Thank you for those of you that could join live and I'm very excited to welcome our panelists today to come to this session. And I hope those of you that aren't able to make it live will be able to benefit from viewing the recording of this presentation. Very excited to bring you this talk today. Our panel discussions on what's called neurorehabilitation career paths, a panel discussion of the multiple options your fellowship training can take you. Specifically, I titled it neurorehabilitation to really emphasize how diverse your brain injury medicine training can, diverse career path your brain injury medicine training can help optimize you and prepare you for. My name is Kirk Lercher. I am the session director of today's talk. We've brought together a panel of experts from around the country in brain injury rehabilitation, neurorehabilitation practices. We're each gonna talk about our collective experiences and I hope you will benefit from hearing from us as well as having an opportunity to ask your questions as you are considering and starting your careers in neurorehabilitation. I am the chair of the brain injury medicine program director member community for the AAPMNR. And this is part of that community stay session. So I appreciate those of you that can join and look forward to a nice discussion with all of you. So some housekeeping notes real quick, just for Zoom etiquette, obviously please keep your microphones muted through the session. There will be a point at the end, we're gonna open it up to a Q&A. I would encourage you to, if you have questions, I hope you do have questions, please put them in a chat. We'll be viewing those and then addressing, I will pose those questions to the panel or to specific panelists that you designate in the questions. And then ultimately we'll have a live Q&A session where everybody will have in the audience an opportunity to ask us your questions. So regarding disclosures, I have no relevant disclosures related to this talk. An outline of how we're gonna do today is each of us are gonna give introductions. You're also gonna gain some historical perspective of the field in general, in terms of brain injury rehabilitation. The panelists will each engage in a discussion about their career paths, what their current practice looks like, and kind of talk about our collective wisdom and our experience in developing these current practices that we're in. And then, like I said, we'll have an open Q&A and ultimately at the end, we'll have an informal networking opportunity. This should serve as normally if this was live, if we were in person at the Academy meeting, we would have an opportunity to have a member community meeting to discuss various pertinent topics. So this is in lieu of that, we'll have an informal session where we can meet informally and discuss whatever you feel you would like to discuss in terms of fellowship and career paths. So first introduce our panelists. So again, my name is Kirk Lercher. I was the Medical Director and Fellowship Program Director at Mount Sinai Hospital. And our panelists, my co-planners for today's session are Dr. Brian Greenwald, who's the Medical Director for Brain Injury Medicine at JFK, Rehabilitation at Edison, New Jersey, and Dr. Kelly Crawford, who's the Brain Injury Medicine Program Director and Medical Director at Carolinas Rehab. And also joining us on the panel is Dr. Peter Janklis. He's the Director of Trauma Rehabilitation at University Hospital in Newark, New Jersey, and Dr. Elaine Magat, who's a attending physiatrist running a brain injury outpatient, busy outpatient brain injury practice in TIR in Houston, Texas. So a little bit more about me. As I said, I was the Medical Director of Brain Injury Medicine and the Program Director of Brain Injury Medicine Fellowship at Mount Sinai Hospital in New York City. Dual board certified in physical medicine and rehabilitation as well as brain injury medicine. I got my medical degree from now Rutgers University, New Jersey Medical School. At the time I went to, it was known as UMDNJ, University of Medicine and Dentistry of New Jersey. I then completed residency training in physical medicine and rehabilitation at Kessler Institute of Rehabilitation. I graduated in 2012. I developed a passion during my residency for brain injury rehabilitation, and that's what ultimately drove me to pursue a fellowship in it. So I completed my fellowship training in brain injury medicine at the University of Pittsburgh Medical Center in 2013. This was before there was ACGME accreditation, so it was an unaccredited fellowship. But at the time, as I said, there wasn't an option for accredited fellowship. And we'll talk a little bit more about ACGME accreditation during today's panel. Out of fellowship, I joined the faculty at the Department of Rehabilitation and Human Performance at the Icahn School of Medicine at Mount Sinai Hospital in 2013. I was brought in as an assistant professor, which was reflective of having completed fellowship. Those that joined faculty without completing fellowship were hired at an instructor level. So I was brought in at the assistant professor level, which was a consideration in terms of deciding whether to pursue fellowship. During the time I was there, I was promoted in 2016 to medical director of the Brain Injury Rehab Program at Mount Sinai Hospital. Concurrently, I was promoted to, that came with becoming medical director of what's known as the Brain Injury Research Center, or BRC, also at Mount Sinai Hospital. I then established and directed the first ACGME-accredited brain injury medicine fellowship at Mount Sinai Hospital, which was started in 2018. And it's flourished in the time. In the subsequent time, we've matched four consecutive fellows into that program and continue to build on the educational curriculum and development of that program. Regarding my volunteerism in the academy, I was nominated to be chair of the Brain Injury Program Director Member Community of AAPMNR in 2019 and continue to serve through this year. That has subsequently grown to branch off into having the member community for current and future brain injury medicine fellows member community, and more of a program director faculty kind of community. And in November, I will be joining faculty at Kessler Institute for Rehabilitation, which is an opportunity I'm very excited about to return to my old stomping grounds where I developed my passion for brain injury rehabilitation and look forward to continued career growth there. So to review some of my clinical practice, in my time at Mount Sinai, I oversaw a 25 bed inpatient brain injury rehab unit. I maintained a personal census of between 10 and 15 patients depending on bed availability and the status of co-faculty during the years that I was there. But in my role as the medical director, I was really responsible for overseeing and making sure that each of those beds were filled and filled with appropriate patients with regards to medical stability, as well as in terms of ability to tolerate rehab and have an adequate discipline plan. And then being part of a larger academic medical center, it was my responsibility to really liaise with the referring providers from neurology, neurosurgery, critical care intensivists to educate and advise as to what makes a patient an appropriate candidate for tolerating acute inpatient rehab and maintain that relationship. So it was a very kind of nuanced role in terms of being the director and overseeing that rehab unit. Now, in addition to those inpatient responsibilities, I maintained an outpatient practice, both a private practice model, which was private insurance and Medicare. And then there's also a Medicaid clinic, which is a weekly clinic dedicated to the Medicaid patient population recovering from brain injuries. And that's staffed by a rotating batch of faculty. And in my role as the director overseeing it, I would triage which patients were appropriate, mainly patients that were more, that needed like specific interventions, for instance, if faculty or staff in the clinic on a given week weren't so comfortable with that, then I would make sure that they're booked with myself or someone else that was comfortable with that among other considerations as well. So I kind of oversaw to make sure that they were staffed appropriately and balanced appropriately as well. And our outpatient practice was made up of discharge follow-up patients from the inpatient rehab unit, but also consultations from the community, from primary care doctors, from neurology, neurosurgery, et cetera. We also saw concussions, both sports-related concussions, as well as mild traumatic brain injury that were results of work-related injuries or motor vehicle accidents. And then as I alluded to, I also performed various spasticity procedures, both intrathecal pump management and botulinum toxin management to address spasticity. And then something I was very proud of to develop during the time that I was there, I developed a robust consult program that didn't exist prior with our hospital systems level two trauma center, which was at the time known as Mount Sinai St. Luke's, now is known as Mount Sinai Morningside. That was our hospital systems trauma center. And at the time, they didn't really have a great relationship in terms of referring patients or even really an awareness of what we provided in our brain injury unit, which was in another hospital building. So I collaborated with members from trauma surgery, from the SICU and neurosurgery in developing what was known as neurotrauma rounds, which was a weekly rounds. And I really tried to fashion it in what I saw in my training, both at fellowship and also in residency to some degree. And it served in developing a relationship, educating the staff. And then also it helped me once I developed a fellowship in providing the brain injury medicine fellow an opportunity to really learn the acute care management of patients with traumatic brain injuries. And in the rounds, we also saw some other traumatic spinal cord injury, for instance, but really my expertise and how I helped the team was really collaborating on