Thank you everybody for coming this afternoon. I hope everyone has a wonderful conference so far. So we will begin our session here. Of course, we're here to talk about global outreach in our wonderful field of physical medicine. I'll introduce myself. So my name is Manish Twari. I'm a PGY4 resident at Ohio State University. Hi. My name is Amelia Nee. I'm a PGY3 at Wash U. And so, you know, we want to be brief here. We want to just establish the reason that we wanted to have this presentation, of course. You know, between disability and, you know, the prosthetics, orthotics, all of the type of ailments that we do treat, there is an immense need not only, of course, stateside but across the world. And we want to acknowledge, you know, kind of some of the efforts that are ongoing within our field and places that we could be going in terms of addressing those. So, yeah, just to respect your time and very quickly to go over, like, what the current needs are in terms of the WHO research. So there's over 1.71 billion people with different musculoskeletal conditions. Main contributor of that would be low back pain and then sensory impairments. And currently their estimates are that the highest need is in the Western Pacific region and the second highest being in Southeast Asia. And currently where we stand, there are only 78% of Latin American countries that have rehabilitation facilities. Only 51% of countries in Asia have a PM&R association offering board certification. And only 57% of countries within the Middle East have postgraduate or PM&R training in general, not even a full residency or fellowship. With 15% of the countries in Africa having some type of PM&R training program. And so, you know, what we want to first talk about and introduce here is that there is the Rehabilitation Alliance with an initiative and call to action with a target date in 2030. The problem is, you know, the scope of our issue here is being acknowledged again through these statements that are being made and recognizing the global burden of disease as it pertains generally, but specifically also to our field. Just as you've probably heard, whether it's on the news or in papers, you know, the idea of the aging population, it applies to the United States, but globally as well. So as the population ages, as time goes on, as medicine continues to get better, we do expect, however, that, you know, rehabilitation needs will also grow proportionately. So without further ado, let's meet our panelists. To start off, we have Rochelle Dee. She's a full-time pediatric physiatrist and clinical chief for PM&R at Texas Children's, and she's an associate professor at Baylor College of Medicine, as well as their vice chair of education and the director of their residency program. She completed her undergraduate in physical therapy and then received her medical degree from the University of Santo Tomas in the Philippines, then completed a combined PM&R residency at Albert Einstein, and continued on to do a pediatric fellowship at AI DuPont. She's triple certified in PEDS, PM&R, and pediatric PM&R. And she's currently a member of multiple societies, very involved, is the current chair of education at the ISPMR, and has participated and served in multiple different short-term rehabilitation outreach trips, including in the Philippines and China, as well as northern Iraq. Next we have John Melvin, who is Professor Emera's chair at Sidney Campbell Medical College in Philadelphia. He is an Ohio State graduate for both residency and medical school and undergraduate. He's had a tremendous career, served on several advisory committees, national committees, and governing bodies. He is the president and chairman of over 12 previous international organizations, and he has chaired the task force that coordinated the merger of the International Federation, which is the IFP, and the International Rehabilitation Medicine Association, into what is now the International Society of Physical Medicine, sorry, Physical and Rehabilitation Medicine. And last but not least, we have Dr. Raj. So he completed his undergraduate degree at Princeton University in the medical school at Rutgers, going on to do his internal medicine year at Abington, then residency at Baylor. He is currently the medical director at Carolinas Rehab, and the vice chair of clinical operations for their department of PM&R, as well as being the chief of oncology rehab for the Living Cancer Institute, which is the first cancer rehabilitation program accredited by CARF. He's very involved in national initiatives relating to healthcare reform, patient accessibility, as well as utilization of inpatient rehab. So we'd like to keep this very interactive and informal. There are questions that jump off for topics, but please do come up to the microphone and just start asking if there's something burning. We can be a little bit more targeted with our panelists' answers. But just to start off, maybe we could go through the panel and talk about what your experiences are in international rehabilitation, specifically what drew you to the area, where were you in training, how did you find these opportunities, and how did you overcome the significant barriers you encountered? Well I think my experience is sort of a little different from some of the others in terms of I haven't really done a lot of actual patient care in international settings. My role has been more advocacy for rehabilitation and improving programs in rehabilitation. And so basically I did that primarily, as you might have seen, through professional organizations and leadership in those. But then that often led, particularly in the international scene, it leads to other things because many foreign countries are very... They like very much that someone who is a president of an international organization will come and speak to them and talk to them. And that works two ways. Number one is that you be able to share your knowledge to the people when you're giving lectures. But if they are advocacy lectures and on what is importance of rehabilitation, often it serves a political purpose. And at these meetings, often the various programs in the countries will invite ministers and other political people to come to those meetings. So basically I got started in 1980 as Secretary of the International Federation, one of those earlier organizations. And so basically I was about 45 then. So that means that I wasn't doing really direct international things. What I was doing was basically national organizational work, which began the day after I got out of my residency. And so therefore I was establishing the credentials that then allowed me to be recognized in the international scene. And as you saw, we took those two organizations, put them together into the International Society of Physical and Rehabilitation Medicine. Notice that internationally, most places now use it, physical and rehabilitation medicine, not physical medicine and rehabilitation. And that organization, I must tell you, I've been very proud of it. It's now 23 years old, and it's really moved along both in terms of the intellectual vigor of its meetings, its influence, its working with the World Health Organization in terms of passing, improving rehabilitation. A lot of the rehabilitation in 2030, the people that were a part of that, putting that together were people from the international society. So when somebody