Hello, good afternoon everyone. We're going to start off and we're going to talk a little bit about We're going to talk about Why is it important to have academics and private practice groups work together to move our field forward? And so I'm going to start off with some brief introductions There we go, okay. We have no disclosures for this, financial disclosures for this talk. There's no conflict, sadly, yes. Although we are willing to hear authors. Yes, absolutely. It was on there we go. Okay. We're gonna start off. Let me see if it's working or not. That's not working It's on but it's not working. I turn it off or not. No, it was they did it Okay, so we're gonna go over the panelists. We have a great Well accomplished panel here. Just wanted to go over them We'll start off with dr. Gittler Many of you already know her. She's one of the past presidents of AAP Menard. She started working at Schwab. Oh, thank you so much She started working at Schwab Rehabilitation Hospital in August of She took oversight over the residency program She later went on to become the spinal cord injury program or the director for the spinal cord injury program She has numerous accolades and numerous leadership positions This includes she was at Schwab. She was a PM in our department chair She was a medical director of Schwab and over the last five years and this is a growing trend that is happening in the field She is now the CMO of post-acute care for Sinai Health Systems in Illinois and DIO of Schwab and as I mentioned before she's a past president of a PM and R And I'm gonna give one fun fact about her. She gives the one of the best lectures on Gang graffiti and she could decipher the differences between gangs. It was one of the first lectures I remember getting or one of the lectures. I remember getting and it's Definitely burned in my brain so We have dr. Jason Gruss, he's the chief medical officer advanced rehabilitation care. He's had Numerous white papers done. One of the white papers was on kovat and the impact it had on the continuum of care for PM and R He's also he was part of the founding a PM and R skilled nursing facility think tank which is in 2020 and He's actually the only physiatrist on the Illinois Medical Directors Association board, which is important And then 2024 the a PM and R innovator and influencer honoree as well Then we have dr. Michael Massey, he's a BMS board certified in PM and R pain medicine and brain injury He's done extensive research Specifically in pain medicine. He is a founding medical director of Centra care neuroscientist pain center and Served as a medical director for the Tampa Bay orthopedic surgery group He's currently the founder and CEO of Gulf Coast pain care and serves on the IAR P for the Florida chapter one fun fact about Mike is that he is colorblind Okay, let's go back to Jason for his fun fact Jason is a lifelong Michigan Wolverine fan He's got he's gone to two two games this year One was a national championship game and the other one was a game where his team lost to the fighting a lion I my team so ILL We have dr. Posse dr. Posse is an assistant professor at Tufts former faculty member with a NAS He is in private practice as well at agility orthopedics He's been published in a pair of reviews and regularly lectures at national meetings Also been a peer reviewer for the PM and our journal. He's also a passport examiner for a BPM and R one fun fact about dr. Kapasi is that he used to have a red mini coupe and He really loved that red mini Cooper and was actually his best friend until or actually before he met his wife. So Me I finished my residency at Northwestern Marion joy in 2010. I founded Advanced Rehabilitation Care It's a national multi-specialty group And I was elected YPS president for the second largest Medical organization in the country called a P and currently I'm the CEO of ARC Also something innovative that we're working on and that we've done is we've created a PM and R led To really put PM and R at the forefront of transitions of care and the super innovative Concept called the super sniff again. The goal of that is to decrease readmissions and reduce costs of care My fun fact is that I co-founded a production company called show B and we produced a musical life of pie on Broadway and We did an upcoming is the Kobe Bryant documentary So today we're going to talk about something interesting we're gonna talk about couples Here are some couples that you guys might know of Romeo and Juliet. They've thus paro and What is something common that all these couples have? It's forbidden love. There are two entities that really do belong with one another But they're doomed to be kept apart due to very specific circumstances So we're going to talk about that today and then we're going to talk about With one another but they're doomed to be kept apart due to various external factors including as we've listed there How about we add one more to that list? one more couple that is doomed to be kept apart or has been kept apart and That is academics and private practice for years academics and private practice have operated in silos But as we're going to discuss there's many advantages of them Ultimately winding up together and living happily ever after Here are various terms that are associated with academic medicine W-2 salary RVU more research resident education And here are some and and again academic medicine stable big names cutting-edge medicine and And then here are various terms that are associated with private practice which may come up in the conversation Okay, so what we're gonna do is really talk about how these two should actually wind up together So I wanted to start off this question with dr. Gruss Dr. Gruss tell us a little bit about your experience not only as a resident Which was in an academic center and then now moving over to a private practice tell us a little about the two your experiences and How the two have been together been put together and your experiences with that? Sure. So like everyone residency at an academic center and went through all of our PM and our rotations and Had some exposure to a private practice type model, but fairly limited and my experience My wife is a lawyer I had two very young children at the time and Had to be a little bit more flexible in my day to day with a one-year-old and a three-year-old or at the time a three-year-old and a four-year-old coming out of residency and You know the with my wife working as much as she was working I had to be able to have a little bit more control of my time on a day-to-day kind of arrangement so To do that it would be really hard to do in a academic model where it's a little bit more Structured a little bit more Oversight there's a lot of layers of administration So I was definitely looking for private practice type model where I could be a little bit more flexible and I could look Towards something that had a little bit more I could craft for myself So initially I was working in outpatient practice for a few years and then an opportunity arose To move towards something that incorporated skilled nursing facility work Which gave me a lot of flexibility in creating my own practice where I could set my hours essentially how I needed and The care could be very much patient driven without the same level of administrative Oversight that would otherwise be Necessary in an academic setting Let's ask dr. Gittler dr. Gittler you were the head of an academic center and an opportunity came and Really started this collaboration with ARC