the medical management and optimization of these traumatic brain injury patients to get them ready for inpatient rehab once appropriate. And then in addition, I helped oversee some community outreach programs, going to community centers, health fairs, and other opportunities to really educate the community in terms of services that were available to them, for two patients recovering from brain injury, various brain injuries. With regards to with regards to the educational practice, I was the, as I said, I was the fellowship director of the brain injury medicine fellowship. We had one fellow per year. And in that, I, you know, oversaw their educational curriculum as well as the development of their elective program and regular training throughout their fellowship year. In addition to that, we had three rotating residents regularly throughout the year. And then seasonally, we had rotating medical students and visiting residents and fellows that rotated through our inpatient rehab unit, as well as through our outpatient clinics, which were staffed, I should say the Medicaid clinics were staffed by residents and the fellow on a regular weekly basis. And then I also collaborated with neurology and family medicine program directors to help bring in their trainees to learn about what we do in the brain injury rehab unit and program. So for instance, neurology has endovascular stroke fellows who would rotate with us on their elective rotations, which served a good dual purpose. They would educate our residents and fellows on like the acute care management of some of stroke patients. And then in addition, they were benefiting by really seeing their patients in how they progress functionally, physically, cognitively in a rehab setting, which they never would have gotten the opportunity to see. So it was a very fruitful collaboration. And then subsequently also the family medicine program director and I collaborated on bringing in their family medicine residents to really learn what we can provide in a rehab setting for neuro rehab patients. Prior to this collaboration, a lot of these trainees really had the belief that you'd only refer to rehab for musculoskeletal issues. And so it was really eyeopening for them. So I found it to be a beneficial endeavor for them to learn some of the basic assessments of patients recovering from brain injuries, but also give them an awareness so that these patients that they may see, and these are future primary care providers, they may see in their outpatient setting that they would be aware of how to refer these patients appropriately, what care that might be available to them. So I found that to be a very fruitful endeavor as well. And in addition, I participated in medical school education. I was a preceptor for the clinical, introductory clinical course for the medical school, which is known as the art of science and medicine. And then I also gave various didactics and grand rounds for various divisions within the medical school. And then from a research standpoint, as I said, I was the medical director of the Brain Injury Research Center in Mount Sinai. What this resulted in was collaborations on abstracts, original research education, educational endeavors that the Brain Injury Research Center engaged in. Ultimately, any studies that had some kind of clinical implication, whether it was a survey or they sought to do an intervention or answer a question, clinical question, was ran by me to kind of gauge whether this was gonna be clinically relevant or appropriate for this given patient population. And then there were studies that they were actively recruiting from our inpatient rehab unit for. So I had to keep abreast of those, my I and as well as the brain injury fellow to educate families and patients about these studies and gauge whether they would be interested in participating. Work with the Brain Injury Research Center in terms of getting them enrolled for these studies. And then there was also community outreach. So in addition to research, the BERC oversaw peer networking groups, weekly or monthly group sessions that were more for longer term patients further out from their injuries. That kind of kept them within the system, kept them access to resources, even if they kind of were further out from their injury, but just to have that kind of coping and network in place. So it was important to kind of educate the community that that existed. And then also relevant studies that they might be good candidates for to educate them for those as well. So that was kind of like my role with regards to research. So that's kind of a summary of what I kind of did in my clinical practice during my time at Sinai. I think I'm reflective of someone that took on a role in a busy academic hospital system and was kind of tasked with kind of doing all of the aspects that kind of entails clinical education and research. And I think I'm also reflective of how things can evolve, how your career path can evolve over time. So even though you're sitting at the beginning of your career, not really sure what you wanna take on or what is of interest, I think if you pulled me 10 years ago, I don't think I ever would have foresaw the things that I was able to accomplish in the last eight years that I've been at Sinai. And I think that I would just tell anybody that stay open-minded and go with what drives you and what you become passionate about, because I think that that will really lead to success. And I think that that's something that I look back very fondly in terms of what I've accomplished and I look forward to what I will accomplish. I hope you have questions or comments. Please put them in the chat. We'll address them in the Q&A, but for now I'm gonna pass the baton over to Dr. Greenwald, who will give an introduction to the field and talk about his clinical practice as well. Dr. Greenwald, the floor is yours. Great. Can everybody see my screen? Kirk, can everybody see my screen? Yes, you look good. Great. I'm excited to give this talk. This is really this talk, although it has this fancy name to it, really the talk is why you should do brain injury medicine over anything else. And looking at this panel and the great people on this panel, honestly reminds me of not only how interesting that the patient care is, but how great the other people that are in brain injury medicine are. So many great people to work with, so many people with a similar passion to myself for taking care of this complex group. So I'm over at JFK Johnson Rehabilitation Institute, and I'm the director of the Center for Brain Injuries here. So let's see. So I have no disclosures. Let's talk a little about the history of it. So I'll go back to 1999 when I was completing my residency over at Kessler. You know, I really enjoyed everything. I can't say that I went through things and said, oh, I definitely don't want to do this. I was really enjoying everything. I enjoyed the neuro part of it. I enjoyed the musculoskeletal part. I felt a strong interest in neuro. And when I was considering going to PMR in general, I considered neurology as an option, but I was looking for a fellowship and a career where I could kind of do everything. So I'll just remind you, this was 1999. This is sort of Y2K, you know, the front of Time Magazine here, people saying it's the end of the world. With that said, I was still figuring I'd just do, I'd still do a fellowship. So at that time, there's really very, there's very few, there's very few brain injury fellowships. So at that point, really there's three brain injury fellowships, really two brain injury fellowships. One of them I didn't get funding that year. There's also very few brain injury medicine applicants. Most of the people really that were doing brain injury medicine had learned on the job. And still if you talk to people a little older than me, most of them hadn't done fellowships. And I realized people asked me, do I really need to do a fellowship also? Right. Since a lot of people had learned on the job, I'd come through a really good program. I had gone through Kessler. I learned a lot about brain injury. I really felt though that a concentrated year of learning to start my career would really help. And then, and I think I was right. I think now even more so now that there are so many fellowships and that there is, you know, ACG accreditation for fellowships, it's that much more necessary to do a fellowship, to have that gold seal. So my own fellowships, I did my fellowship at Virginia Commonwealth University in Richmond, Virginia. But again, this is before ACG and me and there's no real requirements. You know, they were able to say that they had a fellowship because they had the things that people would be interested in fellowship. And so I come there the first day and Dr. Sifu, who is my mentor and was the chairman of the department, he says, well, we didn't have a fellow last year. What do you want to do? And I was like, what do I want to do? I was sort of used to a lot of structure where they told me what I was going to do. And so I looked at it and oh, you know, what I really wanted to do. Certainly there's still the focus was going to be on moderate to severe traumatic brain injury, but I said I'm kind of interested in learning some outpatient also. They have an outpatient clinic, some inpatients, consulting, some procedures. I wanted to be involved with research. I wanted to learn a little about administration also, since I knew that that was going to be a part of my life, you know, billing is we're all physicians. We know that that's going to be part of your life also, you know, leadership school skills and teaching. And those are the things that I sort of set up my year that way to have kind of a piece of all these things. So when I finished up my fellowship, I was kind of one of the few people who had done a brain injury medicine fellowship in the area. And I certainly found an advantage of being fellowship trained the jobs that I offered right out of the bat were very interesting. So where I started is where Dr. Yonklis is now over at university hospital in Newark. It was part of the program that I had done