So welcome everyone to our inaugural session for the International Rehab and Global Health Community. My name is Nina Tamayo. I'm the current community chair. I'd like to welcome you all. We're really excited to bring up our fantastic line of speakers tonight and learn about some of the opportunities for international work that's available to all of us. But before we all get started, we have a few housekeeping notes. As a reminder, this session is being recorded and it will be available along with the ability to claim your CME through the Academy's online learning portal. For the best attendee experience, please mute your microphone when you're not speaking. You're invited and encouraged to keep your camera on and select hide non-video participants. This will ensure that speakers are prominent on your screen. To ask a question, please use the raise your hand feature and unmute yourself. And if you are called upon, alternately you can use the chat feature to type your question. Jenna, who is our resident liaison for our community will be fielding your questions on the chat message. So please feel free to use that. Please note that time may not permit the panel to field every question, but we'll do our best. Just a quick note about the Zoom platform. The microphone and video controls are located in the bottom left of your task bar. Although I feel like everybody should know that by now, two years, three years after COVID. But you can bring those up by clicking on each of those icons if you need that. The raise your hand function is also located in the reaction section on the right of the bottom task bar. To hide the non-video participants, you can click on the three dots at the top and then click on hide non-video participants. Okay, I think we're ready to start here. One second. I'm just gonna share. Oh, hold on. Share my screen. I'll just do a really quick intro. Okay, so like I said, this is our inaugural session. So welcome to everybody who is just signing on. My name is Nina Tamayo. I'm the community chair. So just a really quick outline of tonight's session. We're gonna talk about the community's mission and vision, our future directions. We really want to create this community that's very collaborative, a little bit different from I think what we're used to in some other communities. I'm sort of treating it almost like a nonprofit and sort of running it in that fashion. We'll introduce our speakers after that. And of course we'll have our speaker presentations. We will have some time at the end of each speaker's presentation to do maybe one or two quick questions. But we have a 30 minute allotted time at the end of our session for a full-blown discussion. So the IRGH mission, IRGH, I guess, that's the sound we're going with. The mission is to increase awareness and involvement in international rehab and global health opportunities for our AAPMNR members. Our vision is to form a creative and collaborative space for those interested in international PMNR to share resources, find opportunities and network with like-minded colleagues. I like to think of our community as the how-to community. I think there's a lot of opportunities out there for us. And oftentimes we find ourselves, even though we are bound to AAPMNR, we're all in these silos that are very separated from each other. But my goal over the next year or so is to kind of drop those silos and really collaborate with other organizations that do something similar to what we do. And I think that just makes a better experience for everybody and oftentimes will lead to better opportunities for work abroad. So these are our future directions. If you can see the QR code, please, please sign in and fill that survey for us that is to help us create a directory of contacts and decide on the content you want to see. So you have the opportunity to let us know what you're interested in seeing. Another thing that we wanna do is to create an IRGH community committee of senior and junior attendings and residents to drive our community programs. I have a slide later on to list some of the opportunities for positions for that committee. So we'll talk about that. We're also interested in creating a more centralized resource for opportunities abroad. We're currently working on that right now. Part of the QR code, the Google form that's there, you have an opportunity at the very end to list any and all medical missions or other programs that you know of internationally so we can start putting that in a database. And of course, we want to connect our community members outside of the annual assembly through virtual webinars and networking events. We're very interested to know if that is something you would all want to be part of and if you would attend. So please let us know. We'll have that QR code during the Q&A sessions between each lecture and at the very end as well. So some of the positions we're looking for for the committee, obviously for our junior and senior attendings, we're looking for advisors, consultants, speakers. Any knowledge that you would like to bequeath upon us is very much welcome. We're also looking for program developers, project managers for potential missions in the future. That's a very far off goal, but that is one of the hopes that I have for this committee. And of course, networking gurus. So if you are very good at networking and we can put together a virtual or even live event in the future, that's something else we're looking for. And also, Jina right now is our resident