a private practice group, which is a bit unorthodox Tell us a little about how that came about and what what was the pros and cons of it and what need it filled? Yeah, I think part of the issue with academics is it's very hard to say We don't know what we're doing in a particular area. And in our case, we had a sniff unit in our freestanding rehab hospital, and it was kind of like Rehab light they all got three hours of therapy. They all got notes every day. And so clearly we didn't know what we were doing and I was lucky to know Jason because he was my resident and Like I need help and we crafted an arrangement where we paid for his time as the medical director of our sniff unit and We had residents rotating in our own sniff unit And at the same time we were looking at the post acute spectrum in the Chicagoland area and there was a series of nursing homes that were Quasi affiliated with the University of Chicago, which was one of our academic affiliates and They you know, they were really hung up on Academia and wanting an academic name so when Rupak and I met as well as with Jason we were like Can we create this partnership? Where the physicians that were going to these skilled facilities the University of Chicago would understand They had an affiliation with Schwab. They were the physicians were teaching at Schwab so and Jason was off other physicians were teaching and We put together a contract That passed muster with all the attorneys and once this happened, you know, the unit was going well I clearly didn't know what I was doing with a rehab unit you did. Thank you And then when it became clear I want to say it was in 2019 that a small Subacute unit in a freestanding hospital wasn't going to work. We closed it, but I Continued to reach out to our partners and we created rotation opportunities for our residents to learn about sniff level care and At the same time and Michael talked a little bit about this we created a moonlighting opportunity for my residents to work with a faculty a group faculty group doing Sniff level care where I knew they were getting oversight from people who knew rehab They were going to get some education and I also knew Jason would tell me if they were screwing up So And and that's still happening There's still an opportunity and and I think it's true that several of our residents who had worked with you guys are now your Faculty. Yes, that's correct I want to then segue over to to dr. Massey Mike was actually a resident when this all evolved at previous, you know, we had We had people that had trained at Schwab, but really Mike was the first person that came on board and he had requested a moonlighting opportunity and several of other residency programs did not allow external moonlighting including Shirley Ryan at that time including Mary and joy and Mike approached Dr. Gittler and us about this opportunity and Mike talked a little bit about not only During residency what happened and why was it beneficial in terms of moonlighting? But what did you learn? And you know, how did it really? supplement the the clinical education that you were having Sure. So this is probably my third year in residency and I knew I wanted to go into pain medicine and at the time I think about that book That is old but still might be around the way things work and I used to always think how does all this work how the structure of Medicine how am I going to get paid? How am I going to get into fellowship? and the type of questions that I asked myself was how can I distinguish myself from my cohorts and I knew that if I had a a good capture on the business of medicine that would probably help me and also if I had opportunities to practice independently that I would have a better handle on patient care and I personally feel that that is necessary in order to really grow as a physician and So when I met Rupak and Jason and we talked about the opportunities to moonlight I I was gonna check a lot of boxes. I was gonna learn how to bill. It's gonna learn how to code and That's that wasn't necessarily emphasized as much in in residency it was more about just the medicine and and which is great and part of The necessary training that we need in order to obviously grow as physicians but there's there was definitely a gap in in business and so I had an awesome residency director and she says sure go for it and She allowed me to moonlight and about one to two days a week. I would go and moonlight and had the Opportunity to learn Not during my working time and that was another great thing too is that it was flexible so I was able to go when I could go and I learned how to Develop relationships with primary care providers learn how to manage patients independently If I had if I needed a lifeline, I was able to call Jason and say hey man, help me out with this I don't know what's going on here. What should I do? And he would give me advice and go from there and It was just a great experience and I'll tell you when I Applied for pain medicine fellowship. It was something that they were very interested in. So when I spoke to Various attendings of different programs. They would ask me about this and Oh and the LLC so another another Another thing that I learned was okay. I'm gonna my wife's in finance and she's like, okay. Yeah, let's put this in S-corp. Okay, great. So I created a my first company and it was Massey rehabilitation and pain S-corp or something, you know and learned about how to manage money a little bit when it comes to Working in private practice and that there's a lot of fulfillment that you get when you actually earn the dollars Then it goes into your company and you start working with the CPA and how to how to deal with that So that was great and I would also talk to the the residents about this and they were obviously interested and that kind of sprung up to you know about what it is today, but As far as what? But what it led into it helped me in other aspects of my journey. So when I again applied to Pain medicine they asked me a lot about this and I could tell it intrigued them because most of the time people would talk About the publication that they're on People put it there was a lot of emphasis on what how many pubs were you on least among residents? but the people that interviewed me were interested in that I actually started a medical corporation and actually made money and Talked to them about my experiences with that. So that was great. And in later roles, it just helped me just to work independently and you know now I created we Started my own practice and I just go back to all the lessons learned Way back when I think it's great. It's to have a controlled environment where you can actually Make mistakes when it's not going to have ginormous consequences as opposed to when you're done with training and you're you're you're really on the hook for if you make a big mistake, so One thing that Mike and Michelle both had pointed out to was about how did this agreement come about and I think that's an important conversation because some of the barriers for this is you have an organization an academic center that has many attorneys and you have a private practice group and Really to try to find a way that these two could be partners across multispectrum because what it would did allow for is in the future predicting what else the the two could collaborate on and So there was a working agreement So we had a working agreement where the finances are kept separately the finances were kept separately but it was a working arrangement