Recording this now. Thank you. All right. So, as a reminder, this activity is being recorded and will be made available on the Academy's online learning portal. This is the same platform that you used to access tonight's session. For the best attendee experience during this activity, we ask that you please mute your microphone when you're speaking and then you are invited and definitely encouraged to keep your camera on. To ask a question, please use the raise a hand feature and unmute yourself if you're called upon or you can use the chat feature to type your question. Please note that due to time, we may not be able to get everybody's questions fielded by the panel, but we will do our best. And if there is any other unanswered questions, we will definitely follow up post-meeting. Just a quick tutorial to go over those items I just mentioned. In the bottom left-hand corner is your unmute and start video. With the red X through it, that means you are either muted and or have the video off. You can simply click on it to turn those two functions on. In the middle, you have your participant and your chat. You can bring both of these boxes up. We'll show you who's exactly in the meeting itself. And the chat feature is where you can submit any questions that you may have. In the bottom right-hand corner, there's the reaction. This is where you can click on it to raise your hand. And then in the top right-hand corner, there is three little dots. Click on that. That will open up the menu to hide non-video participants. So that way, anybody that's not on video, you won't see their black box. All right. Having said that, I'm going to turn it over to Dr. Smith. So Dr. Smith, I am giving you remote control. So you should be ready. All right. Thank you, Brian. And welcome, everybody. We're very excited to have this presentation tonight to talk about life care planning and why this would be something you would even want to consider adding to your practice portfolio. And I have a esteemed panel here. Two experts are going to bring a lot of information. My background, just so you know, is that I'm a physical medicine rehab physician. I also do spinal cord injury, and I've been a certified life care planner and a certified physician life care planner, pretty heavily involved since about 2016. Let's see here. And just some disclosures. I am the vice president of the AAPMNR. So I kind of wear a Board of Governors hat on all things that we think about doing and how this pertains to some of our vision and what we're trying to accomplish. I'm also a senior vice president for clinical care of Madrina, which probably many of you know that. And then I also work with Dr. Gonzalez performing life care plans with physician life care planning and have been working with him since about 2016. So let's see here. My little button's not working now. So why don't we do next slide, Brian? There we go. So I want to just tell you a little bit of my story of how I got involved in life care planning. It was totally by accident as much of my career has been where you just land in a situation where there's a need and you do the best you can to meet it. And I did a lot of catastrophic trauma early in my career. I had really big head injury, spinal cord trauma cases. And I was asked frequently to assist with life care planning. And most of the time that I was asked, it was by someone who was a pretty much a non-clinician or not a physician doing a life care plan. And they would put it together and ask me to sign off on it because in most States and jurisdictions, you really have to have an MD involved in a life care plan if you're not a physician. And this was happening more and more. And I actually would read it. There's two ways to handle things like that. You can just sign it and say good, or you can actually study it. And I started really looking at it and recognize that there were lots of differences in terms of variation of quality and methodology. And I wasn't sure how well I could defend it if I got subpoenaed or if I got asked to depose. So it may be kind of nervous. And I decided at that point that if I was going to do this, I need to get good at it and understand what I'm doing and be well-equipped. Next slide, please. I love it. So I didn't know as an accidental life care planner, it would be something that's so intellectually challenging and satisfying. It is totally the most thrilling thing that I do with my brain. It's also the scariest thing I do with my brain and my mouth, because you've got to really be on top of things. But there's some pluses. I have never had to do a peer-to-peer or pre-authorization on a life care plan. And you put it out there, and you always get paid. And it's a straightforward deal, which I love. So I don't have to argue with anybody on the phone about what I've asked for. It's nice because nobody can say no to me. I can say what I think the patient needs. And it's up to the jury. So I love that. It really is a nice diversification. I've gone through enough different situations in PM&R over the decades where some things quit paying and some things pay more. And it's nice to have something that's fairly stable and that has a real economy based upon what you bill. I love the idea that as we do these life care plans, juries and lawyers and other people get to hear about what physiatry is. And it's one more way for us to promote PM&R. And I love that. But the other big thing is, it's a way for us to really be advocates for the system. So as a life care planner, we are never an advocate for an individual case. We are completely neutral. Whether you're hired by defense or the plaintiff, you should have the same report. It should be factually the same and the same approach. But that being said, when I saw the quality, what was happening and the fact that so many people depend upon this for really their whole survival and how we're going to do based upon the lawsuit or settlements by upping the bar and bringing excellence to this and really bringing science and sound methodology to it, it's a form of advocacy for the whole system. Next slide. So with that, I'm going to turn it over to someone I respect tremendously, who's taught me pretty much everything I know, which is Dr. Gonzalez, who I think is probably one of the most established, if not the most established, physiatrists doing life care planning. So Joe, take it from here. Thank you very much, Charlotte. And it's a real pleasure to be here with you this evening and to share some of my experience in life care planning. It certainly has been one of the best things that I've done as well. For the interest of full disclosure, I am the founder and the medical director of Physician Life Care Planning. That was founded in 2011. We currently have about 100 physiatrists that are working with us through