said, tell us what you've done internationally, well I decided that you might want something else because it would take the whole day. But basically a lot of my advocacy has been related to going to different countries, giving lectures and reviewing programs, sometimes seeing patients at special selections. For instance, the Sichuan earthquake, we saw spinal cord injury patients there after that because they didn't really have a lot of help. In Saudi Arabia, they asked us to see some women who, you know, in Saudi Arabia you have to be very careful about how you approach women, and so that was, I guess, sort of an honor in a way to be asked to do that. And then I've written a number of papers with colleagues internationally on rehabilitation, its position, what it needs to strengthen. For instance, there's one, Rehabilitation, the Health Strategy of the 21st Century, which actually has been getting quoted quite a bit these days. There are others where we advocate incorporating function into all of the different medical events that occur and recording that on a database, and so there are papers that relate to that. So basically, it's organizational leadership, individual program consultation, paper writing, and all of the different things that it takes to be politically active in terms of putting rehabilitation forward. And I still am doing one thing right now, I'm a consultant to the Accreditation Council of Graduate Medical Education, and they have a contract with Hanoi Medical University to improve the knowledge base and competence base of their graduates, so I've still got some projects going. All right. So my journey, I guess as you've heard from my background, I was born and raised in the Philippines, and so I did residency over here, so I had some ties, basically, to the Philippines, and from then I was introduced to a Philippine-American physiatrist group, so that's how I started learning a little bit more, trying to collaborate with some of my mentors actually from the Philippines. And then from then on, so as a resident, I was just truly trying to observe and see what, you know, I really can't do much, but at least observing how it is with iDynamics, what we have here in the U.S., trying to understand what the differences are in practices. And then later on, we tried to establish actually medical outreach programs, but we wanted to make sure that there is really some intention of focusing on rehabilitation medicine. So we created, we coordinated a few medical outreach, medical and rehabilitation outreach where in, you know, patients were screened before, you know, ahead of time and made sure we have the appropriate patients that we could see, and then made sure we also have connections with the local physiatry group, and physiatry, there's a Philippine-American, Philippine Academy of Rehabilitation Medicine. So basically, in the Philippines, they do have a very good structure, education, and even skill set of the physicians over there, of the physiatrists over there. It's just that their limitations are usually resources. So we capitalized on that to make it sustainable so that there would be a local group that who would help do the follow-ups, and then we just helped with regards to providing some funding or support for some of the patients that we technically, you know, helped sponsor so that they could see them through. So we also provided some prosthesis as well for some patients that we saw. So it was on a small scale, and then later on, we kind of evolved into a bigger scale when since we had that relationship, it was ongoing, and then there was one opportunity again that opened for us, which was the big typhoon that happened in 2013, 2014, around that time. So they were needing help. The physiatry group over there in the Philippines were very active, proactive, you know, answering to the call, first of all, being a physician and one of the countrymen, and then also incorporating what is the role of physiatry, even in disaster. And so that's where ISPRM was actually part of it, too. So the Philippine Academy of Physiatry, the local PARM, and ISPRM. So it actually became a big paper as well that was written up to see what is the role of physiatry. We do have a role. We can have a role as well. We provided some relief, you know, hygiene kits. So we helped with that, and then also provided some physiatry care. Again, the same thing, provided a little bit of some funding to extend the therapy services or the rehabilitation to cover some of the costs after the short-term, you know, rehabilitation trip. So again, and then I evolved as well. On the other side of it, I had this interest of, when I was looking for wheelchair donations for the Philippines, I bumped into somebody who had, whose father was joining a medical mission trip to China. That's where another journey of mine started. Apparently, it was headed by a pediatric orthopedic surgeon who was based in the U.S., but he was a Hong Kong national. So had the heart for the poor of China, and so I am also Chinese by blood, so I said I wanted to give back to my roots. So I went on my first trip with them, with a team, with an orthopedic team, not knowing exactly how I would be able to help, but I knew that they were going to, they were, they just said the word, they saw patients with cerebral palsy. I was like, okay, sign me up for it, because that's my patient. That's my patient population. And then, then we evolved over the years. So in terms of making it even a multidisciplinary team approach, and later on I was able to help also provide some non-surgical spasticity management, including like phenol. I couldn't do phenol, so I had to do alcohol, you know, for the non-surgical patients. And then it also provided me an opportunity to do like inpatient rehab for the post-op patients who had surgeries, both neurologic or musculoskeletal. So that's kind of on the clinical side, so the, the, my experience. And then throughout that journey, because I was kind of also trying to understand a little bit, like what's the difference? How do other people practice rehabilitation medicine, you know, outside of the U.S., outside of the Philippines and in China? So I was introduced to the International Society of PRM, and so that's where, again, it's like, wow. It was a nice, it was a good way to find out, like, okay, we, we are all, the things that we may be, may have access to, some of the residents may not have access to it in other parts of the world, and they may not even have a physiatrist, they call. And I know Andy is here on the, in the, in the audience, and so also with International Rehab Forum, even in Africa. So I, I hopefully will be able to hear from you as well, Andy, because that's a very, the education part in other parts of the world where there is no physiatry program, no residency program. So they have to start with, you know, physicians, primary care physicians or orthopedic surgeons who would be the next rehabilitation doctors in their area. So I got involved in the education side of it, and, you know, we, we worked together to provide at least a guideline for core curriculum as well as competency in the, for, at least to provide a little bit of a guideline for, for, um, other people around the world, um, to be able to, at least if they were to open up a residency program, at least what are the things that they should, they should know or they should be training