and it was well laid out in terms of what are the roles for each other and There was allowances for to add addendums for specific Collaborations in the future whether it be coverage whether it be residency training things of that set nature So that agreement that working agreement is hugely important and and having the trust Amongst the two parties and picking the right parties is important. So that's a little bit about the contract I also wanted to ask dr. Kapasi Samir is faculty over at Tufts and Samir do you want to tell a little bit about your experience in terms of how private practice and academics Have been able to work together Boston is notoriously a high-cost area for for the population and so consequently You know scarcity breeds ingenuity, right and so a lot of the stuff that these guys are talking about well where I went to residency the private and academic partnership That was instilled into us from the onset we rotated through private hospitals private rehab hospitals around the city of Boston because Number one they were willing to pay for our residency spots Which was wonderful and number two those hospitals got in exchange for us Rotating through and they get whatever help that their faculty need in seeing their patients It was a wonderful partnership, but then beyond that There is definitely you what we got to see as residents was a different side of medicine and The one thing you're one of the things that I remember I was telling these guys earlier. I had one faculty Faculty member tell me okay You should code all your notes in in this blanket way where all your follow-ups are level four follow-ups and all your new patients are level three patients and Looking at back at that at this point in how our academic folks treated our coding of patients versus how our Private hospital folks versus our private practice folks. It's it's remarkable We when we were in private practice. We were taught to take that much more care in that piece of it So that wasn't something that was so foreign to us coming our residency and then similarly when I was in fellowship I'd say the large maturity of what I did from a procedural standpoint with some private practice You Matt Massachusetts Boston in general has one of the most conservative medical groups in the nation We we are 48th in the nation in terms of how conservative we are So a lot of the cutting-edge stuff a lot of the stuff that other states are doing very regularly Academic centers aren't necessarily doing so when I was part of private practice I was able to do a lot of procedures that I wouldn't necessarily get to do in In the hospital setting as well as going back to learning the coding thing I think a couple of people have hit on some important points here and I think one thing that really is important to mention here beneficial for the private practice beneficial for the Academic centers and how we're gonna get into that in a second But something that was brought up is hugely important is, you know one of the goals is to advance payment are forward and and to grow payment are and you know, there are some obstacles that happen and one way that is hugely beneficial for academics and Private practices to partner private practice groups or partner is actually the private Funding of residency positions and I think that is an area that needs to be looked at and tapped in more We've already had multiple discussions about that and there is definitely barriers to it But it is something to be looked at in terms of increasing this profession of ours and so private funding or private practice funding of residency positions but also in terms of having the encounters and having the experiences you have to have experiences and and while there is a lot of unknown happening in health care when it comes to cost and post acute care and in Sending patients to inpatient rehab and there's been some contraction Having working with or partnering with private practice allows for those hours and those experiences and that's something we could talk about as well But that is a huge area that this partnership could be tapped into. I wanted to ask dr. Gruss What are some of the things that and and dr. Gittler as well? What are there some of the things that for example arc and Schwab have been able to do together and this partnership? What are some benefits that? In terms of this partnership Samir said something that was really well phrased and I don't even know if you recognize that you said it but you use the phrase that people saw things different And you said it really naturally but folks practicing in one area will see things a certain way and that's just true That's what all humans do but when you're in an environment you spend a lot of time in the environment you start to see things in that environment a Particular way and when you have partners that are also in that environment You're sharing the same views to a degree and everyone's aware of their biases So you always have to double-check your biases and things like that But when you have partners that are outside of that environment You are going to expand your views just by the nature of having people that aren't in the environment so when dr. Gittler and I are having chats about the nature of physiatry or What's going on in the city versus the suburbs or what's going on at that hospital versus this hospital, we have very different perspectives on the same situation, just given our relative different positions in the ecosystem, and having these different views gives us a much more three-dimensional picture of the reality, because both of us are just having our own experiences, but when we talk to each other about it and having a real trusted partner, we can obviously have networking conversations about this, but when you have a long-standing fundamental partnership from both the academic and the private perspectives, it really does lend this a much greater degree of depth, and that can be shared across faculty, across residents, through training, through multiple layers, because these conversations don't just have to happen at executive levels, that we kind of are, I guess, I mean, technically, they can happen throughout the conversation. As an example, your group does primarily SNF-level care. Yeah, like 75%, yeah, yeah, yeah. SNF-level care, but what will happen is Jason's group will see a patient, they're doing consult-based, hospital-based consults, and they'll see patients who have insurance where it's not covered in a SNF, and Jason will say, call me and be like, this person needs acute rehab. And we're not doing that, and I trust when he says that. It's not a dump. In other places, it's dumpy, but we get... Our job is to advocate for patients, and the relationship is more symbiotic. It's not, if he doesn't get the patient, then he's lost that. It's more that that patient needs care that you can't render, or the facility isn't going to provide rehabilitation services. Or because Schwab is Schwab, and Schwab is a specialty rehab hospital in the neighborhood of the footprint where I do hospital consults, we have other hospital-based rehab that doesn't have brain injury, that doesn't have stroke-specific care. If somebody needs specialty care, the patient just needs something that we can't provide. So patient first, that's where they should go. Can I... So the other thing that we've done together is from time to time stuff happens and people get pregnant, people move, people decide medicine isn't their jam, and it is really hard to plug full-time