my residency in. And so they were eager to have me over there. They were looking for someone who's fellowship trained like myself who could bring something new and exciting to the consulting world there in trauma. And this is an important piece. If you've learned nothing from my lecture so far, let's do this part specifically. So Dr. Sifu, my mentor, like you saying to me, you know, right. And one thing that's really important is to have startup with the right title. And he said, it's always good to call yourself a director, even if you're new right out there. So I told the administrators over at university hospital, I said that I'd be willing to take the job, but my title is going to be the director of trauma rehabilitation. So they looked at me quizzically and said, the director of trauma rehabilitation, we don't have such a title. I said, now you do. And I became the director of trauma rehabilitation there. I was a consultant for the trauma service. I became really intimately involved in their service. So to seeing each of their trauma patients, particularly brain injury patients that work closely with neurology and neurosurgery. And it was fun that it was a specific population of patients who often who, some of which wouldn't end up getting to go to a rehabilitation, but even so needed someone like myself to do education, you know, of the families, of the patients, to help with sort of early management of the patients. It was a very interesting position and I enjoyed it. I was there for just three years before Mount Sinai in New York city, maybe an operator to come and eventually be their director of their brain injury medicine program. And then about after being there for about 10 years, at JFK where I am now, maybe an offer I couldn't refuse to be the director of their brain injury medicine program. So let me look at some of the changes that occurred over this last 20 years. So like I said, I did my fellowship about 20 years ago. So all of a sudden de novo, I had this outpatient practice over at Mount Sinai and all of a sudden de novo, all these concussion patients started coming to my practice. And I have to admit, I didn't get a lot of training in concussion prior to this point. I was kind of learning it on my own. These patients sort of freaked me out a little bit in 2010, 2008, 2009, 2010, because I was used to moderate to severe brain injury patients where they have a lot of findings on CT scan. And the neuro exam is generally abnormal. Here we had concussion patients for those who have started seeing this population. They often have nothing on CT scan or MRI, and yet they're very symptomatic with very specific types of symptoms. I think what inspired that was really a lot of the media coverage that was going on at that time between the military and sports and the NFL specifically, as I got to enjoy and get used to taking care of this population, it really is how great, how nicely suited physiatrists are to take care of this population. Since most of this population have both brain issues, but also musculoskeletal issues. And if you're someone who's not accustomed to take care of the musculoskeletal issues, you're not well-suited to take care of concussion patients because that plays such a big role, the pain issues. I mean, even just some sort of focus like headaches, if you don't understand some of the musculoskeletal issues, you're going to miss and not treat well so many of the issues that happen to this concussion population. So then ACGME. So the academy as an example, and then the people who were working at the academy at that time, it was the Brain Injury Medicine Special Interest Group. They had had a long interest in creating a new subspecialty in brain injury medicine, you know, dating back to before I joined that group in the late nineties. But it was really around 2010, 2012, with all that was going on between the military and the NFL, that the ACGME realized that really, they really need to establish a new specialty or subspecialty called brain injury medicine. You know, they had already established the subspecialty of spinal cord injury medicine, and they use that sort of as, as a way of thinking about establishing brain injury medicine. They brought in the other specialties that might have an interest in this area, neurology and psychiatry. And, and although they made the American board of physical medicine rehab, the lead specialty, they allowed neurologists and psychiatrists to become board certified. They also grandfathered people in over the first decade of the subspecialty. And that continues to right about now. I think the last exam that'll be like that is 2022. Since I was saying that a lot of people, you know, in years past had just like learn to, to take care of these patients and hadn't done fellowships. And, and there's still the, the fellowships are still growing. They allowed people to, to grandfather in with just taking the examination over this first decade of the establishment of the fellowship. So I actually, I love this, honestly, I love this definition of the specialty. I can't say that I was involved in writing this definition, but I think when you, it really talks about what I enjoy about the fellowship or enjoy about being a brain injury medicine specialist, brain injury medicine addresses the prevention diagnosis, treatment and management of persons with brain injury, including the prevention diagnosis and treatment of related medical, physical, psychosocial, and vocational disabilities and complications during the lifetime of the patient. And I emphasize during the lifetime of the patient, I think, you know, oftentimes people going into physical medicine rehab or going to medicine, just in general, are looking for that long-term relationship with patients and looking to feel like they have that long-term relationship with patients. And there are patients that I'm treating now that I was treating back in Sinai, you know, 10, 12, you know, 13, 14 years ago, just that deep relationship that I created with these patients lets them come up here to New Jersey to continue under my care. So ACGME in 2014, PM&M program started to apply for ACGME accreditation. Over these years, you know, the match from the national residency matching program was established and, and then ERES, you know, the electronic residency application service also was brought together. And now there's about 24 ACGME accredited program, a lot relative to, like I said, the two or three that were available when I applied in 1999. But when you look at the requirements and it's worthwhile, if, if, you know, as an applicant, if you haven't had a chance to look at it, go onto the ACGME website and take a look at the requirements and you'll appreciate all the great things that are going on that are, that are required of each program. So, like I said, I didn't, I wasn't so involved with the concussion, but now that that's a standard part of the requirements, concussion, blast and combat injuries, repetitive head injuries, that you have to learn about consulting such an important part of things, pharmacology, prognosis, aging, and brain injury. And that during the fellowship, they're not necessarily wanting to make you a researcher, but to at least give you a taste of research. And that is a required part of the fellowship. Certainly for people who are procedure oriented, and certainly PM&R overall is a procedure oriented specialty, you know, spasticity management. There's certainly so many opportunities with regards to botulinum toxin managing intrathecal baclofen pumps and treating dystonia. And then I think becoming increasingly common is Botox for migraines. And, you know, during our own fellowship here, we make sure that the fellow leaves feeling comfortable treating all these diagnoses and doing a high volume of these procedures. And I think the beauty of it also is that you're still a physiatrist. And I know Dr. Yonkos is going to talk a little bit about this, but you get to use all your musculoskeletal skills, right? So that, you know, like I was saying how important it is to understand the musculoskeletal diagnoses to be able to treat the concussion patients, but for all these patients across the spectrum, you know, understanding the diagnostics and the interventional procedures and, you know, understanding pain management of this population. And, you know, certainly the opportunity to EMG is in neuroconjunction studies, et cetera. These are all a part of the specialty also. It's not like, oh, you have to stop thinking about any of those things. Once you go into, into brain injury medicine, I know for myself, I'm not doing as much of those things anymore because I'm so busy with all the brain injury medicine work, but, you know, certainly you can create the specialty yourself. And I know some of my colleagues are going to talk a little bit more about that. I really appreciate everybody's time. I put my email address here. I'm always eager to take questions from people who are interested in learning more about the specialty. I'd be happy to talk more. I'm going to turn it over now to Dr. Crawford. As soon as I figured out how to stop sharing my screen, that is. All right. Okay. All right, let's see. Everybody hear me okay. Okay. So I am Dr. Kelly Crawford. I am from Carolina is rehabilitation. And for some reason, I am not. There we are. Okay. So I'm Dr. Kelly Crawford I'm from Carolina is rehabilitation and Charlotte, North Carolina. And I am here to kind of speak about academic medicine and the route, you can go into after brain injury fellowship, very similar to Dr. And so I kind of focused on the different aspects of kind of how my career has evolved over the past eight years, and some into the unknown. Some of these titles I wasn't exactly thinking, I was going to be holding in the future. But that's kind of how careers go is, is you evolve into you know as your interest evolves. So, the titles I currently hold right now are the fellowship program director in brain injury medicine here at Carolina rehab, and also the medical director of the brain injury medicine program. However, on November 1, I will be taking over taking