on. So, yeah. All right. So I'll, I'll be, I'll be pretty quick. So, um, so I'm Vishraj. I, you know, I feel bad. I didn't say anything about ISPRM on my bio, but I feel like I should. So, so actually part of my career, so I'm, I do cancer rehab and I do a lot of, uh, clinical operations. And I have to tell you, I have stories about both of these guys because, uh, when I started my career in cancer rehab, Dr. Melvin wrote me the nicest rejection letter I've ever gotten for a job. I still have it in my drawer and I haven't saved. So, so that, he got me, he instead, Bill, Bill Bachanek hired me instead, so I got to do cancer rehab in Charlotte. So I think. You don't even have it now. Yeah. Now, now I can have it. So, uh, and then, and then, and Rochelle and I actually, Rochelle put me on her medical education committee for ISPRM several years ago. She worked me. I mean, you could tell how much she does, has done. She worked me so hard that I had to get out of that committee and start the cancer SIG for the ISPRM and do something else. You graduated. I graduated. So, um, you know, so I'll just say just very quickly, when, when you look at, uh, international, um, uh, medicine in an international way, and especially physiatry, it's a wonky business. So, you know, you sometimes forget, like when you train in the U S and when you practice in the U S you just assume the world is the same way. It's not. And, uh, many other countries are not as well developed as the U S. They don't have as many resources as the U S. Uh, their systems of practice are different in terms of how government pays for, um, or supports the practice of medicine. Some, some countries don't even recognize rehabilitation. They just kind of, you know, do medicine, whatever that is. And then, you know, we see what happens. And so for me, um, my level of involvement started with ISPRM in the cancer world. And then as time went on, uh, we realized there were more opportunities. So I've had the opportunity to go internationally, not so much to practice, but to help consult and teach other people on how to practice. So whether it's cancer rehab or general rehab, whether it's the Middle East, I've spent time in China working with a lot of the rehab hospitals and sort of looking at the ability to develop cancer rehabilitation programs in other parts of the world. And so, you know, what I would say is, you know, what got me interested is just realizing that there's disparities, right? So there's major difference. And so I think when we talk about global outreach, I would imagine many people in the room are thinking, well, how do I get over there and actually do rehab? But even, even, or equally important is not just how you do rehab, it's who's there to support you, who's going to pay for it, is the medical system that in the country that you're going to receptive to rehab. Um, and, and, and also you have to factor in like, you know, the, the cultural context because there's several cultures that don't want rehab. So for example, uh, some of rehab, it kind of defeats the point. So I think these are a lot of variables that come into play when you talk about it and when you look at different regions of the world. So that was just a very quick background on me, but I think there's like a gazillion things we can talk about. I know there's a gazillion people in the audience who have international exposure, so I think it'd be great if people... I can pass the mic around if you don't want to. Thanks for sharing your experiences. I was just wondering how you would go about building a global health curriculum within a residency program? What do you think are key components, key competencies that designers should have before they, you know, go somewhere else and go cowboy, you know? You don't want to do that. So what, how do we prevent that from happening? I know, it's always that million dollar, it's a million dollar question, I'm sorry. No, I mean, it is something that we've been asked as well. So I think it really depends, you have to first define what it is really that we're trying to talk about or what you want to really hone into. Because again, if you probably look at it from a global health perspective, right, there's a lot of angles to look at it. And what is the goal, for example, of a curriculum or what is the ultimate goal, right? A lot of this time, I would say at least like the work itself, a lot of it is usually just stems from like, let's say, you're wanting to either give back for service and all that. And then the learning that goes with it, of course, just, you know, happens along the way. But I agree with you. There are things, especially now in global health, there are some structured curriculum depending on how to prepare somebody if you are going on an international trip, you know, things to prepare for. I think there's something after, because our pediatrics at Baylor, there is a very strong global health curriculum already because they have something that's specific for a global health residency program. So now, if we kind of try to drill it down, for example, in PM&R, that's a different kind of, I guess it will depend, first of all, in terms of what resources are available. We have to talk about funding sources and also the coverage, liability, all the other stuff, supervision. So all these things. I know of some other programs who may have possibly the resources and even the capabilities of doing so. And I think that's where you can at least hone in a little bit more specific in terms of what type of curriculum you'll be able to offer. Service or education area, and then you can probably, you know, make it a little bit more specific with the curriculum. Yeah. And there's a funny story, because even in ISPRM, we've talked about, like, minimum core competencies in different subspecialty areas for rehab. One of the challenges you have is, you have to remember, not every country has rehab physicians to do it. And so, when you're trying to, like, you know... to the requirements of our... I think the point you're making is that there's great variation and one point should be made that in different countries, you've mentioned China a number of times, but China, India, other countries, different parts of those countries are very different from other parts. So just because you've seen one part, don't assume that that's China or whatever. It's a part of China that you've seen. Now, what we're doing in Vietnam is that this medical school wants to produce specialists in physical medicine, and they call it physical medicine still at the present time, because the country's done an analysis of their health system and they have identified that the people with disabilities, people with functional deficits are not being cared for appropriately. And so, basically, the first step was to ask them what competencies would they like to see in their doctors. Now, as it turned out, they went to the ACGME competencies and pretty much paralleled them. There were some differences, but they pretty well paralleled them. You know, there are competencies by the College of Physicians in Canada. There's a combined College of Physicians in the UK and Ireland, and, of course, there's the ISPRM. So there are guidelines for people to put together and the ultimate idea is to think about what it is that you want the people that you're working with to be able to do. It's competency-based, not how