Good evening, everyone. Thank you for joining us for this inaugural event. As Brian said, my name is John Cianca. I am the chair of the Medical Education Committee, or MECC, as we call it. The American Academy of Physical Medicine and Rehabilitation National Grand Rounds was conceived of by MECC with the intent of bringing all physiatrists together to share, to collaborate, to celebrate all that we are, a diverse specialty of many diverse people. National Grand Rounds will be presented once a month here on in a variety of formats to explore, educate, debate, celebrate, and hopefully entertain an intellectual happy hour, if you will. Ultimately, I hope it serves to unify all the diversity in our members, our practices, and the place we work. And now it's my distinct honor to introduce our inaugural speaker, Dr. Michelle Gittler, president of the American Academy of PM&R. She is a graduate of the University of Michigan. She went to the University of Illinois Medical School, and she graduated from Northwestern University Rehab Institute of Chicago after completing a residency in physical medicine and rehabilitation. She has served as the principal investigator on numerous research protocols. She has numerous publications in peer-reviewed journals. She is a passionate educator and a former chair of MECC. She is currently the medical director of Schwab Rehabilitation Hospital, as well as the residency director and the department chair. Basically, she runs Schwab. Dr. Gittler has devoted much of her career to the clinical care of victims of violence and in advocating for those who deserve better. Tonight, she presents to us getting into good trouble, why advocacy should be a core competency. I have the opportunity to preview her presentation. It speaks to the scientific nature and the human nature of our work. I believe you'll be moved by this presentation. Dr. Gittler, the floor is yours. Thank you, John. My name is Michelle Gittler. Thank you for joining me this evening. And I'm going to be talking about advocacy as a core competency. I will never forget my first rehabilitation patient. I was a medical student just starting my first and only rehabilitation rotation. I was told to follow a patient who was on the sixth floor in a room that overlooked the lake. She had just had an amputation after going through over a year of limb salvage surgeries after a crushed injury sustained in a motor vehicle crash. And she told me how relieved she was to finally get on with living. That was my moment. I remember stopping in my tracks and recognizing how wise this person was. For her, resuming her life outside of hospitals was more important than living with a non-functional leg. I was smitten. I remember coming home to the apartment I shared with my medical school classmates that first day of my rehabilitation rotation, being in my tiny kitchen. Can you forward the slide, please? And fist-pumping in the air as I made dinner, telling my then-boyfriend that I love rehabilitation. Sadly, I can't see you all, but I imagine an audience of my colleagues, most of you incredibly learned and talented, some of you my best friends. I'm reasonably sure that most people here are a lot smarter than I am about many things. Could you forward the slide, please? I still have to look up brain stem syndromes. I never really learned the Rancho scale, and I have no idea what a transcortical sensory aphasia is. I do not know what a Bankart lesion is. I have absolutely no capacity for interpreting ultrasound, and I have never done a joint injection, a botulinum toxin injection, and have certainly never seen, let alone participated in an axial injection. We could talk about my training later. There is one thing, however, that I know I am really smart about, and perhaps the best, which is saying a lot in front of this group of people. I am an incredible advocate for my patients. I am an advocate for the people that I serve, which is people, mostly with Medicaid, who have disabling conditions. I also think I am second to none at performing peer-to-peer appeals to advocate for rehabilitation, and so I want to talk to you about what advocacy means, the role of advocacy and agency in healthcare, and why I think advocacy should be a part of the core competencies for physicians, and especially rehabilitation physicians. I would like each of you to take a few moments and jot down or think about a time or two that you went out of your way for a patient, or a time that you spoke out for something in your workspace that you believed in strongly, and also think about a time you got so frustrated with our healthcare system you just wanted to chuck it all or hurt someone or maybe even cry, and now turn your note card or your little sheet of paper face down or put your thoughts in your retrievable short-term memory space, and we'll get back to them. I think you all know that I trained in Chicago. I did my internship at a community hospital and my residency at the Rehabilitation Institute of Chicago. Even then, I found myself asking questions that often went unanswered. I remember my spinal cord injury attending gave me a book at the end of my rotation. He gave me the Emperor's New Clothes. I'm pretty sure this was based on my asking why things had to be done a certain way. Since the completion of my residency in 1992, I have