Physician Life Care Planning. I'm also the founder and the chair of the American Academy of Physician Life Care Planners. And I'll talk a little bit about that in a minute, because I think it's a good home for physicians who want to be life care planners and continue their educational pursuits in the field. I am, as you see there, I am a physical medicine rehabilitation physician, and that is really the anchor of the knowledge base that I believe is required to be a really good life care planner. My pain medicine certification, my occupational medicine certification, those are also very complementary to what I do in PM&R, but also in life care planning. One of the things that you'll find out if you get into life care planning is that the population of individuals that we produce life care plans for really mirrors the type of patients that we see in a day-to-day physiatry practice. So it truly is, as I wrote in my article of 2013 in the Purple Journal, physiatry really is, or life care planning really is a natural domain of physiatry. And it's always been my hope and dream that we, as a medical specialty, can embrace life care planning and own it, call it our own, because there are other medical specialties who would like to do that. But what is highly recognized after, I think, the last, you know, 10, 15, 20 years with physiatry involvement, I think it's highly recognized that we are the premier medical specialty that is most suited to life care planning because of our education, training, and experience in taking care of those type of patients that require life care plans. So I'm very proud of my medical specialty. It has been a tremendous addition to my practice and my career and capping my career. I've been in practice now, well, I've been a PM&R member, this year will be 40 years. So I'm happy to cap my career with my activities in life care planning. And it's always been my mission to share what was so good to me with my colleagues, my fellow physiatrists. And that was one of the motivations for founding Physician Life Care Planning. Obviously, it was also a business endeavor, but truly what I wanted was for my physician colleagues to have the same benefits that I got from life care planning, which includes not only the gratification of producing a life care plan that can be used on a real subject who has real medical conditions that needs resources for their care. If I could do that successfully in a good, conscientious, and credible way, and there was success in the court, and the individual and their families got the resources to take care of the subject, there was nothing more gratifying to me than that, even though I did not render the actual care. So we've been very happy with that. I do think that it's important that we understand the environment, the community that we are going to practice in because it's been kind of a rough ride to get where we are today. I started life care planning in 1988. And at that time, I was asked to do what is now called a life care plan. I didn't know it was called a life care plan, but I was asked by an attorney, what does my client have? What will my client require to be taken care of properly? And what is it going to cost for them to be taken care of? Obviously, they were looking to build their damages model so they could help take care of their injured client. And so I started producing these reports. They apparently liked them, even though I was winging it at the time. But I eventually got really busy with this, and I discovered that there was actually a discipline of life care planning. And I started going to the conferences that were sponsored by the founder, Paul Deutsch, who was a PhD who, in the early 80s, actually drafted the first life care plans, and they were first utilized in the courts in those days. And he had a really good educational program. But what was really obvious to me is that the majority of the attendees were not physicians. They were rehab clinicians that included therapists of a wide variety, counselors, psychologists, et cetera, with only a few physiatrists here and there. And they were mainly used to help give them legitimacy to the work that they did. As Charlotte said, they would often produce these life care plans, ask a qualified doctor to sign it, oftentimes very cursory. They would get what I was discovering back in those days, that they were paying the doctors a very token fee, and they were getting a very handsome fee for their work. And they had a very nice lifestyle compared to many of the doctors that were signing off. Because being an expert does put you in a category that's fairly elite, but with that comes a great deal of responsibility. If you go into life care plan, do appreciate that you are becoming an expert witness. And you will be held to certain standards and certain rules of law, and you must understand that environment. We can go to the next slide, please. So this is just, this is not all-inclusive, but it's just some of the highlights that will give you some sense of the environment and community in which you will work if you choose the life care plan. But in the early days, and I've been in health care for about 50 years now. I started out as a very young man in 1970 in the field of nursing. I was an LVN, then I became an RN, and then I became a PA in 1977. And in 1980, I decided to go to medical school. But I do remember in my nursing days and PA days, when there were legal cases, attorneys would come to the doctors and they would ask them, you know, what's wrong, what do you think's wrong with my client, and what are they going to need, what's it going to cost? That's those similar questions. And the doctor would give answers off the cuff. And it was very much accepted as an opinion because the doctor said so. And in those days, it was adequate and it passed and the courts would allow it. But by the 1980s, when the life care plans started getting into the courts, that there was a need to prove the damages to a much higher standard. And that's in fact what a life care plan does. It proves the damages, the residual or relevant diagnostic conditions, disabilities, and so forth. And it takes a qualified medical doctor to do that. But Dr. Paul Deutsch in the early 80s was astute enough to understand that there was a need for this. And they initially presented it as a case management tool. I think they were just shy to call it what it really was, which is a damages valuation in the legal system or medical legal system. But eventually, and I believe we were the first ones that were bold enough to call it what it was, which is a damages valuation tool by qualified professionals. But Dr. Deutsch deserves a lot of credit. He's often referred to as the father of life care planning. And historically, the individuals that produce life care plans, as