over the residency program director as well as our current program director is going on to be a chair at the University of Alabama. So again, it's kind of one of those things as your career goes on you evolve into different aspects and so with my background in academics and being the fellowship program director, it was just kind of a natural step into the academic world. And so how did I get here. So, I did my residency at the University of Cincinnati. And if anybody is following college football right now go Bearcats, we are up there in the top five right now so fingers crossed. So that's where I did my residency and that that is a residency there you did all four years there. And then I did my fellowship at the University of Pittsburgh. That's Dr. Lercher and I were there at the same time. And then, of course, took the board certification exam. And then, after being board certified in brain injury medicine, I then be went back to University of Cincinnati, and I became the brain injury medicine director at at University of Cincinnati. And I then was also the associate residency director program director at University of Cincinnati as well. And of course, again, things evolve. And with that, there were some changes kind of within the program, and there were openings at Carolina's rehabilitation, specifically the brain injury directorship. And so that's when I then moved down to Carolina's and took over the brain injury program here in Charlotte. And that's where I start I've been here since 2016. And so just roughly going over briefly what you can do and how my career has evolved with with fellowship. I think I'm, again, more of the traditional type when you think of folks who have done fellowship. So I currently do kind of rotate between three rotations. We do have a pretty robust brain injury service here, we have four full time brain injury attendings. And with that, we carry to inpatient brain injury services at a time, and very similar to Dr. Lercher said we carry between 12 and 14 patients, each on the inpatient unit. And so we also have a consult service where we have a consult physician, just working with the brain injury team at the same time. And then we all do our outpatient clinics as well. So as far as my clinical practice goes, really the inpatient medicine we do all acquired brain injuries, we do anoxic, severe strokes, intracranial bleeds and of course your traumatic brain injuries which is what most of us think of. But with that, we kind of do all the medical care, coordinate with the therapists, therapy treatments as well. And then on the consult service, again, as we rotate, that is what we're solely focused on, we rotate every two months. So for two months at a time, we are solely just on the consult service. We work mostly with the trauma and neurosurgery teams, specifically in the ICUs. And I know one former medical student is on right now, who we work in the ICUs really from day one or two when they've been admitted to the ICU. So we really start that disorders of consciousness program treatment, really working one on one with the trauma service and the neurosurgery ICUs. And we cover the whole entire spectrum. So we may get a consult in the ICU of somebody who's still on the vent or, you know, this disorders of consciousness, all the way to somebody who maybe came in the day before and, you know, had a mild brain injury or concussion who will then be going home. But we're still consulted to provide education, what symptoms to look out for post-concussive syndrome, and then setting them up in our outpatient clinic for follow up, should they have any of these symptoms. And then, of course, the outpatient clinic, I think this is pretty standard, but we do do the spasticity management. And that's from baclofen pump management to Botox, phenol, and, of course, medication management. And then we do see concussion and mild brain injury patients as well. And then, of course, along the spectrum of care. So those patients we discharge from our inpatient unit are now being seen in our outpatient unit, our outpatient clinic. And so we really do see that entirety of that treatment. And, you know, some of the benefits are sometimes you can see them on the consult service in the acute care. And you'll see them on your inpatient service when we transition over to the inpatient side and then seeing them in clinic, you know, months down the road after they've been discharged as well. So a lot of times you'll pick these patients up from the very beginning. And then, of course, continue to follow them all the way home. So that's something that has been very beneficial, I think, from an educational standpoint as well. So that's the basis of the clinical aspect and the clinical practice of what I do. But then I also want to kind of go over the medical directorship, too. And I think Dr. Lurcher went over a lot of this as well. But with a medical directorship, you know, again, trying to coordinating coordinate all those different aspects. So there's inpatient medicine where you have to coordinate the different medical providers and rotations. So, as I said, we have four providers that are rotating between different services and kind of coordinating our protocols and coordinating our schedules is always sometimes challenging. But that's what a medical director does, of course, unit management. So there's always those meetings going over nursing and therapy issues, what we can make better, making standards of care, making sure we have educational educational sessions for everybody involved on the unit. And, of course, program evaluation and protocols. So as a medical director, you're in charge of kind of really everything that is involved in the program. And that's standardization of care, making sure protocols are in writing. A lot of the times I'm very surprised about what I actually have to make sure is documented as a protocol because it sometimes seems like common sense. But sometimes you do just have to make sure you have protocols in writing for for certain standards of care. And then, of course, on the consult service, building those relationships with the primary services. Again, specifically trauma and neurosurgery, kind of the bread and butter of the patients that we see neurology as well. But making sure you're keeping in contact. Maybe you're building those relationships by contacting them, providing your consulting services and making your recommendations, but also coordinating any educational opportunities that may go back and forth between residency programs or fellowships as well. And, of course, making sure you're educating people regarding our rehab services. I think sometimes there is the, you know, we get consulted for discharge planning. But really part of our job is also educating on what else we do and what else we can do for the patient. We are not just what your discharge options are. There are other things, especially from a brain injury standpoint, that we can help with, such as, again, spasticity, agitation management, autonomic storming, things of that nature. Which really you build that education and you educate, especially when you have new residents coming in on the other services of kind of what you have to offer. So we do offer our educational services on the consult service as well to kind of help guide, you know, treatment plans and further issues that we can help with and help with treatment of these patients early on while they're in the acute hospital. And, again, program protocols. We're working with neurosurgery and the trauma service, you know, about what protocols and standards need to be in place before they come to rehab. You know, needing simple things and making sure you have lab work done 24 hours, 24 to 48 hours before they can transition. You know, now a big thing is making sure they have a negative COVID test before they come. So little things like that, standards and protocols that you need to make sure that are in place so that there's a common understanding of, you know, what's acceptable and not a lot of pushback of these are things that need to be done before you would make sure that they're accepted appropriately to a rehab setting. And so little things like that, again. And then, of course, the outpatient clinic, we're in charge of referral management, the clinic workflow, whether that be nursing protocols and what nurses are assigned to certain physicians to make sure the workflow goes at ease because I will tell you that the, especially here, our brain injury clinics are the most overrun. We have a lot of patients, more than, you know, the providers can handle at one time. So we need to make sure that our clinics are efficient. So there's different protocols and workflows that we need to help coordinate to make sure that that goes well. And so those are kind of the things as a medical director you weigh in on and you help facilitate. And then just lastly, going over the academic side. So with all of this that we just spoke about, there's all, you know, you have residents and fellows involved. Our particular program, we have five residents per year and a brain injury fellow. And so really, as the program director for the fellowship and soon to be residency program, you have to make sure you have the resident curriculum in place. You have to make sure you're working, they're working with physicians that want to teach and that they provide adequate education or good education. So, you know, just because somebody is a physician doesn't mean they actually want to teach or teach well. So you have to make sure that those standards are in place. There's evaluations and feedback that has to be done on a regular basis and documented. But the thing this does allows for opportunities for research or opportunities for growth. When you have people who are eager to learn and eager to do things, you know, you can do things like case reports and help with QI projects that kind of help facilitate protocols or helping with patient management and care at that point too. So, you know, there's all these other great things that come along with having just the residents and fellows there with you. And then