worked at the Schwab Rehabilitation Hospital. I wanted to work at Schwab because then Schwab physicians were doing the rehab consults at Cook County Hospital, which is really where I wanted to be, but Cook County wasn't hiring their own rehabilitation doctors, so I came on as a consultant for the trauma unit. I learned that Schwab, though only four and a half miles away from where I trained, might as well be hundreds of miles away. This distance was reflected in the patients served, their challenges of social determinants of health, and the paucity of resources for most of the Schwab patients in their own communities. I love what I do. I love what I do. I believe physiatrists in general love what they do. I know what all physiatrists have in common is the understanding that it's an honor to work with individuals who have disabling conditions. It's a privilege to be with patients and families at difficult, perhaps the worst time, and find and crack open a window just a little bit to let some light into what is often a very dark place in their lives. And with that privilege comes a pretty heavy responsibility, really and truly seeing the whole person and crafting a treatment plan that is evidence-based and also based on each individual. In rehabilitation, we pride ourselves on being patient-centric. We don't just treat the patient with a stroke. We treat Ms. Jones, a 52-year-old who works in an elementary school cafeteria and is a foster parent to two children. The patient with a hip fracture is Ms. White, an 86-year-old, fiercely independent woman who has been falling at home and who is deathly afraid of being sent to a nursing home. The individual with the incomplete spinal cord injury is Mr. Rubin, who works as a horse dentist and who has twin daughters who love to dance. The COVID patient is Mr. Harden, a patient who had ventilatory failure in March, a prolonged hospital course, who works in a factory and is so madly in love with and beloved by his wife that she sat in her car the day he was transferred to Schwab from the acute care hospital just to see him for a few moments as he was moved from the ambulance into the lobby. We need to know these things because each of our patients has unique needs, unique fears, and there's a strong likelihood that they will have their own trajectory of improvement. As a resident, I had the realization that being a great rehabilitation doctor didn't mean curing people because the patients of the best doctors were still paralyzed. They still had multiple sclerosis. They still had an amputation. However, I recognized and I was jealous of the near intimate relationships some of these doctors had with their patients, the confidences that were shared, the trust in talking about being afraid of an unknown now, let alone an unknown future, often the tears followed by a deep breath and a smile during a conversation was a level of relationship I hadn't encountered working with other doctors. I saw that being the best doctor for these patients met listening and usually cheerleading for the first words, for the ability to propel a wheelchair, the upgrade in diet, getting through a day with no rescue medication, the independent transfer. It meant knowing about their family, their home, their role in their community and trying to help them regain the sense of self to reassume some small part of who they knew themselves to be. It meant advocating for the patient and rehabilitation still seems to attract those people who understand that role. I would like to lay out a few objectives for this talk so you can get CME and I stay on track. They are to differentiate advocacy and agency from activism, to identify the role of the physician in patient advocacy and to specify opportunities for advocacy locally, regionally and nationally. I'm going to focus on the role of the physician in advocacy and identify not only what we are already doing, but what we can do better. People go into medicine to care for patients, standing by them through their various stages of health and illness and ensuring they get the care and resources they need to optimize their quality of life. In doing this, you are advocating for your patient. Advocating for your patient, getting individuals what they need. Activism consists of efforts to improve society and correct social injustice. It can take multiple forms, including attending rallies or preferentially patronizing certain businesses. Acknowledging advantage is a form of activism. As rehabilitation physicians, acknowledging and being aware of the advantage of ability could be activism. We should recognize that speaking up for accessibility is activism. Of course, I find myself throwing killer stares at the individuals at Trader Joe's who park in the spots reserved for individuals with disabilities. None of these glares have been fatal, but it doesn't mean I don't stop trying. In our routine activities of daily living, most of what we do as physicians is advocacy. There are many ways that we advocate for patients. For me, it means working where I do to ensure that all patients have access to outstanding rehabilitation care. For each of us, it can be different. It means writing a letter to a utility company to prevent them from shutting off a patient's gas or electricity. It means volunteering to complete the peer-to-peer requirement