I said, were nurses, vocational specialists. There were a few doctors. And in 2011, when the survey was conducted, what we discovered was that less than 3% of all life care planners were in fact physicians. And we didn't get the breakdown, but I suspect the majority were even at that time physiatrists. In 1996, the International Commission of Health Care Certification developed their program to get a certification in life care planning. And it's important to understand that while there are certifications out there, it is not a requirement to have one. However, those of us that choose to get certified to the greatest degree possible, I think demonstrates that we are committed to the discipline. It also takes the question off the table when you're being deposed because one of the first things the attorney will ask you, the opposing attorney will ask you, well, doctor, are you a certified life care planner? And if your answer is no, they will want to turn that into a negative in an attempt to discredit you. So I highly recommend that you pursue certification. There is a CLCP that is offered by the International Commission on Health Care Certification. And then through the American Academy of Physician Life Care Planners, which I founded in 2013, there is the, what I believe is a more advanced certification and only limited to physicians. And it's the Certified Physician Life Care Planning Certificate. There are other certifications out there that are mainly, actually, they're only limited to nurses. The Certified Nurse Life Care Planners Certificate is out there, but we don't qualify for that. So I do urge you to go with the CLCP and then later on pursue the CPLCP. I think it will serve you well. Next slide, please. The American Academy of Physician Life Care Planners, when I founded this in 2013, I found that there was a lot of resistance by the non-physicians of physicians becoming life care planners. They liked us in our place, which was to review and co-sign, but they didn't really like us to be life care planners. And I think it was all about a turf war. But in about 2010, I presented to IR, the organization that provided education, a methodology for meaningful collaboration between a qualified physician, such as a physiatrist, and a non-physician, because I was noticing that the courts were starting to pick up on the fact that many of these individuals just didn't have the professional capacity to be given medical opinions, as they had been doing for many, many years. And they were starting to get challenged and stricken from the case, which ultimately hurts the subject of the life care plan. So I proposed a methodology for that meaningful collaboration, and it was completely rejected. They basically were offended that I would suggest that they needed physician input to establish that strong medical foundation, which is really necessary in a life care plan. So it was at that time that I felt that an organization like this was necessary, and it was necessary in an effort to elevate and support the discipline of life care planning through our participation. And mainly it was physiatrists, although this organization is open to all board-certified physicians, as well as other clinicians who practice in the field of life care planning. We have annual conferences here in San Antonio. This year will be our ninth conference. They are extremely well-operated and very informative, and those people that attend give us high reviews because the content is both legal and medical and methodological for life care planning. So people find it to be very targeted, very useful in the life care planning practices. So we look forward to this year's, which is coming up in April, April the 24th, as a matter of fact, here in San Antonio. Next slide, please. In terms of the membership organizations that exist out there, there are basically three. I have four listed here, but I believe the last two have kind of combined or one has switched the name to the other. It's hard to keep track of it. But as I stated, the American Academy of Physician Life Care Planners is a place to join and continue your education. And you can even write if you choose. You can lecture. You can attend conferences and keep up with all the relevant issues of life care planning. And the other one is through the International Association of Rehab Professionals. They have various rehab sections, but one of them is life care planning. And they put on very good conferences as well. They are, however, more geared to the non-physician, in my opinion, although many of these speakers are physicians as well. So they're of a very high quality as well. The Nurse Life Care Planner, I've never had any interaction with that organization, so I can't tell you anything about their conferences or their educational endeavors. But these are organizations you might look to if for no other reason to familiarize yourself with the environment in the community in which you will be practicing. And I believe that's what I've got for this evening. All right. So we'll turn it over to David, and he's got some great information to share with us as well. Thanks, Dr. Smith, and thanks, Dr. Gonzalez. So good evening, everyone. I'm David Hausstein, and I, too, am a Certified Life Care Planner and Certified Physician Life Care Planner. My disclosures. My day job, I serve as the Associate Dean at the University of Missouri School of Medicine. And as a professor of PM&R, the views I share today are my own and do not reflect those of the university. I also own two consulting companies, PM Consulting and Expert Medical Consulting. And I'll tell you a little bit about my pathway into life care planning. So my first job out of residency was with the Louisville VA Medical Center. And as many physiatrists work in a VA setting are familiar with it, I worked across rehabilitation clinics, spinal cord injury, traumatic brain injury, amputees, special equipment, wound clinics, ALS clinics. And then I also oversaw the major medical equipment program for the VA, for the Louisville VA, and the home modification program. So those kind of laid a foundation for my background in taking care of not just the medical conditions of those individuals with catastrophic injuries or illnesses, but also the equipment side and home modification side of their experience. In 2017, I think it was about 2017, I learned about life care planning. I pursued an MBA because I love all things Excel and accounting and finance. And in 2018, I started the Certified Life Care Planner training program. And it was in 2019 that I first started performing medical cost projections and life care plans. If I were to maybe just start with a definition, and then I'll walk you through a sample life care plan. The definitions adopted by the American Academy of Physician Life Care