibility do you have? So, you know, I think that allyship is absolutely what you need to look for when you start, is you need to really take your time to make relationships and to know who you're working with. It's huge. They will dig you out on many occasions. Of problems and stand up for you, but you have to work on those relationships ahead of time. It's hard to do it when you're in a crisis. So spend the time, invest the time rolling on. And I do have to leave. I'm so sorry. Thanks, Cathy. I appreciate it. Bye-bye. Bye. I would never try to unrun you, Cathy. Your containment's too good. Bye-bye. Greg, yeah, I'm sorry for cutting you off, but I knew she had a short amount of time and that question was very direct for her, so. Well, yeah, and I think only she can answer it. And just like anybody, whether it's your skin color, your gender, whether you're a white privileged male, you have to build your allies who you can trust. And, you know, I spend a lot of time, I know David's excellent at this, is, you know, take advantage of PM&R. We are kind of lower on the physician phylogenetic scale when you think of old traditional medicine, which we got to, you know, that's a barrier we need to break. But it's the relationships. I, like I said, we, here's an example. I had built the trust of my system CEO because I went and met and had some meetings. And one time over the winter, over Christmas holidays, a rehab center would drop census. So they would wanna bring people from home in for rehab. We could do it at the time. And I remember one Christmas holiday season, and, you know, New Year's, it turned out we had maybe three days of therapy in the week on staff because of holidays, and three the next. And they wanted us to bring a ton of patients from home in to keep our census up. And we basically said, no, you're not giving them therapy. I'm not gonna waste rehab days by bringing them in. And the CEO of the rehab center sent an email out to my CEO saying, Greg's refusing to admit people. He can't do this. I never got a call from the CEO. He just sent me the email and said, Greg, I think you need to have this as a heads up so you know what's going on. And that was it. He didn't question my, you know, judgment or thoughts. Again, I'm not doing that out of just say no, but it was, okay, you want people in the place, but they're not getting therapy. And they only have so many days and we're gonna waste them sitting here over the holidays away from their loved ones. No, we don't think so. And those are the types of weird traps you can get into. The CEO was mad because our census went down. And I'm not bringing someone in just to help your census. I wanna bring them in to help the person. Thanks. Yeah, I appreciate that. One of the things I hear from what you're describing, Greg, and I think I've experienced as well, is the tension that you feel when you're being treated like you're just there to check off some boxes and, you know, put patients in beds and just do a job, you know, just kind of manage the status quo. And I think we're, those are on the call here. I think all of you are on the call. I think all of you have a calling that's drawing you to leadership. And leadership is much different than management. That was one of the questions that we were posed. And I've run into managers, like that stressful situation where I described to you where someone was managing to a budget. They weren't demonstrating leadership about challenging, you know, the assumptions that were provided to them or kind of thinking out of the box. Leadership requires some vision and some creativity. So a willingness to challenge the status quo, to get to a different place, to take a group through, you know, influences, and sometimes, you know, through challenging change to a better place and to create that vision is really important. So I actually went to ChatGPT and typed this in. What's the difference between management and leadership? How many of you use ChatGPT to prepare for webinars? I do. I think it helps. It literally took, you know, half a millisecond, I think, probably, to say one core difference is the difference between the focus and the purpose. The purpose and focus of management is to oversee and maintain existing processes, systems, and performance. Managers ensure that day-to-day operations run smoothly, resources allocated properly, tasks completed efficiently to, you know, standards. A leader, though, has to think about motivating people, creating change, creating a vision to achieve long-term goals. Part of, you're not gonna be able to learn this in a medical director course. How do you inspire and influence people? How do you guide others to a shared vision? It takes time, and you have to start with a position of authority and trust. One of my, when I came into this role as a chair, I was assigned a chair mentor, so a very, you know, well-regarded, respected orthopedic surgeon. And he said, David, got a piece of advice for you. I said, what's that? And he said, do the hard stuff. Whatever that is in your world, your colleagues need to see you in a position of taking on tough challenges, tough problems, that you are willing and able to do the hard things, whatever that might be. And he described for me what that meant. And so I said, okay. And I think about that frequently. Like, what's the hard thing to do now? It's taking care of the very complex brain injury, you know, patients who no one else feels comfortable seeing them in the clinic. Or, you know, starting a long COVID clinic when no one else is kind of