to get someone into inpatient rehabilitation when their insurance denies them. Or really examining a patient referred with one diagnosis and then recommending that patient get an imaging study when her neurologic exam does not fit with the diagnosis given by the PCP. It means pointing out online coupons for medications for erectile dysfunction. It means seeing a patient because your colleague knows that you will make the right diagnosis, even though you are already behind in your day. And sometimes, perhaps cajoling your administrator to approve a clinic visit or a short inpatient stay for someone who is underinsured or uninsured. Sometimes, advocacy demands activism, a more intentional action to bring about social change. It means marching in the streets on behalf of individuals with mental illness, or as physicians, raising awareness about health risks related to global warming, or consequences from use of nuclear weapons, or sequela of firearm violence. It means understanding how our current healthcare system does not serve everyone equally. Insurance type, assuming persons you are caring for have insurance, affects your patient's access to specialists, equipment, and medication. Advocacy means speaking up to keep people and the communities they live in healthy, which also means having healthcare available to all of us. And yet, the question is raised, why should physicians be expected to be advocates for their patients? It certainly isn't on the test. It's not part of medical school training. You do not get paid extra for it. In fact, you don't get paid for it at all. You actually lose money by spending time on the phone. We have left it up to the individual physician to decide whether, how, and how much to advocate for their patients. Should there be a standard for advocacy? Currently, individual physicians must decide whether and how to get involved in societal factors that affect the health of people in general. It is not part of reimbursement or maintenance of certification. Knowing this, is it even desirable or appropriate to consider advocacy a core component of medical and graduate medical education? And how would you even measure it? Is it part of patient care or professionalism? Is it systems-based practice? What if I am working with students or residents who do not or cannot or refuse to advocate for patients? Could I fail them? And what about my colleagues at other hospitals? Those that refuse to fill out the paperwork for BiPAP or a wound vac that they want the patient to have? Those that refuse to see a patient in follow-up even after they've seen them as an inpatient. Could I report them for non-professionalism? What about physicians with low emotional intelligence who may be super smart but are unable to elicit the social factors that are the root cause of underlying issues impacting health? There are different components to advocacy. One is working specifically on behalf of the individual patient. This is called agency. And we do this all the time. We get prior approval for medications. We do a peer-to-peer to extend a patient's stay. We double document to make sure that our patients get the kind of custom wheelchairs and components that they need. And then make sure that everything we've documented is repeated again in our progress notes and specify that people with paraplegia cannot walk even if they have a walker. We talk to people who know nothing about rehabilitation, who are making decisions on behalf of people they have never met. Over and over again, we find ourselves explaining the difference between a skilled nursing facility and inpatient rehabilitation. We talk with individuals at insurance companies who have denied an imaging study for someone who cannot lift their arm until that person has therapy first. We fill out forms for FMLA and return to work only to have the medical director request an updated clinic visit. And still we persist. Another component to advocacy is activism. Activism is addressing conditions that affect populations or as we have all been hearing about, population health. When we talk about population health and the associated social determinants of health, this is not just about healthcare utilization, unmet healthcare needs, and health insurance. Population health looks at issues that affect the health of communities. This includes medical care, public health interventions, and aspects of the social environment, income, education, employment, social support, culture. It includes the physical environment, such as clean air and clean water, genetics, and individual behaviors. The framework for social determinants of health is based on the improvement of health factors, which can thus improve life expectancy and make communities healthier places to live, learn, work, and play. I've learned a lot about social determinants of health from the Sinai Urban Health Institute. This is the public health arm of the Sinai Health System, which Schwab is a part of. The Sinai Urban Health Institute works in partnership with community members and community organizations to document disparities and improve health in some of the most vulnerable neighborhoods in my city, Chicago. SUI conducts health disparities research, and in doing so, has developed innovative community health interventions, such as training community health workers