Planners is life care planning is a process of applying methodological analysis to formulate diagnostic conclusions and opinions regarding physical and or mental impairment and disability for the purpose of determining care requirements for individuals with permanent or chronic medical conditions. And the reports that we produce, life care plans, these are comprehensive documents that objectively identify the residual medical conditions and ongoing care requirements of ill or injured individuals. And they quantify the ongoing costs of supplying these individuals with requisite medically related goods and services throughout their definitions of throughout their durations of care. So those are long definitions, but next I'll take you through and we'll make this more simple. So the three basic questions that a person wants to answer with a life care plan, number one is what is a subject's condition? Number two, what medically related goods and services does a subject's condition require? And number three, how much will those goods and services cost over time? So as an example, maybe to keep things relatively simple, let's say that our subject's condition, maybe you're approached about a 56 year old male who was involved in a motor vehicle accident and requires a bologna amputation. You also know that that person has phantom pain, depression, and reduced mobility. So those would be like the conditions that you'd be considering. And then when you think about what goods and services they may be required, you might think, oh, this person is going to need prostheses. They're going to need physical therapy. They're going to need maybe medication and mental health therapies. They might need medications for phantom limb pain. So those are the type items that you would consider there. And how much will those goods and services cost over time? Well, you could calculate the number of residual years that you would think that that person would live and then calculate those costs over time. So that kind of puts things simplified. And I will say that many of my slides come from all of the work that Dr. Gonzalez and the American Academy of Physician Life Care Planners have put together. So a lot of this is built upon their years of wisdom and publications. So sample components of a life care plan. So this is just an overview of what you might see when you view a life care plan. There may be an overview or an executive summary. Frequently, there's a medical record review. You may have the chance to interview and examine the individual. You will frequently calculate the life expectancy and the duration of care of those conditions. The diagnostic conditions are those impairments that that individual has. You'll also calculate or list out the future medical requirements that would be needed. Those would be things like, oh, the physician care, therapy care, medications, other things. Then you may have cost analysis or worksheets. And then you can have references or information and materials considered or other sections as appropriate. So maybe to think through our case of that person who had an amputation, you may think about physician services as the first thing that you would need. Maybe PM&R services. Maybe they would need an orthopedist at some point for arthritis occurring on the contralateral limb or the ipsilateral limb. Maybe there's going to need to be diagnostic testing, like, oh, depending on the condition, maybe they need CTs or MRIs or EMGs or other things. They might need medications like gabapentin or pregabalin or other medications. There may be lab work associated with starting those medications or monitoring for side effects. Therapy services, whether physical, occupational, speech, also psychological services. There's durable medical equipment needs and or adaptive vehicle needs that a person may have. Nursing and attendant care, if they are cared for at home versus in a skilled nursing facility setting. And finally, acute care services. So if you predict any surgeries are more likely than not in their future, you can also list those or hospitalizations maybe for complications. One thing that physiatrists getting into life care planning may wonder about is where do you obtain these costs that are associated with these different recommendations? Well, sometimes a treating physician's office has already produced a projected invoice for what that planned procedure will cost. Or maybe the person already has pharmacy bills for what that pregabalin costs or their occupational and physical therapy costs. So that's one source. Another source is usual customary and reasonable charges. So there are national databases that you can subscribe to that can give you the cost breakdown for different CPT codes or DRG codes across the nation. So you can find out what a 99213 would cost in Springfield, Missouri or in Chicago or other areas. You also may find yourself doing research to figure out what the costs are. That may be online research that might be calling adaptive van places or durable medical equipment places in that person's town to find out what the actual local costs are. And then there's other resources that you may engage in depending on what the questions are. And that's doing some of this research is kind of one of the fun things about being a life care planner. So putting it all together. So frequently you'll see some document like this within a life care plan. And this is kudos to the Physician's Guide to Life Care Planning produced by the AAPLCP. But in our case of an amputee, maybe you think that this person is going to need physical medicine and rehabilitation physician visits starting at age 52. Maybe you think they're going to need it three times a year for 26 years, the duration of their lifetime. And maybe that 99213 you find costs $170. Well, when you multiply that all out, you'll come out with $13,000 for PM&R costs. But then maybe you think, oh, this person's developing knee arthritis or something else. And you think, oh, they need to see a surgeon or an orthopedist. Maybe 0.2 frequency would be once every five years. So when you multiply that frequency by the duration, by the unit cost, you'd come up with a total cost. So maybe you're thinking, oh, total physician services might be $14,000 for this individual. But then frequently you'll say, oh, but I want to add in medications to account for this person's treatment of phantom pain. Or I want to account for mental health care or a course of physical therapy as they age. Or maybe with the prosthetics, maybe they're at a K3 level now or a K2 level. But you think, well, in my experience, I don't find that maybe that's appropriate for age 52. But then maybe by age 65, maybe in your experience, they would be more appropriate for a K1 mobility prosthetic device. So those are all things