enthusiastic about it and didn't know where to start. Or volunteering to take call when someone else is sick and has to find someone to help out. Just being willing to step up. Greg, what about you? How do you see the difference in management and leadership? Yeah, that's spot on. And what's your vision? That's leadership to get you to that vision. You still have to manage day-to-day things, you know, and processes and fix processes that are gonna help you get better. But that's not gonna get you to your, you know, vision. Leadership's gonna have to take you there. I always loved the thing someone told me once, lead from the middle. And that's kind of do the hard things like you said. You gotta be willing to put the hours in or the time. It's not always hours, but take on those hard things and show you can do that. I'll go from there. It's kind of like that mission and vision we had a question on, and this was back when I had black hair. So this was very long ago. And they had rocks and chisels and not paper. Was neuropsych was a neuropsychologist was part of every team on the floor. And I think we've kind of watered down rehab or we've kind of diluted the importance. And someone was asking that is, wow, now they may want neuropsych, but you know, it's not as funded the way it used to be. And for us to have neuropsych, boy, I had to jump through 18 different hoops, get a directorship fee for it, that my inpatient rehab center, that was a cost to them. And how did I sell it as a benefit? Well, we had a level one trauma center. So we had a lot of acute brain injuries, acute spinal cord injuries. And without a neuropsych, we weren't doing those patients justice. That was probably one of the hardest pushes of being a leader there was. It wasn't a management, but trying to cast a vision. We need this and why. I'm curious, do you have neuropsychology that came up as a specific question? We do, and we have to provide subsidy for them. So it's an active conversation I'm having. In fact, it's requiring a little bit of creativity because there's another group that has neuropsychologists in our faculty, the neurology department. Neurology is kind of evaluating a different type of patient. Their system is a little bit more developed. They have more psychometrists. Their productivity numbers are higher. So I'm reaching out to them to try to develop a collaborative model. But the hospital does provide some support through our funds flow to help support that. But I have to, and I've never met a physiatrist who truly understands neuropsychologists because they're hard to understand. The care model is very different. You know, the amount of time necessary to write up a report and to do testing and evaluation, it's a very different type of work. And so it's a lot of medical directors are asked to supervise neuropsychologists, but it's very difficult to understand the productivity standards and the right practice models. But yeah, the compensation and the revenue, patient revenue is dropping off. And that's one of the challenges I think in all of healthcare, which is leveling off or decline in professional revenue relative to facility fees. And that certainly will impact all of you in your leadership roles over time. So how do you maintain a physician enterprise and a workforce with declining reimbursements and working with your hospital colleagues on some degree of funds flow, whether that's through contracts for support medical directorship or stipends to support underfunded services like psychology services and social work services. We're all being challenged with squeezing, squeeze on the margins of our healthcare organizations. And depending on where you end up, you will experience that in a very different way, but it's happening across the society now. Yeah. And I would say it's not just you and your location, it's across the country. And once again, that's where I've leaned off many a time, my colleagues who I've made networks with the call and say, okay, we need this. How did you get funding for medical director? Or what's your structure for enumeration for administrative time? And we were able to successfully get you know, some medical directors of spinal cord injury, medical director of X, Y, or Z. Again, though I had allies when I walked into my CEO's office. You know, again, you don't go in just empty handed, you have data, you have allies, you go. So it's what do they need? Here was this kind of interesting one because we're both kind of like to be the boss and kind of get our hands in and being a medical director, that's some of the fun of doing it is, wow, you will get to make some important decisions and you're the one called on. But if I'm a young physician, and the question came, I'm interested in being a medical director, but we have one now. How would you go about learning some of the things you need to without stepping on toes You you were in a different they kind of thrust you in there, but you've had a lot of experience and see how people And you've mentored a lot of people. Yeah, so a couple things first off. I was participating in hospital wide committees So I've been a volunteer to participate in quality improvement projects to work with nursing on developing some protocols And Obviously watching my more senior partner to try to learn from him about various aspects of I did not have at the time An external mentor or a coach nowadays, that's very common If I was thinking about becoming a medical director first thing I do is say hey Where can I find a mentor and I know a pman are and AP provide