For anyone that's already here, if you could just join our poll, because I like to utilize this. You guys can keep just hanging out for a little bit, but you can join the poll by two ways, just texting AaronYang927 to 37607, or you could just join by the web. It's just a good way to get to know our audience, and we'll use some questions in a little bit, too. So thank you. Again, not to belabor the point, but if you can join our poll, that'd be great. Don't want to make any judgments based on appearance, but I'm pretty sure we have some people in B and C that are not filling out, so if you can just log on, and some people are shaking their head no, but there we go. We got a C here. Okay. All right. Well, we'll get started just for the sake of time. Thank you guys for coming here today, and again, I'll put a reminder for some of the other things that, in terms of the polling I'll have coming up, but when you get a chance, if you want to join our poll, basically text AaronYang, which is my name, 927 to 37607, or you can join by the web, and it's a way we can interact and also get to know the panel. So thank you for filling that out. Seems like we have a lot of folks in training. We have some, we don't, oh, we got someone, early career, great. So we got a diverse audience here. So thank you for joining again. My name is Aaron Yang. I'm at Vanderbilt, and just to start off, we're talking about fellowships here, and I wanted to just make the point just to start off that this is not a pro or no fellowship type of talk, but just also to just talk about what's happening with our field, what's happening with fellowships, what may happen with over-specialization, how is that, how are we going to somewhat address this in the future. So I have no relevant financial disclosures. So these were the three learning objectives we initially set out, you know, really to talk about the current landscape among the field of physiatry. Dr. Johns will come up and talk a little bit about board certification. Then we'll initially plan to talk about some of the pros and cons, but while we were already planning this, Dr. McDevitt thought it would be great to do sort of a point-counterpoint type of talk. So we're going to try to mix it up a little bit. So this is sort of our general outline, and at the end, we'll have time for just questions and panel discussion. So I think for a lot of us, whether you're in training or if you think about when you're in residency, I think I even noticed this, that there was a lot more residents who were going into fellowship training after residency. And so this doesn't just pertain to our field. This is the most recent NRMP data of all medical specialties going into fellowship, and it was a record year. If you think back all the way to 1993, we see that this trend just continues to increase. And each year, there's always a new record of fellowships being offered and those going into fellowship themselves. I actually had an interest in this when I was in fellowship, just seeing what data was out there in terms of how that pertained to our field. So there was an informal survey done actually by the Academy in 2008, and it was very informal, but basically what they did see was that there was a growing number of graduating residents going into fellowship. Most of them focused on musculoskeletal care, and Raj and colleagues looked at the academic year of 2004 to 2005, and they saw out of 93 respondents, about 56% of them were planning to pursue fellowship. So as I got interested, we looked at some of the data, and we looked at graduating chiefs for the year of 2013 and 2014, and what we saw was that out of the 68 respondents, which was 72% of them planned to do fellowship, the majority of them planned to do pain, spine, or sports. So we followed that up most recently in 2019 and 2020, so this was open to all residents that were graduating and already matching to a fellowship. So we had 175 respondents, and 74% of them already accepted a fellowship position, and out of the 74% of them, we saw that 80% of them had already matched into ACGME pain, sports, or spine fellowship. And so again, for those who are close in residency or look around to their colleagues, this may be a trend that you're seeing as well, where a lot of graduating residents are entering fellowship, and you can see here, based on the data that we collected, again, tends to be more pain, spine, or sports focused. So I'm going to introduce our first speaker, Dr. Johns, but a good way to get to know your speaker is to do a little game. It's two truths and a lie. So if you have already logged into the poll everywhere, or if you have not, basically you're going to answer which one of these do you think is the lie. Good way to judge your speaker before you meet him. And then I'll have Dr. Johns come up and let us know which is the wrong answer. Couldn't include pictures here. All right. Pretty active poll. Thanks, Dr. Yang, for inviting me to be a part of this. Great discussion. It looks like we've probably gotten most responses in, so a pretty overwhelming majority vote getter was that my nickname is Wedding Singer is a Lie. That's actually true. Oh, it doesn't reveal. Okay. The lie is I've only completed two marathons, not three. I was a cheerleader in college, and my nickname is Wedding Singer. So on to business. So general disclaimer, so I serve as vice chair for the American Board of PM&R. I'm not here representing the board. I will be making some comments in our kind of point-counterpoint that are for the purpose of discussion and not to be misconstrued as representing any thoughts from the board perspective. But I do want to share some information about the board and board certification, and particularly some of the fellowship trends and subspecialty training, et cetera. So these first couple of slides are directly from the ABPMR website to give some historical perspective. And if any of you are recovering surgeons or have PTSD from surgical training, you know every talk starts with history, right? But there is some good reason to bring forward some history here. So ABPMR became an official ABMS board back in 1946. So as you see here, we started with, you know, 91 charter members. Over the first almost 45 years, there was no subspecialty development during that time. And by the end of that, we were at about 3,400 and some change diplomats who were board certified. You jump to the second slide, and over this next about 20 years, now we have subspecialties developed in spinal cord injury medicine, in pain medicine, in hospice and palliative care, and sports medicine, and the numbers of diplomats continue to increase pretty significantly. I'll just go back for comparison, 1990, 3,400 members, 2000, 6,500 diplomats. So significant growth, both in number of diplomats certified and number of subspecialties that are being developed. Fast forward a little bit more, we now have neuromuscular medicine and brain injury medicine as the most recently developed subspecialty back in 2014. And by 2020, we're up to 13,706 diplomats. So pretty exponential rise in number of diplomats, but I'd say you could probably graph that out and make the same argument for the number of subspecialties that are developed in our field as well. So the growth of fellowships in general, you can see here, just as a graphic representation, the most recent one, the dark blue line, those are the brain injury medicine fellowships. The green, also some pretty rapid increase over time, and that's sports medicine. The current number of ACGME accredited fellowships, these are not the non-accredited fellowships, and Dr. Yang just made mention to some. This is from the ACGME website, and you can see, obviously, pain medicine is the largest, and those are multispecialty. And from a recently published article in February of this year, this goes back to 2019 data, though, you see here the subspecialties that I just mentioned. But there are some nuances here that many folks don't know about what things are actually kind of owned and operated by ABPMR as