who are frontline workers, trusted members of the community who facilitate access to services, education, and social support for community members. We are currently collaborating together on several projects. One of them includes COVID contract tracing in North Lawndale, which is where I work. If we look at health outcomes, such as length of life and quality of life, social determinants of health can be broken into several broad factors. Health behaviors, such as tobacco use, diet and exercise, and alcohol and drug use, account for 30% of health outcomes. Clinical care accounts for 20% of health outcomes, and this includes access to care and quality of care. The air and water quality of one's physical environment and access to housing and transit account for another 10%. The remaining 40% of health outcomes is related to socioeconomic factors, including education, vocation, and other factors such as social support, which can include interface with the police and the judicial system. With health outcomes and their background breakdown in mind, let me tell you a little bit about where I work. Schwab Rehabilitation Hospital, the blue heart you see in the middle of the map, is located in North Lawndale, but it has a very large service area encompassing 21 zip codes and 43 communities that reflect 50% of Chicago's population, which is about 1.3 million people. Schwab service area is defined as the largest 75% catchment area for all inpatient hospital discharges from Schwab. Of these communities, those you see in dark blue, 25 are predominantly black and 14 are predominantly Latinx. 26% of the population are children under the age of 18. In 43, 41 of the 43 communities that Schwab serves, the pre-COVID unemployment rate ranged from 9 to 35%. In Lawndale itself, which is 97% black, 25% of adults were unemployed before COVID. Only 17% of persons in North Lawndale are uninsured. However, they have challenges in accessing healthcare and often feel they are unfairly treated because of race or color. As all of us in Chicago know, the violent crime rate on the West and South sides of Chicago surpassed that of the North side significantly. Citywide homicides and shootings in Chicago has seen a 50% jump in murders this year compared to 2019, and most of these were on the South and West side. I have alluded to the difference in life expectancy in Chicago. A striking visual is along the green line, one of the L tracks, whose elevated tracks start or end downtown and go straight West and also head South. Along the East-West straightaway, right here, life expectancy varies from 83 years in Streeterville, where the Magnificent Mile is, to 72 years in Austin, which is only a few miles West. If one goes South from Streeterville, life expectancy drops from 83 to 67 years in Englewood and Washington Park, which is only six miles away. Back in Lawndale, 17% of persons have ever been homeless, and in the past year, 50% of households received Hooved Stamp benefits. While the median household income in Chicago is $47,800, in Lawndale, the median household income is $21,700. In North Lawndale, 59% of men have ever been arrested, booked, or charged with a crime since the age of 18. In a 2019 RAND study, education was strongly associated with differences in arrest rates between racial groups, especially for men and younger age groups. We can identify the primary economic factors that drive inequity as poverty, unemployment, undereducation, and early-age arrests. We have to understand that race contributes to having a record of incarceration. Two young men found with the same amount of marijuana on them will likely have two very different outcomes based on their race. According to the ACLU, marijuana use is roughly equal among black and whites, yet black persons are 3.7 times more likely to be arrested for marijuana possession. This is reflected in North Lawndale and the high rate of men who have ever been booked, arrested, or charged with a crime since age 18. None of us live in isolation. We all live in communities. Thus, the health of the community directly affects the health and outcome of our patients. If people cannot go outside to exercise due to concerns of safety, how can we say they are non-compliant? If they live in a food desert, how can we say they are non-compliant with their diet? If you go to the website for the Cook County Housing Authority, you will find the Housing Authority of Cook County Section 8 Housing Choice Voucher Waiting List is currently closed. It is unknown when the waiting list was last opened or when it will reopen. The waiting list for seniors is closed. How does the patient with mobility limitations get up and down three flights of stairs? They cannot access therapy or doctor's appointments or participate in their community if they cannot get accessible housing. Sadly, along with empathy, volunteerism and commitment to social change declined during the training years. And while we all agree advocacy is important, if there are no RVUs tied to it, no reimbursement, and no mandate, it will happen inconsistently. A blog by a physician named Saba Mann in November of 2017 tries to capture the shift away from empathy as a trainee. She said, I don't remember precisely when the switch turned from eager and enthusiastic to frustrated and empathetic, but it was at some time