Oh, there we go. All right, welcome everyone to this session on filling opportunity gaps in training. A couple of minor things. First, please silence your cell phones. And for all sessions or workshops, we are having an audio recording taking place in the room. And then if you liked it, please put us on the evaluation forms, okay? And if you have time, please go visit the pavilion while it's still going on. So I'm gonna get us started off with Dr. Prather. She will be talking to us about lifestyle medicine. She received her doctorate of osteopathic medicine from the University of Health Sciences College of Osteopathic Medicine, followed by a residency at Northwestern. She's currently a professor in the Department of Physiatry at the Hospital for Special Surgery and Weill Cornell Medical School, and serves as the Medical Director of Lifestyle Medicine and Co Director of the Comprehensive Osteoarthritis Center. Thank you so much, Dr. Prather. It's just a folder. I'm seeing the arrow. There it is. very much. I have a very real black cloud with electronics. Okay, so I'm gonna talk real fast about the Lifestyle Medicine Program. These eventually will be downloaded, so you can see the slides later. I do have very early pilot data at the very end that's not published yet. Got more pilot data in my phone last night, so I might share some of that. But I just wanna tell you about the Lifestyle Medicine Program, we have going, and how it's applicable to our field, and hopefully engage you in that. These are my disclosures. So Lifestyle Medicine focuses on the conditions that consume about 80% of our healthcare visits, hospitalization, and costs across the United States. And less than 3% of Americans live a healthy lifestyle. In fact, less than 1% of Americans are thought to have an appropriate diet based on the American Cardiology Society. So what is Lifestyle Medicine? The definition of this is it's the evidence based, that's the biggie, lifestyle therapeutic approaches including whole food, plant predominant diet, regular physical activity, restorative sleep, stress management, meaningful social relations or social connections, avoidance of risky substances, as a primary therapeutic modality by clinicians who are certified and trained in this specialty to help prevent, treat, and often reverse chronic disease. So that is the definition of this, it's not just have a this or that, it's these six pillars that are applied simultaneously together to help reverse and prevent, treat chronic disease. And then how is that different? Well, there's all these other types of medicine out there, there's integrative medicine, which is really experience based, complementary and alternative medicines, which have some evidence and not as great evidence than others, complementary and alternative approaches or care to currently considered unconventional, probably that's fading away with time as we get more literature of that. But conventional medicine is what most of us practice, which is shorter long term treatments used to eliminate or control disease, and it's where the person passively receives that information. That's the difference then with Lifestyle Medicine, is the patient's an active participant in their care. I am there to enable them to get to their goals, and we use these six pillars in which to do that. So we know there are influences and applications of Lifestyle Medicine, both in specialty care, primary care, and the sciences. I would love us to put physiatry down there in the specialty care, and I'd probably put our whole field because I don't know there's any patient within the field of PM&R that wouldn't benefit from this based on the disease process in which they see us. We also know everyday lifestyle habits act through epigenetic mechanisms, so that's thought to be one of the premises of how this works, and there's evidence behind that. So if you have a gene that says, you know, my family members tend to get a lot of cholesterol, about 60% of that is controlled by your genome, but 40% of it is controlled by your lifestyle. If you choose a better lifestyle, you can affect the intensity of the embedded gene effect, so that's what that's about. The six different pillars, the whole food plant predominant diet, there's nice evidence around how this helps reduce chronic systemic inflammation in our bodies, which helps eliminate those diseases. It's a whole package food, fiber is the most important thing, and we eat the rainbow because there's different phytonutrients in each of the different colors. This study here to the right with the graph red is the Western diet, the blue line is the lacto ovarian, so meaning you're still eating dairy, eggs, and fish, and green is when you're eating mostly plants. The column farthest to the right is all cause mortality, so you can see when you eat toward the green, that line is lower. The next line is cardiovascular disease, the next line is hypertension, the next one is diabetes, the next one over is cancer, certain types of cancers obviously, diverticular disease, kidney disease, and even cataracts. So eating towards the green improves all of these different chronic diseases. Physical activity pillar, it's really getting people to work, and I take a cumulative activity score on everybody and then divide it into what they're doing. You're trying to get people to 75 to 150 vigorous minutes per week, or a total of 300. I think that's a real area that PM&R can really help the lifestyle medicine application because of our expertise in physical activity. Sleep management, again, going beyond just take a pill, it's what are the lifestyle and habit changes you can do to improve sleep. Stress management is a big part of it, really it's behavioral health in general, but stress management is a way a lot of people can at least start to go down the path of addressing that. And we talk about the interrelationship of stress in your body and inflammation, how you physically feel and your metabolic factors and options of treatment for that. Addictive substance and management and clinical interventions, we focus primarily on alcohol and tobacco. Alcohol specifically, people understanding what an appropriate amount is and dosage of that, and it's gender based, and obviously cessation of smoking. And then the importance of social connections, which is probably a lot more... People are a lot more aware of now than previously because of the pandemic, but the implications of that. So we spend a lot of money on this. How does this apply to physiatry, right? So that's all from the endocrine and cardiac world, primary care world, and that's where the biggest part of this movement's been. How does this apply to us? Well, we're seeing lots of people with disorders that are related to chronic systemic inflammation that cost a lot of money and impairment and disability. And I want you to remember that 1%, if we actually change the trajectory of obesity that's thought to be occurring based on current projections by just 1%, we can save over $84.9 billion by 2030. So you get a little frustrated, well, we tell people to do this, but they don't. But if 1 in 10 do, we're starting to move the needle. So how do we get there? We have an unhealthy diet, sedentary lifestyle, high stress, and even some medications lead to microbiome dysbiosis, oxidative stress, and cell injury, which is what creates systemic inflammation and these chronic diseases. Obesity, type two diabetes, high blood pressure, hyperlipidemia, cardiovascular disease, some cancers, and mental health disorders. So some cancers, predominantly prostate, breast, and colorectal. Well, I look at this and say, what about my patients that I'm seeing? Hang on, there we go. And with osteoarthritis, musculoskeletal disease, and spine conditions, they have systemic inflammation and they happen to have this other stuff too. Is this part of why I see them coming in and out of my clinic so often? Because we're not addressing both things. So we know that inflammation is at the crux of this between these disorders and lifestyle medicine is evidence based approach that has great data showing that you can actually treat