an administrative board versus other subspecialties into which a PMNR physician may qualify. So a qualifying board versus an administrative board. You can see that listed there in the middle column, who really owns and operates the administrative board. So when you look at our field, again, from this 2023 article, the pain medicine obviously has the largest number and percentage of diplomates, about 15% of our overall diplomates are subspecialty certified in pain medicine. And you can see after that, the numbers fall off pretty significantly, with the lowest amount being the hospice and palliative care medicine. Of those who have subspecialty certification, there are about 11% who have more than one subspecialty. And there's a mix of things. But the most common in that group are those who have dual subspecialty certifications in both pain and sports. And again, graphic representation here, you can see the color coding, pain obviously the largest subspecialty, the light blue sports is, you know, the second highest, but significantly lower than the others, or lower than pain. But the reasons for some of this growth, I think it's a trend, as Dr. Yang pointed out, not just in PMNR, but more broadly across medicine, there's an increase in the number of overall fellowship positions offered, both from a qualifying board and those that we can sit through other programs. So the second point is the number of other programs into which PMNR residents are qualified and can be accepted into. We also have then the number of non-ACGME accredited fellowships, and a pretty broad reach here from cancer and amputation and integrative medicine, et cetera. So there's a lot of opportunities, and that's why we thought it was important to come and just have this conversation and dialogue. Because as you start to subdivide our field further and further, is that a good thing overall for our field or not? And we'll have more good conversation about that to follow. So thank you. Okay, now it's time to just hear a little from you. If you guys could fill this out real quick, too. We would like to also get to know our audience. Obviously, we have some trainees in here, but for those who are out of training, the question is, would you consider yourself a generalist? And as you guys are filling this out, just wanted to give a little insight into who our panel is going to be. So Dr. Johns is at Vanderbilt with myself. I am pain board certified. I believe Dr. Johns is spinal cord injury board certified and medical director of our inpatient rehab. Dr. Rowe is sports medicine board certified, program director at Shirley Ryan. And then we have Dr. Cabrera, who's had many different hats in the general world and been in academics, private practice, all different settings. And Dr. McDevitt is many clinical hats at Baylor. Is it executive vice president or I don't know the official title. You might be able to tell us that, but... I can. Okay. I'll save it for later. You'll save it for later. Okay. So I wish, actually this, for some reason I can't figure out, but it seems like we have a lot of both. I wish, I don't know if there's a way I could see the percentage, but we're going to, I'm going to introduce you to the speaker. So we obviously have a mixture of both, which is what we're hoping for here. So I want to introduce our speakers by doing the same polling. So first speaker, we'll go through each one here right now, is Dr. Rowe. And so which one do you think is the lie and two of them are the truths? And then Monica, I may have you speak into the microphone in a second. It's moving all up and down. All right. So I think... All right. They do not think you're a black belt. I know they don't because I'm out of shape right now, but I used to be in shape, in better shape and I used to have a black belt in Taekwondo. I've actually never summited Machu Picchu, that's the lie. And when the women got knocked out of the world cup, I went to the Great Barrier Reef and swam with sharks. So that's what, that was my high risk behavior after suffering a little bit of disappointment. So, so I did go swimming with the sharks. Awesome. Okay. Thank you, Dr. Rowe. The next person is Dr. McDevitt. This one's a little tough. I don't know if we can guess here, but again, you're trying to spot the lie here. I think these are pretty great. Are you going to do some sketch comedy for us, though? That would be great. Maybe. Maybe. Yeah. All right. Do you want to tell us which one is the lie here? The trick question. They're actually all lies. He didn't listen to instructions. No. My sister does not play on the LPGA Tour and, in fact, does not even play golf, but the other two are true. So I'm curious how you drove a public school bus right when you turned 16. I've got to hear this. Well, if you're old enough and you were raised in the right part of the country, when you turned 16, you could drive a public school bus, and I turned 16 on December 29th, got my license on December 30th, and early January, I was enrolled in school bus driver training for our public school system and drove a school bus for two years. Wow. And what part of the country did you? North Carolina. Okay. All right. That is very interesting. All right. And then our last panelist will be Dr. Cabrera. Also, this looks pretty hard, too, but. All right. Thank you. Wow, this one looks pretty hard. It's like it's all over All right, dr. Cabrera tell us okay So my dad was a captain of the national basketball team for Guatemala and competed internationally Including the Pan Am Games. He claims that he got a gold medal I have not been able to verify that on the internet yet, but there's a gold medal somewhere apparently and my my dad's great-grandfather was Manuel Estrada Cabrera who was a president and then used that title and quickly turned it into a dictatorship So he was the last dictator of Guatemala. I don't know any physiatrist in Guatemala, but that is where I'm from Awesome. Great. Okay. Now, you know us so you know, basically I wanted to come up with a hypothetical hypothetical case and Again trying to be a little vague just to spur on discussion without getting into too much specifics So our case is a third-year resident And again, this is all hypothetical. I did put a picture of this hypothetical person. So JD is a third-year resident loves PM&R Wants to practice in an academic setting maybe a mid to large size city Loves again all aspects of it. So wants to do a mix of inpatient and outpatient Not necessarily interested in doing spine injections, but maybe some ultrasound guided injections Botox So he comes to you for advice and is wondering whether or not a fellowship is necessary So this is the case That we're going to go off of again. Maybe we'll change up the scenarios a little bit to keep the discussion going. So What would you recommend in this scenario again With that hypothetical case, would you recommend this person pursue a fellowship or not pursue a fellowship? I think we have a pretty overwhelming answer so far Okay, so seems like majority of the folks here who voted said they would not recommend JD to pursue a fellowship So we're gonna sort of jump off of that scenario again All the people here were sort of voluntold which side to pick. I don't want it to seem like oh, we're me. Dr Rowe and dr. Johns are just so pro fellowship again. It's part of the discussion I always want to put that disclaimer out there because I think this is a topic that Again is much more talked about in especially in residency training programs And I think we also need to think about what's the future of our field. So For a pro fellowship or yes to fellowship Myself, dr. Johns and dr. Rowe will be arguing for JD to do a fellowship and then dr. McDevitt. Dr. Cabrera will talk about why they would not recommend a fellowship. So Would anyone like to kick us off in terms of why they would say yes or no to a fellowship We can all just chime in here Yeah, dr. Johns First of all, I feel like we have a little bit of a biased group perhaps by the name of the presentation and Those