late in intern year that I began to lose perspective in my work. While I never lost enjoyment in working through clinical problems and working with patients at the bedside, I spent the majority of my days sitting at a computer relaying information during attending rounds, clicking through buttons and alerts in the EMR, documenting in patient's charts to the standards of my attendings and trying to coordinate dispositions that were difficult. And while I tried to maintain focus that this is what it took to take care of my patients between the constant pager alerts about order clarifications or requests, I felt more like a secretary than a physician. All those years of struggling to get here eventually didn't seem worth it. Neither the LCME, which accredits medical schools, nor the ACGME, which accredits residency programs, nor the Joint Commission, which accredits hospitals, nor CARF, that specifically accredits rehabilitation hospitals and units, have requirements for teaching or participating in advocacy. In the absence of requirements, it becomes less likely that energy and resources are focused in these areas. And in the absence of measurement, it is a certainty that it is not taught. As physicians mature, they often start to advocate for measures that further their professional self-interest rather than changes that will improve the well-being of the public. An example for me personally is that the American Medical Association is opposed to proposals for the U.S. to create a single-payer healthcare system. I personally believe that a single-payer healthcare system will enable my patients to access the healthcare system in a more equitable way. The AMA says that single-payer systems cause long waiting periods. Well, we not already have long waiting periods. There are tens of millions of people in the United States who are not even allowed a place in that line. We know that patients with Medicaid often have to wait months and months for an appointment with a specialist, often only to be told that their managed Medicaid insurance plan is out of network for the hospital or medical group. The AMA says that single-payer systems cause a lack of patient choice. Well, what does that mean? Most private insurance plans have restricted lists that already take away choice of hospitals, physicians, and other healthcare professionals. A single-payer system gives you free choice within the healthcare delivery system. Does the AMA mean a lack of choice of health plans? Well, for many people, the only plan they really want is a plan that allows access to healthcare without being assessed a financial penalty for having health problems. A single-payer system would create that access. However, the AMA also says in its Declaration of Professional Responsibilities that physicians must, quote, advocate for the social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being, end quote. Advocating for changes in our healthcare system would do exactly that. This would, of course, have to include discussions about the restructuring of medical school, financial debt, malpractice insurance, and most importantly, the debacle of documentation and the EMR. We also say that physicians should maintain political and social neutrality. Why should we do that? And when did that start anyway? Richard, Rudolf Virchow, yes, a Virchow's triad, was not only the father of modern pathology, but is also thought of as the founder of social medicine. In the 1840s, his investigation of the typhus epidemic laid the foundation for public health in Germany. He said, open quote, medicine is a social science, and politics is nothing else but medicine on the large scale. Medicine is a social science, as the science of human beings, has the obligation to point out problems and attempt their theoretical solution. The politicians, then, must find the means for the actual solution, end quote. He described physicians as the natural attorneys of the poor, and that social problems fall to a large extent within our jurisdiction. For this, of course, he was expelled from the Charité Hospital, though he was reinstated five years later. As physicians, if we really want to have an impact on health, we need to do more than treat or fix those who are sick or harmed by preventable disease. We need to push for changes that will positively impact the health of individuals, and also the communities in which they work, live, and play. Physicians have a responsibility to identify problems and solutions. Many of the problems or solutions are way more complex than any one individual can grasp. As physicians, I believe we have a responsibility to talk with each other, those maybe we disagree with, and learn as much as we can about various perspectives related to problems and solutions. Doctors struggle with the issue of medicine and politics. There's been a call by multiple medical societies for policies to help mitigate the rate of firearm injuries and deaths in the United States. Several individuals in our own specialty are concerned about the academy supporting a, open quote, politically charged more so than medical concern, end quote. We must frame firearm violence as a healthcare crisis. There are more than 37,000 deaths annually due to gunshot wounds, with the majority of them over 22,000 annually from suicide. We don't even know how many