these chronic diseases. Why should we not try applying it to what I'm seeing in the clinic? And that's where it came. There's lots of data on behavioral health, around 20% of people with OA have anxiety, depression, less function associated with inflammation. If we look at osteoarthritis and lifestyle impacts of diabetes, type 2 diabetes, patients with type 2 diabetes are more likely to have bilateral hip and EOA and more likely to have more progressive radiographic changes on imaging. And those with metabolic syndrome are more likely to have OA as well. Cardiovascular events are more common in people with OA. There is a link and we should be addressing it. The relationships of that and smoking, obviously we're quite aware that smoking increases your pain report. Alcohol, it's not quite so clear what the link is, but clearly when people eat, drink consistently at high levels, they have progressive OA. So I got a little frustrated, this is self promotion here, sorry about this, but I got a little frustrated with how do I find all this links to chronic inflammation as they relate to the pillars, as they relate to the patients I'm seeing. So this just came out, it's in the journal of... HSS journal, it's a small narrative review, it goes through each of the pillars and each parts of the science related to chronic inflammation, how they apply to osteoarthritis. And I focused a lot on how this was independent of just BMI. We can't just lose weight and fix the problem. So why did I get into this and why might you be interested as you're coming out of training or things you wanna do in addition to training is, I saw all these patients with all these problems, got really fed up and I was frustrated by the lack of incentive I had in the clinic to educate people. I didn't have a comprehensive program I could send it to and had a hard time getting a model in place for patients to get access to care for things that weren't reimbursed by our insurance companies like a dietician. It's pretty simple, but that's not necessarily available to everybody. We know that the people with chronic diseases have the same circular pattern between obesity, non movement and weight gain. Again, applying this to reduce inflammation is where we need to go. So what do we do? We developed an interprofessional lifestyle medicine approach for people with arthritis and we designed it to actually go after root cause of the problem and not just to treat the symptoms. So obviously, we gotta solve this in a way different than what we've been doing and this is our template for the lifestyle medicine program at HSS. It's 90 to 150 days, it's patient directed goals. So the patient sets their goals of what they wanna do. We make goals that are actually in our epic chart and then we put an interprofessional team together for them and we apply some of this through group programming. So they receive one on one care from a dietician, health coach, counselor, therapist, physical therapist, exercise, kinesiologist, smoking cessation and go for dry needling or medical massages needed for pain control and some of this we deliver in a group method. We meet as a team every month to discuss the patients to make sure we help coordinate their care, message the patient and actually learn from each other as a team. The first one of these I started is at Washington University School of Medicine and I'm very, very, very proud of them. We opened these doors and pandemic hit the next day and they turned virtual but they made it through, limped through. They've seen 1200 patients. They had a donor give them money for lung COVID and they received the Dean's Impact Award last year, Devyani Hunt, the medical director from the university, presented to her by Dr. Fauci and then Abby Chang has just won a $5 million award to study COVID through the Living Well Center and it's in a relationship with the community. So this is alive and going and working and we were just in Australia together showing our research. So how do patients get into either of these programs? They're very similar. We built both of them so they kinda look the same. The patients are referred or self referred to the program. They go through a triage center where we ask them where they are in an active state of change. We take an initial intake, which is quite lengthy, go through all the six pillars, their behavior, their metabolic measures. The patient sets goals, assign a contract with them and then we apply the Center for Professional Team approach. They get close to achieving their goals and we measure those things again. So it's not just we gave them something, we measured, we had an intervention and we measure again. And I think that's where we gotta get to, to show this. So this is an example of how the care pathway goes for patients and you'll see at the end, we have to expect that patients will have... Will stumble and will need help in maintaining and so we have digital programming that we're still in development for. What does the actual patient cohort look like? So this is one of our first pilot patients, a 65 year old with severe knee OA and low back pain, was seeking health optimization prior to total knee arthroplasty. Her health works were that she was a class three obesity, so her BMI was 42.8. She was pre diabetic and had vitamin D deficiency, which she didn't know she had until she came to our program because we screened for it. Her CRP level or acute inflammation marker was 15. She had zero minutes of physical activity per week and her average pain was seven out of 10. Her goals were to reduce weight, stabilize her metabolic measures, increase physical activity and reduce pain. She was in the program for eight weeks. She attended four dietician visits, one physical therapy visit, three visits with the health coach and attended our group programming for nutrition. She lost 10% of her body weight. Her hemoglobin A1C normalized, her vitamin D normalized, her CRP went from a 15 to a 1 and she now was up to 100 minutes of physical activity prior to her knee replacement. Big deal, two out of 10 pain and she's successfully undergone total knee arthroplasty without complications and she's almost nine and a half months out now. So that's what one patient's journey, obviously I'm showing you a success one, of what it can look like. What does the patient say? Changing what I ate and not how much I ate was a big part of my success. I liked the coordination and I felt like I had a team around me. So we base this off the trained theoretical model for change. There's other ways we can do this. It's kind of where I've stabbed in the dark starting it. So patients are not in an active state of change, they're going through pre contemplation, contemplation and preparation. And at that time, the evidence says if we link their things, if I link that your knee OA with swelling is linked to the cheese and the five steaks you ate last week and associate that, that's where we are in pre contemplation. And then we kind of walk them down to, okay, let's go get some running shoes, haven't gotten out the door. When they get out the door, that's when they're out in the active stage. So we're trying to provide programming for the people in whatever stage they are on. Happy to say the pilot happened, and in May of 2023, the hospital decided to mandate it for patients at high risk, and I've developed two tracks of people that are engaged in active change and people that are not. I don't know of anybody running a lifestyle medicine track with unengaged patients, but we have one. And so I'm just trying to follow the evidence. We do work with an obesity medicine physician who can give medications, and my new data says that less than 16% of patients are actually actively seek that. So patients really are seeking a way to help themselves. Social connections is really a huge part of this, and our group programming has been a big success, and this is something anybody can incorporate in their practice. There are codes that you can build for just in the group, or you can do individual sessions ahead of time. We have published some feasibility on it. We've published that we don't