Thank you for joining us in person and virtually at the 2024 AAPMNR Annual Assembly. We hope you enjoyed participating in groundbreaking education, hearing from our inspiring and well-regarded speakers, and connecting with your PMNR peers. Thank you to our Program Planning Committee, faculty, and attendees who helped make this the best annual meeting for PMNR. AAPMNR remains focused on providing a unique assembly experience, and 2025 will be no exception. Join us for four days of innovative learning opportunities, valuable networking, and cutting-edge research. You'll hear from inspiring industry leaders and experts, learn about the latest advancements in our specialty, and connect with your peers at memorable social events. Be sure to mark your calendar for October 22nd through the 25th, when we'll be gathering in Salt Lake City, Utah, and virtually. We can't wait to see you all there. Stay tuned to aapmr.org slash assembly for the latest updates. We need your expertise to help shape our 2025 Assembly. Your diverse knowledge and experience are what makes this meeting so valuable. Play an important role in the Assembly's educational experience by submitting a session proposal and or research abstract. Visit aapmr.org slash assembly to learn more about submitting. See you next year. Good morning, everyone. Please welcome your 2025 AAPMNR President, Dr. Scott Laker. All right, I owe you $5 for that. Good morning, everyone, and happy Sunday. Thank you for joining us today and for this entire week. As we look back on the Assembly, we continue to be amazed by all of you. The knowledge-sharing during the educational sessions, the connection you've made in person, and those online, and the little catch-up moments you squeeze in in between events to say hi to colleagues. All of these activities help make AAPMNR's biggest event of the year an event to remember. And now on to the main event. This year, the Program Planning Committee had the difficult task of choosing our Fizz Talk presenters. We received incredible submissions this year, and we hope that that continues in the years to come. Over the course of the next 90 minutes, you will hear from six physiatrists. We ask that you listen to each of their presentations, because near the end of this session, we're going to ask you to vote. I'll provide the directions later on in the session. Please also note that these presentations are the personal stories of each speaker. All statements and opinions expressed do not necessarily reflect the opinion of the AAPMNR or their employers. Dr. Meyer? So first up, we have Dr. Sam Mayer, who is presenting the future possibilities for PMNR, preparing trainees for practice in 2050. Thank you. Hello, everybody. So I'm going to talk about training our future residents and medical students for what life is going to be like in 2050. I have no disclosures, and I have to say that my opinions are my own and don't reflect those of either my employer, Johns Hopkins, or ACGME, and you'll see why that's important later. So what do I know about the future? What's the future going to look like? Is PMNR going to be viable in the future? And the truth of the matter is, I have absolutely no idea. I had no idea what was going to happen last Tuesday, and I have no idea what's going to happen in the future. And that's a pretty auspicious way to start a talk. I hope not too many of you are rushing for the door right now. But what I'm going to talk about is what I think has been the most impactful thing I've worked on since I started this career 30 years ago. So what will the future bring? Will we still be here in 2050? How can we best prepare our learners for their careers? So the reason I got involved with this is I happen to have the honor of being the chair of the writing group that's rewriting the requirements for residencies. And this is a process that we go through once every decade or more. The last time they were done was in 2012. It's a two-year-long process. And the intent is to develop a residency curriculum that will prepare learners for practice 25 years from now, thinking that's at least the average length we're all practicing. Certainly I've practiced longer than that already. So the process, we start with a blank slate. And it's really a big involvement of a lot of people. So I cannot take credit for this alone by any means. We surveyed stakeholders, everybody from private practitioners to CEOs of health care systems to chairs and program directors. We were lucky we had the involvement of the Triag organizational report on GME, which was a joint effort by the AAPMNR, the AAP, and the AABPMNR. And if you know anything about the internal politics of those organizations, it's kind of hard to get them to agree on anything. So they did on this. And then we had a strategic planning workshop, which is mostly I'm going to talk about today. And then when we're all done with the requirements, writing them, this spring there'll be an opportunity for public comment. I really encourage you all to please comment on those when they come out. You'll get announcements from ACGME if you're in a residency program and look for those. And then finally it has to get approved by the ACGME board. So we looked at threats and opportunities. And I think almost anybody that's done strategic planning understands that every threat is an opportunity. And if we don't treat it that way, we get ourselves in trouble. So these are the threats that we thought about. So technology. So everything from artificial intelligence and robotics to regenerative medicine. Intrusion by government or by industry. We're certainly experiencing that today. And I think that's only going to worsen in the future. Then there'll be competition or cooperation with other professionals. Climate change is going to be a big deal. So thinking about that. Thinking about its impact on the world, including epidemics and migration of folks from poor countries to rich countries because of climate change. And there's going to be a lot of civil strife probably in the future as there is now. So that's kind of unavoidable. And lastly, thinking about patient autonomy. Patients are increasingly in charge of their own health care. And we will need to figure out how we manage that as well. So as I said, we convened 35 stakeholders. And it represents the whole gamut. And we looked at four very different futures with the idea that no one knows what the future is going to look like. But we looked at four worst case scenarios. And these were developed by the Future Strategies Group, which is the consulting group ACGME uses. So I can't take any credit for these. But I'll tell you a little bit about each one. And we're going to have you vote for your prediction of which one you think is the most likely future. So there's no right or wrong answers on this. But just to get you up and moving a little bit and thinking about it and paying attention, we're going to make you stand up for what you believe in. So the first one's called the New New Deal. And in this one, it's probably the most optimistic of them. So the technology's been developed to have nuclear fusion. And there's carbon retrieval technology. And so they've avoided all the problems of climate change. And the economy's booming because of this. And the US has turned into a Scandinavian-style democracy. So think about John Lennon and imagine. So imagine this. All the doctors are going to be working for the government. So also imagine that. Now you're on your own is a very different world. This world's controlled by 10 corporations, 10 global, multinational corporations that are monopolies on everything. And government is virtually nonexistent. And everything is global. Everything's controlled by the Elon Musk of the world. And the corporations have their own hospitals and medical schools. They employ all the physicians. The government's contract with them to provide all the care for the poor and the elderly. And everything is done on a corporate level. And of course, we're going to have to deal with corporate greed. One giant leap. So this is climate change goes unchecked. The global economy's in a shambles. There's millions of refugees. There's been a number of pandemics. The health care in the US is now bare bones because the US