traumatic brain or spinal cord injuries result annually from gunshot wounds because that data isn't tracked. And yet we do know that 3,536 people died from drowning between 2005 and 2014. And as of January 13, 2020, there have been 2,602 vaping-associated lung injury cases and 59 deaths, according to the CDC. In September of 2019, after seven vaping-associated lung injuries resulted in death, there was a national bipartisan call to restrict vaping. As physicians, we spoke out, and we have the responsibility to protect the health of our communities, even when it's uncomfortable, especially when it's uncomfortable. Henri Dunant won the first Nobel Peace Prize, not just for founding the Red Cross as a humanitarian assistance organization, but also lobbying to codify the rights of combatants in war. In 1861, he advocated that the nations of the world should form relief societies to provide care for wartime wounded. Each society should be sponsored by a governing board composed of the nation's leading figures and should appeal to everyone to volunteer, should train these volunteers to aid the wounded on the battlefield and to care for them until they recover. On August 22, 1864, 12 nations signed an international treaty, commonly known as the Geneva Convention, agreeing to guarantee neutrality to sanitary or healthcare personnel to expedite supplies for their use and to adopt a special identifying emblem in virtually all instances a red cross on a field of white. Swiss physician Albert Schweitzer, renowned for humanitarian work in the Lamberne Hospital in Gabon, used the prestige of his Nobel Peace Prize to publicly expose those experts who declared radiation effects of above ground nuclear weapons testing to be negligible. In 1980, the American cardiologist Bernard Laun, the inventor of the defibrillator, joined with his Soviet colleague, Evgeny Chazov, to co-found the International Physicians for the Prevention of Nuclear War, citing the first principle of the medical profession, that doctors have an obligation to prevent what they cannot treat. This global federation of physician experts came together to explain the medical and scientific facts about nuclear war to policymakers and to the public, and to advocate for the elimination of nuclear weapons because of the profound health risks attendant to their use. For their work, IPPNW received the Nobel Prize in 1985. In caring for physicians, for individual patients, physicians have a two-fold opportunity. We diagnose and treat disease, or in the case of rehabilitation physicians, we optimize functional independence and prevent secondary conditions and complications. We can also identify and call out underlying societal issues that cause harm in the first place. That is, we have an obligation to prevent what we cannot treat. I would like to draw your attention to an extremely successful stab at advocacy and activism that hits very close to home. In fact, you know these people. Over 2,300 rehabilitation physicians wrote letters to the Center for Medicare Services opposing the proposed change that would essentially eliminate the role of the physiatrists in the inpatient rehabilitation facility. This language had proposed that any non-physician provider could perform the three face-to-face visits necessary for patient care in an IRF. Your colleagues, probably many of you, knew that this would definitely cause harm. You have seen what happens when non-physiatrists and non-physician and other healthcare providers with no specialized training attempt to care for physicians for patients with spinal cord injuries, traumatic brain injuries, chronic back pain, spasticity, amputations, and the consequences of prolonged hospitalizations. We saw how successful physiatrists were at treating patients who were recovering from COVID-19 and how disastrous it was for those patients to be sent to skilled nursing facilities where, in fact, physiatrists were deemed non-essential. By the power of your words and the strength of your convictions about what is best for your patients, you changed history, but we cannot let our guard down. CMS is never done trying to reduce costs. We will need you to continue to help speak up for our specialty and, in doing so, advocate for our patients. As successful rehabilitation physicians, we all work in partnership. Rehabilitation is the original team-based specialty. Each member of the multidisciplinary team has talents, special knowledge, and skills that we bring together to serve our patients. In rehabilitation, we've always done that. How often have you identified issues and then, together with your team, searched for solutions to a problem, whether medical or social, for a patient or their family, which was either dismissed or actively ignored in their prior healthcare setting? This is what we do. We advocate. So now think about those little things that maybe you jotted down or you put in your short-term memory. Think about those things that you identified about how you went out of your way for your patients, how you were frustrated with healthcare. You have already participated in advocacy in some way, but nobody told you how to do it. No curriculum helped you to become proficient or helped identify resources that might even make you more effective. That's what makes each of you special. You figured it