openings. And so we have had the opportunity. I've had the opportunity to say, I am crushed. Can I buy part of one of your people to cover my spot for, I don't know, three, four months? And it's someone who is already licensed in the state, who already understood the landscape of what was happening in our locale, and that's a big deal. Like you have to understand the culture of the locale, and thank you. And we're able to rush through privileges, and the person came on as teaching faculty, and so we paid. I paid as though they're teaching faculty, and they were answered to me. There was a little bit of answering to you as well. But there was not... You have two different mistresses or masters, and that's been kind of wonderful. Yeah, absolutely. Because we did that a couple of times. We've had some people on staff who sort of have stayed on staff and helped to plug some holes, and I believe that if someone's helping me plug a hole, my responsibility is to pay a reasonable salary. It's not going to be like a locum's salary, but it's basically a per diem if they're working X number of days a week, and it's great. It takes a lot of trust that when you have a partner, you've worked for a long time, and you have an established relationship, because this isn't a transaction that we are walking away from after it's completed. This isn't a one-off. This isn't an exception. This isn't an employment arrangement for a single deal. We have a longstanding relationship that covers a lot of different areas, and because the contract we came up with many, many, many years ago at this point is this very short, simple agreement. When things can't come up, we make riders and addenda to it that allow us to broaden in for a period of time what we need to do, and Dr. Gittler, essentially being who she is, can get this done at her location, and we're in private practice. We can kind of just do what we want, because we don't have the administrative burdens that you have. So... So that's actually a great point, by the way. I think one big difference, and why these two entities belong together, is you have two contrasting families, or contrasting views. On one hand, and both are beneficial, but in different ways, and you're basically complementing each other. You have private practice groups. They're smaller. They're flexible. More agile. There's innovation and processes that are happening, and when you have academic centers, you have clinical research. You have education. You have large. You have stability. You already have an existing footprint, and you have already built in reputation. So the two of them working together, you can have, in certain situations, you can have something where it might be more difficult to go out and get a locums, or in a short time, you can use your partner and talk to your partner. And again, that's an important thing, is to pick partnerships correctly and properly, because there is this level of trust to rely on them and say, hey, great, you know, I need someone for three months, but I need someone in the next, you know, month. Is it possible? And again, a private practice group is more agile and flexible where that they can do that. And then there's benefits to the private practice as well. Again, a larger footprint, being able to have that stability, to have CMEs and education, continuing education. Those are definite benefits. Other things, partnerships that have happened, coverage that we've talked about, resident education with a residence rotator, Moonlight, and then I wanted to ask the team a little bit about didactics. Okay. I want to just jump on the resident rotation. For anybody who runs a residency program, the F word, funding, is a big deal. And when residents rotate at skilled nursing facilities, Medicare doesn't pay for that. So one of the things we've created, we've created a series of different kinds of rotations. We have a newer rotation now where people spend a day, sometimes two, within a week. So in this four or five week rotation, one or two days a week, they're with my partners. But most of the time they're with me. So I'm getting paid for them. And it gives people an opportunity to see, you know, see what's going on, because we can't do it all. Part of the other thing is in terms of what is the future of PM&R. We're talking about advancing physiatry forward and certain models of care are emerging. About transitions of care across the whole continuum. So it is important to have, for residents to have, and other physiatrists, to have a viewpoint of the whole spectrum, across the whole continuum. In the hospital, academic side, IRF, but those patients are going to private facilities outside or private outpatient clinics outside sometimes. So there is that importance of the whole transition in a 360 kind of a view. So having that experience is important. And the other thing is in academics, the residents, and I love my residents, but everybody gets used to being in one place and they do one thing at a time. They're on the stroke rotation. They're on outpatient. And the real world isn't like that. You know, you're running around like a little chicken. And the opportunity to do that, to have a rotation where you're doing three things in a week, that's pretty important. It gives you just an opportunity to taste it. Absolutely. I think the other thing is we talked a little bit about didactics and in terms of how the private practice groups can add to that as well. For the private practitioners, like in our group, it's important to, we've had, whether it's Northwestern, whether it's at Schwab, have had education on the clinical side, which is great, whether it's CMEs or something, you know, Grand Rounds, but really on the didactics for the resident side, actually doing is important where they're rotating or moonlighting. But a little bit about some of the lectures that Samir, Mike, Jace, some of the areas that we've talked about to the residents about. So for me, when I got out and... It sounds like you were in jail. So after fellowship, I was recruited to establish a pain medicine service line and had to find the space, and this is with a big organization. It was like 10 hospitals, 30 clinics, and they were just doing independent guys and they wanted to build it out. It was a very fun job. And part of the opportunity that I saw was when you meet with, they had a family medicine residency program there and they did not know how to prescribe opioids. So an easy thing to offer the program was for me to give lectures on how to prescribe opioids. And that created a few things. One, it created a good pipeline of patients to kind of help feed the program. And also I would develop relationships with the residents I would roll through. They would come here and there and we would talk about how to prescribe opioids, how not to prescribe opioids. And we did just like a poster. And when you do those types of things in private practice, it's great marketing. And you just start... People actually... It kind of blew my mind. People found the poster and they would ask me about it and they would start coming to clinic. And so currently, I find it very beneficial to have medical students, residents, give grand rounds, give lectures when possible for the practice, primarily because it's a great pipeline for patients. And also you just get plugged in with people and you get to know the community and you start to learn who the players are and what the needs are and how you can better serve the community. And what I would add to that, it definitely