over utilize visits. The average person, if they're one on visits, are around two to three for the professions they do use, and they do have some early data, not published. So when you see the slides, don't quote it to anybody, but just the proof that we are collecting data on each of the measures. So this is my early data from my pilot study. I just got my data last night from the mandate from May until now. 91% of people are meeting their goal to get into the program. So I'm very, very excited about that. Their patient reported physical and mental health scores are changing, their weight's going down, their hemoglobin A1Cs are getting better, and their mental health scores are getting better. So hopefully you'll see lots more from us. If you're interested in getting involved, I would encourage you to go to the American College of Lifestyle Medicine website. There's actually lots of things that you can do that's self paced. If you have a hard time finding that, contact me. I have a code, you can get five hours of free CME through the HSS model. If you wanna get jump started on trying to see if this is something you're interested in. I did sit for a board, there is a process you go through for that. It's not arduous, it's something you can do. You do need some experience, you need to go to a meeting. I would say the biggest lift for me was definitely the nutritional piece. I am whole food plant based myself for eight years, but I still like diving into the literature and understanding how to read nutritional literature. It was... I had to do on my own, but... And go to meetings, but it is doable. So, thank you. Alright. And I'm going to save the questions for the end, okay? So next up, I have Dr. Carolyn Geis. She received her doctorate in medicine from the University of Texas and then residency training at Loyola Marion Joy in Chicago, where she was a chief resident. She currently practices at Brooks Reap Cabin, is an adjunct professor in neurology at the University of Florida. So, welcome Dr. Geis. I'm just starting up the... Great. Thank you, Rosie. Good morning, everyone. Thank you for the opportunity to talk about what I think is a really interesting and practical topic, filling opportunity gaps in training, getting experience that you didn't. And I'm going to focus on kind of medical knowledge, but also on procedures. Those are my disclosures, neither of which are relevant to the talk today. This is a little bit about what we're going to cover. So we'll go through one study that we found. There's not really much literature in this area, but one study that I think was relevant to what we're going to talk about today, which reviewed variability and procedure volumes for PM&R residents. We'll go through some suggested areas to fill gaps during residency program at that point of transition from residency to career, and then during your ongoing career. And we'll also hold questions till the end. This study that was published in 2022 by Nelson and Silvestri looked at retrospectively at PM&R residents who graduated from 2014 to 2021. And what they really were looking at was temporal trends and variability in the reported procedure volumes. And specifically what I wanted to share with you, the number of residents that attain their minimum requirement for the various procedures in PM&R that are required by ACGME. Before we go to the study, I also wanted to just emphasize the difference between the minimal requirements that we're going to discuss and competency, right? These are two very different things. And when I think of competency, you know, you think of the ability to safely, effectively provide a quality treatment procedure to your patients. And that may or may not be met by the minimal requirements that are required. So, you know, these are a guideline, a minimum basis, but you may very well get your minimal requirement but not have competency. So as you're evaluating your own ability to provide a procedure for a patient, you know, make sure that you're clearly understanding, I've met my minimal requirements, but competency may be different. So just to refresh, I think you probably are familiar, these are the minimum requirements per ACGME for PM&R in the different areas. And so what I will show you is that, you know, we have total requirements and we have performed requirements. Total represents observed and performed, and performed is just performed. So if you look at the numbers there, for EMG total, 200, 150 of those need to be performed. For our axial injections, 5 is the total number. And for our peripheral nerve joint injections, 20 is the total number, 15 is the performed. Botulinum toxin injections, 20 total, 15 performed. And then ultrasound total, 10. So I think as an incoming resident, it's important for especially your PG-2 residents to make sure that they're familiar with those requirements. So if we look at that study, there were a little over 3,000 PM&R residents that were included, and basically they looked at the procedure logs for track procedures, and those were provided to the study investigators by ACGME. And what they found was kind of a, this is a waterfall diagram that shows you the least commonly performed procedures on the top part of the waterfall, and then as you go down the waterfall, the more commonly performed procedures. So we have EMG, peripheral joint injections, and botulinum toxin kind of on the downslope of the waterfall as the most commonly performed procedures. And then we have phenol, peripheral nerve injections, and some of the other categories on the lesser performed side of that. So I think what's helpful about that waterfall diagram is you can kind of benchmark what your program looks against kind of what is happening in the aggregate there. I thought this piece of information that they found was interesting, and it shows you the performed versus observed. So the procedures are listed across the bottom. Everything in orange is performed, and everything in blue is observed. And so I think that's a helpful piece of information when you're looking at that to see what's the trend there as far as what residents are performing versus what they're observing. And you can see there's a couple areas there that are more likely to be observed versus performed, and those are the things that you would expect in that kind of fourth, fifth, and sixth column are more of the spinal axial injections. So part of what I think you can interpret from that chart is that you may need a higher number of exposures to those procedures in order to get your performed because the tendency is going to be higher to observe those procedures. This was their data that looked across time from the time periods from 2013 to 2015, and then 2015 to 2021, and it looked at those residents that did not meet the requirement for their procedures by category. And I think what's nice in this slide is on the far left side you can see that the number or percentage of residents that were not meeting the requirement significantly changed from the earlier time period to the later time period. The one area at the very bottom, which was still at about 22 percent, oops, sorry, was ultrasound. So still in the later time period from 2015 to 2021, about 22 percent of residents were not meeting that requirement. So for program directors, I think that's a helpful piece of information to know that that's a challenge for us as a field. So just a couple take-home points from that study. Procedure volumes increased over the study period, which is encouraging, and more specifically, more residents were coming into the training field, and that procedure volume increased as the number of residency slots was increasing. So the percentage was staying pretty consistent. The percent observed versus performed was pretty stable over time, and like I said, ultrasound seemed to be the challenge area in the later time period. So the next couple slides, I kind of broke it down into, you know, how do you fill opportunities to fill gaps during residency? How do you find them as you transition from training to your career? And then how do you find them once you're in your career? Obviously, everybody