mentorship? Programs where you can link up with Someone more senior more experienced who can provide that kind of feedback outside of your organization to give you some guidance When I after I'd become a medical director, but I was thinking about taking on larger roles. I had at my I was I Reported to the department chair of internal medicine. We were a section of internal medicine and He was a trusted, you know colleague outside of my medical directorship role And he was able to give me some real direct recommendations really great recommendations about learning how to Learning more about leadership. One of those recommendations is start going to some leadership courses on the weekends so there was a group called the AAPL American Association of physician leadership and He said he kind of did this as a as a reward for people who are volunteering on committees He would fund you to go to a weekend course. So he said go to an AAPL course And I think it was on negotiation or maybe it was on, you know conflict resolution pretty common topics but I really enjoyed it and I actually ended up going back to those courses three or four times and That's where I saw there were tables set up about getting an advanced degree Get an executive MBA or another degree called an MMM and I said what the heck is that? And I went back to my department chair and I said do you think this would be reasonable because there's this other option for leadership training in the institution it was an Institution only leadership training a year-long course. He said that's a good course. It's not very expensive But I got to tell you you get what you pay for at the end of that course if you do it within the organization You're not going to have any letters after your name It'll be it'll have some credibility within the organization, but if you ever leave the organization, it's not gonna it doesn't travel well He said why don't you get it an MBA? And I started started kind of planted the seed and thinking about that. Like maybe I could do it. Maybe it would be helpful maybe it would open some opportunities or Make me help me think differently about my future role and that's the decision then to do it Made all the difference I am where I am now because I went and did that MMM course and I had a coach and I thought about What do I really want to do? Yeah, I bet lots of you are in that same space now thinking about what you really want to do Yeah, I think Dave you put it on the spot you you first volunteered for organizational interest you did the work You showed progress I was after I'd been in practice ten years at my job that I went back To my boss and said the same thing. I want to get I need the tools To and knowledge and I like to learn and that you know That's when they sent me back for an MBA at the time. It was you go away and they paid for it now Do I need an MBA to do the things I do? No, did it give me a little bit way back then not many physicians had it So, you know, it was a big time investment and commitment. Fortunately my work gave it to me, but You have to first show the interest and go to things go to get on committees get on You know at your earth get on it and go talk with the med directors if you're not one now and ask them They become interested maybe in this in the future and you got a way that your situation Are they brand new and they want to stay there forever? And will they see it as a threat or they like me a little longer in the tooth and want to say hey I can mentor you along Don't be shy I mean and Flattery gets you a lot of places, you know say wow you do such a good job as a medical director I can you teach me about this? I know nothing about spreadsheets. How would I learn on this? You seem to know this how did you and I Would say first start local and then spread You know, but definitely get some get Education outside of your system now, it doesn't have to be a degree but it does have to be some learning courses and Management courses because there's a science to some of the management and having those tools will go a long way All right, here was a question and they said this may not be Set for this talk, but I found it interesting They were saying wow They're getting pressure from their facilities to take patients and admit them prior to getting their prior authorization Have you seen that anywhere? Rehab centers taking patients before getting a prior off on a non Medicare a and B patient Well, we did back where I was before But I hadn't a kind of an understanding with the Blue Cross medical director. Yeah, they kind of explained she apologized she said, you know, we're closed on the weekends and We know this is causing a delay and your ability to bring patients in and I said, you know There are some cases where we know it's an it's a slam-dunk. This is a patient meets criteria Well, and and we came to an agreement where she said we will retroactively approve those You know until we run into some challenges, but I trust you you're you're good at understanding our criteria We work together for a while So if you bring those patients in on a Friday because you know, they meet criteria or even on a Saturday You just you know, help me out send in the referral on Monday or the authorization, you know I'll look at it and we'll get it done Yeah, because I was explaining to them that we had these unnecessary delays that were causing a bottleneck in our patient flow coming from the acute care But it can it can present some challenges I think if it's an institutional decision is trying to force you to do