you'll work through. And they're quite detailed. So if you love Excel, and you love being meticulous, and you like financials and things, life care planning is a lot of fun. So this kind of brings me full circle to the schematic of a life care plan produced by the AAPLCP. So maybe to start at the bottom, this is kind of like a house that you've cut in half. And you're looking at what are those things that are on the foundation? What are those things on the first floor? And then you build the second floor and the third floor on top of that. Well, the foundation of a life care plan is your credibility and your transparency. So your experience as a PM&R doc and with your ethics forms some of that baseline material for producing a life care plan. The facts are frequently the review of the medical records, the interview, and the examination. These are kind of your objective findings from the case. On top of that is your opinions. The opinion section answers the first two questions of the life care plan. What is a subject's condition? And what medically related goods and services does that subject's condition require? That also plays into those disabilities or impairments that the individual has, the probable duration of care, and those future medical requirements that you're projecting out. The conclusion is really what answers the third question of life care planning. How much will those goods and services cost over time? This is your cost analysis and coming up with that definitive value or number that you're looking for for the case. And you'll see kind of the outside walls here are linearity and continuity. By building upon these things, you really establish a linear pattern of thought for the attorneys or anyone else who will be reading your report. So sample resources, if this kind of whets your appetite for our life care planning, some common resources in this lane, a Physician's Guide to Life Care Planning produced by the AAPLCP that Dr. Gonzalez mentioned earlier. Roger Weed has a book, Life Care Planning and Case Management Across the Lifespan. It's currently in its fifth edition and is a great resource. And then the AARP that Dr. Gonzalez mentioned earlier has a journal of life care planning that's also a good resource. So those are kind of some life care planning resources, some of them out there. But I find that as I'm doing a life care plan, while I'm in these materials, I'm also frequently in Dynamed and UpToDate and the primary medical literature trying to find out what those clinical practice guidelines or best practices are for caring for each of the conditions. So in summary, as physiatrists, we play a key role in bringing medical expertise, rehabilitation knowledge, and a patient-centered approach to this process. Dr. Gonzalez, I believe your article, you said it was 2013 or 2014. And this phrase that you used, I feel like is kind of the coined phrase for PM&R docs in life care planning. But life care planning is a natural domain for physiatrists. Those patients that I've been seeing for 10 hours today, those are the same people that I'm producing life care plan type reports for. So it really functions kind of seamlessly. Maybe to clarify, life care planning, you don't have a physician-patient relationship, but that knowledge of what you're doing on a day-to-day basis really comes into play in life care planning. And then the last thing is just to remind you that those life care plans assist in answering the three basic questions. What is the subject's condition? What medically related goods and services does that subject's condition require? And how much will those goods and services cost over time? So with that, that concludes kind of the formal part of our presentation. I'll hand it back to Dr. Smith. Sure. And we're going to open it up if people have questions, feel free to put that in. I also kind of just want to tee up something, this natural domain thing. One of the reasons physiatry is good at this is we're used to coordinating care and looking at people holistically. And there aren't a lot of specialties that do that. Orthopedists may look at the orthopedic issues, but they don't look at the neurology. And that's one of the reasons I think our specialty is so well-suited to this. The other thing that's really, I think, a challenge, I'd love to hear Joe and David, what you guys think. One of the biggest challenges in life care planning is we're so used in the healthcare system to what's your chief complaint today? You know, what are we going to do today? What's our plan? It's very hard to get doctors to opine. What is this person going to need over the years? What are they going to need in 10 years and 20 years and that type of thing. And I think that's something, again, that if we are well-trained physiatrists, we know that information and it brings a lot to the table. What other things would you say, Joe and David, you know, that you think were some of the biggest challenges as you took this on or things that were different than just medical practice? Yeah, I think that you're right, that what people often struggle with is projecting over time how to account for those phase changes that will occur. And I think as physiatrists, we understand pathology. So an example, we understand when a joint has been damaged or an intervertebral disc has been damaged. We understand how these things change over time, either because of age or continued wear and tear, but a damaged joint or disc is going to degenerate at a greater rate. So physiatrists understand that we tend to see people for a long period of time and get to actually experience those changes and deal with them. So we can put that to practice. The other thing is we see people at different ages, at different times of their life and actually see radiographically how these things progress. So I think that struggle is one that continues to challenge us all, but I don't think there's anyone better suited than a physiatrist. But you do have to give some meaningful consideration to how these people will change over time, whether it's a spinal cord individual, an orthopedic case, or an amputee with wear and tear issues that happen over time as they age. And we have to do our very best to account for that. And in the end, what we are offering is our best opinion of what things will be. And the legal standard for that is to a reasonable degree of medical probability, which means we're given an opinion that is more likely than not to be accurate. So it's an opinion and as experts, we are opinion experts, unlike a treatment doctor who testifies, he's a fact expert. Exactly. Did you have anything to add to that, David? No, I think that was a great summary. Something maybe that I hear from physiatrists and I was this way, I think of myself as a super nice guy and I didn't know if I