in the room is going to experience a change as time goes on and new procedures come into our field, and I certainly have seen that over the last 20-plus years that I've been practicing. But while you're in residency, I think a couple things are helpful. I think recognizing the gaps early, both procedurally and non-procedurally. So it's really important to talk to your more senior residents and your chiefs so that you gather their wisdom from having gone through. Much easier to fill that gap early if you know what it is early. So communicating with those that have gone before you. I think early on, identifying a mentor is really important, and I put the S there because remember, you know, one mentor cannot cover everything oftentimes, right? So it's not unreasonable to have kind of a general mentor and then like a secondary mentor that can help you, especially if you know, you know, I'm really interested in going down this track for a specific skill set. You know, it's not unreasonable to find a mentor just for that skill set. So early identifying a mentor or mentors. There's opportunity to gain additional training during your elective time that may be inside your institution in a different department if it's not in your department, or it may be outside of your training program and in a way elective if that's possible. The other suggestion there is to investigate your simulation labs or your anatomy labs experiences in your institution or outside. We've used our gross anatomy lab at Florida to do kind of the pre-anatomy training for some of the fellows that are going to be injecting botulinum toxin for the first time and that's been really effective. And then internal and external courses, really looking for those that have hands-on training. A lot of those have been available here at the academy and that includes some type of testing format. We know that your retention of knowledge will be better if you pre-test and post-test and then retest. So the situation I think oftentimes comes to where you're finished with your training, you're now interviewing for a job and maybe that job needs a procedural skill that you maybe have a little bit of training, but you've met your minimal requirements, but competency may or may not be there. So what do you do in that situation? I think it's helpful to use your in-service exam results to identify again, identify where you may need additional training, like that's a nice subjective measure. Considering fellowship training is kind of the obvious choice there, but not everyone needs to do a fellowship. But if there's a certain, you know, specific skill that you're going to use long term in your career, fellowship training would be a good option. I think if you're not thinking of fellowship, one important thing during the interview process is really as you're looking at that job opportunity, assess who the other physicians are in that practice and what the other resources are in that practice. And I'll just use the example of when I came out of training, my first job was as faculty at Emory. I had no background in my residency training for toxin injection, but I knew there were two attendings there that were really strong in toxin injections. So it was easy for me to kind of have them be my mentors and give me the opportunity procedurally to develop that skill. So kind of looking to see what your resources would be within that practice opportunity. And then again, looking for additional training resources within the practice, within the institution, and then outside in your community. And then how do you fill gaps while you're in practice? We're all going to face this because medicine for PM&R is changing. New procedural skills are coming in. Ultrasound didn't exist for us, you know, 10 years ago. Dr. Ackerman's agreeing. But you know, there are lots of different courses, and I think what you really want to look for in those courses are this combination of didactic and hands-on components that include testing and retesting. And those are available here through some of the national professional organizations. The academy has their step series now, which is a combination of didactic and then hands-on skills training. And even at the state level, so our Florida State PM&R Society has partnered with our pain society, and they're offering similar courses for didactics and hands-on training. Certification courses through the professional organizations, I mentioned a couple of those. And then, you know, the other option that's out there is industry-sponsored events or training, and you know, you have less restriction on you once you leave training. And I think that those can be a good resource for you if there's a specific procedural skill. Some of the industry-sponsored events, they'll connect you with a preceptor. They'll give you hands-on cadaver training. Lots of resources there. You just have to be cautious. You know, there is the marketing side, and then there is the educational side. And one should clearly identify the difference between the two, but can be a good resource for you. And I always put the last picture of the kids, which just reminds us that, you know, career is super important, and developing these skills are super important. But when it all comes back, make sure you make time for those that you love. And I think Dr. Prather commented on that importance of maintaining your social circle and your family circle. So this just reminds me to say that at the end. So thank you all very much. We're going to take questions at the end. All right. Thank you, Dr. Rice. So I'm going to introduce myself. I'm going to be talking about research. I'm currently a PGY3 at the University of Florida. I graduated from the University of Belgrade, and then did a PhD at Case Western, followed by preventive medicine residency at UC San Diego, where I also got my MPH in health management and policy. So I've kind of covered the gamut of anything you can come up with as far as training, except an MBA and a JD, but it's never too early, too soon. So I have no disclosures at this time, and the objectives are to explain research steps and types of research, and kind of discuss starting at various career points since I've pivoted several times. So I don't know if you guys know this, but research among medical students has grown. This graph demonstrates the number of publications looking from 2008 to 2022. Because of the loss of step one pass fail scores, I predict this will become even more exaggerated. And this isn't just, you know, your dermatology or orthopedic surgery. This is within physiatry, too. I know this is a busy graph, but physiatry is like down here, so it's kind of grown from, oh, I can't see this, but anyways, it's grown. And there's also been a rapid growth of journal publications. So this was from orthopedic surgery, because they couldn't find an article that said it's a PM&R, potential research opportunity there. From 2018 to 2020, look how much, like, the number of papers has grown almost by 20, like 10%. So how do I really get started? There are some steps, right? First, you got to kind of figure out what's your research question going to be. Then, you know, depending on what kind of study you're doing, you have to do an IRB approval. Then you got to figure out how is this going to get paid for. Then you have your data collection steps, data analysis, presentation, and then finally publication you're hoping for. So really, it kind of depends on what are your personal goals, what kind of training do you have, and what is the infrastructure that is available to you within your residency program or fellowship program or within your job, right? So kind of have a couple of, like, low-hanging fruit things, right? Things like case reports, case series, and then you kind of transition into medium-hanging fruit, which is these retrospective studies where you're creating your own data sets, secondary analysis of existing data sets. Those are things like SEER, Medicare data, industry-sponsored data, depending on what you have access to, and then there's things like systematic reviews, or you could do updates for things