who chose to be here. So I think there's a sampling bias. I Think clearly the trends as we just saw are to pursue fellowship And as we talk about this case I think there are some things that are maybe missing and what residency program are they in how much exposure? Does this resident have to some of the interventional procedures that he has expressed interest to pursue? But since I've been asked to take the pro side to this I would say these particularly the ultrasound guided injections to be competitive especially in the academic world that he wishes to pursue I think to Really build that skill set in a way that's marketable and desirable Particularly again in an academic setting where things tend to get very sub specialized I think he would almost be forced to to pursue a fellowship To get a job in a medium to large size city at an academic Medical Center Any other there's more to it Curious we I don't think we have this question up here and the lights are bright So I can only see the people in kind of the front rows But no offense, but they look way too old to be thinking about fellowships at this point, so I can't see in the back Are they? How many people in the room are here because they're actively? Discerning whether or not they should do a fellowship just out of curiosity Okay, and how many people are here because they actively counsel people and they're curious what they should tell residents when they come in And how many people are here because they didn't want to hear another talk about Botox Or Xeomin So there again is as everyone has said And we'll say probably 15 more times during this session anything worth debating It's not binary. It's not black and white. There's neither right or wrong answer It's going to be gray, and it's going to be very situational dependent so having said that I think Jess points a good one if you're in a High powered academic medical center with really powered powerful departments Having that credential in some cases is probably going to be really important so I've got a number of Cons, and I will say honestly philosophically I lean towards the con side all other things being equal I think we tend to over specialize a little bit in in medicine And I'll just highlight two things to start which I think are somewhat related And one relates to the risk of obsolescence that you train you get more and more subspecialized you learn to do whatever trick it is you learn to do and That trick is great But then all of a sudden We don't need that trick anymore, and it's replaced by something else. So what are the chances that could happen? well talk to a bariatric surgeon and the current Führer over GLP one agonist and I've been asking our bariatric surgeons now are coming saying we went out a guy And I'm saying to them what do you think GLP one agonists are going to do a bad trick bariatric surgery? Do you think that man's going up or down? Interestingly their professional society is saying oh well This is going to normalize obesity around the country and everybody want to get treatment and surgery is going to go way way up I don't think that's true. I think we're going to see bariatric surgery decline Well, there are a ton of surgeons in this country that did general surgery residencies worked in the trauma Bay Were really really good general surgeons with a strong skill set and a diverse skill set That then woke up one day. I mean they became a bariatric surgeons they haven't done an appendectomy or gallbladder in months or years and Suddenly their trick is at risk of going away So there I think you never I think I think there's an absolute You never want to subspecialize to the point that your economic and professional livelihood hinges on doing one thing I think that's a critical mistake, particularly when we heard the the keynote speaker today Talking about innovation and how quick things are changing. I mean, there's nothing we're doing now That's going to be around in 15 15 years so that that's one issue is the risk of obsolescence and and sort of the the the brother risk of obsolescence is economic vulnerability That kind of goes hand-in-hand But you do a lot of facet joint injections and posterior and blocks and that that's great It's great until Medicare looks at the literature and says, you know, I don't think those are terribly useful We're not paying for him anymore at January 1st. I'm not going to pay for him anymore you never want to be in a position where you are at the at the Hest at the mercy of the regulatory body to say We'll make your job go away because we're not going to pay for it anymore. So those two things risk of obsolescence Burnout or the I'm sorry, the economic vulnerability are my one and two. I got I got a ton more though Monica yeah. Yeah, so I You know, it's interesting I like the question about how many people view themselves as general physiatrist because I would as a specialty board certified Subspecialist I would consider myself to some degree a physiatrist first so I do consider myself a general physiatrist the Residents and my residents in the room who've seen patients with me have seen stroke patients come into my office They've seen me prescribe AFOs. They've seen me do things in my sports medicine clinic And so one of the things I would say and it sounds like I'm arguing for the other side But that being said is when you pursue a subspecialty fellowship, you can still be a general physiatrist So it is one year additional of training. Absolutely But after that year when you go get your first job, you can decide now You've got more options of what to pursue You can choose to practice in that subspecialty if you want or you could choose to actually back off and do something slightly different And go back to maybe inpatient rehab or whatnot You're not gonna lose those skills if that's something you value in your own career And so a great example of this is one of my partners who's sports medicine board certified after a number of years Said she missed some inpatient rehab and she's she covers our inpatient rehab unit from time to time even though she's a board certified sports medicine fellowship, but what's really hard to do is is to start as a Generalist and then maybe two or three years later try to go and and get your subspecialty fellowship I think it's really hard to go back. I mean, I do know that some people do it We had a graduate of our program that that is doing that he's out in practice for one year and he's going back to Get a fellowship But but that being said it it takes a lot to walk away from the attending salary I think to go back into fellowship So now's the time to do it and if you have an interest I would say you can always do that But then choose to practice differently later on So I'll follow up on that really quickly because I was in that situation I was in my first year as an attending after finishing my my residency training and was notified by the Director of the interventional pain fellowship at my University that an opening just popped up and that I did really well on the rotation and if I wanted to I could go back but at that point I Was the first time? Yeah, I was making attending money. There's it was very hard to convince me to go back to being on a call schedule Having to study to prepare for a test. I was I was in what I thought was my lane So it was a hard decision to go back absolutely is But I will give a couple of I guess disclaimers about myself I did not do a fellowship, but I am board certified in brain injury medicine I was able to do that because of the grandfathering for the first test and I Also, I'm not in academics. So I've been in an academics setting twice in private practice Twice and now I'm actually in a non-clinical Career, so I've seen a lot of different aspects of it and I've seen the value of keeping your skill set very general if I were to meet with this This case if this gentleman was coming to sit down with me and say hey as somebody who's been outside of my academic bubble What would you tell me? I would probably stay away from giving