liaison. So we're also looking for other liaisons to other organizations, content creators for social media and newsletter mailings. So please let me know, let us know if you are interested in any of those positions. Some of these are possible future topics. You know, I've just been surveying people who are interested in international rehab and global health. So these are possible future topics for our webinars and possibly for next year as well for our community session. So Rehabilitation 2030, a World Health Organization initiative, insights and perspectives. I don't really know how many people actually know about that, but it's something really interesting that the World Health Organization has included us as part of their plan moving forward. Obviously we've had multiple disasters recently, whether wartime, natural, of course the pandemic. So I think one of the hottest topics right now is the role of the physiatrist in a pandemic or natural wartime disaster relief. So that's another thing that we may touch on in the future. And I have a few colleagues who are expats or were previous expats and then came back. So we'll touch on the idea of working abroad in PM&R and what that process looks like. So those are just some things to kind of whet your appetite about what we can bring to you. So again, please fill out the survey. We'd love to get to know you, help us create content you would wanna see and help us build our resources. So one last thing, one of our speakers tonight, Dr. Rochelle Dee, she is actually speaking on Friday. Again, we will all be there. Well, most of us at least we'll be there or try to be there. We'll do a little Q&A session or a meet and greet afterwards if you're interested in talking to any of us about our experiences. That session is on Friday, October 21st from 2.15 to 3.30. And the title is Global Outreach and PM&R Opportunities, Disparities and New Horizons. All right, so I'm gonna give the mic over to Jenna and we will introduce our first speaker. All right, thank you everybody so much for coming here. I'm sure we're all very excited about hearing our wonderful speakers. I have the opportunity to introduce to you first, Dr. Lauren Shapiro. Dr. Lauren Shapiro is an Associate Professor in the Department of PM&R at the University of Miami where she provides care for many international patients. She has also volunteered abroad in St. Vincent and the Grenadines and the Bahamas. So without further ado, Dr. Shapiro. Thank you very much. I'm just gonna go ahead and share my screen. Oh. Yep, I'm just stopping there. There you go. All right. Okay, so I'm very happy that this group exists and very excited to be here tonight. I have the opportunity to speak about high impact short-term opportunities in global rehab. I've done international work for many years in different capacities. I started out as a second year attending. The nurse manager of the unit I was working on told me about a charity she ran in the country where she was born, St. Vincent and the Grenadines which is a small island in the East or chain of islands in the Eastern Caribbean. And she had brought a medical mission group the year before primarily seeing persons with amputations. She needed another physiatrist to join the team and I went. And as is usually the case, the first time someone goes on a medical mission I learned far more than I contributed that first year but I continue to go back. I went a total of five times over six years and it was an extraordinary experience that I'll talk more about tonight. I was also involved with some disaster relief work in the Abaco Islands following Hurricane Dorian that I'll also review. And then of course I work in Miami which is a very international city and very frequently care for persons from a variety of countries in the Caribbean as well as South America, primarily in the inpatient setting but also in my outpatient clinics. I'm a botulinum toxin injector and several island countries do not have any injectors. And I do have a number of patients who do fly in to see me every three to four months for injections just for specificity management. So I'm going to start my presentation. So I think I'm gonna start out by just summarizing where some of the issues arise when rehab physicians and other rehab professionals are interested in getting involved in global health. I think a lot of us wanna make a difference. We wanna learn about a different culture and perhaps a different healthcare system. And many of us wanna advance our problem solving skills in a lower resource setting. Some people look at it as a potential antidote to burnout although that can be very problematic. If you're experiencing severe burnout, I do not recommend going abroad. I have seen that end very poorly. But I have found it somewhat restorative to do international work because I have this opportunity to do good. I often have very grateful patients and what we'll say most of the time, but certainly not always, there's a little less bureaucracy and paperwork to do abroad. The challenge. A lot of the speakers that will follow will talk about fantastic long-term work they've done abroad and that's amazing. Unfortunately, a lot of us have limited time away from work and family, particularly earlier in our careers. Other challenges include, we might not have a lot of knowledge about the culture and the healthcare system. Established mission programs rarely have a rehab focus, although some do. And when you partner with organizations, they may just not