like PM&R Knowledge Now, and then there's meta-analysis, too, that's also using already published research, but you have to partner with a librarian, probably, to help you search for things. And the highest-hanging fruit, these prospective studies, which require a lot of funding and planning, or, like, randomized controlled trials where you may have to go to industry, et cetera. So kind of, what can I do? At any point in your career, the key thing is find a mentor. They can be at your institution, they can be national or international, going through various societies or industry. Some societies have a specific mentor-mentee matching. I encourage you to consider those, or, you know, if you're already at the later stage in your career, you feel like you can mentor someone, please do. And then there's things like classwork. If you feel like you want to learn how to do statistics, you can always try to use some online platforms like Coursera or Udemy, or there's some places that offer institutional training for research where they will give you some time off to go through a specific course. When I was at Case Western, all of the internal medicine residents had to go through this, like, 401 basics of research. It was over the course of two weeks, and it was in the mornings, so residents did that. And then, you know, graduate classwork, which is kind of what I elected to do, getting a PhD later on. And then finally, you have external research programs like RMSTP, that's kind of like resident to early career, or NIH also has some research programs as well. Within your residency, you could do research electives. You could do intra or kind of post-residency research fellowships. There are several residencies that offer this, but post-residencies, there are these T32 programs, which you can look at. The QPMC, for example, has one. And beyond residency and fellowship, you kind of, every time you switch institutions, you kind of have to figure out what is the infrastructure that you're working with. What are the IRB requirements? Some places have your, a research coordinator that pre-reviews your IRB before it can even go on to the next step, and that requires more time. Then you have to figure out what are going to be your collaborators, different departments, et cetera. And then, you know, do you have access to statisticians? Time. Time is a problem, right? We all want to have time for our families or do the things we do, so you've got to establish some protected time to be able to do research. And then, you know, along the way, what have been like the biggest barriers I've faced? Sometimes it's finding a mentor or at least one in your field of study. If your institution doesn't offer it, it becomes a lot more difficult for you to figure out, like, who am I going to contact? So coming to conferences like this and seeing is there a topic, is someone discussing what you're interested in is kind of key. Funding. I've actually, I've applied for one grant. I didn't get it, but it's a, that should tell you how hard it can be to get. So it can be through different societies, like the floor, the foundation of PM&R has some, NIH industry offers grants as well. Again, make sure you don't sell your soul, but keep it in aware. And then time, you know, how much time do I want to spend on this one thing? Anyone in the room who has submitted for a grant or done research can tell you it's not, it can be very, very hard. So kind of in summary, know what your goals are. You know, what are the chances that I'm going to run a lab that's basic science when all my training has been clinical and epidemiological studies? Zero. But some people who have a real passion for it are able to develop that even if you didn't get specific training to it. Like I worked with a guy at UCSD who has his own lab, even though he has like a master's in research, but he never really pursued a PhD. So it's not the end of the world if you don't pursue graduate coursework. Your life's a lot easier with a mentor. They can guide you for grants, research opportunities, etc. And really it's never too late. You don't have to be the next NIH top 30 researcher. There's small starts. So that's kind of it. This is pictures from San Diego and New Orleans. So looking forward to seeing everyone at the next conference. And I'm going to have Dr. Milani come up. All right. Thanks so much Rosie for inviting us to talk. So I'm going to kind of switch gears. This is less clinical but in my view it's kind of just as important. So I'm going to be talking today about advocacy health care policy and advocacy and really you can kind of view advocacy from the standpoint of everything that we do clinically matters to our patients individually. We see patients in the office every day but on a broad scale what we do is very affected by health policy at large. So laws that go into place that sort of affect the way we practice affect what we can do for our patients. That all affects what we you know what we can bring clinically. So I'll just give you a little bit of background. My name is Carla Malani. I'm an attending physiatrist at the Hospital for Special Surgery. I work here with the APM and are on the reimbursement and policy review committee. I'm an advisor to the American Medical Association's relative value scale update committee the RUC for the APM and are. And so this committee is one that values all the CPT codes that we bill on a daily basis. So I work as an advisor for our specialty to that committee. We do have representation on that committee which we just won a couple of years ago. I'm also an alternate delegate to the AMA House of Delegates. Along with Dr. Connick and so what we do there is represent the APM and ours policy interests in the AMA HOD that can then go advocate on behalf of physicians and patients. So this these first few slides are going to be kind of you know word heavy. But it's not to put you to sleep. It's more so because maybe maybe people don't have so much experience with what health policy is and what health care advocacy is. So what is health policy. Some of these terms feel nebulous. So health policy is a set of decisions plans and actions undertaken to achieve a specific or specific health care goals within a society. So health care policy involves development implementation and evaluation of strategies to improve lots of things including public health health care delivery and overall well-being health policy will affect access to care quality of care public health interventions health care financing and organization and regulation of health care systems. So when legislation gets passed it has broad reaching effects. What's health care advocacy. So advocacy contributes to creating more just and effective health care policies and environments for individuals and communities. It involves government initiatives varieties of stakeholders from the health care sector including industry and those who are providing care and of course those who are receiving care the patients. So why should we care. So I think we're all feeling it. But health care for physicians and patients is changing constantly and in today's environment more rapidly than ever. So the pace of change is constantly increasing and we can already feel that you know with the introduction of A.I. tools policies are signed into legislation that affect the way we practice. So those who take Medicare and Medicaid are probably seeing some changes including dipping into prior authorization and that those sorts of regulations in terms of scope of practice and payment that that affect access to care for patients and access to quality care. All of these all of these things directly affect us even at the trainee level and we don't get a lot of this in training if any right. So policies tend to be written and created by those who've been in medicine for decades or even people who aren't in medicine. So there's wisdom that you know comes with experience and that's great. But we also want trainees and early career physicians to share their voices and to represent the future of medicine and really help shape the future of medicine. So again why is it