could enter that medical legal world very well. And yet with life care planning, you're really just standing behind your report. So it's not like you have to be adversarial or anything. You can just say, this is my opinion based upon my education, training, and experience that these are within a reasonable degree of medical probability, what a person will need for the rest of their days. So. Exactly. That doesn't mean they're going to be nice still, they still may come after you. And you got to have a pretty thick skin, because even if you do a perfect job, you know, what you recognize in the legal system is, you know, their goal is basically take shots at you, you know, to basically destroy your credibility or unnerve you so that you don't have as good of a witness. And also, I think, you know, to get you to second guess yourself. But you know, as long as you can defend your opinion, you know, usually anything we do is going to have more credibility than other people that are doing this, because again, of our credentials, and because of the types of patients we manage over time. So it's just really important to be able to stand behind your report. You know, a couple of other things that come to mind, Charlotte, as things that are challenging, particularly when you're starting out, is to get in that right mindset. One of the things that we must do as life care planners, we have to undo what so many of the health care payers have trained us to do, and that is provide care that is quote, approved, or allowed. In life care planning, our obligation is to project optimal care, which means if the need is there, we should do our best to fulfill it. When we when we project the future medical requirements. The thing that I often see with our new doctors is that when they look at the value at the end of their life care plan, oftentimes they kind of get spooked. Because it's often particularly in a catastrophic case, it's a very high number. And I always remind them, look, it's not our job to concern ourselves about what things cost. Our obligation is to project what is necessary, and let the value fall where it may. You know, as long as you're using sound methodology, and your resources are valid, and you can stand behind them, that number will support itself. So don't worry about the number, just do your very best to project need that reflects optimal care. And I think that's something that requires people getting over because we're, we're a little sensitive to the cost and money and that sort of thing. Absolutely. And it is shocking, people will look at the number and they go, do you really think they're going to need this many physical therapy visits? And it's like, let's talk about that, you know, let's talk about what does this look like this year? What does this look like next year? What does this look like in 10 years? What would a typical patient need during those times? What kind of problems are going to have? And then you can backtrack it and make it typical to what you would see as you're following a patient over time. And again, if you can explain that in a way that the other side understands and makes sense, and is what you do in your practice, again, that's pretty compelling. Well, again, one of the one of the things that will help you when you're developing or projecting the need is to follow the methodology that calls for fulfillment of four distinct clinical objectives. So as you're thinking about what the individual needs in total for all their different conditions, we have to fulfill four clinical conditions. And I'll briefly state them. The first one is to provide the goods and services that will eliminate or diminish pain and suffering, whether it's physical or psychological. The second is to provide the goods and services that get them to the highest level of function and sustains them for as long as possible, i.e. PT, OT, etc. The third is to provide the goods and services that will prevent the complications that they're uniquely susceptible to because of those conditions, i.e. pressure relief, UTI prevention, etc. And the last one is to provide the goods and services that will provide them and their family the best quality of life possible given their circumstance. Now, with that said, if you enter an item of need, that item of need should go to the fulfillment of those four clinical objectives. And that is your shield. As long as you can say yes, you know, a non-steroidal anti-inflammatory agent will go towards the relief of pain and suffering, then you're solid. So use that as your shield because that really should be your guide for projecting the future medical requirements. A preventative, proactive model. So we are anticipating what lifespan will be and what their clinical course will be with optimal care, not based upon every single complication that can happen, but based upon with excellent care following treatment guidelines that are appropriate or standards that you 've used in your practice, what does that person's future look like? And I think that, you know, falls into this whole question about life expectancy and what future needs will look like. So, you know, when I go through those four clinical objectives, say in front of a jury, at the end of it, I like to say, this is exactly what all doctors should be doing for all their patients. It's no different. It really isn't. That's so true. We have a couple of questions. I'm sorry. It really, it really sticks with a jury when you, when you phrase it that way, because they understand and appreciate that we as doctors should be doing all those things for our patients. Yes, absolutely. Yeah, it's kind of funny. I've had juries where I explain things and you're teaching, which of course we do all the time. People from other states call and try and get appointments for my clinic. It's like, how do I find a doctor that like spends time and talks and listens and teaches like you do? And it's like, well, let's just get you in the right physiatrist, you know, it's our specialty. Okay, we do have some questions. Dr. Park was asking with the advent of AI, what is your opinion on AI models doing life care planning, and whether or not they will replace life care planners? Yeah, right now, that's all the buzz. I joined a lot of webinars, we, a lot of our folks attend a lot of legal conferences. And that's the big buzz. And it's also in medicine for certain tasks. It does not replace the expert. So if you use AI, it's my understanding that we are to disclose it. And ultimately, you have responsibility for that content. But at the end of the day, you still need a human expert to support and substantiate the contents of your life care plan. So I don't I don't think they'll replace it should make it easier for us, perhaps, but it won't replace this, in my opinion. What do you