know how to use your unique skillset as a physiatrist. And then of course, I think the biggest challenge is much of what we do are not really one and done services. So, ophthalmologists can go and do cataract surgery and bring about dramatic change in someone's quality of life in a really short period of time. In PM&R, fitting someone with a prosthesis or orthosis is probably the closest we come to the one and done service. Although certainly most of these patients need good follow-up care as well. So if you're interested in doing medical mission work, the first time you go, I would strongly recommend joining an established team, which is what I did. They had gone before, they knew the local needs, they knew the available resources, they had already developed relationships with local healthcare professionals, other organizations that were working in the region and other helpful people. Our team has always been remarkably assisted by retired nurses who have helped us out, as well as nuns who have helped identify patients who would benefit from our care. An established team will also have clearer roles and responsibilities in general, and they can help prepare you. They can advise you as to the process to get appropriate licensure and waivers, and even what to bring. You never really want to assume if you're going to a low resource setting that they'll have basic functional medical equipment. One way you can make a short-term medical mission sustainable is to commit to return. You're far more useful with experience in a region. You learn the culture, you learn the system, and people learn who you are and what you do. I am a very pale ginger, and I really stand out when I go to St. Vincent and the Grenadines. So people know exactly who I am, and they stop me everywhere I go, grocery store, pharmacy. But it's great because they tell me about other patients who need to see me, and then I make arrangements to see these patients. So we started out seeing people with amputations, but over time, people referred me, individuals with spinal cord injury, people with congenital limb deformities, and all sorts of other patients who really benefit from care from a physiatrist. And I found the more I went, the resources and training needed to provide optimal care really became a lot clearer to our team. We figured out some of the barriers to good care. Many of the patients we were seeing were diabetics because we were primarily seeing amputees, and there were tremendous barriers to providing good diabetic care. So we added a dietician to our team, and we started bringing down hemoglobin A1C monitors because they had no way to check A1Cs. And we, you know, over time, just we knew how to best help these patients more holistically, not even just with their rehabilitation needs. And by going back year after year, the changes we were making were very much sustainable. And by the fifth year I went, they were really pretty independent providing the care, you know, for persons with amputation, even without us. It can also be extraordinarily helpful in the short term to bring, well, in the long term too, to bring necessary equipment. I have found in my travels, what's usually needed are wound care supplies, splinting materials, ACE wraps. Crutches and wheelchairs are extraordinarily helpful, but very difficult to transport. Fortunately, the Rotary Club does a really nice job with wheelchair delivery. If you're seeing persons with amputation, prosthetic components, socks, mirrors and nail clippers are often in high demand. And we found it was really helpful to communicate with the physical therapists in the hospital we were partnering with about any equipment she might need. And we did bring down small pieces of equipment with us. One year I brought actually a cervical traction machine in my duffel bag because that's what she requested. It can be really helpful as well to train healthcare workers while you're there, but it's important you focus on topics and skills that they identify a need for. So, you know, they were very interested in learning residual limb care. They realized that these limbs were coming out kind of misshapen and they asked us to provide that kind of education. It's important if you bring down any new equipment that you in-service them on, you know, how to use it. You never want to assume a lack of knowledge when suboptimal care is provided. It's almost always a resource issue or a systems-based problem. And in many countries, there are community health workers who do a lot of the day-to-day work and they are usually minimally trained, but very hungry for knowledge. And it can be very helpful to involve them in any training sessions you're providing. So as I mentioned earlier, I did some relief work in the Abaco Islands after Hurricane Dorian through my university that had set up some coverage for some very overworked, exhausted local healthcare workers. As physiatrists, we can provide care to those with new serious disability from the event, but also there are a lot of injuries that occur in the rebuilding phase. So this is a picture I took there about two months after Hurricane Dorian. And you can see that the cleanup process had not yet fully begun, but some people were just beginning. And they were getting hurt. There were concussions, there were sprains, there were fractures. Moreover, I didn't include in my slide, but we can help ensure the care needs of people living with chronic disability are met in the aftermath of a disaster as they're often