something that you don't feel is right That that's a Problem the issue that was described in the question though seemed like the risk was being borne by the organ by the hospital Not by the medical director. Yeah there was very little kind of personal risk that was like it was just that the hospital was willing to take that risk and The issue is that as a medical director you may have to do more peer-to-peers you may have to Try to justify denials that you don't really feel that great about And be you know ultimately go in front of an administrative law judge to make the case and it can be For a lot of medical directors. That's the stuff that's not so fun Yeah Yeah, I think that that'd be my only concern is if while they're trying to shift patients that you do not feel meet the criteria appropriately For an acute inpatient rehab setting now, that's probably rare But boy, it can happen if you're moving patients So that would be my one concern much like you said make sure you have to feel okay about taking them period You know With those I'm just looking through our list of questions Let's see Hey, I'm I mentioned something. I think someone asked about working for two different organizations where yes, I did work at an earth their physicians were university physicians or fellow colleagues of mine the earth staff was and CEO and all the Administration was for an or profit company and then the total joint venture which it was an LLC was a split between the University and the for-profit company and Yeah, sometimes my head would be spinning on who did I work for what was the mission as long as though you kept the patient? Number one you were okay But I can't say that with a straight face without saying yes, I got squeezed in many directions many times And you just have to try and be consistent with your thought process, you know, we are gonna take this You know, this is inappropriate or no, we can't take this because of we're not staffed to this level Don't get me wrong. Whenever we had a joint venture meeting. I sat on the board. I mean the first 20 minutes was talking about Dollars and cents revenue profitability EBITDA things that way and then we do maybe five or ten minutes on quality and throw out some slides, but I Had to make the CEO locally at the earth he or she and I had to be partners to say this is our house and We need to you know work together There'll be times that you will be on maybe at odds with the CEO on some decisions or with Her or him But you got to just stick to your guns and be consistent. It's uh, and no, especially there know your allies I built you know Allies with my university and at the university that would support me I never had and in the 19 years someone called me and say no Greg You got to do this your doctors have to do it. No, but it took a long time to build that credibility Thanks, Greg, I'm uh, I see that we had a question I was just about to ask if there are other questions that people wanted to pose Question is how do you convince administration to hire more outpatient support like attendings nursing social work for an overwhelmed outpatient clinic? Yeah, that's a that's a good question about resources and I think the key thing is I mean, I certainly recognize the cost of burnout cost of turnover and Most managers and organizations kind of understand that that retraining people and having to fill you know But if you're understaffed and there's puts more more stress on the existing staff So I think it gets at again kind of sitting down with your either the manager of the clinic or the administrator to help describe the problem now one thing that I notice a fair amount in my role now, but really over time is that sometimes frontline workers will do an end-around and they won't go to their supervisor their manager they'll come to you as the physician and they want to shoulder to you know cry on or they want to kind of get your attention and they'll tell you about a Challenging their a challenge they're having in their HR Relationship with their manager. I had this happen just recently with one of the the parking valets who was upset about their schedule and they came to me and said Is it right that someone does XYZ with your scheduling and blah blah blah and I and I was like, I Am NOT an HR expert, but we do have an HR department and I would encourage you to talk to you know Call the HR people and you know explain the challenge that you're having with your manager Because I'm not I'm not in their unit I don't know the policies and the rules and it's easy to get sucked into Some type of conflict between frontline workers and their managers And that's not always your job and it's not always a safe space to be in because there can be a lot of challenges that happen in that kind of Organizational hierarchy that's part of this complexity is that you might see that there's staff members who are stressed out that the Staff members who are stressed out that the ratios aren't great, but you don't know the whole story And it's very important to kind of understand that HR rules can become complex And it's important to work within your organizational structures Greg how would you answer that question? first I'd know my clinic a Is it a straight and is it am I serving a mission of the organization? That's one to do longitudinal care not just in hospital care number two is Look at what type of patients you're seeing in clinic I used to argue that it's spinal cord injured patients need help transferring that someone in family medicine walking in for a cold check Doesn't so once