many hours or that sort of thing. And so, that's the first step. Then we're going to be going into looking at what their resources are, and you kind of mentioned that, and then also the political environment. Now, as it turns out, in Vietnam, and this is true of a lot of places, the political environment is looking over every step. In other words, they have already looked at what's been going on two or three times and either approved it or actually made suggestions. The reality is that actually their governmental review group has reinforced more of the things that we thought would be good than the university came up with the first time. So they're in evolution, but I do think it's important to focus on what you want people to do and I think as you've already heard comments, it has to be lasting. It has to be something that's going to go on. It's not just your visit there and all of a sudden you provide it, then you're gone. And then the other is, I think, there are standards to go to. Curriculum, when you get into competencies, are kind of vague when you...or not specific. They say, well, you should be able to do all of these kinds of problems, but it doesn't tell you how exactly you're going to teach people how to do those problems. But the competencies capture the essence of what is rehabilitation. In other words, focusing on people, their function, their life, what makes life better for them. And that actually, somewhere along the line, there's a question how do foreign programs sometimes vary from the U.S. That's one of the places where there's been a lot of problem in the past and that is that in many of these countries, the physician role was a hierarchical one and that there was really not a team effort and an integrated across all of the various life adjustment functions that one needs. And so the competencies generally include that to emphasize it. Thank you. Hey, I'm Andy Hague. We've done a lot of work in this area. I was John Melvin's medical student. But I'm not John Melvin. So he's like been legitimately the president of everything and I'm not, so I formed my organization so I can be the president. It's just how it works, okay? And Miriam Chun is over here. Miriam, could you, yeah, she's our executive director of the International Rehab Forum. And what we really did, and it was with John and some other people when I was a younger doc, we looked at what's not happening well in global rehabilitation and said, how do we solve the problem, okay? None of us are moving to a foreign country. If you are, go, fine. But all the rest of us are basically people who can come in and be servants to the people in the country who are doing the work, who are smarter than us about the politics, who just don't know some of the stuff we have and who just need some legitimacy so that their friends and neighbors and deans and ministers of health go, well, the Americans think so, right? So it's really funny if one of us folks in the states trying to help out, we're going there as servants. And we go there first really as tourists, right? It's like, wow, what's going on? Do I like this country? I met this woman who's brilliant. I think she can run with this. And then after a while, you're like, well, I think she can run with that. I wonder what I could do to help her. And you have these conversations, right? So the Rehab Forum wrote a really funny paper that made fun of the fact that there were only seven rehab doctors in all of Africa, compared the number of doctors for Africans to the number of doctors for penguins in Antarctica. And it got published in five different journals and was part of what changed World Health Organization policies, because it's pretty embarrassing to see seven doctors for 750 million people, right? And then we did something about it. And we started a residency program. The WHO Director General, Dr. Tedros, was the Minister of Health of Ethiopia when we met. And he said, just go build something. If it's good enough for you, it's good enough for me. So we have a residency that now runs in Ghana, Ethiopia, Cameroon, and South Africa is going to join us pretty soon. And are kind of looking for other countries where there's enough of a consistent presence between somebody on our side and somebody on their side to say, hmm, you can find a young doctor who wants to join our online fellowship. Then maybe we'll do it in Botswana is a place we've talked about. There are other countries like that, right? So we've started that, and the team has organized it pretty well, and we've graduated six doctors now in these three countries, and more are coming along. So that's maybe an example of how you move forward, right? But it's also something you can join up with us. I'm looking at people on the podium there who's taught our African fellows, thank you all, because they come in as guest lecturers or people that sponsor people coming back to the States to hang out with us for a month. Imagine doing a two-year Pimanar Fellowship and having never seen a rehab hospital, right? Are they at the same quality as you are? No. But my young friend, Abina, is so passionate about it, being the very first rehab doctor in her country, that she's now on a WHO panel, and she's building, and, you know, ten years from now, this two-year fellowship of ours will be last off, and the old people like Abina will be viewed as incompetent, and the young people will have had a four-year training program. We also do a bunch of other things. Like we held the very first meeting on disaster rehabilitation and pulled in people from all these places, but then handed it off to ISPRM, which is a really big, powerful organization that gets stuff done, right? And then the last part of my ramble here is our biggest big challenge these days is to build the academic field of global rehab, and this is kind of where your question is, right? Like if you're in obstetrics or orthopedics, there's probably one department in the country you can go to where half the faculty has MPHs, and they all hang out in Haiti, right? Right? Can't really find that in our field right now, and so a bunch of you who have an interest in contributing overseas, doing research overseas, building a residency rotation, building medical student competencies, that's academic global rehab, right? And you're all going to have to hang out together because there's not a department that's going to sponsor you all, right? So my final ramble there is if you're interested in that stuff, rehabforum.org, or talk to Miriam who's got us all organized, and you're looking at, right, a whole network of people. It's not us that's doing it. It's all these people who are hanging out with us to do things. So that's our spin. Do you want to talk? This is more a statement than a shameless plug, but I'm Nina Tamayo. I'm actually the chair for the International Rehab and Global Health Community, so it's a new community, so I'm really excited to see all these people here. But we actually have a few of our speakers, and to answer the question earlier, Dr. Amy Matthews during our community session actually addressed some of the issues for creating a curriculum for global health, so definitely watch our video. We also have a QR code that I would love for all of you to fill out, but our goal is to, you know, connect with all of you and to pair you with our esteemed colleagues who have done this kind of work, create really a