Absolute recommendations, right? I mean, we don't want to tell somebody to make a decision and then then blame us for potentially not working out So I would I would take a more Socratic approach and I would ask questions The first question that I would ask and I'll sprinkle these in whenever they are appropriate is is there a skill set? That you need or want for your dream job or your first job right, because if there's if there's a procedural skill set that you need a Fellowship will give you that skill set and help you achieve more competence in that skill set The flip side of that is question number two. Are there skill sets that you're not willing to give up or willing to give up? If you spend a year doing a certain skill set There is a risk that it is very hard for you to get back into other things So if you're not willing to give up EMGs And you're going to a specific fellowship that just doesn't do EMGs that may be hard to jump back in So you have to ask yourself? Are there certain aspects of general physiatry that you're willing to give up to go into a fellowship from my experience? Not giving up those skill sets of general physiatry has has played in my favor Yeah, or dr. Johns you want to say something we can get that The Well, I'll keep going then They just a couple of things just to reiterate Part of what Monica said summarize some things. I think there's kind of three good reasons to do a fellowship If you are like really weak I mean you're lacking skills You need more time and you've got enough sort of self-awareness to know that you just have to percolate a little more not not that Not that you're not confident, but you really don't have the skills necessary to practice then sure extend your practice I think that shows pretty good insight If you're doing something that is highly technical and usually procedurally based That may require that you get a credential that others recognize that you do this highly technical thing and do it Well, probably a good reason to do a fellowship If it is your life's ambition to be a spinal cord injury doctor And you have a reasonable degree of confidence that you are going to take care of people with spinal cord injuries Now and next year and for the rest of your life I think probably doing a fellowship is the right right answer, but but outside of those three sort of focused areas Generally, I would advise against it and I'd certainly wait for our character character here on my list I Would add to this the issue of burnout and job dissatisfaction and I came out of residency Again, there's some people still it's still in residency here. But I mean medical school residency it's fabulous because you when you do a one-month rotation a two-month rotation you You love it or you hate it. You can't get along with your attending and it's miserable It's okay because you know another week I'll be on another rotation and you rotate on to something something else One of the most shocking things for me when I went to work for in a like a real job Is I got to like the three-month mark and a little clock went off the back of my head and said what's time to? Rotate and said no, you're not right. You're you're stuck. Yeah, this is what you're doing now for who knows? Who knows how long? So it is very sort of appealing to think that I can do this thing and this thing is so attractive to me That I'm gonna be really happy doing this forever. Well forever is a long time and after you've done that for six months or a year or five years the monotony and lack of Variability, I think becomes a real real issue. And in my case, I did a ton of different things. I Ended up doing pediatrics exclusively for three years because we couldn't find anybody else to do pediatrics for periods I'm much to the chagrin of the entire pediatric rehabilitation community but I have really enjoyed in my career the ability to Not necessarily change organizations, but change functions and roles and do something different and that variability I think that variability prevents burnout Keeps you fresh keeps you more engaged over time and I'll finish this little bit of the diatribe Okay, I get commonly asked by physicians Should I get my MBA? It's a little bit of an aggression, but it's a common question. Should I get my MBA? My answer is generally no that Some somebody if you're applying for administrative jobs Sometimes you like to have to have the credential to get in the right on the right pile in the stack But it's more important to actually do a job Go to work take what you got create value Demonstrate that you can create value and that that's how you get jobs That's how you advance not because you get the letters behind your name so if it comes down between investing your time and your money and your economic future in For doing a fellowship and going out and working and doing stuff and acquiring skills and creating value I think there's more value in the working piece of that than necessarily Putting in some additional time so you get another credential What one of the comments just to see if this would change your answer or Enforce it more, you know again, we showed a trend where there is Majority entering what seems to be a procedural fellowship pain spine and sports medicine You know, I tend to see people who want to perform ultrasound guided procedures so outside of spinal procedures, so thinking about peripheral joint injections Botox for spasticity If this particular person wanted to do those things in an academic center Would it be more beneficial to do that? So you're not competing with other subspecialists who are doing that who may would there be an advantage of? Doing a fellowship in that scenario Really critical question and I think if we ask that question of 15 or 20 people in this room We get a slightly different answer because it's very regionally dependent. It's very system dependent I'm at Baylor College of Medicine in Houston There've been physiatrists in Houston, Texas, forever, since we were a physiatrist. It's very well established, and there's no issue with the anesthesiologist saying, no, you can't do that, and people kind of know what PMNR does. That is way different than when I went to North Carolina, when there were no physiatrists in the state of North Carolina way back when. It was a brand new thing, nobody knew what we were. In that case, it probably is more important to have the credential for certain procedures. I would say for joint injections and that sort of stuff, I mean, no, there's no, somebody disagreed with me, there is no credentials committee in a hospital on the planet that would say, I'm sorry, you can't do a knee injection. I don't see that as being a really out there fellowship requiring sort of procedure. I think the comment, Jim, about risk of obsolescence is real, and I share that concern, and I think that's an important one to consider. I made one of my initial comments about, particularly in a nuanced situation where if a residency training experience was weak in particular procedural skills, then there might be a reason to pursue a fellowship. I'll add to that comment now that it really, in deciding about which fellowship to pursue, and we made this case about intervention spine sports because we just saw, those are the top two, right? But it needs to be more about learning the knowledge and skills about managing patients with particular conditions, so in this case, musculoskeletal conditions, spine conditions, sports-related conditions, et cetera. And once you learn those general management approaches, then as new things come along, the technology talk we saw earlier, advances in healthcare, et cetera, you have that depth of knowledge through the fellowship training that you are prepared to build and grow and evolve your practice that's not dependent on one procedure or two procedures that may quickly become obsolete. So it's about the depth of knowledge in a specialty population. It's easier to see that when you get into something like spinal cord injury, PEDs, brain injury, but I think that it's important, if