again compare apples to apples My clinic is different than family medicines clinic or someone else's clinic and if I'm in a big organization Second is look also Accumulate what downstream revenue you're making oftentimes we do use quite a bit of Botox and Botox not the actual procedure but the medication is a big driver of revenue because of the way most hospitals can Buy their drugs and what they can charge for it Baclofen and then I get the baclofen pumps if the neurosurgeons are putting them in I'm making sure the neurosurgeons are one of my allies Or if it's the orthopods whoever's putting in because oftentimes it's PM&R then that manages the pumps and does that And then referrals to PT OT if you own your own PT and OT EMGs and MRIs all of those things. I want to know what are non-direct revenue producers that this clinic is doing for us as well as meeting the mission and then Describing the patients we have and how they may differ from other patients. Once again, I'm just trying to break it down So I have the best knowledge I can I'm not just walking in and saying I need more people in clinic I need more doctors in clinic. Well, if I say more docs are gonna say, okay, show me what their schedules are What's their fill rate? What's their no-show rate? I want to know that clinic and the metrics I'm being measured by So Okay. All right team. Let's figure out. How do we go about this scientifically? And once again, it's like asking for something else I want to go in there with data and Information because you're the expert in PM&R and just like, you know, and everybody on this call knows Most places still they don't know what PM&R is. We have to always be marketing ourselves and explaining to them What is it we do and the type of patients we help I don't know if that's helpful, but that's how I approach it Yeah, thank you, Greg. I think it is helpful. I know we are at time I've my only last comment I was going to make is if you view these challenges as QI projects and you pose it you find a common ground with whoever you're talking with that says I've noticed we have this You know Challenging problem the problem itself is not the staffing The problem is the outcomes that good staffing leads to you know, and it could be you know, prolonged room turnover or you know Delay in getting back messages or refilling prescriptions if you can define the problem and share that problem with whoever you're talking with and say Let's work on this together to see if we can, you know Come up with some either better efficiencies better processes or maybe the solution is staffing who knows but go with an open mind be curious as a medical director asking those kinds of questions and Whatever you do don't take it personally. Don't get angry. I made that mistake many many times That's probably the best advice I've blown up a few times and I've regretted almost every time I felt good at the moment, but it is you know You do but there are certain times you need to almost show a little emotion Yeah, I mean so you can't bite your tongue. Totally. Yeah, be curious. It's fun I I was luckily at a university but we would we had students in there doing a cycle times with stopwatches From the time the person checked in how long till they got in how long did I mean? There's a lot of different you yeah and make it fun for the staff doing it because they'll get into it, too you know, I Know we're at time I know David you feel the same way as I do if you see one of us at a meeting you got questions stop And ask I mean, that's what that's how I learned is You know, I used to always volunteer to drive the guest speaker to the airport I'll do it and then you know, he or she I would ask billions of questions, too So Brian, did we have anything else that questions or any other? I'm sorry. I'm on my phone the whole time. So No, we had one question that came through that was addressed and I believe you took care of the four questions or the questions that came through pre meeting Yeah, I would same as Greg I offer, you know, anyone who wants to reach out feel free to reach out through my University of Utah email. I think that has been shared More than happy to you know set up a chance to chat There's also like I said mentorship opportunities through the Academy and I know there's a great resources out there We're all willing to help you all developments and you know along your your journey. So yeah, there's a One thing I do want to mention and I found this I called Kathy a mentor and mentors are not always older You can have mentors that are younger than you So when we use that term mentor I get mentored a lot from med students and young residents on IT stuff and So keep your eyes open people are mentoring all over the place for different things so David it's always a pleasure working with you. Thanks for taking the time and I Look forward to working with you in the future Excellent Well Having said that my greatest regret is I haven't been able to you know Chat with each of you and hear your own voices, but thank you guys for spending this evening with us It's getting dark earlier and earlier Waking up in the dark out here in Utah and for any of you down in Florida. I wish you the very best and, North Carolina You know healing and you know wish you all safe and happy Fall here as we head into the getting closer and closer to Halloween. Enjoy the journey Absolutely Thanks, everybody

medical leadership

mentorship

collaboration

professional growth

formal authority

influence

gender dynamics

organizational challenges

quality improvement