directory of information or resources for all of you, because I know the biggest question is, how do we find these resources? But there's so many physiatrists who have already done this work, so we want to collate that into a directory, get all of your information. My mission and goals for it is to really create a collaborative space for you all to connect with all of us, and also tell us what do you guys want to see in the community. And of course, we're looking for collaborators as well. Dr. Hague is an amazing wealth of resource. Everybody on the panel is an amazing wealth of resource, so we want to make sure that we're utilizing their wisdom and their experiences to inform us in terms of how to move forward in the future and how we can affect change, you know, globally, so it's just really a shameless plug for, you know, that, but I would love to see you guys, you know, fill out that QR code. It's in the community session, but I believe Amelia has it up here, too, later. So I guess my question for you all is, what were some of the challenges, or what was your greatest challenge in terms of providing culturally relevant care when you went, you know, in these different countries you've been to, and how did you deal with it? How did you address it? What were your solutions? Maybe I'll start. Before I jump into that question, let me ask a question of the crowd first. So how many people here have done international work in rehab? Okay. All right. So second question, how many of you identify yourselves as American? Okay. All right. So the reason I say that in response to this. So I think the most valuable thing I learned first, whenever I've gone internationally, is to shut up and listen. Like, you know, when people think of Americans, they think you're going to come in on a horse with a cowboy hat and boots, and you're going to come in there, and you're going to wrangle everybody up. And we as Americans think that's, you know, that's what we do. We come in, we're like, all right, let's go get this done. We're going to go fix rehab wherever you're going. And that's the worst thing you can do when you work internationally. Because the reality is, if you come in like a, you know, the stereotypical American who comes in and, you know, does that kind of thing, you're basically disrespecting the culture that. situation is that provides challenges for them to deliver their rehab care, or even identify what they're doing really well, so that you understand how you have to come in. And then you come in on the back end with suggestions, ideas, things that work in the context of what they're already doing. But I think it's super important, because we're so egocentric, right, in the US, that everything is what we do, and if it's not what we do, it's not right. That's not really a correct thing. I remember when we went to China, and I was talking about cancer rehab, and we were talking about spinal cord injuries, I went with Leighton Chan, if you guys don't know Leighton, he's the chair at the NIH. And I did, and of course I listened kind of, but then what happened was I gave a talk and this director of nursing at one of the big hospitals near Shanghai got in an argument with me about ICP, like intermittent catheterization, and she said, I don't think it works, and I'm like, what do you mean it doesn't work, and I'm like, of course it works, that's what you're supposed to do with a spinal cord injury, and she went back and forth. I didn't handle that correctly, but the idea there is that in that culture, Well, I agree with you mostly. Okay. Is it about the ICT or the catheter? Oh, no. Well, actually, I was going to point out there are cultures in the United States where they don't use intermittent catheterization. That's true. That's true. Skilled nursing facilities very commonly don't. But see, sometimes they want you there to answer questions and then you have to figure out how do you help them change something that's cultural to be able to achieve the purpose that they've asked you to help them achieve. So I think it's even more complex because then you have to really approach it in a way that everybody retains their dignity and yet you do communicate what might be something that has to be done. Now if it is not something that has to be done, then it's no argument that if they want to do it that way, that's fine. So I think that just to make it even more complicated, for instance, in China, and again, you all have mentioned China, I've mentioned China, but a number of institutions in China have been seeking CARF accreditation. And when the CARF surveyors started talking to them, they found what I was mentioning, that they didn't have team conferences. They had absolute physicians and that sort of thing. And then they would come to me or some others and say, well, what can we do to get CARF accreditation? Well, you have to move them a little bit from that culture or they're not going to be able to get it. Yeah. One other thing over the years that I've, aside from, yeah, ask, be quiet, and ask more. Understand the local medical practice. Sometimes when you provide a service, you might actually be hurting other, you know, you might be providing a service to the patient, but you might actually be, you know, hurting the other physicians who are practicing in that area. So that is also at a programmatic level of, you know, like looking into a bigger comprehensive kind of program, how you actually roll something out. And then again, too, as I said, the sustainability, we go back again to that, you know, if you plan on doing something, maybe, of course, in the first, you know, you survey, is this going to be a partnership that you can continue? Is it sustainable? Do you have the same values, you're your side, their side? So those things, and it may not necessarily pan out, but it may, but you just need to also, you know, be cognizant of that and make sure, you know, what happens in an emergency? Who's going to pull out? What's going to happen? Who's going to see the patient and all that? So that is one thing, and before you even provide a service, make sure that there's local people who would be able to, what is your follow-up plan, if in case, so just don't leave, you know, like, okay, goodbye, that's it, no contact, and no other resource for them to be able to somehow, you know, go to. Yeah, just one quick thing, you know, Dr. Melvin mentioned CARF, now I'm not plugging CARF, you know, everybody, you know, CARF is an independent organization, but one great thing about CARF is that CARF has standards. Sometimes when you have that, that gives you a little more validity in terms of what you're trying to accomplish. Meaning that if you have these standards that are written, and let's say, you know, we bring up China because that was the whole reason we were all there, right? I mean, everybody was like, we want to get CARF accredited. What you sometimes have to do is you... right at the question that I was gonna ask, which is, you know, I speak to a lot of people and they have so many different channels that they're using to get to, you know, different projects that they want to work on, whether it's in China or other countries, but how do you know that it's gonna be sustainable? And, you know, Dr. Di, you mentioned about sustainability, and I'm from the background where we are trying to They are the ones that are experts on what they need. So when you