pursuing a fellowship, to think about not just how many procedures will I get, but what will I learn about evaluation management of the overall patient population? So I was gonna say, Erin, you lumped botulinum toxin injections together with joint injections and ultrasound, and I would actually consider them very differently. From the standpoint of, as a program director, and you look at the ACGME requirements for a residency program, for a residency program, spasticity management is inherently a part of a residency curriculum, and what we're asking people once they complete a program to be a competent physiatrist, I think spasticity management is definitely within that purview. And additionally, joint injections, non-guided or anatomic-guided joint injections are also part of the purview of a physiatrist in training. That being said, ultrasound, even though we have a procedural number that everybody has to hit, it's five, which is, you know, we can sit here and debate the number, I don't know that we have fully gotten to the point where we think that all physiatrists who leave a residency program are competent in ultrasound. They're not competent in diagnostic, nor are they competent in procedure-guided ultrasounds. Now, some residency programs might have a different experience than others, and some people might feel confident to go out and do that without any additional specialty training, but it kind of goes back to that other point. So we have to really also look at what are our specialty guidelines for how, standards for a competent physiatrist is, and when you leave residency program, if you are competent as a physiatrist, what does that encompass? And I think that there are some things that are going to be inclusive of that, and that if that is truly what you want to do, and you're okay with spasticity procedures, and you're okay with palpation-guided joint injections, I think that is absolutely fine. If that's what you want to do, you don't have to proceed with a fellowship. But that being said, and I think it's been said multiple times on this panel already, where you want to go to practice is really important, because in my experience of now doing this for a number of years, we've definitely had graduates who have tried to go out and practice in not even academic centers, but they're just looking for a job in to do musculoskeletal, general musculoskeletal care. They're calling themselves a physiatrist, but they're not going to be doing any sort of inpatient care. And in certain cities in this country that are saturated with a lot of sports medicine physicians, not even physiatrists, sports medicine family medicine docs or internal medicine docs, they have a hard time finding a musculoskeletal job. So, and they have to join a PM&R department, and they have to be okay then seeing all the all comers in general physiatry. So if your interest is to be, yeah, I don't want to be the team physician or whatever, I don't want to do a sports medicine fellowship, but you really just want to take care of musculoskeletal care, and you're not interested in taking care of the full breadth of PM&R, you have to really kind of look at yourself and see if, are you going to be happy with that? Because is that, is what you're... And where you want to work also becomes very important geographically. I agree. I think the where you want to work and what's your ideal first job or dream job, final job makes a big difference. In this case, you know, one of the... They need that fellow... For the department. So I think it's important to know where you're working and also who you'll be working for, like what are your chances of getting that job? So certainly having that chairs that are going to tell you, you're going to be penalized for being more versatile and having more skills. At the same time, if there's a niche that needs to be filled in that department and they need somebody to create a program and you've identified yourself as having that ability, yeah, I mean, they may require a fellowship or they may request a fellowship. So that may have to go into your decision if you want to stay in that academic department. I'll also push a little bit on the where. We've all heard the statistics of how many people stay in their first job. I was in my first job for three years and had to move because my wife is an orthopedic surgeon and she did a fellowship outside of where we were. We were in that location for three years and she got her first job after her fellowship and it got to the point where I couldn't commute an hour and a half, two hours each way every day. So I made another move outside of academics. Then both of our careers kind of stalled where we were in that part of the country, so we made another move back into academics. So my flexibility to be able to do more than just one or two tricks has allowed me to reach out and find jobs that also help my wife find for something. Anybody in here that has a spouse or a loved one in a highly competitive field, not just healthcare, knows that you have to have several tricks in order to make it easier to find a job. And I think that the general aspect of PM&R makes us probably more flexible than other specialties. The plenary speaker today, I don't know if everybody heard the plenary speaker. He talked really, really fast and said a lot in a very short period of time. But really early on in this talk, he made a really quick comment about arbolization. Technology's branching and branching, or ramification might have been what he called it, that concept that it's more and more subspecialized. I think that's the other risk. In your career, if you're trying to be innovative, if you want to sort of be excited about the next big thing, if you get too far out on a branch, the innovation is gonna occur over the entire tree. And if you get too subspecialized, then you're not necessarily going to benefit from exciting stuff that happened. You might have to jump over to another branch. So it sort of builds on the boredom and monotony, that sort of thing. It's maybe, in a way, the same point. But it gets back to the point that being a broad generalist, at least to a degree, keeps more doors open for you in the long term. One of the things I was just going to mention is recognition of what we do. And as we become more hyperspecialized, for example, for someone who just wants to do peripheral joint injections, and you join a department, how do you get those referrals from primary care docs, unless it's already built in, or other specialties, because they start to see our field as, oh, there's a sports medicine provider, or there's a spinal cord injury person. And sometimes, like you may have alluded to, it may be hard for referring doctors to know what a general physiatrist does, and to send them a procedure. What are your thoughts with that? Any comments or experience with that? I do have, so, I mean, this is all under the assumption that having a skillset is viewed as a positive by everybody. But if you're going into sports medicine, into a community that has a family medicine, sports medicine program, and an orthopedic sports medicine program, you may be looked at more as competition than an advantage, right? So there's something, again, know the environment that you're in. I live in Texas, North Texas, Frisco. Frisco probably has the highest density of sports medicine doctors in the country. It's up there. So my wife's a sports medicine shoulder specialist. Not a great skill to have in that area, but for the department that she works with at UT Southwestern, they didn't have anyone in that area to compete. So, again, having a skillset, having a fellowship can be looked at as a positive for yourself, but in your environment, you may be looked at competition as well. I'm gonna hearken back to the title of our talk, is that fellowships is at the death of the generalist in PM&R. And I wasn't assigned a role in that debate, but I think you've heard pretty clearly from all speakers so far, and I would echo those comments, that it shouldn't be the death of