out. I'm proposing that we create some standard for teaching and valuing advocacy. Physicians have a societal responsibility to be health advocates, and we must act to positively influence public health and policy. It is time for advocacy training to become more prominent in training future physicians, as the skills developed will enhance students' comprehension of how to deliver optimal patient care at the population level. And it is time that employers and payers value the energy put into advocacy or agency for individual patients, which helps keep them healthy. Physician advocacy extends beyond the provision of good clinical care and agency on behalf of individual patients to include collaborations with people and organizations that combat interpersonal, structural, and systemic inequities in our society. Advocacy is the bridge that links patient care with efforts to address social determinants of health and inequities that patients and communities face. Physicians are especially qualified to advocate on behalf of social change. The prestige and credibility that we command may serve as valuable resources in advocacy efforts. I want to thank you for your attention. I conclude by paraphrasing Menachem Mendelssohn Shearson. He was an American Orthodox Jewish rabbi, and he said, if you see something that needs to be repaired, that needs to be fixed, and you have an idea of how to repair it, then you have found a piece of the world just waiting for you to complete it. But if you only see what is wrong and what is ugly in the world, then it is you yourself that need repair. I look forward to repairing our world together. It's been an honor to be with you tonight, and I do look forward to seeing you all when our world changes. Thank you. Dr. Gittler or Dr. Sienka, there have a couple of questions come in. I don't know if we won't have time to take this, or... Sure. Yeah, Brian, we've got about 10 minutes, so go right ahead. Okay. First question was, many physicians often feel that politics and advocacy are endeavors that are not worth the effort, personal and professional cost. How would our academy convince the ACGME and the ABPMR that the time and dollars spent educating medical students and resident fellows are necessary? Well, I would respond by saying, if we really believe that reimbursement is going to be tied to population health, then we have to understand how to address those health issues that affect populations. And in order to do that, people need to be aware of them. So it becomes, I think, a backwards issue. I think that once we start getting reimbursed for it, money talks. But I do think that integrating population health into medical school education and residency education, where aspects of your training and the issues that confront your patients are reflected in the various aspects of population health, will be really important. So we have meaningful review of systems and meaningful social histories. But we'll look forward to everybody leaning on the bigger organizations as we roll that out. Great. There's another one that I think it's a combination of just some of your perspective on here in terms of what are the next steps, what has been done as far as developing a curriculum and how can we get involved to assist? Gosh, that's a great question. My understanding is that there is no requirement through the LCME, which is the body that accredits medical schools regarding advocacy. I think that the way to go about it is to reach out to public health colleagues in your universities and ask them and ask the curriculum coordinators, because all medical schools have them, how to start integrating a curriculum regarding social determinants of health and population health, even if it's just a lecture or two. But I also think that this is, you know, I'm going to say something maybe a bit provocative. This is certainly something that our EMRs should be helping with. You know, there should be a way that our frontline staff, as they're interfacing with patients at some point, start asking these really important questions about the communities that patients live in, about some of their social behaviors, about their environments, so that we're able to capture that information and then maybe tied to reimbursement because then we understand why there are issues related to different outcomes with patients who really want to get better. If they, maybe they can't get better because there is no store near them or there's no public transportation for them to get the right food for their diabetes or hypertension diagnoses. All right. And then a question coming, actually coming from a third year medical student is, what is the best way we can share good advocacy stories or good patient care stories from a staff perspective? I think this would be FIS form, but to promote that, but is there other areas that you see within the community, how people are sharing this? I really don't know other than chat sites. I think it's something we should celebrate, but right now, no, I don't know. I think that one of the really exciting opportunities for sharing though, is when you as medical students who really get to spend the most time with patients, start digging a little deeper. Nobody plans to grow up and get a diabetic foot ulcer and have an amputation, right? Six-year-olds don't dream of