Dr. Greenwald alluded to this, but you have ACG requirements. You have to go through that twice a year and making sure that everybody's meeting their milestones, making sure your program is meeting all the requirements that are required for you to sustain your program and departmental requirements. So not only do you have to worry about the education piece, you also worry about if you're meeting the department requirements associated with all that. And then beyond that, you have to look at your academic, which means your publications, your case reports, oral presentations, or posters, and then your clinical production. Just because you're spending all this time doing some education and doing things with the fellows and residents, you also have to do your clinical production too. So there's always this thought that you have to make sure you're seeing patients, and that's the bottom line. Your job is there to take care of patients, and that's kind of what we went in to do when we first started this. But over, you know, the past seven to eight years as I've been doing this, obviously a lot more time has been geared towards doing that education piece. So the clinical production year by year has gone down a little bit, although some still expectations in some areas. But, you know, a lot of that time does go through the paperwork and the evaluations and the feedback and a lot of meetings. Sometimes you're in meetings about meetings. But there's a lot to coordinate when you're going through the academic and the clinical aspects of things. So just something to consider. I love it. I love working with residents. I love working with fellows. I thoroughly enjoy it. There's also the research aspect of it. That was not my cup of tea. I'm very much a clinician and educator. Not that that doesn't mean research, but, you know, we do have our own research department here within our department. And so we do have a head of our research department that kind of facilitates more of the research aspect of it. So I kind of weigh in every once in a while and help out. But that, by all means, my part is more the education and the academic and clinical production part of our department. So that's kind of where I've come from and where my career has taken me over the past seven to eight years since I finished fellowship. And, again, not necessarily where I thought I would be. I don't know if I ever thought I would be running a brain injury service and kind of working as an attending physician. I knew I wanted to do academics, but I don't think I thought my academic career would kind of evolve to where it has over the past few years. So that is my background. With that, I will hand over to Dr. Peter Yonklas. Hello, everybody. Thank you, Dr. Crawford. This kind of feels like a homecoming for me, at least with Dr. Greenwald, because I took over his consultation service years ago that I'll talk to a little bit. But I was asked to speak about consultation practice within brain injury medicine. I often encourage many of my residents I'm attending, as you can see, within the Department of PM&R. But I have a primary appointment as a director of trauma rehabilitation, again, thanks to Dr. Greenwald within the Division of Trauma Surgery. But I talked to him about how that specialty fellowship training, as Dr. Greenwald mentioned, still allows you to do so much more. And I think hopefully this talk will show you what you can do. I have no financial interests or no disclosures today. I'm one of the older people. I guess Dr. Greenwald is a little bit more my predecessor. I graduated residency in 2003. And like probably many of us who consider rehab initially, I was interested in sports and spine, having played college athletics. But I also always had an interest in neurorehab. I originally was accepted to a pain fellowship out of residency, but wasn't sure I wanted to do that. So I took a role as a practicing attending, if you want to think about it, where I learned some interventional spine, as well as got a quick crash course brain injury fellowship under Dr. Greenwald. At the time, I believe there were only five fellowships, and none of them were ACGME accredited. So I'm one of those people who was grandfathered in in 2014, taking the test when it was first offered. I currently, again, thanks to Dr. Greenwald, serve as the Director of Trauma Rehabilitation, a title he created, within a level one trauma center in Newark, New Jersey. I've been the primary PM&R consultant for 18 years. We've had a few other people, and I now currently have a PM&R partner who's fellowship trained, who helps with the care of our brain injury patients. And as I said before, I'm primarily appointed within the Department of Surgery. So for the first five years, it was in the Department of PM&R. And then the last 13 years, I've had an appointment primarily within surgery. So my role has really expanded over the years. I started consulting mostly on brain injury patients, but because I think in part my interest and the opportunity, I expanded into all relevant PM&R related diagnoses that you'll see in an acute care hospital, as well as you'll see in a trauma service. The key idea is that the subspecialty focus allowed me to get a foot in the door to expand to doing more things that I wanted to do. Currently, I do a host of things like almost everybody on this talk, and it's not even including everything I do do. I still do primarily trauma consults. I'm mostly now focused in the ICU and less on the floor. I do brain injury medicine, as well as other PM&R consults for our entire hospital. Most of those are focused on acquired brain injury, whether it's anoxic brain injury or strokes or neurosurgery patients. I also direct an acquired brain injury clinic that serves our underserved population within Newark. And I've now, through my role with trauma surgery, serve as the co-director of a trauma survivor clinic in that we manage patients who spent time in our ICU, at least two days in the ICU, and they follow up with us for continuity. These are patients who may not go to rehab or patients who've gone to a rehab facility but need long-term care afterwards. And I'd say at least 60 to 70% of those are brain injury patients that I see as well as spinal cord and other trauma injuries. I run two concussion clinics, and believe it or not, I still serve as a team physician, still seeing some musculoskeletal athletes within the community. And I treat, like Dr. Greenwald mentioned, both athletes, and Dr. Lercher mentioned, and non-athletes, as you've seen. There's just been such a growth of that field over the past 10 years. I continue a private outpatient practice where I see general PM&R as well as do electrodiagnosis. And educationally, I'm still involved in teaching with a brain injury fellow who rotates with me, two spinal cord fellows, as well as two residents. I think the key thing, as Dr. Crawford and Dr. Lercher and Dr. Greenwald all mentioned, there's great opportunity within the field to do many different things. And a trauma consultation service really provides an excellent opportunity to practice brain injury medicine as well as treat other complex diagnoses. Through my years, I feel like I've evolved. I remain a brain injury physician, but I think I've become a little bit more of a general physiatrist as well because of all the other issues that I end up managing. There's such a tremendous opportunity to practice multiple skill sets within the field. As Dr. Crawford mentioned, I am involved in TBI management from essentially trauma bay to discharge and follow-up. And that sometimes will be meeting people in the trauma bay to clear them to go home if they've had a mild head injury, as well as meeting families early on if there was a poor prognosis with a severe devastating brain injury. With the trauma surgeons, we'll often get my input involved early. And then I will be involved in brain injury management from dysautonomia, arousal interventions, post-traumatic agitation, as well as spasticity management, post-concussive mild head injury symptom management with headaches and vertigo. I'm also involved still in management of spinal cord injured patients. I perform the INSCE exams with a fellow or by myself and my residents and help manage many of the same issues you would deal with in an acute care center with neurogenic bowel, bladder, autonomic dysreflexia, et cetera. As I said, I became a little more general. I'm now more involved in managing some of our amputees on the trauma service early on, as well as peripheral nerve injuries, both in diagnosis and management of them. I continue to do musculoskeletal. There is a lot of soft tissue injuries. Dr. Greenwald mentioned, especially in whiplash injuries where people may have myofascial pain. I no longer do any interventional spine procedures, but I continue to do peripheral joint injections, trigger point injections, as well as Botox. My role in surgery has had me evolve. As Dr. Crawford mentioned, I became very protocolized and very involved in our critical care services. So I have taken a more active role in delirium and agitation management, partly at the request and partly out of need, but I'm actively involved in establishing protocols for reducing ICU delirium, as well as assisting with medication management for delirium as well as education. As I mentioned before, one of the things that I find very rewarding is I'm involved early on in prognosis, meeting the families, discussing brain injury, the course, and it's very rewarding, as well as unfortunately sometimes not so good meetings when it's more palliative care. And I still am involved in team meetings as you would in an acute care setting. As Dr. Greenwald mentioned, we do have a large number of patients who don't have resources to go to an acute care rehab facility. So I am actively involved with our therapy department in coming up with plans to get these patients home safely so that we can then follow them as outpatients. And my residents always ask me, how do we develop this service? And I give Dr. Greenwald some credit because he really laid the foundation, but it can be done anywhere. And I