important to advocate. Well we can shape health policies to represent the needs and rights of patients to advocate for the interests of health care professionals. There's a saying that goes you know if you're not at the table you're on the menu. So it's kind of crass but I mean it's true if you're not there with the decision makers or at least advocating on behalf of yourselves or us you know nobody else is going to do it. So promoting equitable access to care to quality care improving population outcomes raising awareness about public health issues basing policies on science and evidence to practice the way that we know evidence is intended excuse me. Medicine is intended to be influence legislative decisions and foster a health care system that responds to the needs of diverse populations. So everything on this slide is stuff that we learn in training right. These are all the things that we we study for we get and pH is for we do PhDs for. I guess when I was going through training you know I kind of saw a couple of tracks actually trained not too far from here at Tulane School of Medicine and they had a track for an MBA program at the time it was one of only about three or four in the country and they also had an MD and pH and I you know I kind of from my pre-med work I had I had worked with some physicians who had ideas about health programs they wanted to implement at their hospitals changes they wanted to make and they they knew all the science they knew everything that needed to be done clinically but they couldn't sort of communicate that to their hospital administrations. So as I was going through you know about to start medical school I was thinking OK what do I want to do how do I want to make sure that I can help leave my mark. And for me it seemed to me that you know on the policy side that an MHA or an MBA was going to be useful to try to help you know improve that communication because we learn a lot of these things but if we can't get this across to those who make decisions then they kind of fall short or at least have the potential to fall short. So what's organized medicine. So organized medicine is this thing that you know it's kind of an even more nebulous term. So I come out of I come out of medical school start residency and I'm talking to people about some of my interests and they say well you know are you involved in organized medicine. And I I was thinking like a medicine cabinet or something I don't know what you're talking about. So organized medicine is actually a specific term and it refers to the structure and coordinated efforts within the medical profession to address health care issues and set standards and advocate for the interests of physicians and patients. It involves medical associations medical societies and institutions that work collaboratively to enhance the practice of medicine promote ethical standards and influence health policy. So this is from the CDC. You know this is a figure that they made not too long ago and they advocate for health in all policies. So every at every level is legislation all sorts of community planning. They're saying you know that health should be top of mind and how it affects communities. So on this this figure you can see there that you know they reference injury and violence free living. They reference tobacco free living. They talk about eliminating disparities or health disparities and empowering people providing healthy and safe community environments. So there's a lot that goes into this public health and informs policy or this public health effort and informs policy. But they need you know the CDC is one organization and there's lots of angles to our health care system. So you know probably now more than ever is is a time where if you wanted to affect change you could PBS and Rutgers researchers not too long ago found that Gen Z voters are not only interested in politics but are very engaged. So for a Gen Z physicians you know this is a generation you know this that cares about public problems wants to solve public problems and most importantly sees politics and the use of political institutions as a way to solve problems. So influencing health policy is kind of you know right in the realm of the interest for our younger generations. So now is really the kind of the time to get involved if you're if you're motivated. So in just a moment I'll go through some slides about you know kind of the structure of of organized medicine. But these are examples of organizations where people can get involved. So you've got specialty societies you kind of see the Cesar just the specialty societies. Societies like the APM and are that that you can get involved through there's lots of committees and ways to get involved and volunteer the A&M is another society that a lot of people in our field belong to and they're very active at the AMA. You have your state medical association so I've listed a couple examples up here. I'm now in New York state and so I'm a part of the Medical Society the state of New York up there you see the rooster. When I was a resident I was part I was in Washington state so I was part of the WSMA the Washington State Medical Association up there in green and all these all these societies including even the International Pain and Spine Society or Interventional Society of this now they're all part of the AMA and they contribute to the voice of the AMA that then goes out and advocates on behalf of physicians and patients. And by the way whether or not you participate in any of these organizations they're speaking for you so you know if you want to get involved and have a say in sort of you know what the directions that they're taking medicine then you know I recommend it but regardless they're speaking on our behalf. So that's why I think it's so important for everybody to get involved. So if you look here at this this structure I've just kind of kind of laid out at the base of all this are the medical specialty societies just gave some examples a PNR any state medical organizations and then other selected stakeholders. So there are other stakeholders from around the health care industry that get to participate in the AMA House of Delegates. And why do I keep referencing the AMA because it's the single largest voice for physicians and patients in the US when the media wants to know what doctors think in America about any particular subject. They go out and they interview the AMA president or they they they interact with the American Medical Association to try to understand what physicians have said what the policy of the AMA says because the policy that the AMA puts together comes from all of these organizations. We just had our interim meeting a week ago. We were in National Harbor in Washington D.C. The meetings bounce around for the middle of the year meeting and then the annual meeting in the summer as always in Chicago. But we all come together to help develop health policy like a compendium a policy compendium that the AMA then points to or uses to go out and advocate on our behalf. And so it's ever changing. You've got 500 delegates or more that all come together in a democratic process that actually functions pretty effectively. So I also recommend if you just want even go to an AMA meeting see how democracy really can work well and function well in a respectful way because there's tons of differing viewpoints but everybody's very respectful and really is just trying to get to you know reasonable ways to address problems. So they take this policy compendium and so they use that to then go send lobbyists to either Washington D.C. state legislatures or talk to other national organizations to do their advocacy work as a side thing. The AMA actually also does provide a lot of educational value and I'm just going to have one slide on that later but but this is sort of how advocacy works in organized medicine and there's tons of ways to get involved. I you know let's see if we keep going. This is just kind of my path to to to advocacy. I kind of mentioned you know the whole MD MBA thing in the beginning. That was my route. And then as a resident I was a part of the resident