is now a third-world country. And we look like Mad Max. All right. It only gets brighter, guys. And there's Exploribus Unum. And in this scenario, the US has gone through a civil war. The union did win again, but just barely. And the states are in control of everything. The federal government's very weak. And everything is so divisive. And there's such cultural strife that there's no progress. Technology's kind of stagnated. So which one do you think is most likely? And I'm going to have you stand up for each one if you think so. So any new dealers out there? We don't have any hippies in the audience? OK. How about now you're on your own? Stand up if you think that one. All right. So that one's. All right. So which one do you think is most likely? And I'm going to have you stand up for each one if you think so. All right. Sit down. And then one giant leap. No Mad Maxers out there? All right. Exploribus Unum. Are we going to be at civil war? All right. So what we had to do is come up with strategies that would cross all these and be effective no matter what happened. And that was our task in our strategic planning summit. So here are six strategies that we think will work. First is remember the ampersand. So in PM&R, we're the only specialty that has one. And it's really critical to what we do. And I would really urge everybody to think about this in their own practice, is that no matter what specialty you're in, where you're practicing, what world you're going to be in the future, I think it's going to serve you well to focus on things that the physical medicine side, the exercise, injections, pain control, and the interdisciplinary side, the rehab side, and the interdisciplinary teamwork that we do. These basic techniques work well across everything that we encounter in all subspecialties. And it can't be replaced by AI or robotics. Then we need to provide care across the entire care curriculum, everything from in the ICU to acute care, inpatient rehab facilities, skiffs, and at home. And be prepared to provide care no matter where it's at. Because rehab is not a location. And it's not a phase in health care. It's a concept that we need to use throughout our patient's voyage. Next, we need to advocate for and with people with disabilities. Not only is it the right thing to do and the moral thing to do, but from a purely selfish standpoint, as there's more patient autonomy and patients have a bigger say in what they do, they're going to be our greatest allies. So remember, make friends with your patients. They're the ones that are really going to be the ones that will help you out the most. Manage technology. So don't let technology manage you, especially AI. Learn to evaluate it with evidence-based medicine. Remember, the latest is not always the greatest. A very wise professor of mine in medical school always told me, never be the first to prescribe something or the last to prescribe something. And I think that's a good take-home message. Next, we need to advocate for and with people with disabilities. Lastly, learn to live with less. So in all these worlds, there's going to be limits on what health care can provide, even if it's a rich economy or a poor one. Natural disasters and civil strife are likely to lead to temporary or long-lasting limits on technology. And in a scarce economy, or even in a country And in a scarce economy, or even in a rich economy where we're dealing with Medicare Advantage plans, we're going to need to get down to bare necessities. But the overall message is, we're going to survive and we're going to thrive in this. We heard over and over again from our consultants at ACGME that of the 10 or so specialties they've gone through this with, we're by far the best prepared. So take that home. And even though we presented a lot of downers today, I think you can take the helmet up that I think we will survive. Thank you very much. Thank you. Thank you, Dr. Mayer. Please consider extra points for use of Civil War and Mad Max slides in the same presentation. Our next presenter is Dr. Orinicha Jumriyanbong, who will be presenting us Healing Beyond Boundaries, the Power of AI and VR in Global Pain Management. After you. Growing up in Thailand and having spent part of my childhood along the volatile borders where military conflicts were frequent, I thought it was the norm. I also experienced lack of resources, especially medical care, particularly through my grandmother, who suffered from spinal cord injury, chronic pain, and multiple failed back surgeries. I think that her quality of life could have been improved if she has access to rehabilitation and also innovation available here in the United States. One of my earliest memories was learning English from American volunteers. These individuals came into our community not just with the knowledge but also with the belief that things could be better, something that I was struggling to see these days in my American colleagues. They sparked a hope in me that change was possible, even a small contribution could ripple and make a significant impact. So like many immigrants, I pursued the American dream. My journey from Thailand to the United States was driven by my mission to increase health care access at a global scale through innovations. I received a scholarship to attend Stanford University, where I studied computer science and health technology policy and management. I then later on received a FlexMed Early Assurance Scholarship to Mount Sinai Medical School, and later on residency in New York City. I feel at home there as a gay immigrant woman of color. I am very privileged to take care of patients of color, It was a jarring experience as I saw the same gaps in care that I had witnessed in Thailand, but now in one of the richest cities in the world. It became clear that this issue of accessibility wasn't limited to developing countries, it was a global problem. This was evident especially during COVID-19 pandemic when I see disparities in health care. This experience had became personal to me because the same day that people were calling us health care heroes, I was on my way to the hospital when a man came up to me, he called me China virus. He assaulted me, he dragged me across the street. I called for help, but no one came. I was in a dark place, and I think the only thing that was helping me crawl out of that was to look back to why I began this journey in America in the first place, and that was to increase health care access at a global scale. I thought back to my grandmother who inspired me. She has chronic pain, so where do we go from here? How do we scale our knowledge? How do we rapidly transfer what we know here, our innovations, our practice, to areas in America and abroad that are in desperate need of care but lack the technical expertise to provide it? I started working with institutions in the United States like Harvard, MIT, Cornell, Stanford, and Mount Sinai to develop various technologies, combining both my passion in both technology and medicine. I started integrating multilingual AI and VR technology to train procedures available in 32 languages. A gasserian ganglion block involves injecting medication near the trigeminal nerve ganglion to alleviate severe facial pain, commonly associated with conditions like trigeminal neuralgia. Here we demonstrate how to do such procedures using artificial intelligence-assisted virtual reality training module. Learners begin by wearing a VR headset. The display creates a 360 immersion experience. Anatomy models appear as hologram and manipulated by learners. They're labeled in preferred language with definitions and clinical correlations to reinforce learning. First, we must review the cranial anatomy. The foramen, or opening in the skulls labeled here, are foramen lacerum, jugular foramen, and the foramen magnum. In blue, we are labeling FL, JF, and FM respectively. It is important not to mistake these openings for our target site, the foramen ovale, which label in red as FO. Patient is placed supine. We tilt C-arm caudally by 15 to 20 degrees obliquely ipsilaterally by 5 to 10 degrees. Note that a towel is placed underneath the patient's neck, and this C-arm tilt will allow us to localize the foramen ovale. It will position the foramen ovale just below