the generalist. There are clear benefits personally, professionally, to maintain skillsets beyond just one area of PM&R. Job searches, unexpected or planned geographic moves, fulfillment, protecting yourself from burnout, availing yourself to evolutions in the field. And then I'll layer on to that, the strength in numbers that it takes to advocate for our field, for PM&R. And you talk to anybody, I see a lot of people in here who are very involved in the academy, in leadership, that we need numbers, and that's not just by membership in the academy, and that's part of it, but it's that we can all confidently say we are PM&R physicians first, and that we have a shared understanding of what that means, and that's the general approach to optimizing function and quality of life for our patients. Then you can layer on to that, whatever that subspecialty is, fellowship or not, I also grandfathered into my subspecialty certification, and I have practiced specifically in spinal cord injury medicine, and I have also pivoted and done a number of different things from EMG and outpatient and consults and brain injury and burn and amputees, and I've run lymphedema clinics and prosthetics and orthotics, and it's been a really, really fun career, and I love spinal cord injury medicine. So it is possible to maintain those general skill sets and have a subspecialty. So I think it's important to know that fellowship versus board certification isn't, they're not one and the same, right? We're reaching a point where a lot of board certification does require a fellowship. Grandfathering is time-limited, right? You can't always grandfather into stuff. So you can't, and I did the same thing, so having a general skill set has helped me be a brain injury specialist for a period of time, and then when it did not meet the needs of myself professionally and my family, then I pivoted away from that. So I think it's important to know that you can still get some board certifications without a fellowship. It's getting harder, though. Well, the grandfathering period for brain injury has expired. Yes. So it would only be for any new upcoming subspecialty. Yeah, and actually, I mean, that brings up a great point because I actually think that, I don't think, everything current right now, you cannot get, you can no longer get grandfathered into pain, you can't get grandfathered into sports, brain injury, PEDs, spinal cord, but you're right. I think if we created a new fellowship, like a cancer rehab fellowship in the future, there could be some grandfathering in. There would be a period of time-limited eligibility. Yeah, and so I think what's really interesting, obviously, since half the audience is trainees, it's important, you know, some of the mentors that you may have in your home institution, or even some of the people who've been up here, you know, who are up here talking, I think there was a day and age where you could do a little bit of everything, and you could get hired by all these places, and they let you become a brain injury doctor, and they let you do this, and they let you do that, but I would say that I feel like a lot of those days may be gone, and when you think about the job market, if you're going into a tough job market, and you want to do brain injury, but you don't have a fellowship training, and there is someone who also wants that same job, and they do have fellowship training, you're not going to win that one, right? So you won't win that battle, no matter how great you are. It's just going to be a hard sell to make it, and so that's why it's really important to know. Obviously, in our case, he really, you know, JD really is kind of, you know, likes everything, doesn't seem to have an opinion one way or the other, but if you really want to take care of a subspecialty population, and that is your lifelong dream, you should really think about the fellowship track, because I think it will also bring you closer, and then, of course, everyone said very thoughtful, and reflective, and beautiful things, and I'm going to say something superficial, which is, in most academic centers, there are just, you know, pay scales, and fellowship trained people often end up being a little higher on the starting pay scale than non-fellowship trained people and so that is another kind of superficial reality of why you might want to consider fellowship training if that part of it's important to you, but of course, we always want to do what's best for us first, don't do everything because of money, that's not a good, that's not what I'm saying, but you will get paid a little bit more with fellowship subspecialization in most academic centers. I'll push back just a little bit on the first point you made about the hypothetical department that has this job for this specialty need and you're competing with the universe of physiatrists and if you've got the specialty credential, then you've got a better chance of getting that job, true, but there are also hypothetical departments out there that have the need for generalists and if you're a specialist, you will be at a disadvantage if somebody comes with good generalists that are flexible and willing to do what the department needs, so I think that sort of swings both ways. I don't think it's an argument for or against a fellowship, I think it hearkens back to where we started was you have to know your environment and sort of plan according to your environment. A different point, this is, I had lunch with somebody who might be in the room, an old friend of mine who does spine. We were talking about, like the AAPMNR and the AP and he said, do you know when I trained, I started doing spine, I stopped going to the AAPMNR, I stopped going to the AP because I really felt it was better for me to go to my spine meetings and that's another part of the phenomena is there is a little bit of a sense of professional isolation the more you get specialized and myself, for example, I can't spell spine but I enjoy coming to meetings and talking to the crazy spine guys and kind of learning what they're doing. I find that very interesting and engaging so I would miss, if I just went to a brain injury meeting every year and didn't interact with all of you in this room, I think I would lose something in that. So I think there's also a risk as we're tallying up the pros and cons of sort of a sense of professional isolation as you get more and more specialized. I think there's a really interesting conversation nationally going on about identity, especially in the sports medicine world with everything that was going on with the NBA and their exclusion policy of physiatry. I think it's very important as sports medicine physicians to call ourselves physiatrists. I think it's very important that the people that you work with as in your subspecialty know exactly what you do, and the patients that you serve know exactly what you do. And I do think that, you know, I think we agree on that point in terms of absolutely physiatrists first, and even if you go into a subspecialty, like I said at the beginning of this, you should consider yourself a generalist in physiatry because that is how you should be practicing pain. You should be looking different from the pain anesthesiologist. You should be looking different than the family medicine, sports medicine doctor. You should be looking different than the internal medicine, hospice, palliative care doctor. Absolutely, you should, because your core training is in PM&R. And so we have to embrace that first, and as a specialty, that becomes really important as we kind of continue forward, no matter how much arborization might be happening in our subspecialty. Clearly, these numbers are growing. I see it. I interview over a hundred, you know, medical students every year going into our specialty. I read all these applications. This, I mean, these numbers, I see it dated every day. And what's really fascinating is I also, you know, I bring in 12 residents into our program every year, and without fail, out of the 12, there's at least one or two every