gets the name of the field out. People still confuse us with psychiatrists at the end of the day. So when you're lecturing to other fields, it definitely rebrands you and tells people the scope of things that you can do. Now, what I do a lot and what my practice does in general, I'm part of an orthopedics practice and so it's musculoskeletal and pain. We do so much in terms of didactics for the residents because at the end of the day, we have a retired orthopedic surgeon who only does ultrasound stuff and he just wants to teach all day. And so they get that as part of the package. They get me doing whatever anatomy teaching, whatever as part of the package as well. And so it ends up working well because what we're freed of in private practice because we're all trying to go down this combined road is the political aspect of larger hospitals where you have three different fields doing the exact same thing, but they're not working together. I mean, when I was in fellowship, we had a pain management service. We had a physiatry, a spine physiatry service, and we had an interventional radiology service and we all did the same thing and never worked together. And we're doing it this way. We get to show people how easy it can be to work together. And so I think that this is important because you have two specialists, you have MSK, you have interventional pain in terms of their shared experiences of being in private practice and still partnering with academics and how that's done. Jason, just asking some of the lectures that we've given. We've given lectures, we've been brought in to do lectures for the residents beyond the rotations and moonlighting. I think some of these are hugely important in terms of resident education, some that aren't part of a standard clinical didactic schedule. Jason, do you want to talk about some of those that we've done? So I still return to Schwab, give lectures fairly consistently, and some of my recent residents who have rotated with me are in the audience today. Hello, fellows. And one of the things, as Dr. Gittler mentioned, they're with me once or twice a week. And I have them for three or four weeks. And it's sort of a, I don't want to say cobbled together, it's very organized. But it is kind of a patchwork of a rotation. And for senior residents, they often have away things they're doing. Sometimes it's a time to take vacation times, unfortunately, for me, because I really like having them around. But because it's not hospital-based, it's not inpatient-based, they don't have to get coverage during that time. So it's perfectly reasonable that that occurs. So sometimes I only get like two or three or four days over the course of the month. I'm not going to give a tremendous amount of clinical information across four days. I'm not giving them their fundamentals of spinal cord injury, their brain injury rotations. But what I can give is my perspective that they wouldn't otherwise have. What can I teach them that they haven't already learned from people way smarter than me at Schwab who taught me? So what is unique about what I'm doing? I know my environment really well. I know where I'm at in the spectrum of physiatry quite well. What is required from a regulatory perspective? What does the spectrum of care look like? Why is this patient, who everyone recommended should go to acute rehab but was denied, and is now with us at this subacute? What does that look like for the patient? And what is our role as the physiatrist when if things had gone the way we had recommended, would be at an acute rehab facility being seen five times a week by physiatrists directing their care, and now we're here once or twice a week at this skilled nursing facility. How do we impact the care there? So these kinds of things and the change in the environment is what I can teach. And the other part of it is what we spoke about earlier, a lot of the billing, coding, professionalism, things you do a little bit more independently when you're kind of out there in a non-academic setting, when you're out away from home base, when you're outside of your base healthcare system where you have a lot of those support structures, when you're doing notes in a foreign electronic medical record system, when you have to do your billing on your own. Those kinds of things that what I tell the senior residents, the day you graduate, you have to know how to do. Your first day of work, if you bill wrong, you are responsible for the errors. Your bosses aren't going to say, ah, it's okay, they're new. You are responsible for doing it accurately. CMS, I assure you, will want to take their money back if you did it wrong. So just as you're responsible for all that academic medicine that people started teaching you day one of medical school, you are just as responsible for the financial part of the picture, and I have four days. So I also want to just say quickly, the goal is common. The goal is very important. The goal is to advance physiatry forward, and that means the academic side of teaching the fellows and residents as well. Whether it's on the clinical side, whether it's the business of medicine, all of that is important. And so the goal is common. The partnership, you have two people who have some commonality, and that is the commonality, and that partnership works, so that relationship works because of that commonality, and it's basically complementing each other. Sometimes opposites do attract, and I think Dr. Gittler had the mentality to say, hey, I want to do what's best for my residents. Even if it's not in-house, let me talk about partnering with an outside group that can supplement what we're teaching in-house, and so they have other opportunities as well. And after that, so first was actually, Mike was the first Moonlighter that came to us. After that, shortly after, you had other big organization, academic centers who said, yeah, we should allow them to moonlight as well. We had Marion Joy follow suit and allow their residents to moonlight with us. We also had Shirley Ryan, for the first time ever, have their residents and fellows moonlight with us after that. So again, it takes that mindset, that role of being an administrator on the academic side, but also the foresight and the partnership of wanting the same thing, which is to advance PM&R forward and for the best of the residents and fellows. So I want to, as we want to have some time for questions, so I want to take some takeaways here. Some takeaways before we get to questions. Again, put a nice picture up here. We have all these forbidden love or couples that couldn't be together, but sometimes- We're still together. They're together, but not as great of an ending. Sometimes the couples do, even though their opposites attract, they do wind up together. And I think private practice and academics could live happily ever after, and we can advance physiatry forward. Some of the things that we talked about and takeaways, ACGME residency requirements in this volatile healthcare environment with patients going to different levels of care. So that's a possibility where private practice could help with that. There's a private funding of residence positions that is something that could advance this field forward. The business of medicine in terms of didactics both ways, in terms of private practice giving it to residents and then as well as academic centers helping the private practitioners out with their clinical knowledge and continuing clinical knowledge. And then together we could have a larger footprint