disproportionately impacted. And it's important to note, as I think most of us know, there are needs for services for a really extended period of time post-disaster, long after the camera crews return home. So as an inpatient rehab physician and someone who sees a lot of patients in clinic as well, I'm very comfortable with primary and inpatient hospital care. And I was able to relieve the healthcare workers in that way and was pretty comfortable doing so. I would recommend avoiding ER coverage. I kind of got roped into covering an emergency room, which was very much out of my wheelhouse. But I was very grateful that I had memorized the Parkland formula for the boards as we had two acute burn injuries because people were using a portable stove in the house and there was an explosion. So there I was in the ER by myself managing pretty severe burns, but that Parkland formula really came in handy. And it's important when doing disaster relief work that you help orient the new group that follows you so that they can hit the ground running. Last, I also advise in our MDMPH program, and this is a conversation I have like on an almost daily basis, because our students have not been able to do international work in quite some time because of the pandemic. But it's always important to remember that you don't have to travel far to work on improving access to healthcare for vulnerable persons, which is really what global health is all about. I'm very fortunate in that I am able to do international health from my home base, and that may be a possibility depending on where you practice. I have known several individuals who have volunteered with refugee health programs and have just loved that experience and talk about how important that has been. And then there's remote area medical as well, which does medical missions in the United States to areas that are underserved. I had the opportunity to go to Wise, Virginia several years ago, and it took some time to talk to them about what it is I could do while I was there. But there are a lot of patients who have chronic low back pain, who have other musculoskeletal injuries, some who had neurologic disorders, who very much benefit from physiatric care. So if you have an opportunity to do that, I would recommend it. It's extraordinarily eye-opening. I was working in Virginia at the time, and in the very state I lived, it was shocking how difficult access to certain health care services were to people who, again, lived in the same state I did. So I recommend that highly. With that, I'll end. But I thank you for your attention, and I'm looking forward to interacting more with the group. If anyone has any questions for me or wants to collaborate in any way, please reach out. Thank you. Thank you for that, Dr. Shapiro. What a wonderful presentation. The question that I had, you were talking about getting involved. Even as a resident, it's very hard to find the time to pursue these opportunities as a trainee. At what point do you think would be the best time to do this? Because as you said, you're relying on also internal medicine, your skills as an internist, or wound care, or even surgical. When would be the best time, would you say, to pursue international work as a trainee? I think it can happen at any stage, as long as you have the right crew and the right setup. So I think some of our other speakers have done fantastic things in their residency program. I know Dr. Rand can probably talk more about that. I personally was very grateful that none of my trainees had gone and done disaster relief with me, because that's a bit of a different, more chaotic situation. It might have been okay for someone who had done it before. One of my colleagues had prior experience in an NGO, and she was fantastic, even though it was her first real disaster relief situation. But that can be really stressful, and it's hard for the attending to also stay on top of how the resident is feeling about that situation. So I don't recommend disaster relief, but other kind of planned medical missions with good supervision, I think, are an outstanding opportunity for those who have that available. Great, thank you so much. All right, go ahead, Jenna. Yeah, that's really great. Thank you so much, Dr. Shapiro. I loved your talk. You know, one of the things that really stuck out to me was how you were able to do this disaster relief. I was wondering, how did you, you know, sadly disasters happen a lot. How did you get connected with being able to help out at this particular disaster relief? So our university, because of its location, is involved in a lot of disasters in the Caribbean. We have very close relationships through the, there's like a global institute, and they make partnerships with ministries and often help provide relief, as they did in Haiti many years ago as well. So they, the call went out to people who would be available in what, at the time, they thought were appropriate specialties. In the end, since the need wound up being more emergency room, they did start kind of marketing more to those people. But I had done some research with regards to the care needs of people with disaster, with disability and disaster. And I also was very, I collaborated many times with two individuals who were kind of in the planning committee. So it was a little bit easier for me to get involved because of that. Gotcha. Location and connections. Wonderful. Another question for you, you know, working at a university, you know, there's a lot of