year that thought they wanted to do sports or spine that changed to brain injury, or they changed to general, or they changed to EMG. And so there is something about what we need to do as a specialty to make sure everybody understands the full breadth and scope of our profession. And that's not something that should be the burden of JD or anybody that's making this decision. I think that burden falls on the residency program directors, fellowship directors, to make sure that that identity of physiatry first continues to be put in our training programs. So it's fantastic that Dr. Rowe says that we make sure that we're training really good general physiatrists, and because of that really good general training, you can take one person to kind of realize, actually, that's not what I wanted to do. Here's my passion. So we can't allow the unintended consequences of more fellowships to change the way that we train good physiatry residents. I'm going to agree with Jim and also counter the comment about involvement in other subspecialty societies. It can be a both and, and there's important reasons to consider getting very involved in both. So I'll use myself as an example here. So I still am very involved in the Academy of Spinal Cord Injury Professionals. I was the president of that organization for two years. But it's not at the expense of seeing myself as a general physiatrist and maintaining strong involvement more broadly across our field. So it's a both and. And so for JD, in pursuing a fellowship, it can and should be both and. Anybody change their mind so far? Oh, we got the poll coming next. But I think our panel is starting to get blurred of who's on what side, because I feel like we're starting to all lean towards one way. But so you guys can answer here. Can you guys, we'll see if the answer changes at all. But I think I have a suspicion what people will say. So would you recommend? Oh, okay. I think we're pretty, I suspect that people would still be more on the no side. Again, I wish I had the percentages here. I apologize for that. It's highly scientific. We'll be publishing all this data. Yes, yeah. You know, I wanted to spend some time just having a discussion with you guys, too, if you have questions. So we see here, again, maybe more towards the no side here. So this is an opportunity for you to, again, you guys are already in the poll. You can just type a question in there, and then it's gonna pop up here. No other questions coming up. The one thing by design we didn't talk about is this was all through the lens of a resident deciding to do a fellowship. Next year, there's a whole other set of questions around societal use of training resources, and from a public policy perspective, is it the right thing to have a proliferation of fellowship programs? As many of the people in this room know, now that we have an unfunded mandate that you shall provide protected time, paid time for leadership of all these fellowship programs. It's a requirement now that's built into the thing. Limited resources, spread more thinly. At some point, and at a high level, you think, well, should we train more family doctors and less neurosurgeons, or is it at that level? But in PM&R, should we train more generalists, or should we train more specialists? If there's a limited training dollar and a limited energy in a department to get things done. So I think there's a whole societal question out there to ask, too, that we're not gonna cover today. I'll add some comments while we, oh. So what I just wanna say is there's, this isn't just a healthcare issue, right? And there's good resources for you to see the bigger picture of specialization and generalization, right? So whenever I talk to a resident who is kind of in this situation, I would recommend them read a book called Range, Why Generalists Triumph in a World of Specialists, or Specialization, by David Epstein, who was a sports writer for years and stumbled into writing books in certain areas. And this is kind of the book that famously debunked the 10,000 hour to become a specialist or to be proficient in anything. And I also recommend people to look at things like organizational psychology. The one that I really like is a guy named Adam Grant. He has a podcast named Work Life that talks about just how you make your career happy, to avoid burnout, to identify weaknesses and attack them earlier. And then I also think another topic is the law of unintended consequences. So when you make a decision, there's a domino effect, and how can you predict some of the third, fourth, fifth dominoes that are gonna fall and how that should impact you in the future? Okay, so I wanna just start off with the initial question that someone posed. What are the best ways to stay competitive in academic environments as a general physiatrist? And we can sort of define stay competitive maybe based on busyness or reputation. Any thoughts? This is sort of resident advice 101. It's been the same advice forever, so I apologize. But I mean, one concept is when you look at an environment to work, that you have a choice. You can either take your skillset and try to impose that skillset on an organization and say, wouldn't it be great if you did this? And then beat your head against an administrative wall for months and months trying to get the organization to acknowledge that what you do is good and important and something they want. Or you can be savvy enough to look at the organization, look at your skillsets and say, what can I do that is going to benefit this organization? And I'm obviously leading the witness here, but then you're peddling downhill. Then it's sort of easy. So at some level, the answer to the question is to be a little bit of a chameleon. And again, it is always important what you're doing and what your job is and what you enjoy doing and what your call schedule is and all this sort of work-life balance things that you have to consider and you should consider. But I think you actively have to look at the environment you're in and think about how you create value for the organization and be flexible and embrace opportunities when things come up to show that you create value for the department. And as you reflect on this, every one of you can think of people in your own departments or practices today that are in their zone, that they're never gonna help out, they're never gonna be the person to stretch. And every one of you knows the person that holds up their hand and says, oh, I think I do that, I could cover that. So I think the success is to be that second person, not the first person. I agree, I'll add to that, since we're dropping book names and authors. I'm currently reading Brene Brown's book, Dare to Lead. And one thing that I was just reading about is this concept of, in her organization, having this open vulnerability and when there's a task assigned, it's fair to ask not just what does done look like, but they say paint done. So paint a picture, what does done look like? And really what that says to me is, what do you want me to accomplish in this role? So as far as maintaining your competitiveness in any job, how are you gonna be evaluated? And it's not so you can just produce more widgets, but healthcare is multifaceted. And it is somewhat about productivity, there's a lot of that, but there's also patient satisfaction and other things that are important. And certain departments are gonna weigh things more heavily than others. So having that open conversation of, basically, what do you expect from me? And how will I prove to be successful to you? Part of that's gonna be flexibility and willing to step in, but even in your primary job responsibilities, paint done for me. What does success look like? So another question is, and I was thinking about this, would we have different recommendations if they were going to practice in maybe more of a community private practice setting as opposed to academic? I think it's crucial to talk to people in both environments to see what fits you better. I think that's a really, I'll let other