think having, as I said, that subspecialty focus allows you the opportunity to do that. But one of the biggest barriers, as you probably all have seen with PM&R is there was a lack of understanding what we can do. And I think as Dr. Crawford mentioned, education is key. Surveys suggest that PM&R consultation is present up to 91% of level one trauma centers and the American College of Surgeons makes it a requirement for level one trauma surgeons to have PM&R involvement. But what that role is, is quite variable. As you know, emphasis in the trauma system is really trying to stabilize the patient, save their life and performing whatever fixative treatments are necessary before they're moved out of the hospital, either to home or to rehabilitation. And unfortunately, in some institutions, the physiatrist may be viewed only as a person who really helps with that discharge planning and determining an appropriate discharge. In many facilities, particularly that have a associated in system rehabilitation hospital, the physiatrist usually only has a role in determining the appropriateness for admission into that system. And therefore it can be frustrating. And I think having that specialty focus that I'll talk about a little bit more allows you to start to grow your role. So it's not just that. The other assumption that we encounter as physiatrists and sometimes even brain injury physicians, they don't know what we do, that they assume that we're a therapy doctor and our goal is only really to assess the patient to begin therapy, which again can hinder what we have to offer and can also hinder your job satisfaction. So as Dr. Crawford really mentioned, if you want to start a successful practice, education is key. I think I learned this from Dr. Greenwald when I was working with him, but you can do this formally or informally and both are equally effective. Formally giving grand rounds as much as possible, like Dr. Lercher mentioned, to start a collaboration is fantastic. And I've given grand rounds on PMR related topics from ENT to pediatrics, to neurosurgery and trauma. The other opportunity you have is giving didactics. I'm often involved in our neurology and neurosurgery didactic education. And it really is a chance to promote what you can do as a physiatrist and more specifically what you can do as a brain injury trained physician. I also will give in-service educational sessions to nursing and social work so that they're aware and have more eyes on kind of the patients and what needs might be there. But I think what ends up being probably, as Dr. Crawford alluded to, most effective is more the informal teaching, whether it's as Dr. Lercher and Dr. Crawford have said, taking other services and teaching other residents will often have neurosurgery residents and orthopedic residents rotate with us. But I'll also take the opportunity when I'm rounding in the ICU to educate their critical care fellows, as well as their residents about why we are doing something and helping so that they're aware that they can look to us for help if they need it, but also to show them what we're capable of doing. So when they go out in their future careers, I'll keep that in mind. Another great area to educate, to really show our knowledge base and what we can do is educating through notes, explaining why we might be starting certain medicines for storming or for central fevers, as well as why you want to use certain medicines for agitation and others not. When we had paper charts, leaving articles is a great idea. I know it is very good for our medicine service. We'll quote with a PubMed reference why we want to start certain medicines. And it's a very effective way to kind of break that barrier and really help to understanding for other services about what you can do and how you can grow a very rewarding and satisfying practice. The other barrier we sometimes encounter and Dr. Lercher alluded to as well is that there's competition or overlap with other services. Neurology in some institutions have traditionally historically been the primary physicians responsible for management of brain injury. There's also overlap with geriatric medicine for elderly trauma patients who may or may not have a brain injury. Psychiatry as well is a big issue that I think I had to learn to work with as I began to take over more of delirium management in our ICUs, as well as overlap with neurosurgery, orthopedics, plastic surgery when dealing with peripheral nerve injuries and ortho sports, as well as dealing with soft tissue injuries. The general idea, if you are doing a trauma consult services, these patients are generally extremely complex and there is room for multiple services in their treatment. And again, education becomes very important to help people understand how we may provide different services than neurologists or than orthopedists. And you can establish that by showing how we are similar yet different in your notes without insulting that service. If any of you are graduating fellows or residents want to remember this going into a future practice, a gradual introduction into an established service is probably better as to not offend the service. I know I gradually began to take over more of the agitation management, co-treating with our psychiatrists. And I attempted to always do it slowly as well as cordially so that there was not any offense given. So I oftentimes will suggest to my residents and fellows that you give a shout out when you're co-treating with another service that you agree with their management so that at least you all know you have the best interests of the patient at heart and you recognize multiple ideas that may be appropriate for a patient. And then perhaps the last area that I think is sometimes a barrier for patients, I mean, for physicians, specifically brain injury physicians to establish a successful consult service is provider comfort. As you've already seen, there's a breadth of diagnoses that you can encounter in a good acute care setting, but we're well-trained as physiatrists to handle them. Sometimes this can be intimidating if you have extreme comfort in one discipline, specifically brain injury and not another, say spinal cord, but you do have the training to fall back on that really I think can make it an extremely rewarding career that can help you grow. I think part of the reason I've stayed here when I've had opportunities to go elsewhere is it's just been a continual learning process and I'm continually challenged. And when I have questions, I am humble enough to contact colleagues who may be spinal cord trained or colleagues at a different institution when I have issues so that patient care is always the primary goal and taking care of the patient is the best thing for them. And sometimes swallowing pride is not such a tough thing. Lastly, for those of you who are graduating, and I think everybody touched upon it, Dr. Lercher, Dr. Greenwald, Dr. Crawford, is that there is a time required to establish one of these successful practices. And I think Dr. Lercher gave a very good outline of how you can begin to make inroads with other services, but you should always keep in mind the three A's of consulting. And I often add a fourth A. We've all heard the three A's, the available, the affable, and the aptitude. Probably the available and affable are actually more important than the aptitude, but you just wanna have a presence by making rounds, interacting so that people will know who you are, and just be pleasant. The aptitude comes with practice and time, but that really can set you apart. And I think really what lastly can set you apart is the A I add that I learned during my training is that adding value, something to the management of the patients will make your service grow. It's not just simply starting therapies, but looking at the medications to see how changing it may benefit a patient. Certainly if you're dealing with specific brain injury issues, you can make certain recommendations, but invariably this will be well appreciated by the consult service and allow you to grow. That's it for me. Like Dr. Greenwald, I'm happy to take questions with my email afterwards, and then I'll certainly take questions at the end of this session. Thank you. And next is Dr. Magat, who'll be talking about outpatient practice. Thank you. Let me just figure out, stop sharing. Let me see if I can share my screen. Okay. All right. Looks like everybody can see my screen now. So let me introduce myself. My name is Elaine Magat. I am an assistant professor of physical medicine and rehabilitation with the McGovern Medical School, the University of Texas Health Science Center at Houston, or UT Health for short. And I am also an attending physician with the brain injury stroke and spasticity programs at Memorial Hermann Tierre at the Texas Medical Center in Houston. I do not have any financial disclosure or financial conflicts of interest with the presented materials today. My professional background and career path, likely in general, would be similar from my other colleagues who presented before me. My interest in the field of rehabilitation medicine started and was solidified while I was getting my bachelor of science in physical therapy as a pre-med course. And so after I finished med school, it at least to me felt like it's a natural transition to go into a residency or to specialize in rehabilitation medicine, which is what the specialty was called back in the Philippines. Maybe where I differ from a lot of you is when I moved to the US, I had to do a second residency. Also in the field of physical medicine and rehab. Where I did my residency, the program was very strong in neurologic diagnosis. And it was also a big interest of mine, particularly brain injury and spinal cord injury rehab medicine. But there was this particular aspect of brain injury training that I really liked. And it was the procedural based, procedural aspect of treating spasticity, particularly chemo denervation and neuralysis. At that time in my residency program, the brain injury attendings were the ones who mainly did these procedures. And I really wanted to improve my skill, maybe