by synergizing the relationships. And then again, we talked about CME and continuing education as well. So I want to take a minute for any last thoughts and then we can get to questions. Does anyone have any last thoughts? I just have a quick question and I've always kind of wondered this. You kind of talked about this. You have a very unique partnership that I think is very beneficial. It could be very beneficial for other programs. Can you just talk about the must-haves and deal-breakers to ensure that the partnership works for both parties? Yeah, absolutely. I think from our end, I think the important thing is that there's trust. You have to pick a good partner. That's some of the cons on this. There's always a learning curve. When we started the partnership off, we had some moonlighters that joined and we didn't have these rules and processes in place. And some of the moonlighters worked for three days and basically it was just not a good setup. So we need to talk about expectations and what is it going to look like and what are you going to get out of the moonlighting arrangement? And vice versa, in terms of Dr. Gittler relying on us, in terms of what is our roles? When there is a need, how can our partnership help them as well? So I think it goes both ways. But the deal-breaker is really to have partners that you know and you trust and then have a good, strong working agreement that can then be amended when new situations come up. So I'm a little bit, I always think I'm a little bit like the fulcrum of this relationship, right? Because Dr. Gittler was my program director and I tell the residents she's always my boss. But Dr. Parikh is literally my boss. So I'm kind of, you know, I'm not serving two masters, but yes, I am, right? But for me, bridging this relationship, which is, and we all get along wonderfully and we talk all the time, but communication, obviously, like any relationship, any partnership, any marriage, any talking all the time and feeling comfortable saying, no, I can't help you with that. I don't have somebody right now, but let me get back to you. Let me find somebody else. Being eager to try and help, but knowing where your boundaries are realistically, or when you can't do something, I just can't do that right now, is okay. If you don't say you can do something that you can't do is important. So being able to, just like in any other relationship, just like I do with my wife, I can't tell her I'm going to stop and pick something up. If I can't do that on the way home, she'll be more upset if I say I'm going to do it and then I don't than if I don't. So if we can't deliver something, we have to say we can't. That builds trust. So the way we deliver on the trust is by having that good communication with, and that means having boundaries and being able to say no when we can't do something. It also, in my mind, I have residents in this audience, so with love, there's some people who aren't ready to moonlight. They should not moonlight, and I need to say no, and I get to make the decision. They know that they need to run it past me, because, you know, not everybody's ready to moonlight, and so I have to be honest about that. And the other thing is when we had you running our unit, as soon as I knew that there was a possibility we were closing that unit, the SNF unit that was embedded in our freestanding hospital when the regulations changed, like I let you know before it was official. You need to know this thing is probably going to close in X number of months. You're like, oh, great. I got other things to do. But that was a big deal, you know, because you had time devoted to that and to teaching. Yeah. And yeah. Just constantly talking. Like any, with all partnerships. If you get blindsided by something negative, it's awful. But if you plan for, if it's open communication, it's really easy to arrange for. Yeah, again, everyone's on the same team. I think it's a common goal. Those are the important things, and communication is paramount, just like in any other relationship. I want to take a moment for, and we have time, so questions, any questions. Great question. I'm just going to repeat the question for the microphone, because it's all being recorded. And that was a really, really good question. We had actually talked about this a little bit beforehand. So thank you for asking the question that you didn't know we were talking about already. So the question was, and the statement leading up to it, the residents obviously, and we talked about gain from visiting private practice organizations. What does the private practice gain from the residents being present, essentially? I mean, there's the implicit, you get to resident code, right? There's that piece. But then the other piece is, at the end of the day, we've spent our lives in some way or form, to get to this point, we've spent it as students, as faculty, as whatever, right? So throughout our residency, we're teaching the younger years, and we have this thirst for knowledge in all of this. And so, I mean, my personal take on it is, if I don't know something, I'm going to look it up, and what's going to encourage me to look it up that much more is having resident along. And beyond that, I like having residents along, because there's a lot that I can teach them. I love that aspect of that piece. I mean, the financial piece isn't really the part that I benefit from. It's the fact that there's that outlet for me that I wouldn't get otherwise. I think Samir's point is great. I think there's a couple of things that I want to talk about. The currency in private practice is currency. That's what we had talked about before. That's what the currency is in private practice, is currency. So there's also monetary benefits. Samir mentioned that in terms of the resident coding. The other thing is that, from a coverage perspective, it can help with coverage. It depends. You absolutely need to look at how you're doing this, but it can absolutely help with coverage. It can help with marketing and relationships. We talked about before. Use the synergies that we have to expand your footprint. We probably talk three times a year just on strategy. What's the landscape in the Chicagoland area? What this hospital's doing? That unit is going down. This unit is not happy. Those are leads for us, and they've definitely manifested those leads. Having people that were former alum join our team. Creating the pipeline and training your future partners. Those are all ... They're not immediate benefits, but they're long-term benefits. I have a quick question. Does anyone in the audience hire? Is anybody out there hiring physiatrists? We all are, right? Is that easy, or is that hard? It stinks. It's hard. I don't know where you guys work, but it's a pain, especially if you replace somebody. For us, in private practice, it's particularly hard. When we have folks who are coming through more often, that makes life a little bit easier sometimes because we get that exposure. Absolutely. Also, we said, if you are ... Again, you have the big, stable, recognized brand name, huge academic centers. To be part of that as a private practice, you get the benefits of that. Again, we talked about our currency is currency. You get the benefits of that without having to run that big show. You get your name attached to it. You are doing multiple links together. Again, we're training the future potential employees. No. You should make them adjunct professors. I should. Beyond that, that's how you're really attached, right? You