that. So understanding a little bit about why things happen the way they happen and finding out more about the people we serve, if we can start creating better stories about the people we're taking care of, I think that will evolve. But I accept the gauntlet that's been thrown down, how we're going to curate some of these stories and share them. A couple have come through from wanting to know your personal experience in here and just knowing that you are happy and cheery and carry that smile. How do you maintain your hope and not become cynical with such a big problems in our society? Okay, I won't talk about alcohol. You know, I think for me, I'm a bit Pollyanna and I'm a bit Don Quixote. It's not that I never get pissed off and it's not that I don't cry, but individuals just tell great stories. And every time I'm feeling a bit irritated and pissed off because there's one more note on my desk from one of my patient's mothers and I need to call and of course, I haven't seen the patient in a while and I call and she says, Dr. Gittler, I just wanted to thank you for taking care of James, you know, and I smile. And every time someone brings me tamales, I smile. You know, I think I'm a half glass, half full person. This world is so big and it's now really hard and really mean. And so more importantly, now than ever, taking those extra few moments to learn some stories, I think will help. It's a hard time. It's a really hard time. And just imagine if it's hard for us, how hard it must be for the people we care for. Great. And reading through this one, within community hospitals, are there departments that collect the information regarding outcomes and determinants of health? So that's a great question. And since I don't know every single community hospital, I don't know. But I do think that one of the issues with trying to collect social determinants and certain health outcomes, which people do because your Medicare dollars are contingent on that, you know, and some of that is central line associated bloodstream infections and UTIs and stuff. But people want to recap or recoup as much reimbursement as they can. And so if a hospital or a community hospital doesn't demonstrate that the individuals that they're caring for are more challenged in the community in ways that they currently don't capture, I think it's worth their effort because then they can go to the payers and say, see what we're doing. In many states, hospitals that care for a large number of persons with Medicaid get add-on payments in recognition for the complexity of care. Of course, it's never enough. But, you know, don't assume that people have thought about this and discarded it. A lot of times people don't connect the dots of looking at the communities and looking at patient outcomes and tying it together. And currently there is a mandate that hospitals all do community health needs assessment. So the community hospital should have a recent CHNA, a community health needs assessment. And you can look and see what the priorities are for your communities. Some of those are really hard to measure. And I'm happy to talk to people offline. But that's a start for the community hospital. It's their community health needs assessment. You know, are you measuring the right things in the community? And maybe could you be measuring more? Great. In addition to a lot of thank yous and great presentation, I think we have time for one last question. You mentioned the issue of reimbursement. With the financial pressures in today's healthcare system, do you see how payment models might be able to change to support advocacy? What can we do as physicians to support this? You know, I really think that we need to hold, as I said, both our employers and the payers feet to the fire. And we need to be better about documenting what we do. But every time I present prevent a readmission or a visit to the ER, you know, I should get paid for that. So, you know, documenting your discussions, specifically all the things you do for the patients, the amount of time you spend on hold trying to call in medications, you know, you should document that. But we have to figure out how we get a voice with the payers. Because they keep throwing population health at us. But they're not giving us the tools to measure those issues that affect our patients as relates to population health, which means that we would get added reimbursement. I mean, if you're working with a patient that's undomiciled, has food insecurity, is under educated, and, you know, has a problem with mental health, you should get an add on bonus for that, even if you're just treating the patient for back pain, right there, because two people with back pain aren't the same. And we have to keep speaking up for that. If you're going to hold population health over our heads, then we get to use population health for reimbursement. That's what I think. Michelle, on behalf of everybody that attended, I want to thank you, most of all for bringing back to the front and center, the very notion of caring for the people that we treat. Thank you very much. Thank you. And I look forward to seeing you guys at some point. Take care. Stay well. Good night.

advocacy

medical practice

physicians

patient advocacy

medical education

social determinants of health

activism

population health

public health