improve my confidence and comfort level in performing that procedure. And that's what kind of pushed me towards really going for a fellowship training. And just like the others, the fellowship training at that time was not ACGME accredited. After I did graduate, I did receive a certificate saying that I did finish one year of brain injury fellowship. Immediately after graduating from training, my career, I went out in the community, but ultimately landed in a position wherein it was also academic affiliated. And I was an attending physician PM&R for an acute inpatient rehab unit slash hospital. But the diagnosis of patient or the patient cases that I took care of were mixed, mostly mixed diagnosis. Shortly thereafter though, two other possible career pathways or opportunities presented to me. I was offered to come back within the fold and back into the hospital where I trained. One career path would have been being the medical director of a small rehabilitation, acute rehab unit, wherein I will work directly with the neurology stroke team, receiving their patients after a few days of them treating and stabilizing acute strokes. And the other pathway or the other opportunity that was presented to me was being an outpatient-based brain injury medicine physiatrist. And between the two, I did choose to go for that mainly outpatient-based practice in this hospital. And then nine to 10 years later, I'm still here doing what I'm doing. So what do I do and where do I work? So I work out of the TIR Outpatient Medical Clinics. It's part of the TIR Memorial Hermann Hospital here at the Texas Medical Center in Houston. TIR is an acute inpatient freestanding rehabilitation hospital. So the clinic is within the hospital and our clinic is patterned on a multi-specialty quote-unquote based clinic where in the other specialties are anchored around the PMNR or the physiatrists and our patient population needs at any given half day of the work week. So we measure the amount of time spent in clinics in half days. There would be different PMNR subspecialties that would be going including spinal cord injury, cancer rehab, pediatric rehab, brain injury, MSK interventional pain. And there was at one point also a specialty clinic. We kind of designate those diagnoses that don't fall under brain injury and spinal cord injury tree as a specialty case. So currently the other specialties that hold their clinics out of the tier OMC or the tier outpatient medical clinics include the urology, OBGYN, internal medicine, neurology, sleep, epileptology, podiatry, psychiatry, general surgery, wound care, physician. And I'm sure I may be forgetting a few, but I think you get the drift. Initially when I started my clinic, obviously you have to build your practice. So I wasn't really purely brain injury based physician. At some point I was also staffing the post-polio clinic here at tier. And then I was also doing some concussion clinics, patient population of which I share with other PMNR physicians that practice out of the clinic. As I stayed longer in the position, my practice grew. And currently most of the patients that I see in the clinic have acquired brain injury diagnosis, about 99% of them or so, and including strokes, the moderate and mostly severe traumatic brain injured patients and anoxic brain injury. I do sometimes get to see patients with primary brain tumor or metastatic brain cancer diagnosis, cerebral palsy. A lot of times though, because we do have a cancer rehab subspecialty clinic at tier OMC, I would transition these patients out to that clinic. I do have a handful of multiple sclerosis patients, polytrauma, peripheral nerve involvement and such. A lot of my patient population do have spasticity and a lot of them require neurolytic injections, specifically botulinum toxinase, what we use here. And so that really kind of is really up my alley and is my interest. So what may it look like for somebody who chooses a career path of being mostly or mainly outpatient based? So what you're seeing in this slide is what it is for me, but keep in mind that there might be several different formats of how one might conduct their clinics. You've heard from our colleagues who previously gave the talk that they have a mix of consults, inpatients and clinic. Other hybrid or forms would be doing a few half days in clinic and doing research, or a few half days in clinic and doing consults, or with clinic covering for a primary brain injury attending in the brain injury units, or there is the private practice model as well. I do have one or two colleagues in the community who solely do brain injury clinics, and that would also, aside from the regular follow-ups, they also sometimes would do procedure-based spasticity management. For me specifically, Monday to Friday, I do clinics morning AM or PM half, AM and afternoon clinics, except for one half day, wherein, just like the rest of us, it's something that I set aside for administrative duties. So aside from doing clinics and being the clinician, I'm also the medical director of Tier Outpatient Medical Clinic. We do also have a residency and fellowship program, and then we do actively participate in teaching and education. So for right now, a third of the clinics for any given month of my clinics are dedicated for procedure or injections, and the rest are regular patient encounters, may be new visits or follow-up visits for established patients. I also do provide coverage for the inpatient rehab units, brain injury for a tier hospital on the weekends, and as needed. The as-needed part, not as much nowadays, because we now have a relatively full complement of brain injury docs handling the inpatient side. Coverage for the inpatient helps with productivity and helps with sustainability of the position that I'm in right now. And I already mentioned this one, that prior to being able to develop the clinic, my clinic as it is, I was doing non-brain injury follow-up care as well. So where do the referrals come from from my clinic? So originally, this position that I am in right now was created to ensure the continuity of care of brain injured patients after they are discharged from the acute inpatient units. And also to deload the inpatient folks, because at some point your outpatient volume will be so large that you'll get over, you may be, that the physician may be overwhelmed. So true to that objective, I'm still receiving referrals from the acute inpatient units for brain injury within the hospital at Tier Memorial Hermann. So aside from that though, I also do receive referrals from the other acute tier acute inpatient rehab units in the relatively smaller hospitals of Memorial Hermann within the system scattered around the city and adjacent communities. A lot of times though, I do also get referrals from the outpatient therapists in the community, mostly belonging to the tier outpatient therapy network. And a lot of times it's more spasticity related issues that they asked me to follow. There are a few like three post acute residential rehabilitation facilities in the city and then in the adjacent communities. They also send referrals over to me for spasticity management while the patients are still in the facility after they're discharged so that I can continue their care given that if they live within the area. So community physicians and other specialists within UT Health also do tend to refer to us here in clinic, mainly neurology and the primary care physicians, your internal medicine, your family practice. Patients themselves sometimes call and say, I would like to be seen by somebody in clinic. And then there are other physiatrists in the area that do private practice and will refer to us. So how do you maintain all these referrals and how do you maintain the volume? It wouldn't hurt to have good working relationship with these inpatient folks within the system that I'm working in. Doesn't also hurt that the medical directors of the post acute residential rehab facilities in the area are friends of mine or their colleagues or somebody I trained previously and always being responsive to the needs of these referral sources and acknowledgement always goes a long way. And I think in closing, I think it's very, I think considering the path of outpatient clinic-based practice for a brain injury medicine physiatrist is very important, especially if there is an inclination or interest on y'all's part. There's a need in the community and then if there is an opportunity, I think it's the outpatient-based brain injury medicine is very important or contributes a lot of important things for the continuity of care for this special and complex patient population. You know, the goal, you know, just like Dr. I think Dr. Greenwald mentioned it earlier, it does afford a lifetime worth of relationship with patients and family and especially true in the outpatient setting because you do follow these patients for a longer period of time compared to the out inpatient setting, there is that possibility of, you know, forming strong bonds or even relationships with the patients and families. And also, I think we are in a very unique position to be able to assist these patients through their recovery, whether the goal is for the patient to be able to go back to work, school, drive, or just reintegrate into the community to a lower level goal for those more patients who have devastating injuries, such as ensuring patient comfort, you know, easing caregiver burden, and also preventing complications of immobility as best as you can, you know, and it can also be rewarding at times as you are part and a witness of the recovery of patients. Maybe it may be small progress, big progress. It does, it can be rewarding. So again, in closing, in considering your path after graduation from fellowship, especially if there's interest and if there is the opportunity, please seriously consider looking into outpatient-based brain injury medicine patient care. Thank you. I think we will be open now for questions. Yes. Thank you, Dr. Magata. I appreciate your insight. Thank you to all the panelists. Please, if you can turn your videos on, we're going to open the