think, David? Well, I think it's a fascinating topic, but I have no opinion. Be here to see what the years may bring. Yeah. And I will say, Charlotte, with that, I'll say that at our conference this April next month, here in San Antonio, we will have an individual that's going to talk on that very subject. So I'm, I'm excited to hear him talk about it. Yeah, I can't imagine an AI or a robot doing a deposition. And the given critical thinking is, you know, one of the things that's most important about life care planning is you really do have to critically think and respond quickly. You know, when people come at you with things that come up with answers, you know, without taking 10 minutes off, you've got to respond quickly and succinctly. I just have a hard time believing that our AI systems could do that. Theory's pretty good. But I do think it'd be easier to replace an attorney that it would be. That's funny. That's funny. Well, they might be more polite. That'll never happen. Well, they might be more polite than some of the ones we deal with. No, not really. And then Matt McLaughlin had a question. He's asking for David, are you doing this work apart and away from all your work in the health system which you practice? I assume you never utilize your health systems resources for this either. Correct. So that is correct, Matt. So at least in my model, my, my health system employs me, you know, 40 to 50 hours or whatever is required for the week. And life care planning is on top of that. So it eats away your nights and weekends. So at least for my model, but there might be others who have carved out time of their practice and or integrate with their practice so that the life care plan plans flow through their practice administrator or something like that. So there might be more Yeah, my, my involvement has changed depending on what I'm doing and busy. And there have been some years where I don't do very much. And then some years where I've done more, you know, I try to average it to about 20% of my work week, in terms of seeing clients and you know, doing the actual part of it. And then like David said, I tend to do nights and weekends a lot for the actual work. But I think it is helpful. You know, certainly if you have a clinical practice, you know, you can do a lot of I think it is helpful. You know, certainly if you have a clinical practice to some extent, you know, we need to be like Dr. Gonzalez, he can do whatever he wants, and they're going to respect him. But, you know, you will get that question a lot, you know, like, you know, are you actually a practicing doctor? Are you just a hired gun, you know, and so you will get that question. And that kind of falls into this next one that Andrew Tom had, I think is a fantastic question, Andrew, about whether or not it's more suited for longer practicing physicians, and how would a newer attending be able to pave away? I think if you haven't managed patients for a number of years, and across settings, it is harder, no question. Because you know, it's hard to project out something, you know, 30 years. And I think, again, we're better equipped than people that are not physicians, but you have to decide each of us what we're comfortable with, like there are going to be sometimes complex cases that are burns or, you know, pediatric complexity and other things, and you have to decide what you're comfortable with and what you can do. But I don't know, what do you guys think about that, David and Joe? Go ahead, David. Well, I Oh, yeah, go ahead. Go ahead. So I think one unique thing about PM&R, and we've kind of talked about this is when you go through to get your certification for life care planning, you might be studying alongside anesthesiologists or ER docs or other people who've never or don't have that lifelong treatment of burn victims or spinal cord injury or traumatic brain injury. So you actually from your education and training, you come in with a lot of knowledge into this space. So I, I also think that a young physician who's just out and practicing might have certain advantages, like they might be up to date on the latest clinical practice guidelines or what the what the medical literature says. So, so while there is some probably maturity that happened, there is maturity that happens over the course of your career. I don't know that I would discourage you as a younger doc, and might just say, mentorship might be really important. And going slowly, you know, maybe just doing, you know, one case at a time, you know, in a month and getting better and better and more proficient. I think, Joe, you can opine on this, I think a lot of this also boils down to your personality. You know, how comfortable you feel with situations like, you know, testifying, when you know that there's going to be a lot of intense discussion and debate, and you have to respond quickly. And some people love that, you know, some people, it's like, oh, heck, no, I don't want to do that ever. You see, you have to decide if you really have the personality, I have to go into character. So I just pretend to be a famous doctor that's a forensic expert who's doing a drama, and then I don't get nervous, I can't get my heart rate up. And then the knowledge comes and it takes away the fear. But I mean, you know, the first time I ever did this, I had a brain injury case that was a kid that had one hit on the field and ended up cleaning a persistent vegetative state for like about 25 years. And it was a lawsuit against the helmet company. And so I'm in a room and there's like 30 attorneys from all over the world. And I'm like the one being asked questions by all 30 of these. And, you know, it was like trial by fire. And you know, my theory on this is, you know, we have a lot of great tools as physiatrists, and we have a lot of resources, and we think quickly. And Dr. Grayboy's always told me just try things, you know, and so my theory is like, you know, I try to just do the best I can and not make things worse. And, and hope that you get better at it over time. And you do, you know, I've made a lot of mistakes, you know, one thing that is challenging that you need to think about is, in some ways, you're only as good as your last deposition or testimony, you know, and there are some fatal errors and things you can do that, you know, you have to learn. And that's where going to these meetings, and learning, you know, basically some of the just, just the hedges of protection that you can do is important, because you wouldn't know it, you know, unless you're a psychic, you would not know these things unless you're taught. And we have a question from Dr. Fareed about is within a reasonable degree of medical certainty, a standard that is used for items included in the plan, for example, a hot tub might enhance a patient's psychological function