leave after your project is finished, have you, I want to hear any other, other than CARF, like what other evaluation processes you've used, you know, that you can go back and see. I guess I could, so from a clinical standpoint, the one that we did in China, so I've, so the China has been, I've gone since 2012 until 2017, 18, when China closed down, but every year I committed myself to going once a year for two weeks for that particular, just one area. My team went to other places in China, but I just said, okay, I'm just going to commit to one area. So it was more like patient care, basically, as he saw some of my patients year after year. What we did on the ground there was that we had some local people who were actually, actually some of, this was a faith-based organization that I went with, so we had local teams who actually helped do the follow-up from a clinical care standpoint. Since it's an orthopedic or surgical team, we had a smaller group who went back eight weeks after to do the aftercare and then the orthosis and then some physical therapy services. So that's kind of how, just, you know, it's a very kind of short midterm kind of clinical service, and then we did the same round again every year. So we kind of are doing, we're doing the same model with Kurdistan in northern Iraq right now. So we're in, we also partnered with a local non-profit organization with the same values, and they were one of the biggest stakeholders that they were also looking at as a community, because we were serving the Yezidi refugees, so they had also other plans aside from rehabilitation just to kind of push it further, not just the medical part. Well, I was just going to comment that doing services around a very technical procedure that someone comes and provides creates a different situation than if you're just working with rehabilitation and ongoing care of people with rehabilitation. And I think it's been pretty well discussed that the target there is to work and improve the capacity of the people who are there and will continue to be there. Different countries have actually looked at it from a political standpoint or a strategic planning standpoint, and my understanding is that most have found that it doesn't pay to bring in foreign physicians on a contract to run your rehab centers. I think Saudi Arabia actually tried that, but rather you have to work out a system so that your doctors learn how to give the rehabilitation. And here's a point that I wanted to make, was you don't actually have to go overseas to help international. You can have your facility provide training programs. The program that I had, we would provide sometimes up to two years, that led to a PhD, but up to two years. We would go from maybe one week to two years, and it would include physicians, therapists, and administrators even. So that was one way for them to get a sort of in-depth idea about what we did. Then they, of course, would have the option of how they... It's interesting because they had, it's a terrific place. They have like four locomats. They have seven pools. I mean, seven really big pools. It's very impressive. I mean, we can't even get one pool in our rehab hospital. So, I mean, that's pretty cool. But where they needed help was maybe the organizational, structural execution of how you deliver rehab. And so, you know, we did a site visit. Of course, we learned some stuff from them as well, and they're learning from us. But to Dr. Melvin's point, you know, some of the ability But then the other part is now with technology, I mean, especially during COVID, we finally learned how to do virtual and zoom calls and teams calls and all this stuff. So, you know, with our partners in Qatar, we're doing, uh, we're doing more than monthly calls with them on so many different things that we're talking about. And the idea is that, like, you link up people to people, they kind of learn and you have regularly scheduled meetings. I come into this discussion with zero experience in this arena. I was actually going to ask about that very issue you just raised. What have...how has this whole practice changed with COVID? sort of insights in that, I'd be curious to hear. My other question was, you know, our specialty is inherently dependent upon many other disciplines, you know, prosthetists, orthotists, all the different skilled therapists. So how, what have you learned about bringing those other specialists along to provide adequate care for, you know, people in these countries? I'll just say one quick thing. to do. But you know, quick story, like back in Charlotte I had this pulmonologist call from another healthcare system. He was from India, right? So I guess he knew I was in the rehab hospital and then he saw my name and he goes, oh, well, this guy will know what to do. So, you know, he calls me and he goes, hey, my brother-in-law had a brain injury in India. Where do I send him? Like, so I'm like, oh yeah, that should be pretty easy. I'm Indian. I can figure this out, right? But no, it wasn't that easy. So like I went on Google, I tried to figure out like where there was inpatient rehab in all of India. And in a country of over a billion people, you would find like inpatient rehab in like every block. But no, not the case. And I mean, I spent hours and hours trying to help this guy. And then we finally settled on an inpatient rehab that was run by a neurosurgeon. And there was a nurse and there was one PT. And I still didn't understand how they paid for it. And I didn't understand how the insurance worked. I didn't understand anything. And this was in Mumbai. And he was four hours away from Mumbai with a severe brain injury. And so I guess my point on that is when you're looking at, you know, what the options are, how do you deliver the care? You just don't know what you're going to get. You know, we think rehab, hey, we're going to go do it. You would think the Indian guy could figure it out, but I couldn't figure it out for myself. And so it's not that easy to figure out what to do in a lot of these situations. You guys probably have different experiences. Yeah. Sometimes. So like for us, when I did the orthopedic team, so we really tried to find if there was like an orthotist or prosthetist as local as possible, I guess, just so that there would be some follow-ups, if not at least like the closest possible. So Kurdistan, it was close to, we were in northern Iraq, but there was really nobody, no OMP person that would at least have at least a good, fairly good quality. So we had to outsource somebody from Turkey that adjacent. So at least it's still relatively close and feasible enough for the patients to be able to be followed up and, you know, have the services provided. As you can imagine, that's a tremendous problem. And China, for instance, when it was looking in a global view, it was, I think, hundreds of thousands of additional therapists would be needed. So some countries have tried to develop what they call a rehab specialist, which is a non-physician specialist who bridges OT, PT, and I suppose some social work and that sort of thing. And I'm not really sure I know anywhere that that's really worked out and everybody has all the people that they need. And also, it's an extremely politically vulnerable area on the international scene. The international physical therapists... By the way, internationally, the most universal other therapy is physical