the space between the mandible's coronoid apophysis and the superior petrous ridge. We are able to magnify and collimate the image to focus on the foramen ovale. After we find the foramen ovale, we then carefully advance the needle with intermittent fluoroscopic guidance in a coaxial view until reaching the foramen. We then turn the C-arm to 90 degree for lateral view. This captures a sagittal image of the clivus bone, which is the danger zone. If the needle goes too deep, we can puncture the dura and result in CSF leak. Thus, we must ensure minimal parallax error by wig-wagging the fluoroscope and aligning the auditory meatuses. Note that we aim the needle at the junction of the clivus and petrous bone. Advance it carefully to the bony junction, ensuring correct trajectory. Once in the foramen, the needle tip should rest 5 to 15 mm below the cellar floor to maintain safe positioning. Fluoroscopic guidance is used for confirming proper placement. CT can also be used. The puncture site was positioned approximately 3 cm lateral to the corner of the mouth. Needle was inserted and slowly advanced toward the foramen ovale, encountering slight resistance as it penetrates the pterygolar ligament and to the target site at Meikle's cave. We created this AIVR training module by using AI generative code for fluoroscopy 3D model and C-arm motion, selecting 2D fluoroscopy images from peer-reviewed articles as cited, juxtaposing it with 3D skeletal and gray scale models on virtual reality softwares. We then utilized artificial intelligence voice-generated software for ease of editing and future applications such as 1. real-time subtitles, 2. multi-language support, and 3. AI-generated multiple choice questions based on this VR training module to help reinforce learning. The proof of concept models offers promising avenues for remote learning, scalability at a global scale, and enhanced practice and assessment capabilities, highlighting the need for further research in this AIVR innovative educational approach. This technology could also be used for patient care. My grandmother, who suffered from chronic pain and later on dementia, said in her lucid moments that she'd like to hear my voice. She also liked the beach. So here I created an AI voice cloning technology and integrated with a VR environment where the environment is generated through AI text prompts. Imagine you are walking through a beautiful place that makes you feel safe and calm. As you take each step, notice the sounds of nature around you and feel the warmth of the sun on your skin. Take a deep breath in, feeling it fill your lungs, and slowly let it out, releasing tension with each exhale. Now, picture a loved one next to you, someone whose presence always brings you comfort. Hear their voice as they gently speak to you, reminding you that you are not alone in this moment. They are here to walk beside you, offering support, love, and strength. That technology is also available in multiple languages. I've begun using AI to generate 3D anatomical models. This can be done in seconds, enabling rapid prototyping and hypothesis testing. These models allow for validation and hypothesis without patient data. Through virtual experiments on digital models, this technology can predict outcomes and refine ideas before clinical studies, accelerating discoveries even down to the molecular levels in protein and vaccine developments. This technology also empowers personalized pain management and rapid development of simulated training environments as seen before. Moving forward, my mission is to expand and deploy these technologies around the world. Currently, I'm working with the Ministry of Public Health in Thailand and leading an AI research team with members funded by the Thai Royal Family. I've also partnered with clinical sites in the Middle East, Latin America, Asia, and here in the United States. This is my grandmother. Unfortunately, she passed away last week. I was not able to attend her funeral because of my visa issues. But she had left a speech at her funeral saying that although she had only finished fourth grade in rural Thailand, her granddaughter is now an American-trained doctor helping those around her. As someone who struggles with imposter syndrome, I have difficulties accepting her pride, but I will try my best to honor her and carry on the values that she imparted for me. This is more than just a talk about technology. It's a talk about carrying on the legacies of those who suffer silently before us and hopefully in our own ways create a better place for everyone. Thank you. Thank you very much, Dr. Jamarion Vong. Our next speaker is Dr. Amy Ng, who will be presenting When the Doctor Becomes Patient. My journey as a physiatrist and breast cancer survivor. Well, thank you so much for allowing me to give my story today. And I will start out by saying that I did not know that or I did know that Dr. Flannery was giving the plenary, but I had no way to know that I was going to follow him as he opened and then I closed and sharing our journeys. But I find that more and more of us are being diagnosed today. And I remember back when I was in medical school and they actually told me, stand up and I want you to stand up and look beside you to your left and to your right, because one in eight of you will be diagnosed with cancer. And I had no idea that that person would be me. And today I'm so honored to share with you my journey. These slides that I made are pictures that I've never shown anybody and I never showed everybody anybody because I was not brave. As much as people told me that you are brave, you are a survivor, you can get through this. I was not. I never shared these pictures with anybody because I couldn't get over the look of a cancer patient. Ironically, I work at MD Anderson. I do this every day, but it happened to me and I did not know that it could happen to me. But it did. And I have some learning points, you know, that I will go over at the end, sharing with you my journey. But it all started when also the world shut down and I went to my doctor just for a regular visit. I was never late for my mammography. I was the perfect patient. I actually, in fact, sat there for three hours and waited for her to see me. And I thought every moment during those three hours that I was waiting that I was going to get up and leave. But that day she found a lump. And perhaps a doctor is the worst patient because I forgot to check. I didn't really check. I had a new baby and I just thought everything was fine and maybe I had some changes on my breast, but I didn't really know because I never bothered to check. And I thought whatever was happening was just a natural thing from, you know, doing, feeding my baby. And on the picture on the left was my mastectomy. And afterwards, this is the baby that, you know, was my last baby. I wasn't given any choices after that, you know, going through chemo. And after that it was, they asked me, do you want to freeze any eggs? Do you want to have more children? And I was, you know, I said I guess we're done. It does make you a little bit mad because it is the fact that, you know, this was chosen for me and not a choice that I made. A middle picture, you could kind of see that I'm missing a breast. And then the right picture going from, you know, messy long hair to shortening my hair prior to losing all my hair for chemo. And then this is actually, this is a day that I realized that I was done shedding my hair. This is actually not me. This is one of my therapists who has become like such a rock for me. And I did not ask her to do this. She was an occupational therapist that I worked with. And this is the barber. During COVID, the world shut down. We had nowhere to go to shave your hair, but my hair was lost. I had no hair. It was coming off, chunks, clumps, whatever you name it. And we had, we used to have a barber that would come and cut your hair. So, in the, I don't know if you can help me do the middle video. I don't know how to do that, but basically, if you could play that video. I don't know if that's working or not. But she, she had gorgeous lots of hair. And she's getting it shaved off here. I never asked her to. She came over the same day. She asked me, when you're ready, I'll be