responsibilities on your shoulder, being a physiatrist, taking care of your patients. How did you work with your admin so that you were able to go back and have that continuity so frequently? I used vacation time. It's that simple. You know, even when I did it through the university, I did have to use my vacation time. So just like any other time, I have to have a covering physician. I make sure I'm, you know, if I'm in a region where I know my internet access and phone is going to be spotty, I let everybody know because, you know, we work with such big team members, they can get really frustrated if, if you're, you know, out of commission for a little bit. But yeah, if you use vacation, you know, it's, it's easy, but just make sure you have time to rest as well. That's great. Thank you so much. All right. Go ahead, Jenna. Our next speaker. Yeah, perfect. Unless anybody has any more questions, I'll go off. I have the opportunity to introduce Dr. Andy Haig. Dr. Haig is the founding president of the International Rehabilitation Forum, an organization credited for launching the field of disaster rehabilitation and building Africa's first PM&R residency. Professor, he's the professor emeritus at University of Michigan, and he practices in Vermont and directs the federal Vermont routine grant. So thank you, Dr. Haig. Oh, you're still muted. I don't know. I don't know if you know. Sorry. Try again. Yeah. I said, we've got leaves up here and there are all kinds of pretty colors. So I'm glad to be up here this week. Thank you. And, and, you know, like, listen to Lauren, man. She, she, she really has that, that part down. Yeah. So, so the, the, the theme is like, what are you going to do anyhow? Right? So I'm going to start out. Come on, give me a new slide. There we go. My first bright idea is to make an ass of yourself. So I'd like you all, first of all, to interpret this slide. Yeah. We sent this to the journal and the editor sent it back and said, you forgot the data. And I said, actually, no, we didn't. Right. Second picture in that paper is this above this Adelaide penguins in Antarctica, below Homo sapiens in Africa. Both groups have a statistically similar chance of interacting with a physiatrist. Note that the penguins all have legs, right? What do you do with that kind of bull, right? What you do is you change the world, right? It ended up getting published in five different international medical journals, simultaneously against all the rules of publishing. It ended up really that what we were as a disruptive innovator, we shined a light at something and said, Hey, you're blowing it. Right. And eventually the WHO new policy cited this paper over and over and over again in saying what we found, which is there only seven rehab doctors in all of Sub-Saharan Africa, only seven. Right. And the WHO policy now citing this says, you know, it's not enough to have community-based rehabilitation. Oh, timeout. I've been advocating for both community-based rehab and community-based neurosurgery. So if you're going to teach grandmothers how to take care of kids with disabilities and replace rehab doctors, we also need to teach grandmothers how to do craniotomies. Right. And these governments and the WHO have been assuming that if you're poor, you don't have brains and you can't have doctors trained. And this really changed. They said, Oh my goodness, we have to have rehab experts in these countries. It's not enough to have community-based rehab. Next dumb idea, repeat their mistakes. Grow medical rehab from CBR. Basically this amounts to taking the poorest, least educated, most ostracized people in society and have them come around and change hospitals and universities and governments. I use the grandmothers because that's what community-based rehab is. It's the grandmothers that do the work. You get in these grandmothers in rural villages taking care of the kids. They don't have a voice. They have something to say, but they don't have a voice. They're not heard. Right. There's also an interesting conflict of interest between the needs of community developers, community dwellers with rehab and the needs of hospital dwellers. And I ran into this in Liberia where the disabled people's organization, I think they call themselves, wanted curb cuts in jobs and were oblivious to the fact that people in the hospital needed prosthetic legs and IVs. And they're the people, this is about them. It's not about me and us and our job. But because the people in the community have such a large voice, the consumers who are in the hospitals and the ICU, who often have tubes in their noses, don't have a voice. And so trying to grow this from the community backfires for that political reality. Next is build it from physiotherapia, right? So there are physiotherapists in all the countries you can imagine, and they're smart people, and they're dedicated to rehab. But you show up long enough and you realize they really don't have nursing skills. They really do not know psychology. They certainly don't know how to prescribe drugs or spasticity, speech language pathology. And so over and over again, I'll be in a country and they say, we have rehab. I'd like you to meet Jane or Dave, the physiotherapist. And I'm like, that's not rehab. That's just a little piece. So the whole system believes that physiotherapy is sufficient. And you and I know they're really important, but they're not the whole story. In Africa, in most countries around the world, the therapists are seen as technicians. They're