physicians council which is now called fit or physiatrist and training because now we include fellows too which is great. I was able to participate in the in the role that Dr. Connick participates in right now as a delegate to the resident fellow section and then an alternate delegate to the House of Delegates in AMA participate in the Washington State Medical Society had a pause during my fellowship year and then now in my current role as a delegate to the young physician section and then an alternate delegate to the H.A.D. again and then I kind of mentioned the other stuff that I that I work on as a part of the RPRC in the ruck so so how you know how is the academy getting people or I should say how is the academy advocating on behalf of people. Well our physiatrists we should go to a human our dot org backslash advocacy because the whole advocacy center there. It's great. You'll see what the APR is currently doing and how they're working with state medical societies they help individual physicians who who highlight local problems with their insurance companies or you know regulatory burden that sort of thing. So they'll go out and advocate on behalf of individual you know physicians in certain circumstances you know ideally with addressing problems that are there affecting multiple practices or you know a region. But then they'll also do though they'll combine advocacy efforts with states and and other national societies. They make frequent comments to to Medicare and Medicaid services and and are often coming up with position statements as well. So the priorities here are reduced reducing physician burnout addressing payment reform scope of practice issues telehealth advocacy maintenance of service certification and those sorts of things. They also have at the member Action Center. They talk about or have information on a human or his hill day where we go to Washington D.C. and advocate directly on behalf of a human are and then in the future leaders program. There's also I believe a separate Hill Day that the AAPMNR does. So just as a couple of examples, what are we doing and advocating for at the AMA? So these are just a couple of resolutions that were passed or addressed at this last meeting. So one was that our delegation received a request to address changes to the US Census for persons with disability. There's going to be some changes to the questions that help identify persons with disability and degree of disability in the upcoming census, which is like, you know, seven years away, but they're making the question changes now. And so they didn't, the committee that was going to in charge of changing the questions didn't consult the disability community. They didn't consult AAPMNR, they didn't consult any other disability organizations. But those who identified the issue estimated that it would change the estimates of persons with disability in the US from like 14% to 8%. So potentially a huge drop in the estimate and resources available to people. So we were able to go to the AMA and ask them to advocate on our behalf and our patient's behalf to those on the committee to pause and consult the disability community before they go forward with this. So we'll see what happens. This is going to the board of directors of the AMA, and they're going to go out on our behalf and advocate. Another resolution came from medical students about universal return to play protocols for collegiate, actually athletes of all levels, so youth, collegiate, and professional. And they consulted the AAPMNR because they wanted to, they wanted input on their resolution to make it as good as possible. So it required some reworking, you know, so that we could make sure it was evidence-based. But we were able to work with them and make this better. Another example comes from our June annual meeting. And this is just a lot of verbiage here. But the kind of summary, the too-long-didn't-read summary, is that we asked the AMA to work with payers who fund services for wheelchair repairs to allow patients to work on their own, to work with vendors and insurances, to allow patients to work on their own equipment without breaking the terms of their warranty and that sort of thing, and to start ensuring that patients have access to tools to work on their own chairs. Because this was a big deal, and it was in the news recently, maybe in the past one to two years, about how even very simple repairs required long wait times for patients and really impacts, you know, their ability to go through their activities of daily living, community access, and everything else. So this was a big deal. A lot of people weren't aware of this in the AMA. But this got a lot of traction. And so the AMA now can go out and work on these patients' behalf. So what else is the AMA advocating for? So this is a chart that shows Medicare reimbursement for physicians over the past 20 years or so. The lines that you see here on the graph on the left, you see the percentage of change in reimbursement on the y-axis. And on the x-axis, you see the years. All these lines represent either outpatient hospital settings or skilled nursing facilities or inpatient hospitals. But the line on the bottom down here is physician reimbursement. When you adjust for inflation, this actually goes down. So physician reimbursement has been flat without any inflationary adjustments for 20 years. This amounts to a 26% cut in physician reimbursement. On the other graph here, you can see, again, the percentage change and then the years on the x-axis. And you can see that consumer prices have steadily increased. And we're all feeling that right now with inflation and practice costs. So the AMA has been able to use graphs like this to go talk to Congress about what type of adjustments we can make in Medicare reimbursement. And as we know, Medicare reimbursement kind of sets the floor for commercial insurances and everything else. So this is a huge problem. MIPS and MACRA and everything else is also a huge problem. So the AMA is constantly working on these things. And it can be easy to feel a little cynical at times because it has been 20 years and they've been trying to address this for a long time. But we're actually kind of at an inflection point. There's been a little bit more traction now. So hopefully we're on the precipice of seeing some sort of change, even if it's just an inflationary update in perpetuity. That would be great. So these are the types of things they're doing. They also have something called a Steps Forward campaign, which I love. They started this back in 2015. It's grown since then. The Steps Forward campaign is really something that is intended to be a resource for all physicians. And you don't have to be a member to access these modules. But there's probably like 26, 30 modules that focus on talking about prevention of physician burnout, creating organizational changes for your private practices or your institutions, and then lots of practice efficiency improvement modules, or practice improvement and efficiency modules. They also have a podcast, which is pretty great. So this is a side plug, only because I think it's relevant for everything we talk about at these meetings. But it's also sort of a side benefit of advocacy. So this is just going back, reminding us again that there's a lot of ways to approach advocacy in health care. It's whatever you're passionate about is what you should get involved in. And there's lots of ways to make meaningful change. The American College of Lifestyle Medicine has recently been able to gain delegates to the House of Delegates. So we heard from Dr. Prather, her talk. I mean, I think there's a lot coming down the pipe from lifestyle medicine. And so that's going to be really exciting in terms of how that affects health policy change and how we design communities and that sort of thing. And then I found this diagram on the internet, which I thought was pretty interesting. This is from a science researcher, I should say, a research website that intends to affect all policies, all public policies, in an evidence-based way. It's called Frontiers. The address web link is frontiersin.org. But