people talk briefly, but I strongly believe that you have to meet with somebody that's made the decision that you're going to make on both sides and talk to somebody who's done that five, 10 years down the road. That's hard with some of these fellowships because they're pretty fresh, but I think you have to talk to both of them, and not immediately, so get out of your bubble of training, not the new faculty that came in that just finished their fellowship. Talk to somebody who made that decision and stuck with it five years down the road. It's always the same answer. It sort of depends. I think it sort of depends on the environment because on balance, I would say a academic environment with a lot of high-powered departments, the need for specialty sub-certification on balance is probably greater and probably less in a community-based practice, but having said that, it depends on the community and the politics in the community, the established dynamics of the specialty mix, how well-established PM&R is in that community. Are you going to be doing like a brand new thing that people aren't used to physiatrists doing? I think those are all sort of to your point. You have to sort of ask those questions and figure that out specific for that spot. And we'll talk a little bit about the non-clinical role in a second. We have another question. We have jobs that don't require fellowships. What is your opinion as to how willing fellowship physiatrists are, again, sorry, it's cut off, may be willing to take a job like that after fellowship that does not require fellowship? I'm making a guess here, but if someone asks that question, if they want to clarify, please feel free to do that. Can you attempt to restate the question? Yeah, I'm not sure I understand. Is there a way you can show the rest of the screen? It's cut off, yeah. Yeah, it is. So if anyone wants to come up, I'm sorry to call you out. If you want to come up to the microphone and ask that or. What about any of the other questions here? I don't know if we can, I'm going to try to read some of them and guess, but if you're looking to practice as a generalist, how do you keep your skills and knowledge up if your patient population lends towards? More narrow people. Yeah, possibly more narrow scope within PM&R. You're sort of meeting the needs of where you are. No. I would just, a couple of pieces of advice there. Opportunities like meetings like this, where you have opportunities to attend sessions outside of your current practice area, things that you want to either grow or maintain skills in, even though you're not currently clinically practicing in those areas, out of just interest or maybe preparing yourself for future job opportunities. Offering to do that extra cross coverage or taking call if you're in an outpatient setting and you want to maintain some of your inpatient skills. I'm sure the inpatient team would be more than happy to have you rotate into that call schedule. So there are opportunities like that that you might be able to avail yourself to, even if you're in a private practice setting that's all outpatient based, there may be an inpatient unit that may need some inpatient coverage at time. They have one physician who's on medical staff there and it's a small unit. They need to take vacation as well. Setting up an arrangement where you could step into that role on an interim basis or helping with cross coverage. So there are ways to work that out that you could keep up some of those skills. It's an excellent question though, because I went 10 years between this conference because I took a job that I really enjoyed, but I didn't have coverage. So for a long time, there was no way that I could actually take this time off because there was no one else to do the job and my employer wasn't willing to bring somebody in most of the time. So I would say we are not prepared to be organized for this leaving residency. Like nobody tells you how to get started with the maintenance of certification. The information is out there, but you have to look for it and be prepared. So you have to get organized early on because if you find yourself in year three or four and you haven't gotten your CMEs and you haven't come up with a plan, it's a lot harder to catch up. So I would say get organized, learn, ask questions about how people are getting their CMEs and how to best leverage the MOC program that's in place right now, which we have two experts in that area right now. I would highlight the innovative nature of this particular session is most sessions, they put the questions up and they answer half the questions. In this session, we put the questions up, but we answered half of every question. So it's a different sort of approach. One more question here. So would you recommend a fellowship to JD if they were going to practice maybe half day or one day a week in TBI or PEDs or maybe even musculoskeletal? What would you say to them? So it's not their full time, five days a week, but maybe they're doing a little bit of TBI. Like a fellowship in? Fellowship and maybe TBI and they're doing a half day of TBI clinic a week. Would a fellowship be needed? Would that vary based on how much TBI they did during that week? Maybe two days of TBI a week. I think the tricky part about that is if the job is gonna hire you without the fellowship training to do that, that's great. But if you can't even get that opportunity to do that without the fellowship training, that's tricky. And maybe this is getting at one of the other questions where there are some people in fellowship training programs that when they come out into the job market, they have a hard time finding a job, taking care of that exclusive population. I think spinal cord injury is probably one of the bigger ones. Pediatric rehabilitation doesn't seem to have a problem with that as long, because there's a great need for that. But with spinal cord injury physicians, sometimes they have to do something else and then they're trying to get a day a week in their own specialty. So again, if you look at the place that you're working, if you see that there's a spinal cord board certified person who is seeing maybe consults, all comer consults four days a week, and one day a week just got a spinal cord clinic, the chances that you're gonna get a spinal cord clinic ahead of her is probably gonna be low, her or him or whoever, it's probably gonna be low. So I think really looking at the situation of the place that you wanna work is gonna be really important. No. No, no need for fellowship. Do you think that there, I mean, again, I know a lot of us, we've talked about different scenarios of where you practice in terms of region. Is there significant variability that you've seen within academic centers? I get the region, but what about academic centers? Are they tend to favor one or the other? And that is a little hard question because many of us may have spent most of the time at one academic center and haven't seen others, but. Yeah, I'm not, go ahead. No. I was gonna say, my biased opinion is that I think academic centers favor fellowship-trained individuals. In general. All right, I'm gonna finish up this case conclusion. So J.D. pursued a sports medicine fellowship and he was offered a job of a lifetime as head athletic trainer for his Florida State Seminoles. And so he left academic medicine, unfortunately. I'm just joking. This is my chair, just as an FY, who does not know who that is, that's Dr. Kennedy. So that is it. Thank you so much for being here. If you have any questions afterwards, please feel free to come up. Just as a plug, we do have a session on non-clinical careers Saturday at 9.15, I believe. So if anyone wants to hear about some of those opportunities, please feel free to attend. I'm also happy to stay, whoever had the question, I can stick around here and meet with them specifically. Thank you guys. Thank you.

perspectives

merits

fellowship

physiatry

specialized training

marketability

obsolescence

burnout

career aspirations

job market

comprehensive care