smart. They don't get traction with the university medical school or with the university hospital because they're just the technicians, which is just ridiculous, and also empirically, it doesn't work. We tried. Other people have tried. One of my friends, we got her a PhD. She's a PT physiotherapist with a PhD now. She's faculty in the PT school, and there's been no movement at our hospital to do real rehab. Bringing them to America, this is the way of the 1950s, and it worked back then a little bit. Howard Rusk was bringing people to America to train. But we don't practice African or South Asian or other medicine. We really order too many MRIs and get too many surgery. They have AIDS, and we don't have it the way they have it. So it's not the best, although they need to understand about us, and they need to get confidence that they're not dumb. They show up in America and go, oh, I've done 40,000 of those, and these Americans have done 10. So they come here to get experience, to get confidence, but actually doing the training here doesn't fit. And more and more and more, we end up draining brains. I had that experience with a bright young doctor. We got a scholarship for him. He lives in America now with his wife, and I don't quarrel with him doing it. It's just not accomplishing my mission. Next, invest in their careers. International Rehab Forum, after we made fun of all this stuff and put penguins in articles, went about to do something about it. And we took years of work to meet with clinicians, administrators, governments, to find people that really had a passion for this in African countries. We'd meet with a hospital, and they'd say, yes, and would you please buy us a new truck? And I'd be like, well, write your check for $3,000. It's all the money we have in the bank, and then we'll walk away. Or we can engage and help you to build what your hospital needs. And then the hospital president will set their coffee cup aside and say, okay, you're that kind of people. Well, let's talk. Here's what I need. My surgeons are sick of following these people on a 40-bed unit, and they're getting no place, and the government's da-da-da-da-da-da, right? So there's a stereotypical old rich American missionary kind of thing that happens in a lot of country, which is how they get their money, but it's not advancing the mission very well. In the end, though, and I'll quote Paul Clyde, who's an economist who went to Uganda with me. Paul went to see if rehab could help support the mission of a general medical hospital, and all of his math and all of his research says, yeah, rehab is so needed in these countries that if you have a competent program and have people pay rack rate, you can deliver babies for free and take care of trauma cases. So rehab is really valuable to them, but as an outsider coming in, you have to slowly help them see the value. Took us a long time. It turns out Tedros is the current WHO director general. When I met him in Ann Arbor, Michigan, he was just the minister of health at Ethiopia, and we were talking about this stuff, and he goes, just do it. Just make up a training program from a distance, and I'll approve it. So we go back to Ethiopia, and now we have four fully trained Ethiopian rehab doctors. I would not say their training is at the same caliber as you folks who've done four years in an American university, but they know what they're doing. They're practicing rehab medicine. They're doing research, and they're advocating, right? In Ghana, Abina Tanor was our first fellow. She was dying to be a rehab doctor. She got it through the family medicine, so it's actually a subspecialty of family medicine with a separate board, an examination. Abina now actually is a leader for the World Health Organization, as well as her work in Ghana and member of our board. My brother, Tom. So I got into this after Tom broke his back. He was one of the world's top cliff divers. That's a long story. Retired and smacked his back out in Portland, Oregon, and after that, the two of us said, hey, we got to do something. Tom is a gifted broadcast journalist, a documentarian, so he ended up coming up with this book that's coming out next month, which is kind of fun, which tells part of the story, but he looked at this whole thing and said, I just got to make him famous. I got to teach him what to do and make him famous. So he did documentaries. If you ever Google Tom Hague, look at his videos. Documentaries in Ghana, one of them got an international award for the video, basically talking about rehab for each country in its own language or in its own area so that they could use it to say, this is what I do. The doctors aren't any good at doing that. You and your friends might have certain other skills that help to make them famous. He went to Dakar, Senegal and said, you know what, we don't need to have broadcast journalists do this. We need to teach kids and give them cameras. So we went to the school for kids with disability, taught them how to do three camera shoots and interview people, and he had local kids realize that instead of basking weaving, basket weaving for a career, they can become broadcast journalists. And he got out the last airplane out before COVID, thank goodness. And in Nepal, Raju Dakal is a young Nepalese guy that we met in Bangladesh, who was in training there. Then they had an earthquake. Then Raju went home to take care of the earthquake and he asked Tom to come. And Tom, as a guy in a wheelchair, made all kinds of instructional