there. I called her one day when all my hair was going. And I said, please come over. And so, she, she was able, she did this. She took her hair off, and then I took my hair off. I'm just going to go to the next video because we're. This picture is when the day that I got my port placed. They stuck me, after my mastectomy, the next step is the chemotherapy for me. And everybody's journey is a little bit different. Some people have chemo. Some people then do surgery, but mine was surgery and then chemo. So, they put a port in so that I could have these weekly injections of chemo. So, my left arm is the only arm I could be stuck in. Afterwards, the mastectomy, you can't move your arm. You can't lift. You can't lift your child. And so, they stuck me eight times on my left arm to get a vein. Couldn't get a vein. That's just another picture of what happens when you're, when you're undergoing cancer treatments. I lost all my hair. I wore a scarf or a cap. And then, this is a funny picture because this is my first wig. I didn't know what to do with a wig. I had it all different placement. I actually had to call some friends and say, please help me because I don't know what to do with a wig. And I found out that there's different versions of wigs. There's, you know, fake hair, nicer fake hair, and then real hair. And eventually, I got the hang of it. But I started in August. This was the full-blown treatment. Steroids making you puffy face, bigger face. My hair was gone. Every single hair I lost. Even your nostril hairs, your eyelashes, everything. I had some tattooing on my eyebrows. And then, this is my birthday. I celebrated my birthday. Again, the wig is a little bit better. And then, I rang the bell after my radiation was finished. My hair started growing back in December, 2021, January, February. I took these selfies every month so I could see what my hair growth was like. And then, I went to various conferences. I wanted to show you this picture because this was the picture after I had one of the implants placed. And I went to this conference, this rehab conference, international rehab conference. And I traveled with a drain. And nobody could tell, but I had a drain. And I kept that drain in for most of the summer, from June until September. I had a drain in. And then, one day, I woke up, and my chest was leaking. It was like fluid coming out of my chest. And at first, I thought my kids were playing an evil joke on me. And they had spilled water all over my bed. But in fact, it was that my incision had opened up, and my seroma leaked. And once it opens, that's it. I tried again, and I tried again. And here I am, a year and a half later, still failing. But next year, after I got it taken out, because once you've failed, you can't continue to have implants. So, they took it out, and I ended up being flat. So, I used a prosthesis. And I found a prosthesis just on Amazon. But you can also get many other types of prosthesis. And that's for a different lecture, too. And then, in last year, August, I underwent another reconstruction surgery. I did the deep flap. And then, went back to the, I like this picture because it compares one year to the next, my journey. And then, in May 2024, my daughter got a certificate. But actually, I feel like I got the certificate because I felt like I was actually done with my journey. But what I wanted to share with you today, in my short time that I have left, is that becoming a cancer patient was not by choice. It was something that was thrown to me. I don't think I'm very brave. But, you know, it just, it happened. And I wanted to share this experience because what it has done is it's given me some talking points, like, to share with my patients. Number one, seek support. Always seek support. My colleagues, my friends, as you saw, my family, my mom actually moved in with me so she could help raise my children. So, seek support. Take support. When people give meals or, you know, encourage your patients to actually take the support that they're offered. I actually, coming from an Asian background, we actually don't do any kind of counseling. We've never heard of counseling. There are no counselors, I felt like. But I reached out to psychiatry and I had a monthly session because I had to be so brave at home. I couldn't let my kids see me cry. I couldn't let my husband see me cry, who was not in medical. And I could not let my mom see me cry because she was trying to help me as well. So, the only place I could cry was talking to my therapist. And so, every month I would just have a crying session. And that got me through. And the whole thing about COVID was that it was an isolation period too. So, it wasn't that I was surrounded by friends and could see everybody. I was also, you know, compromised and couldn't do anything else with my friends or family. But I was able to do the virtual counseling. So, encourage your patients to seek help. And I also developed a sense of empathy. When I understand now what it means from going into menopause. But I skipped all the perimenopause. I went 40 to 60 really fast. Everything hurts on me. And I told one patient of mine actually is a flight attendant and she couldn't do the things she needed to do. Lift the trays, bend down. I asked her to talk with her oncologist and switch off of one of the aromatase inhibitors. And the only reason I did that was because I myself had knowledge of what it felt like to be on those drugs. And to switch off to a different drug. So, that you can have a little bit more functional recovery. And have quality of life. And so, I leave you with this. Find joy in everything you do. And I tell my patients that every day. You know, because they're undergoing the same or a different journey. But in sort of the same way. But find joy in all that you do. What makes you happy? And that's the most important thing I want you to get from this. For us, thank you. It was a blessing to be here. And then the sun setting as we end out AAPMR. Thank you so much. Thank you very much, Dr. Ng. Our next speaker is Dr. Max Hurwitz. Who will be presenting disability and homelessness. How street medicine tackles health injustice. Thank you. Excellent. Thank you. So, let's start with some audience participation. Raise your hand if you've heard of street medicine. Oh, wonderful. Wonderful. So, the type of street medicine that I'm going to talk about started in Pittsburgh in 1992. When Dr. Jim Withers and Mike Salos left the walls of the hospital and the clinic. And went outside to treat patients. It's a model of healthcare where we go to the patient wherever they are. On the street corner, under bridges, and in homeless camps. And here you can see me and my colleague, Julia Lamb, headed to a camp. So, since street medicine started, homelessness has continued to increase nationally and internationally. In 2023, there was more than 650,000 people experiencing homelessness in the United States. That's a 12% increase over the prior year. And globally, it's estimated that there's more than 150 million people experiencing homelessness. All increasing due to conflict, climate change, housing shortages, housing costs. But also disability and substance use. And mental health. On my first street medicine rounds, I joined Dr. Withers and his team at a camp close to downtown Pittsburgh. I was asked to see a man there that was reporting problems with his hands. When I met him, he had correctly self-diagnosed himself with ulnar neuropathy. It was awesome. He was so excited to share with me the research he had done to come up with that diagnosis. But also when I met him, I couldn't help but notice how his hands had atrophied from avoiding healthcare. And the role that physiatry could play in healthcare for the homeless. We have since gone on to start a street rehab consult service, treating patients with both acute and chronic disability living on the street. So why street medicine? Why not traditional health care? There are so many barriers to care for people sleeping outside. Meeting the basic needs of food and shelter interferes with going to doctor's appointments, taking medications, doing therapy. But when individuals do access health care, they tell us that they're treated poorly. They're dehumanized. They're shamed. But also, our