can say you teach, but you want to have a title that would attach you. That seems to have a benefit. The thing is, that has a benefit in academics. I think there's this credibility. It's a credibility thing, but the whole adjunct professor ... beginning back, I'm a big. Loving teaching isn't the currency like we talked about, it's not going to... I'm sorry, I want to translate some of your comments for the recording. That is a wonderful point because loving teaching is what all of us, I think, in this room are about. But not everyone in private practice brings residents in, brings fellows in, brings students in. And not all of the people who work for all of our different practices and not all of the private people that we work with want to teach. So the residents that rotate through our group want to teach. It's a perfectly volunteer thing. So Dr. Gittler is very selective about who she wants the residents to work with and we are very selective about... Dr. Parikh and I can't have our providers who are, let's say, less efficient, also have a resident during days where they are less efficient. That doesn't work for us. So we have to pick people who are able to do this efficiently, who are good at it, who want to do it, who also get Dr. Gittler's blessing. If all the lights turn green then we can launch. But also the strategy that we had discussed. So, again, your question is really about what is the benefit for the private practice. We've talked about the coverage, we've talked about how it generates some revenue. It talks about also how the future residents may join your team to make it easier. And you get a sample of them. Like, oh, this is a great person. I want to recruit this person. I already know their personality. You also start training them how to bill and code. That person who I just taught how to bill and code, they might go somewhere else, but they might come to me. And now I already spent that three-month ramp-up time. What we actually do in our contract is interesting. If you moonlighted with us, and it might only be one day a week, I give you credit for those months as if you work with me when you join our team. So you already spent, so let's say Mike worked and moonlighted for us actually a year and a half. We have our next escalation in percentage at a certain point. I give you credit for that. Why? Because we just trained you how to bill and code, how to be professional, how to talk to people. This is part of our training. So that's a secondary benefit for it. But the big thing is a lot of times we talk about strategy. We talk about strategy in the landscape and inpatient units, and then we go in together and we say, hey, we're partners with Schwab. We already are partners with Schwab. We already train residents. We already do this. Then it introduced and opened the doors to Shirley Ryan. It introduced and opened the doors for Marion Joy. So also when people are looking at, again, a name brand, you have Schwab next to a name brand. Oh, they're partners with Schwab. If they're making a difference, a choice between our private practice group and another private practice group, there you go. Also, in terms of some people, they want a little bit of both. They do want some experience in academic medicine, but they don't want to go full-fledged. They want one toe in the water, but they also want to do private practice. That's another benefit. It gives you a different scope of candidates that would wind up coming to us. So let's go to the next question. Go ahead. So the question is, if you are going into private practice in an area where a lot of the private practice are getting bought up or absorbed by the larger institutions in that area, hospital, academic institutions, or other even big corporate institutions in some regions, how would you as an individual provider, somebody who's earlier in their practice market themselves as wanting to bring in residents, bring in fellows, or something like that, to do some teaching as a part of their private practice or to be on this academic private practice marriage, this relationship, and to avoid just getting totally absorbed and leaving everything behind? I can answer this one. Does someone have an answer? Do you want to say that? No, no, no. So this one, this is interesting. I think it goes based on the foundations of fundamentals of marketing and to a private practice group. Our philosophy always is to be, add value and be indispensable. If you can add value and be indispensable, then they're going to allow you to teach the residents. Or that's part of self-marketing. One of the other things that we do when we do talks with different residency programs, I had this question asked at Northwestern Marion & Joy, and they said, what is the one piece of advice you can recommend to me as a resident? You are your best marketer. You are your best agent. No one else is better than you. So you have to understand, what is your value add? You're going to hear that a lot. And what makes it so that they need to partner with you? What is it? And that's the thing, that role you have to fix, especially if you're just starting out. It's not easy to go from just starting out to being able to train the residents. You have to find the missing piece. It's like with anything else. All these great entrepreneurs, they've solved a puzzle. They've solved a piece. And the question is, what value add do you give? Once you can answer that, then it's not a problem. Because then at some point in time, as you start growing, you don't have to rely on them for patience or the entity that's going to try to buy you out. So that's my two cents advice on that. I just want to piggyback something on that. So I started my practice about a year ago. And I was siloed prior to that, so I didn't know anybody. I would encourage you to determine who the players are and determine, talking about value, you got to be able to do what they won't do. So in my world, in interventional pain medicine, nobody wants to work in-house. Everybody wants to be an outpatient nine-to-fiver. I would offer your services to do a lifeline consult. If someone's getting killed in-house, you'll come in every once in a while to help out, to help get the meds right, or whatever. And in my world, you'll be known as the pain guy. And they'll just start sending you patients. And that, along with offering lectures just here and there, just do the stuff that nobody else wants to do. And you'll start getting patients. I have. There will be something that you like. You don't have to love. It doesn't have to be your favorite thing. But something that you enjoy a bit that has fallen off the radar that adds value. And in part of my clinic, I did headache medicine. I did Botox injections. I was never a headache guy. I was never. But like, yeah, it was OK. But nobody else was doing it. And all of a sudden, I had this pipeline of headache patients. I don't know where the hell that came from. It was very easy. And there was just a gap that I filled. Similarly, I mean, nobody wants to treat coccidemia. You could be the coccidemia specialist. And that's so true. That's so true. If you market yourself to different groups in a certain way, then you'll build it. And the same spectrum works in inpatient care as outpatient care. There are things that. And SNF level. Yeah, absolutely. There are, like, nobody wants to sit on the pharmacy committee, right? Nobody wants to do whatever. And whatever level of care you want to practice at, whatever part of the spectrum of care you