session with the group. I do have one question that was in the chat. So I'm going to address that. That was, what challenge, this was directed at me, but I will answer and see if anyone else has any insight. What challenges did you come across when trying to establish, expand your consult service in an outpatient, or sorry, consult service in the inpatient setting? Were there other services such as neurosurgery, neurology, et cetera, eager to work with you, or did you get pushed back? So I think my personal experience was, you know, I benefited, I did my residency training, as I said, at Kessler, and I benefited from the tutelage and observing how Dr. Yonklas kind of navigated this role that he served there. And I think that, you know, basically the gradual, I appreciate what he said in his presentation, the gradual kind of introduction of what you can afford or provide to the service and show that your value to them is kind of the MO that I use in establishing this relationship. It was a very gradual process. It was years in the making process for me, to be honest. You know, I think I initially got my foot in the door with an interdisciplinary meeting. I met the director of trauma and met the director of neurosurgery there at the consult hospital. And I kind of developed that relationship. I advised of what my training was like in terms of what I saw, the relationships I saw in my residency training, and then also kind of the neurotrauma rotation there, rounds that existed in my fellowship. And I got interest to develop something like that there from them. And, you know, gradually I kind of, you know, showed my, gave my input, as Dr. Yonklas mentioned, providing journal articles is very helpful, especially to the intensivists that are very driven by evidence-based guidelines. So when you're able to kind of give that input, provide that reference to an article, offer to, you know, be there for a journal club, really kind of, you know, open that relationship. I think it was particularly challenging in my situation in that it was the hospital system had kind of acquired that trauma hospital just before my starting there. So there was some pushback initially, as just generally from that hospital in terms of having some resistance. So I think I was very mindful of that too, and navigating that very cautiously and diplomatically and saying like, look, you know, I'm not part of the bigger mothership. I'm trying to ultimately help do what's right for patients and try to get them the best care that they can provide or can get. And I think it became a very successful program over the years, and I'm very proud of it. And I definitely, like I said, I owe a lot of credit to those that trained me. So Dr. Yonklas and, you know, by association, Dr. Greenwald as well. And Dr. Gary Galang in Pittsburgh, I think, you know, he was very, it was his neurotrauma rounds that he had in collaboration neurosurgery that, you know, really I referenced in trying to establish something similar in New York. Does anybody on the panel have any kind of insight to that experience that they had in terms of consults, navigating relationships with other services? I would add the same thing as just as what Peter had said, just as far as adding value. Although that's the trick to it, is how to get your foot in the door so that you can improve, that you can add value. I know for myself, since I'm not doing consulting work so much anymore, but yet kind of want to keep these relationships going as to make sure that people will continue to send their patients to us. I'm always just stoking these relationships. So, you know, going over, chatting with people, trying to look how I can add value, you know, and keep good relationships with these people over a long period of time also. So that they'll help us with model systems issues and want to continue to send those patients. I know one of the changes that happened here is we, JFK had the choice of going with Rutgers, Robert Wood Johnson and St. Barnabas, or going with Hackensack Meridian. And interestingly enough, they went with Hackensack Meridian as far as the system. But because they had had these rich relationships with Rutgers, Robert Wood Johnson, and despite the fact that we had a change, academically speaking, and, you know, as far as who we were affiliated with, the hospital system-wise, and the physician relationships were so deep that I went there and one morning we talked about how we're above all that. We're above sort of like the fray of kind of what's happening with that. We want to really do what's best for our patients. And because I had these deep relationships with people, they understood that was continuing to send patients to JFK was the best for their patients. Yeah. Just to add, like Kirk said, and I learned it from Brian, it's just chipping away, taking time. And I think you'll grow. And then I think the other thing is sometimes you'll take almost any consult and try to add value to it. And I think that really sometimes is a way to engender respect. You might just help with a simple, making a phone call to one of the relationships you have with somebody like Dr. Greenwald, who's at JFK, or somebody at Kessler to help with an admission. And then they'll start to consider you for more things. As long as you don't come in there gangbusters and say, I'm going to do this, this, and this, but just approach it slowly, help out here and there where you can, even if it's not necessarily what you want to do, they'll appreciate that. Yeah. My experience was that definitely went a long way to adding that value and being available to them. Even outside of the neurotrauma rounds, the PAs, the nurses, all of them had my cell phone. I was very happy to help them and engage them even outside of those rounds. And I think that basically it helped to ingrain myself as being considered an integral part of their team. And then once I developed the fellowship and I had the fellow be part of it, they were very welcoming to them. So it just became a great thing that kind of grew. You just have to nurture those relationships. So I think, all right, we don't have any other questions in the chat. I think we can go ahead and probably move to just a more informal Q and A, open it up to the audience to, you can unmute yourself, put yourselves on camera and ask any questions you'd like if there's any in the audience. Feel free, please. Okay, doesn't look like we're getting any. Don't be shy if anybody has any questions you know we're all, we're available now. Also, you know, please feel free to reach out, either, you know, to through our emails or through the AAP&R's FIS forum you can ask us questions even outside of this panel, or for those of you that watch this in recording. You know we can, we can answer questions offline. Hi, I have a quick question I am curious how often you know everybody here is clearly obviously in the academic setting and through residency programs but I'm curious how much TBI is seen in private practice. I'd be happy to sort of pick up on that a little bit. I think concussion itself has become such a hot topic that you could, and one of my colleagues here that's basically what she's doing is just doing a concussion work. She's here part of our practice but I'm not, I'm not telling Christine to go anywhere but but she certainly could move her practice to a private practice setting. You know she, it's all about, she spent these last years, you know, building up a great referral sources, kind of doing all the things that we've just talked about that you need to do. And there's no doubt in my mind if she wanted that she could be often in a private practice doing this world. She enjoys working, I think, in the academic center and all the things that go along with that. But that, I know people who are doing spasticity also similarly kind of in a private practice type setting, you may be doing some other neuro rehab on top of that, but you know one of the colleagues I know, he basically just does spasticity. These again, these are people who want to come back to you again and again and again, right, because they need their Botox on an ongoing basis. They need their pump refilled, they need all these and then once you get known in the community as a person who is willing to manage all these things, and you use all these resources that we just talked about. I think there's just a lot of opportunities that way. And even honestly even taking care of the patients, the moderate to severe patients, if maybe you open up your practice a little bit more to doing also some headache management to doing, you know, spasticity management sort of other things I think there's lots of opportunities in the private practice world. There's a lot of downsides to the private practice world in general. The plus and minus of that but I think that there are opportunities that way. I would agree with Dr. Grunewald. I have some former fellows who are doing concussion work, spasticity, but they're also in a subacute world where they may be doing some brain injury within subacute patients who never went there. So they're able to create a practice that they like. Some do consulting at brain injury, long term care units, do some spasticity, do some concussion and then get their fill of kind of some neuro rehab with either strokes or more severe brain injuries in subacute and are doing well financially in that setting. All right, thank you for those answers and thank you everybody on the panel for your presentations today. I think it was very insightful and very helpful. I think we're going to formally stop the recording and move more into the informal networking time for those of you that can stay on and would like to ask us questions, we'll stay on for as long as anybody needs for the next, I guess, you know, 15-20 minutes. So we'll end the recording and see if you guys want to have any questions for us.

neurorehabilitation

career paths

panel discussion

Dr. Kirk Lecher

Dr. Brian Greenwald

Dr. Kelly Crawford

Dr. Peter Yonklis

Dr. Elaine Magat

open-mindedness

Brain Injury Medicine Specialty

clinical aspects

diverse career paths

fellowship training