health care system isn't flexible. Our health system is not designed for someone without an address. It's difficult to establish with primary care. People are late or miss appointments, and they're labeled difficult or non-compliant. These themes, they may sound familiar. They're also reported to us by people with disability when talking about our health care system. Street medicine attempts to address these barriers in a few different ways. One, through flexibility. We go to the patient to avoid problems with missed appointments and transportation. Relationships. Our focus is on collaborative care in building relationships of mutual trust. Trauma-informed care, which is an approach that attempts to address the unique needs of each individual, understanding the impact of personal trauma on development. And also, harm reduction, which tries to reduce the negative impact of substance use through clean needles, smoking kits, naloxone without requiring abstinence for treatment. And then also, care coordination. We connect our patients with shelters, with housing, with social work and case managers. With all of these tools together, street medicine works. It's been shown to increase engagement, improve well-being, and decrease health care costs. I was asked to see a patient in a camp after another team had saw him, and he couldn't move his arm. When I met him there, he told me that he was standing on a corner, and a truck drove by and hit him in his neck and shoulder with its side view mirror. He immediately had pain and couldn't move his arm. But rather than go to the emergency room, he went back to his camp. I asked him about that, and he told me that when he does go to the hospital, he's treated so poorly. He's treated like trash. Homelessness has an enormous impact on health. The barriers to care, transient lifestyle, poor health literacy mean that our homeless patients have higher rates and worse control of chronic disease. And the rough sleeping homeless, meaning those individuals that sleep outside, have even higher rates. These diseases take their toll. The mean age of death for an unsheltered individual in the United States is 53 years old, almost 30 years younger than the national average. And if you live anywhere in this country, you will see homeless individuals pushing walkers in wheelchairs, on crutches. The US Housing and Urban Development definition of chronic homelessness starts at the age of 50. The definition of chronic homelessness starts with a person with disability. Let me repeat that one. By definition, 100% of individuals that are chronically homeless in the United States have a disability. And so many have unmet rehab needs. The study presented here was completed in an inclusion health clinic in the United Kingdom. Reports 53% have unmet needs. That's a huge underestimate. But even if it isn't, there is an enormous gap in care. When I learned about this, I couldn't help but think, what can we do? What can rehab doctors, the doctors for people with disability, do to help this group? That's where street rehab medicine comes in. So while physical disability is common, and it's been more than 30 years since Dr. Withers started treating patients out on the street, rehab doctors are not typically part of the street medicine team. And there's a lot of barriers to care. Admissions to post-acute rehab facilities are often limited. Rehab-specific facilities like respite care have a lot of variability in the type of rehab that is provided. And at the community level, outpatient therapy or outpatient clinics or home health, it runs into all of the same problems of any of our community-level care. Often, this means that homeless individuals don't receive care after brain injuries, after strokes, spinal cord injuries, trauma, amputations, on and on. And we've seen this in Pittsburgh. We developed a screening and treatment program for homeless individuals with brain injury and ran into barriers when using traditional care. But when therapists and physicians started to go out on the street, this improved enormously. I'd like to take a quick moment to tell a story of a man that I had the privilege to take care of. He was admitted to one of our hospitals in the winter with frostbite on all 10 of his fingers and had amputations of all 10 of his fingers. But at the time of admission, he wasn't connected to a street medicine team. And when it was time to leave the hospital, he wasn't accepted at a nursing facility. And so he was sent back to the street with no ability to care for himself, no ability to dress, feed himself, go to the bathroom, and he certainly couldn't do his own wound care. He needed a whole team to help him. And a team came together, completed his wound care, developed tools for self-feeding, taught him how to care for himself again. And over time, he healed, and he regained his independence. Street medicine providers across the globe work in interdisciplinary teams. Yet despite the need, rehabilitation doctors are not typically part of that team. And I think that needs to change. PM&R BOLD proposes that we act as experts across the care spectrum. I propose that the street, or the home for people without shelter, is part of that care spectrum. To make that happen, we've developed an interdisciplinary street medicine team, which will sound very familiar to anyone working in this field. Our team includes occupational therapy, physical therapy, social work, nursing, primary care, and physiatry. As rehab doctors, we can go to patients wherever they are and provide patient-centered, trauma-informed, rehabilitative medical care. But I think that when we do that, our goal should not be to just address impairments, but to help our patients develop the skills necessary to transition from the street to housing. Because it is during this transition that so many succumb to loneliness, addiction, and chronic disease. So I'd like to finish by returning to the story of our first patient with a hand weakness. He went on to get bilateral ulnar nerve surgery, completed therapy, returned to work, and was housed. More than two years on, he continues to work and live independently. And I spoke with him recently, and he reminded me of something. He is so much more than just a formerly homeless individual. He's a unique person with goals and dreams. And now he has the tools to make them happen. Thank you. Thank you. Thank you, Dr. Hurwitz. Our next speaker is Dr. Marcos Enriquez, who will be presenting The Beauty of Global Health and International Medical Mission Trips, a chapter in my home country, the Dominican Republic. Thank you, Marcos. Morning, everyone. I'm excited to be here. This is something that I have been contemplating for such a long time. I wanted to share the story about an international medical mission trip that we did with my program in my home country. It was the first one in our program. So it's going to be a story from my perspective. But let me start with one question, one thing that I want to bring up. Have you ever been in the situation where you have to take care of people, but instead those people are taking care of you? I'll come back to this question as I move forward. So then again, I just want to give you a brief preview of what we did. There's a couple of videos of our days in the Dominican Republic. I'm not going through them. I'm not going through all of them today because it's going to take some time. But you can find it on social media. Again, my journey started when I joined the residency program in 2022. I moved from the Dominican Republic, my home country, to Chicago, where I found another home, Rush PM&R. One of my seniors at that time, he was trying to organize an international medical mission trip to the Dominican Republic. What a perfect situation. I just came to Chicago. He asked me if I wanted to join in this journey. Of course I did. Why not? So we started having a bunch of just trying to find resources. And at the end, we made it. And on January the 27th of this year, we joined forces with Rush Orthopedics. We had two arms, a surgical arm and a non-surgical arm. And you can see me on the right side of the picture. Right next to me is one of my seniors. His name is Dr. Bas Bovian. He's doing his pain fellowship at Rush right now. And then