therapy. And they're a relatively aggressive group in terms of the plans of their international society. And so they are very jealous about anything that would seem to interfere with their span or scope of care. But the OTs also have their international group, which is also that way. So that when you're starting to talk about melding or not defining these specialties in the way in which their international groups define them, it becomes a tremendous political problem. And so when you talk about knowing the culture, again, this is one of those places that you have to move very carefully. Hi, I'm Michael Lee and I'm chair of Baylor College of Medicine. And prior to joining Baylor, I was at University of North Carolina, Chapel Hill. I just wanted to share a couple of the experiences that I have and maybe it'll show you a little bit about different approaches, but extending what the panel is saying. One is that about 25 years ago, a young physiatrist from Korea approached me and he wanted to come to US and spend some time with us. And he did. And that translated into about 40 physiatrists coming from Korea. Korea is very well advanced in PM&R, but they started coming to UNC and Baylor. And over the last 25 years, we have had 25, I mean, 40 or so academic physiatrists coming to our program, spending some time learning about what we do in clinically and research and service and delivery and other things. The point after that, they go back and they go back to their universities or private practice or whatever, and they practice there. But what they've done recently is that they're starting to invite people from Indonesia, from Thailand, from Vietnam to come to Korea and learn about the rehab and do more of a visiting fellowship that I did with them so that they are giving back to these other countries. So that ball rolls and continues to grow. So I think there are different ways that we can make an impact in the global rehab areas. Back to, I think, your question regarding the allied health thing. I did a similar thing with occupational therapy students. So in Korea, they have several occupational therapy schools. And during the summer, they want to go visit different rehab hospitals and learn about the U.S. way of occupational therapy. So we actually invited a group of students with their professors into our institutions, spent two, three weeks teaching them about how we approach the occupational therapy, teaching them from driving eval to everything else. And they then go back and do the similar thing in the sense of teaching other students or other countries occupational therapy. So I think there are different ways to do that other than the mission trip or consultation trip that we all do. Anyway, I just wanted to share that. Thank you. Kind of on the same theme, Mike. There are some difficult political truths that you need to know when you're trying to do work overseas. It's true that the politicians in physical therapy are militantly, we do it all. And of course, it's also true that physical therapists are really smart people and they're smarter than us about what they do often enough, right? So like, it's not to dis PT. But it's even more so true that they're not everything. So when we started our programs, my goal was to build rehab medicine up from physical therapy being stronger, et cetera, et cetera. We got a doctoral degree for one of our PTs in Ghana, for instance. And she's awesome and it bombed. Partly because she truly didn't have the breadth and scope of what you know, okay? And partly because sadly, even though she had a doctoral degree, the physical therapist is viewed by the other physicians as a technician, right? So she both really didn't know our stuff and she also really didn't have the power. Now, if we went off to Kumasi, Ghana, which we did, and said, we got it, we got a doctor, we got a program. Being a doctor does not make you a leader or an administrator, right? Who's in charge of rehab services in that hospital? The head of PT. Who probably got there because they're a really competent leader and all of a sudden, some chair of cardiology at the hospital is like, guess what, I'm going to put this young doctor in charge of your system, right? Doesn't fly real well. But it's critical that there's rehab medicine. We tried so hard not to use rehab doctors to do this. It won't work, okay? What you have to do then is you have to start asking questions like, where's the rehab nurse? What do we do about swallow and speech pathology? And you have to not try to say, I'm more important than the PT, because they're really good at what they do. I really respect them. But you have to start calling out the other players on the team that you orchestrate. And when you start talking about the other players, that's when even the PTs say, gosh, I really don't know how to put a suppository in and I don't want to. And you got some nurse on the floor, some head nurse going, my people can do this. And this is where you kind of triangulate amongst them. The second political difficulty, I think you've all heard and we all very much respect this idea, nothing for us except for by us, right? In other words, the people with disability have the right and we have a job to work for them. They're the boss, not us, right? And we all believe that. But then you go to Liberia and you hang out with the disabled people's organization and you realize an absolute conflict of interest when there's limited money between the people who have a voice and the person with a tube in their nose in the intensive care unit, right? And it's kind of a weird thing, but the governments and the politicians really respond to the people who are out in the community and want curb cuts and jobs and nobody's speaking for the person who just got their leg cut off, right? So the little bit of what we do for the people with disability, it's a little bit, okay? But it actually needs extra advocacy because it's way too easy to simply say, we put out curb cuts and taught these kids how to weave, therefore we took care of the disability community. Whereas if we could only jump in early on, those people would have a better life, right? So it's a funny conflict of interest among people that want to have good things happen. So there. So I know we're approaching time here. I want to get through our folks that still want to ask some questions. We'll just try to keep the responses on the briefer side. I will put a slide up here just kind of talking about some next opportunities with this QR code. If you are interested to learn a little bit more, there'll be a link that you can follow. But please, let's, yeah, everybody that wants to ask, let's get it through. Hi. I just have a quick question. So... If any of you have implemented this at all, has it worked well? Is it a good? I think that you can be replaced by a grandmother in a rural village, and a neurosurgeon can too. True. No, that is correct. I agree with you. I agree with Andy. I think the community-based we have, it's really hard for you to start it. It has to start locally. You give them the concept or the principles, and then as Andy was saying, like, okay, Grandma, you do this, Dad, you do this, or whatever. Just give them the idea and the principles, and it has to be really an initiative as well, and you have the stakeholders from the local community. But it's not, even that concept, it's not foreign, even in the US, that