here in this particular journal, they have like 200 journals. They're talking about a learning health policy system. So this is really just kind of like a quality improvement process, PDSA cycle, plan, do, study, act. And so you have involvement of a lot of stakeholders, and you're measuring the implementation of what your strategies, and then you observe the outcomes, and then you use that to inform the next round of health policy that you make. If only it would work like this, right? But I think that we can get to a place like this if everyone gets involved. And again, it's really just find your passion and figure out your access point, whether it's your county medical society, your state medical society, a specialty, or something like that. But any of these organizations would be happy to have you. So with that, I'll just close. We'll have time for questions. All right, everyone, if anyone has any questions or wants to step up to the mic, because this is all being recorded, and if not, I guess I could start with one. So every once in a while, we decide that we have a gap in our training, and we kind of want to try to fill it. But then maybe we decide that that gap was not the right one to fill. How do you go about, you know, stepping back and being like, never mind, I didn't actually want to do that, like, whether it's for a procedure or on the clinical setting or for advocacy if you decide it's not the right fit? Can you guys hear me okay? Is the mic on? Maybe I'll try to answer that question, and I think that question probably applies as you're out in your career a little bit more than when you're in training. And so I think you kind of touched on it. You know, it's so important for us to advocate on behalf of the procedures that we feel are important or the clinical skills that we feel are important for our patients to make sure those are being adequately compensated so that if you're in a private practice or for-profit situation, your reimbursement is enough for you to provide that service. Yeah, I think if you go down a path of, you know, you think there's some extra training you didn't get or there's an area of medicine that you want to sort of delve into that you didn't learn about in residency, like lifestyle medicine, and then you find out that, you know, that's really kind of not for you, I think taking stock of what your goals are, you know, at each stage, you know, at various stages of your career are important. So you can think about your first five years, your first 10 years, you know, and beyond, but kind of having an idea of what your goals are, not just professionally, but in life. And then maybe developing a plan about how you're going to go about getting there. And then if it changes, that's fine. You know, kind of giving yourself enough grace to pivot and change course as your priorities change or, you know, in life and career. I would think when you go to explore something that you think is a gap, which really probably is a special interest, right? It's an exploration. And you don't have to, you know, there's no set stone, you have to commit to that you're going to grow from something, even if it's education, you get that doesn't maybe end up directly going where you end up being, I thought it was gonna be a stroke, real doctor. I work in Manhattan. I mean, that was not where in the plans, you know, to begin with, but like, I think you just go towards what you're interested in, but also go towards what you're good at, right? Because your energy drives that. And so if you end up learning about an injection, but don't incorporate it into your practice, that's okay. You're gonna, you know what your patient may need to send to somebody who does that procedure, but you still grew, you still, that was still, you know, an advantage to your practice. So I would just say explore. All right, thank you. And I guess another question would be a big component to think of all our training is trying to identify the right mentor and trying to find mentorship during training. Do you have any specific tips on how to go about that? Go ahead. So I've, I mean, I've, throughout my training, I've been to a lot of, you know, mentorship type talks and it, in our department, our chair talks a lot about building a mentor team or a mentor roster, and I subscribe to that. I think, you know, just like all of us have different strengths, you know, any mentor that you would work with will have a variety of strengths. And so not everybody can, you know, serve or fill all roles. And so I think it's important to, as you know, when you're trying to figure out what you want to do throughout a career, and again, it doesn't have to just even be early career, it can be mid-career, you know, whatever you want to do, thinking about it in a deliberate way of, you know, who would I want to go to for advice about how to further my interest in a particular direction? And really having a diverse group of people you can go to, mentors, and otherwise is important probably. I think I would agree with all of those comments, and I would only add that I think that the degree of a relationship that you have with your mentors varies from mentor to mentor. And so I think, for me, I kind of think strategically on how to pick those mentors when you're deciding this is going to be kind of my general mentor, this is going to be my mentor in a specific clinical area, this is going to be my research mentor. And the other comment I would make is that if you can hold on to those relationships of your mentors through your whole career, I still have people that mentored me as a resident that I stay in touch with. And the advice that I get from them is still very relevant all of this time later. I would just echo that last piece, and I came up in a time where there was no formal programming for mentorship. It wasn't any of that. And, you know, I had one lifelong, career-long mentor, and then I've had a research mentor that's really stuck with me. But make sure it's a real relationship. It's not, I was assigned this person, you know, and that's good. That can get you jump-started. That person can, may help you into finding the person who is going to fill one of these specific needs gaps. But, you know, I talk about you're a champion, and you're this, and you're that. I don't know that it's that well-defined in real life. It needs to be a real relationship. And then it's truly your mentor that you can have a career-long relationship with, which is unbelievably wonderful. So that's what I would encourage. I also just wanted to add one other thing, and that is to just really encourage everyone to be a mentor. And that doesn't have to be a super formal relationship. But as you go through your career, and you develop your area of expertise, pay that back. And that may be very informally. It may be formally. But, you know, it's really important, even if you're not in an academic center, if you wind up in private practice, to encourage that next generation of physicians and physiatrists. Thank you for that. Anyone? Any last thoughts or comments? Or anyone have any questions? It's an exciting time to be a physiatrist. All right. Well, I agree. You agree? I agree. It's very challenging to decide. So as Dr. Malani mentioned, I've been involved in so many things, research, advocacy, and then trying to pick which pathway is the right for you. But I think if you don't decide to explore, you'll never really know. Maybe you would have been a really good fit for something. So I encourage you to explore. Figure out what it is that you want to do, and what it is that you want to do in your practice, and as part of your day-to-day life. The AMA meetings are free, so no conference registration. You just got to figure out how to get to, you know, Chicago, National Harbor, et cetera. So yeah, I encourage you to try. And with that, I'll conclude this session. Thank you so much for listening and joining us today.

mentorship

advocacy

healthcare

finding mentors

ongoing education

research barriers

physician advocacy

American Medical Association

physician reimbursement

universal return-to-play protocols

burnout