that's the rest of the team of Rush Orthopedics. Once we got to the Dominican Republic, we thought that we were taking care of people. They're taking care of us, if you see it over here. They just received us with such great food. The Dominican food is amazing. One thing that I want to bring up, we then went to Oswa. That's a small city that is to the southwest of the Dominican Republic. I'll show you where it is. But I want to bring this picture, the lady that is wearing the green scrubs. This is Dr. Stephanie Crane. She's the global health director at Rush. And she's been organizing medical mission trips for about 20 years. And she has almost like 20 trips to the Dominican Republic every single year. And we wanted to include one chapter of PM&R in those trips. So Oswa, one of the things of PM&R that is meaningful for the specialty, we try to understand where the patients come from. We try to understand their surroundings. And that way, if they have a disability, we can truly understand how this disability is impacting in their function. So again, it's one of the 31 provinces of the Dominican Republic. It's localized west from Santo Domingo, close to the Dominican-Haitian border. And the hospital that we went to, it's one of the regional hospitals. It's called Taiwan Hospital. And it gets feeded by patients from all the cities surrounding Oswa. So it's a regional hospital. And it lacks a PM&R service. But if we look closer, what people in Oswa do for a living? They rely on farming. They have coffee farms, plantain farms, fishing. It's a lot of physical work. So any physical disability, it's going to tremendously impact their function. And again, they're living in their farms to sustain themselves. Whatever they grow over there, this is what they're going to eat. And they're going to commercialize it as well. If they're not able to take care of their crops, that's going to compromise the way they're going to sustain economically. And it has such a tremendous impact. But then, what do we have in our toolbox? Just the conventional things that we do have over here. We had home exercise programs in Spanish. We tried to get an ultrasound machine. So we reached out to one of the companies that I used to work at in the Dominican Republic. And they lended us an ultrasound machine. And they lent us a shockwave machine as well. And we started treating patients. The very first day that we got there, we only saw 21 patients. Those patients, they're starting spreading out the words of something new, new specialty of doctors doing something different. So that doubled the following day. And it stayed sustained in about 40 to 50 patients per day. And then, again, we had an ultrasound machine. We had a couple of procedures. This is a lady that actually had a coffee farm. She was having terrible knee pain in the posterior aspect of her knee. Unable to walk around her coffee shop, her coffee farm. And this led to a lot of distress for her. We found a Baker's cyst. Very simple, if we think about it. Something that we find over here every single time. But she was unable to get that care in Oswa. So we aspirated her Baker's cyst. She was surprised that she was able to walk. She went back to her farm. And then, these are a couple of treatments that we did with shockwaves while we were there. But I want to take a pause, because I don't want to make this talk about what we were doing. Actually, I just want to talk about the fulfilling moments that we had in Oswa. What we got from the community. Every single morning, we woke up, we had this beautiful sunrise. Followed by coffee that we had every single morning from the coffee farms nearby in the mountains of that area. And then, phenomenal food that they were making. They were actually asking us constantly, if we were eating, if we wanted something more. It was a tremendous, I think that I came back to Chicago with even more pounds when I got to the Dominican Republic. We then made such a great effort to go to the beach and catch the sunset. One day in that beach, we saw this man selling sugar cane. We had such a pleasant conversation. He wanted to take us to his community, show us an even better spot. And we didn't go, unfortunately. But we had such a pleasant conversation. We just met this man, and he wanted to introduce us to his community, his family, and even try some of the things that he was growing on his farm. A couple of days went by. One patient came back that we treated. And this is a Dominican version of a pumpkin, if we think about it. And she brought us this. It didn't stop there. Another patient came back, feeling much better, and brought us a 40-pound bag of plantains, mangoes, coconuts. You name it, it was all there. And then this is all that we had at the end. Unlucky for us, we had to make it back to Chicago. So imagine me trying to put all of this in my bag. Hell no. So the lucky one was actually my mom. So she kept everything. She's looking forward to a next trip, because she knows that we're going to come back and bring all these bags again. And then I just wonder how many PMR programs are going to international medical mission trips to the Dominican Republic. I came across this article. I don't know if there's more evidence out there. There's a lot of physical therapists going to the Dominican Republic. But I don't know about PMR programs, physiatrists going to the Dominican Republic. And I do think that there's an opportunity for us to go to places like the Dominican Republic. Our impact, I just want to bring this. But let me go back here. Every single day after we saw patients, I had this face of, I thought that I was in mania. I thought that I had a manic face, so I was so grateful. I was talking to my senior the entire night about how happy I felt. And that was sustained for a couple of months. It was tapering down. And then we got this video, like three months afterwards. This is someone from the community sent me a video via WhatsApp just as an update. Uh-huh. If we can get the volume up. I'm going to see you all. You may see a physical. They'll speak to that. We will see that in the city of Chicago. And especially, I'm going to go to this. Marco, Sol, Yvonne. If I don't, it's going to make the decision. But I'm going to give that up. In the name of ASWA, in the name of Community Empowerment, in the name of the hospital, Taiwan. We want to thank you for the wonderful work you did during the entire week that you served more than 200 patients with difficulties, with pain, who needed a physical therapy service. A service that is very difficult to have and a service never before received in the province of ASWA. So thank you very much for taking your time and your professionalism to serve us with dedication, with love and dedication. We invite all members of the program to join Sol, Marco and you and come to our beloved ASWA to continue serving these people who are waiting for us with open arms. So guess what? What now? I have to go back, obviously. So we're going back in February. So we're going back to the community. And then behind this, I just wonder why I was getting all this manic thoughts that I was talking about, right? Before I was applying to residency, we had to do a personal statement. And then I came across one of the draft that I wrote. And it's actually on the webpage of our residency program. But this is a couple of sentences that I had from one of my draft. And I do think that the Dominican Republic is one of the places where physical disabilities come in different flavors. And since you don't have almost any PM&R over there, it's the perfect setting to fully grasp the impact of PM&R. So I do want to invite everyone to actually have those manic thoughts that I had and that constant happiness by joining and participating in international medical mission trips. And lastly, I just want to thank the people that joined me, the people that have received me in Chicago, and they're now part of my family, but also the people that supported this trip, and especially the team that went with me to the Dominican Republic to complete this international medical mission trip. Thank you, everyone. Thank you. Thank you, Dr. Enriquez. Our final speaker, we have Dr. Amy West, who will be presenting A Tale of Two Shoulders, Healthspan, Lifespan, and