we do this, right? So like in cancer rehab, which if you guys know a little bit of cancer rehab, it's not that well established in the field, even though we act like it is, there's still a lot of growth. There's not enough supply of physicians or therapists who do this kind of work. So you rely on like a nurse navigator. Yeah, resources and advocates, right? And that's what you need. So, I'm tying you on my microphone here, right? So, I made my funny joke because it's a bit of a 30-year-old scandal, okay? The WHO decided that people in poor countries weren't smart enough to be trained to do what we do, right? And there's one study in China that was a good randomized trial where community-based rehab worked because it was very, very tightly tied to an academic medical center. All the other research does not show that CBR makes a difference, okay? There's not any good research that says it helps unless it's tied to you in a very, very tight way, right? So, this condescending sense that people in poor countries can't learn to become doctors has failed Africa horribly because there's no rehab doctors in the whole continent. It can be done if it's very well tied to you. And if the grandmother realizes that this kid is a little more complicated and needs to see the community rehab center, who realizes that this kid is sort of complicated, and needs to see the person at the Invercargill Hospital who does a phenoblock and gets the kid back, right? Like there's this chain that has to do with you leading that is the only way a CBR program really succeeds and that's what the Chinese showed and all these other programs really have not shown much difference at all. Yup. Thank you. Hi there. So, I'm a medical student and I'm gathering that a big part of the PMNR global health is to educate and is there any ways for medical students or maybe residents who may not be in an educated role to get involved in global health? I think I would kind of put a plug in, I guess, especially of course like as a medical student, but within the things that you needed to complete or do, but maybe one small step as well is the International Society of Physical and Rehabilitation Medicine has a group also of young physicians, the young physiatrists. They have a group of residents and a young career, it's called the ISPRM Youth Forum. Is that correct, Tony? Yeah. They dropped the world. Yeah. So, that is one way to even get to know from a culture standpoint, you know, residents from other countries, collaborate with them. So, what we did during the COVID period, we ran like 10 webinars that was with the help of all these, the people from the World Youth, the Youth Forum from an education standpoint. I think that in itself is a very enriching kind of, you know, even let's say you're talking about how do you do bracing in one part of the country and you realize, oh, you have this type of technology or non-technology, so to speak, but still works in another part of the country. I think that could also be very much enriching and as you exchange ideas, exchange, right? That's the word, and you can learn from each other as well. We can all learn from each other. The ISPRM also has exchange opportunities where people can go to other countries and spend time doing various things and I think there actually are some that are related to... Well, I know there are some related to resident education. I think there might even be some that are related to medical student education. So, you should look it up on the website if you... and you want to become a member. Why there are a lot of, I think, different options. One in particular is it's networking, so you learn about the opportunities, because one of the things about the international scene is, as you've just heard from all of us, all of us have been to China or have played roles in China. I never saw any of them there, which means it's uncoordinated. And so, I think getting involved in a group that where you have organized networking would help find whatever you're looking for. I think the staff is showing up. Can we take our last question here? Thank you. Please. Hey, everyone. My name is Lornee. I am a BGY for Mount Sinai Hospital in New York. I guess mine is a mix of my experience in global health rehab and a question maybe at the end as well. So, my experience with global health really started as a medical student or actually before medical school, after my family is from Haiti, so originally, and really the work kind of in me started after the 2010 earthquake and getting involved in that pre-med and then kind of went in medical school started volunteering a little bit more. Through that experience, I, you know, was looking for organizations within Haiti or others that, you know, had more of like a rehab concentration to it, which it was a lot more difficult to find throughout my research. And basically, at this point, I'm involved with an organization called Society of Haitian Neuroscientists where it's a mix of neurologists, neurosurgeons, just kind of like within that field, both that are Haitians working in Haiti and a mix of that are in the U.S. Currently, there are no physiatrists in Haiti. There are about 22 physical therapists and maybe a handful of occupational therapists and kind of my role so far, especially as a younger physiatrist in training has been, you know, pushing the envelope on the need for physiatrists in Haiti and one of the ways we've kind of started doing that a little bit is contributing to, I guess, the education already of the neurology residencies in Haiti currently and educating them about rehabilitation medicine in general and the importance of it and hoping to kind of like get a buy-in and of having them understand what that's like. The other side of it has been working with an organization called Community Rehab Project, which is fully run by physical therapists, mostly Haitian in Haiti, and we've gone from renting out a space and doing therapies within those spaces to now building our own freestanding physical therapy unit that's one of the largest one in central Haiti, northwest Haiti right now. I guess my question would be, what is your advice in terms of, you know, being dedicated to a country where there's political issues? It's a low-income resource country in terms of that and there not being currently any physiatrists in Haiti and even within the Caribbean, there are maybe three that I know of that are sort of spread out within the different islands, whether it's like greater or lesser Antilles. So what advice would you have in terms of like developing a smaller island like that, but also like even in the Caribbean, which is wide open just like in Africa in terms of the need for rehabilitation medicine or physiatry specifically? And of course, we can stick around after this session. We try to limit to one or two minutes here. Just my, there's another. I was going to say, that's a pretty complicated question. Yeah. So maybe that's better. Sorry. Why don't we take that one offline and Dr. Higgs here, so we can all, you know, we can address this before they kick us out. Yeah. We're over. Thank you all. Well, thank you for coming again. Thank you very much.

global outreach

rehabilitation medicine

challenges

opportunities

physical medicine

global health

rehabilitation services

access to rehabilitation facilities

international rehabilitation work

sustainability of projects