and make them feel good, but wouldn't generally be medically necessary. I'll let you go that Joe. Yeah. If you have a strong medical foundation that would support that either, because of the physical or even the emotional condition, it would qualify as a reasonable future medical requirement. However, there are some things that aren't worth fighting for, if there are small items that are going to just put you under so much scrutiny and take a lot of time, and, you know, I don't put those in there. But if you feel strongly about it, if there's a history of being used, and it's beneficial, that also helps support its inclusion. But if it's just a thought in your mind, hey, this might help. And you don't have strong evidence that it truly has helped in the past, I probably wouldn't go there because it's just not worth the fight. There's probably bigger items that are more important to include in your life care plan that will be beneficial to the subject. So that's kind of the approach that I use. But many of our doctors do include things like hot tubs and spas and things like that. But they have a therapeutic purpose that fulfills the clinical objectives. Did you want to add anything to that, David? No. Yeah, I agree. I mean, I think again, this is the, you know, proactive preventative model. And you know, if something like a gym membership or something like you know, a hot tub helps, and it can prevent the secondary complications, you know, in my opinion, it's justifiable that meets those four criteria, one of the four. But you know, everybody has different levels. I know there's some things juries don't like, and I have attorneys that please don't put in any cannabis gummies. Okay, I want that. Juries don't like that. And you know, things like that. And you know, as you get to work with your attorneys, and you know, they'll also give you some guidance, because a lot of this depends on where this is going to be tried. And, you know, what the jury's gonna be like and the jurisdiction and that type of thing. And, you know, so a lot of this is really, you know, working with your plaintiff or the client, and then working with the legal team, they'll give you some guidance, which is helpful. It's good. Dr. Wilson makes a very good point that the vast majority of professionals performing life care plans are not physicians, but nurses, vocational rehab, and that we're the experts. And you're absolutely right, Dr. Wilson. What was the statistic, Joe, you had said, what percentage of life care plans do you think are done by physicians? I'm curious. Well, in 2011, the survey showed that it was 3% or less. The latest number that I've seen is about 10%. So we're still very low. And I agree with what David said that even I wouldn't discourage any doctor who is a board certified physiatrist from entering into life care plan, regardless of their years of experience, because exactly what Dr. Wilson said, is the vast majority of life care planners out there, number one, don't have clinical practices. They're not physicians, they've not been trained at all the things that your residency and your internship and your experience has trained us in as physiatrists. So even though you may not have a whole lot of years of experience, you're way ahead of 90% of the life care planners out there. And you have the ability to study, read and learn on topics because they'll make intuitive sense to you because you've already studied that somewhere in your medical career. So I think it's, it's open to all physiatrists, as long as what you said is there, the right mindset, the right demeanor, a little bit thick skin, and the diligence to be thorough and effective as a life care planner, because being a good doctor, or a great doctor isn't necessarily equal to being a good or a great expert. And you have to work at being a good expert or a great expert, that takes a little bit of finesse, because it is a gamesmanship that we're not used to playing in medicine. Yeah, very good. Well, we are very close to time, we may have time for one more question if anybody has any. And if not, just any closing comments, David or Joe? I would just say if you're interested, there's plenty of organizations that are happy to, I think help facilitate your entry into this. Certainly, those of us at PLCP are happy to talk to you and show you how to get into it. But even if not through that avenue, I'm very accessible, always happy to talk to you and give you my best advice on how to get into it and how to pursue your career. So I'm sure David and Charlotte probably feel the same way that they can be approached and on an individual basis. We're happy to help. We're all physiatrists and I'm happy that we're making some progress into, you know, embracing the life care plan and discipline. That's really an important thing. I agree very much. David? Yeah, I would just say, oh, I feel like physiatrists might be a little bit risk averse people, or at least I felt that way. And so I would encourage you, give it a try. Yeah, feel free to reach out to any of us or, or the organizations and maybe just experiment and see if this is a component of your professional practice that you would enjoy. It's great for patients because they're getting sound medical advice. It's good for the system because they're getting honest information. And it's really good for our specialty because it raises awareness. And ultimately, the other thing, when you look at burnout, and you look at just the challenges that we're having in healthcare today, it is so satisfying to be compensated appropriately for your work. And to feel like, you know, you're an expert that people listen to, because you know, when you get all these peer to peers and these authorizations, and you have people telling you no, and you're in this just terrible situation, because you know what needs to happen, and you can't do it. This is very satisfying, you know, and I just I would encourage everybody to that's interested to learn more and to reach out to us. And we really appreciate you signing on tonight and hope that you guys have a great rest of your evening and either maybe more information coming through the academy in this area. If people are interested, you know, keep your finger on the pulse of what's happening with the AAP Menar because we recognize this is an area that could really have great impact and everybody involved and anticipate there will be more opportunities for education and to help people that want to go down this pathway. So thank you very much and good night. Thanks, everybody. And thank you, David and Charlotte. Thank you. Good night.

life care planning

physiatrists

chronic medical conditions

American Academy of Physician Life Care Planners

future care needs

cost analysis

rehabilitation medicine

certifications

patient care