Physiatry. Thank you. All right, so wake everybody up here. One last go. So I'm gonna be talking about two patients that I saw right in my clinic. So I'm a sports medicine physiatrist in New York, and this story starts with this guy, so we'll call him Bill. And Bill was sort of typical 60-something-year-old man who came into my office. He said he was having some trouble working on his car. His shoulder was bothering him. He couldn't put his coat on anymore. He was having trouble sleeping. And he just started to get fed up with it. But he was the kind of person, he told me straight up, I don't like doctors. I didn't even wanna come here, but my wife made me. And she said, yeah, he never goes to the doctor, but I'm sick of hearing him complain about it. So I said, all right, so we did our little workup. Shoulder X-ray, eh, not much going on there. Ended up getting an MRI of his shoulder. Some tendinopathy, some mild arthritis. Overall, nothing all that impressive. So, you know, told him, start some physical therapy, offered him some injections, some medication, sort of the usual things that we do. And he went on his way. So down the hall, this patient was in my office. Her name's Janice. And Janice is roughly around the same age as Bill. She owns a gym, super active. And her chief complaint to me was that she couldn't do as many pull-ups as she used to do. So, you know, she used to do big sets, and now she's after five or 10. She's like, it's killing me, I can't really do it. But she's still doing it. And actually, this picture was taken after our visit. So she's still hanging from things, but just wasn't as easy as it used to be. And that was her shoulder X-ray. Now, for those of you who don't look at shoulder X-rays often, that's not normal. She basically has almost pretty much end-stage arthritis in her shoulder, large osteophyte. Basically, in most people, that would act as a doorstop of motion of her shoulder. And I said to Janice, it's kind of blowing my mind here that you're even moving that arm, nevertheless ripping out pull-ups. Most people who have shoulders that look like that on X-ray, needed surgery 10 years ago. So that started to get me thinking. When I compared Janice's situation, who had terrible imaging findings, and somewhat minimal effect functionally, as opposed to Bill, whose imaging findings were pretty innocuous, and he basically wasn't living his life anymore, said, well, what's the difference here? Why is one person doing so well and the other one isn't, with the pathology being so different? You know, here was Janice, she watched what she ate, she exercised regularly, she was super active, she was sleeping, and then when I asked Bill, what's going on with you? I had him come back into the office for his follow-up, and I said, what's going on with you? You know, what kind of food are you eating? And he, yeah, you know, whatever my wife cooks for me. I don't really pay attention to it. He frequented the gas station for his food, so you know, the kind of stuff you find in a convenience store. Are you sleeping? Meh, never really slept well. I do what I can, sometimes I take some medication to help me sleep. You know, are you exercising? Laughed at me, I don't do that, I don't got time for that. So I said, hmm, we gotta do some more investigation into this. So that's when I spoke to his wife, and I said, okay, we have to do some more investigation here. She said, you know, he hasn't been to the doctor in years, he doesn't go. And I said, he's gotta go, we gotta see if any of these things in his daily life that are affecting how he's able to function. Now, let's get some labs, let's look further into his metabolic health. Sure enough, when we did that, we found that his A1C, 6.4, so basically, borderline diabetic. And he'd been living with prediabetes probably for years. And he never even looked into it. So, through that, after finding that out, we essentially got him treatment for his diabetes. He started an exercise program, started eating better. And over time, I watched that shoulder pain of his become less and less intrusive. So that got me thinking. All of the things that I see in my clinic on a daily basis, things like adhesive capsulitis, trigger finger, gout, tendinopathy, osteoarthritis pain that's out of proportion to the x-ray findings, sarcopenia, fragility fractures, carpal tunnel syndrome, chronic pain, all of these things, now when I see them, light bulb goes off in my head. More investigation needs to be done here. So that often triggers a metabolic workup. And nine times out of 10, we end up finding things related to metabolic syndrome. So, visceral obesity, hypertension, insulin resistance, hyperlipidemia, all have gone previously undiagnosed until they presented in my clinic with some kind of functional musculoskeletal problem. So, it's kind of a scary picture, but one in three adults in this country have metabolic syndrome. 27 million people with diabetes, 79 million people with prediabetes, and those are the ones we know about. 67% of people are overweight, 50% of people are obese, and we watch the trend with that picture. 1990, sort of the bluish cool colors between zero and about 15% obesity rates, now in the 20, and then later in 2018, all of those rates have changed to be greater than 30%, or most of them greater than 30%, and the trend is only getting worse. And as far as musculoskeletal conditions, there's 1.7 billion people in the world living with a chronic musculoskeletal condition, costing over $381 billion a year to treat, and it's contributing, 149 million years live with disability, so the largest contributor to that statistic is actually chronic musculoskeletal issue, non-traumatic pain. So, the rates of metabolic syndrome have been steadily increasing over the past 20 years. At the same time, chronic musculoskeletal conditions, like osteoarthritis, are also steadily increasing. Is that a coincidence? And the answer is, nope, these things are all related. And it has to do with our mitochondria, so I'm not gonna talk about the Krebs cycle right now, so before you all run for the door, we're not talking about that right now, but the mitochondria, from what you remember, basically the powerhouse of our cells, right? So it produces energy from food, it also controls different chemical reactions that have to do with regulating aging and cell death, it's basically the engine that keeps us going, keeps our cells going. And just like an engine in a car, it needs the right fuel, it needs the right oil, it needs the right gasoline to keep it moving well. And our mitochondria are no different. So, to keep a mitochondria functioning well, things like physical activity, good environment, healthy food, all help the mitochondria make energy, keep our cells functioning normally. Whereas, with mitochondrial dysfunction, the combination of processed unhealthy foods, stress, lack of physical activity, environmental toxins, result in the production of free radicals, reactive oxygen species, which lead to inflammatory cytokines, further metabolic dysfunction of our cells, and ultimately chronic disease. And chronic disease is an epidemic in our country and in the world, contributing to things like diabetes, kidney disease, cardiovascular disease, infertility, cancer, in fact, nine out of 10 leading causes of death in our country right now are related to chronic disease. It also contributes to things like mental health. So, if you read a book by Chris Palmer called Brain Energy, where he examines the effects of mitochondrial health in certain kinds of mental health conditions. Also, dementia, which is now being called diabetes type 3. Also, infectious disease susceptibility. So, we all saw that with COVID-19. The patients that fared the worst were the people who were in the most state of metabolic dysregulation. So, often forgotten in this conversation is the biggest organ system in our body, which is the musculoskeletal system. So, things like tendon and ligament quality, degenerative disc and cartilage degradation, muscle mass and bone density. When those things are all dysregulated, you end up with things like sarcopenia and osteoporosis, and injury recovery. So, the ability to recover from an injury, the ability of your cells