want to practice at, find an area that is underserved, that adds value to the overall picture. But part of your question was, correct me if I'm wrong, how do you attract programs so that you can get residents to rotate through with you? So I mean, the way that I did it or the way that we've done it in our area is it's always been with residency programs that are local to us that we know because, well, we came out of them. And so we have these pre-established relationships and, you know, your program director trusts you or the person who became the program director used to work with you. So it's organic, basically. We do have two questions here. Gentleman in the blue shirt. I can just give you my Experiences working with the VA system in Chicago. Jesse Brown VA Medical Center. We lost our residents very quickly from another academic affiliate that I will not name. So then we were caught in a quandary. We had a 12-bed car for credit in an inpatient rehab unit, treating mostly dysvascular amputees, stroke victims, total joint replacements. And so the therapists had a lot of expertise in taking care of those people, but we needed physician guidance to direct the rehab unit. So I conferred with my colleagues and three other attending physicians. We decided to keep that unit open ourselves, by ourselves, without residents. So that's what we did. Just, that was a no-brainer. We did it. The same time, Dr. Rao approached us. He wanted to expand his program at Marion Joy. And so we started working with Dr. Rao in that perspective. Now just what you said about trust was understood. Dr. Rao was as solid as could be. There was no wavering of commitment from his standpoint. What I had to do and it opened up perspectives I've never seen before. In the federal government you have to approach the Office of Academic Affiliations to open up a new academic affiliation with Marion Joy and Jesse Brown VA. Those negotiations, those dialogues, that was a time before we had virtual contact. Phone calls mostly, documents. Took the better part of a year to get just the academic affiliation agreement approved. Then things I didn't realize, we had to work on a disbursement agreement because the academic affiliate has to pay Marion Joy for the residents' positions and the salaries, the workers' comp insurance, the health insurance, the vacation time. All that has to be put together in a disbursement agreement so that once it's approved and starts the dollars can flow to Marion Joy. So all that took me the better part of a couple of years, but you were one of the first residents that came to us from Dr. Rao. And really the VA benefited from having help with our inpatient unit, but then also you, the residents, got experience in our outpatient... It took a lot of effort and time and opened my perspective to things I never really had thought of before. It was actually that partnership is the reason that I'm a physiatrist, because I was one of the out of match spots for that year. Wow. Did not know. It was that spot. We should probably have corrected this a little bit, because the VA system too is not quite academic. It's not quite public. It is a governmental institution. It's its own. It is such a unique track that we're all here playing rock, paper, scissors, and the VA over there, they're just brick. It is its own thing that doesn't fit into the whole system, and yeah, bravo for negotiating that whole process. I consider it one of the highlights of my career. It is wonderful that you were able to do that, and we're very happy for it, because that left- Thank you, so that I could- ... to work with us. Yeah. Appreciate that. We had another question over here. I think that's probably true regardless of whether it's a public, a private academic relationship or even relationships that you have with other organizations as the healthcare systems divorce and marry and, you know, have girlfriends on the side. You know, whatever they do. Like, it's very weird. But I do think that having something codified, whether it's, you know, a memo of understanding or some kind of contract, like, and having it be very short so you can always do addenda, it's there and that is not dependent on the... The relationship is really important and that takes some time to make it sufficiently specific about the relationship and yet at the same time vague. Flexible. Flexible. Thank you. About what that can entail so that it's not dependent on Michelle Gitler, that it's already existing. And so recently I borrowed three and a half, four months of coverage and everyone was like, oh my God, how are we going to do this? And then we found... You know, we have the document and the lawyer's like, oh great, just an addendum. And the craziest part about that was it wasn't done between Dr. Gitler and I. It was actually someone else who left three months later after the agreement was signed. It was Dr. Sandin actually who signed it. So absolutely. I think it goes back to the communication is huge. Having a document and an agreement, I cannot stress it. A memo is great. It is not sufficient, especially when there's a lot of dollars on the line. It just happened to us recently, different state, massive healthcare system, 10 hospitals this partnership is at, 10 hospitals. So now 10, but the same thing, we had an agreement in place. That document is there. It was, it took three months to get to that document. But fast forward, you know what happened? They got bought out by another system, the healthcare system got bought out. The leadership positions all, people got elevated and changed. People came up with their own agendas. They go back to working in silos and then they come to us and say, oh yeah, but we didn't know. Boom, there's a document. The document was with their legal attorneys. It was discussed because all those people that were there when they, three years ago, when we created this document, they're gone, they're not there anymore. But that document helped preserve that. All, all we can do is create the best environment for success. But your point and your experience is the most likely scenario. And when the hospital CEO leaves and the hospital gets bought out, when a private practice gets bought by some venture capital group, or when the three people in charge move and get replaced by junior people, when, when these big shifts change, then big shifts change and relationships just change. It is a working agreement. It talks about zero financial relationship. The one with the other group, the one with us has zero but the other one talks about, it defines the financial relationship as we don't share money. Well, no, that's the one with Dr. Wittrop, but the other organization, it's it, regardless, it specifies what the financial nature is, regardless of what the specifics are. It does do that. And at the end of the day, it goes back to what the other individual asks. If you make yourself indispensable and there's a value add there, even if 50 people change, because this happened, it was close to ending. And we probably had about $2 million worth of investment in staff, et cetera. But again, if you make yourself indispensable and you're, you're, you're filling a gap that they don't, then it's going to continue on. And that's luckily what happened in this situation, but absolutely that the turnover is happening all the time. You're going to see that. So, and I, that is our time. Yep. That's our time. Thank you guys so much. Thank you so much. Have a good day.

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