to repair themselves after injury and do so quickly. Chronic inflammatory conditions and systemic inflammation as a result of metabolic dysregulation. Pain. So, not only just the pathology, but how we feel the pathology is affected by our metabolic health. And things like depression, because guess what? Painful, dysfunctional bodies are often unhappy ones. So, this is also contributing to the mental health crisis in our country. And because of this is why we have this discrepancy between lifespan, literally how long our bodies are alive, and healthspan, how long those bodies function well. And the distance between healthspan and lifespan keeps increasing. And now it's over a decade. So, people are starting to become sick, dysfunctional, and ill almost 13 years before they actually pass away. And in that meantime, they're living in assisted livings, they're in and out of hospitals, and they're not enjoying their lives. And looking forward to 2050, the obesity rate is estimated to be approximately 60.6%. So, more people in this country will be obese than non-obese. One in three Americans will have diabetes. Musculoskeletal disorders will increase 115%. So, we're looking at potentially almost 850 million people with back pain, and over a billion people with osteoarthritis. And as a physiatrist, as a sports medicine doctor, you may say, oh, that's a lot of injections for me to give. But there's a bigger cost. The direct and indirect costs of this metabolic health crisis will cause increasing healthcare costs, but also costs to society. People retiring early, people out of work, people unable to enjoy their lives, as well as a national security issue. As of right now, one in three young adults are physically unfit to serve in the military. This also affects things like our police force, our firefighters, who are basically physically incapable of participating fully. But this is treatable, and it's preventable. And really, the key to it is actually you. So, physiatrists are uniquely trained and have a unique worldview, such that we're able to put this health crisis on our backs. And one is an identification. So, the way that we're trained, the way that we are trained to look at patients and treat patients, one is we can identify functional disorders before they become problematic. We look at people's function. We can also, when people present to a clinic, they often present with a functional problem. I can't do the thing I used to do. My finger is getting stuck when I try to turn a jar. And often, those things are canaries in the coal mine of underlying metabolic dysfunction. So, it's up to us to see that and to start the treatment plan as soon as we recognize that problem. Two is teamwork. So, I did my training in Boston, and I was there during the heyday of Tom Brady. I'm a New Yorker, but I can recognize that he's damn good at what he did, right? He's a great quarterback, and we're great quarterbacks in medicine. We have the ability to work in teams, to coordinate multidisciplinary teams, to refer to different providers. Our egos don't get in the way. And that's imperative if we're gonna tackle this metabolic health crisis. It's imperative that we coordinate with other providers to help patients get the best care. Three is the approach. So, I came to physiatry through a lifestyle medicine interest group. I met Dr. Beth Fradies back at HMS a long time ago, and she was talking about root cause medicine and treating underlying causes of issues, and that really spoke to me, and hence how I ended up here. But really focusing on the root causes of problems, focusing on quality of life, function, rather than covering problems with pills and patchwork. It's super important in treating this. And really, it involves reframing orthopedic care as musculoskeletal health. So, going back to my friend Bill from the beginning, orthopedic care, in that case, would be give him a steroid injection, send him on his way, see you in three months when something else starts to break down. But if we look at his care as musculoskeletal health and finding out the underlying cause of his pain and dysfunction and being able to treat that, we're actually preventing him from becoming dysfunctional and ultimately dependent on other people. So, this is really a call to action. Become the detective, have the conversations, ask about things like food, exercise, sleep. You know, there's been a saying, instead of asking somebody, hey, how you doing? Say, hey, how are you sleeping? That'll give you more information about their health status more than anything else. And if we can focus on doing things to optimize longevity rather than dealing with the functional decline after it's happened, we can prevent a lot of these things from getting out of hand. So really, we have to think about, instead of managing chronic disease and chronic musculoskeletal pain, really think about curing it. Because that's how, ultimately, we're gonna prolong longevity and reduce mortality and morbidity from these issues. So, I want you, I want you to go out and start looking at things in this way. It's really, because we really, as physiatrists, we now have the opportunity to really show what we can do and show how our approach to care is ultimately the best approach to this problem. Not only do we have the opportunity, but now it's really an obligation. Because we have the unique training to address this problem better than any other specialty. So, physiatrists quite literally have the opportunity to save the world. So I've got one question for you. You in? Thank you. Thank you very much, Dr. West. Let's take a moment to give a big round of applause to our Fizz Talk presenters. It's a very brave thing to share personal stories and to share things that are particularly important. So thank you again. Now, it's time for a bit of friendly competition. So using your cell phones, please scan the QR code shown on the screen to vote for your favorite presentation. While everyone's voting, I wanted to take a moment to express my most sincere gratitude for you being here today and being online for this last day of our annual assembly. As I kick off my presidential year, I am most excited about the opportunities that lie ahead. As you'll read in my first presidential editorial in The Physiatrist, I believe that the road ahead for the academy is filled with both challenges and opportunities. As the healthcare landscape continues to evolve, the AAPMNR must remain adaptable, forward-thinking, and committed to its mission of improving patient outcomes through innovative rehabilitative care. Whether it's through the advancing role of technology, advocating for value-based care, addressing healthcare disparities, or fostering interdisciplinary collaboration, the academy's leadership is working on behalf of all of you members to ensure a thriving future for our specialty. Now, our road ahead is bright, but it is not without risks. Our members are prepared to meet those challenges, and the academy is here to help lead the way. I hope you will all get involved and help us to advance the future of PMNR. To that end, has everyone completed their polling? We will announce the winner here shortly. Please take a moment in these last seconds to complete your voting. We were briefly discussing imposter syndrome and how we all deal with it, and I said that these guys are all now contributing to your imposter syndrome on how well they did presenting, so they apologize in advance. So it looks like the votes are in. The winner is Dr. Max Hurwitz for his presentation, Disability and Homelessness, How Street Medicine Tackles Health Injustice. Congratulations, Dr. Hurwitz. Please come to the stage and accept the 2024 FizTalks Award, and a big thank you again to all of our FizTalk presenters. Thank you, everyone, for attending the assembly. What a fantastic week it's been. I hope to see you next year for our 2020 assembly being held in Utah on October 22nd to 25th in Salt Lake City, Utah. We're planning an in-person and virtual meeting once again. For those of you here in San Diego, safe travels home, and for those online, please have a great rest of your Sunday. Please join me in thanking Dr. Hurwitz.

AAPMNR Annual Assembly

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