videos that have been hit on like a quarter million times or something now, and calving and wheelchairs and stuff, all written and spoken in Nepalese. So there's a bunch of things you can do to help them become famous and to help them have tools that don't have to do with your practice of medicine altogether. Hannah and Emmy. So the International Rehab Forum board, I'll show you Hannah and Emmy. Some of you have been involved in our young leaders group, which has occasional meetings. This is one, you see Lauren's in there and all kinds of other people are in there, Vanisha. And we just try to make all of you future leaders in the field stay together. And there's Raju down in the corner, the Nepal dude, right? And Farooq Rathore, who was a resident in Pakistan when they had an earthquake, and he and his friends admitted something like 150 spinal cord injuries to the women's hospital and did data. And he actually is now more or less the father of disaster rehab because we published some papers and led from young Farooq doing his work. So these young leaders have great ideas and we just need to pull you all together, right? And we have this thing that's kind of useful. It's kind of like a merit badge, the Global Rehab Certificate Program. So if you follow our certificate program, we give you a certificate, but it also is a thing that forces you to think about what you're going to do in the country. Beyond, I'm going to hang out with Dr. Smith, the pediatric rehab doctor, it kind of requires you to make a short video, to visit the Disabled People's Organization, to look at the CIA date fact book on the country, to interview people and see what makes the rehab people in the country get their careers. So beyond just observing, it requires you to go do stuff. And as a result, it requires your hosts to help you do stuff. And also when you're struggling, especially as a resident, to get your department or your university to approve your time away, they're always looking for, you know, what's your educational goal? And it's one thing to say, I think I'll learn a lot. It's another thing to say, there's this established program and I'm going to get a merit badge at the end, right? So where do we go here? Come on camera. There we go. Yeah. So Medical College, Wisconsin, Emmy Nelson is faculty, Mary Elizabeth Nelson at the Medical College, Wisconsin, and Diane Braza's group has really agreed to try to be a bit of a host and a home base for this kind of thing. And we need more and more academic homes where you folks can look at, where the new medical students coming out can say, I think I want to do my rotations in my rehab residency there because they've got a professor of global rehab, right? If you look at obstetrics or orthopedics or cardiology, you'll find those departments. We formally looked at that across the United States a couple of years ago. There was no department that had a career pathway for faculty in global health, right? So there's Hannah, there's Emmy. They're my heroes. They're awesome. A good idea is doing research. Research is kind of interesting when I'm in private practice now. And I was before I went to university of Michigan and it was really interesting in Northern Wisconsin. I write a crappy little case report. It shows up at the front page of the newspaper. It was on brain injury. And some doctor calls up and says, you did that case report. Well, I've got an amputee. And I'm like, I did brain injury. I don't know amputee. There's a halo effect around research would validate somebody, makes them famous, makes them more honest to themselves about what quality is. And it also builds their career. So if you jump in with somebody overseas and do a project, it's gonna help your career, right? It's gonna help you become an assistant professor and convince your department that they need to give you a couple of weeks off and so you don't have to take Lauren's vacation from her. It's gonna help them get stronger. So these are just kind of fun examples, right? The language independent functional evaluation. You've heard the Barthel index, the can you eat, dress, bathe, et cetera, et cetera. We turned it into a video game. No words, took it to four different continents and showed that this video game is more accurate in the Barthel index than the Barthel index in reporting actual function, okay? And of course, you know, German has five different ways of saying speak and French has six different ways, right? So translating function from country to country was dumb. The other one that's even sillier that you can steal from me is called the walking watch. And we haven't published these papers yet, but it's really stupid. We did it with a bunch of undergrads. We're driving through an area in Africa and we're saying, has trouble walking, doesn't have trouble walking, I can't tell and counting them, right? What happens if you do that before the entrance of a church that has a wheelchair ramp versus the entrance of a church that doesn't have a wheelchair ramp? All of a sudden you have data that says, hey, you're God's host and you don't have a wheelchair ramp and you have one third as few people, as many people with, you know, who have walking problems showing up or a football stadium or a university. You know what happens at the University of Michigan when you do this, just see who can walk and who can't walk. You find out that even though the university is all about party and football and go blue and stuff like that, people with disability are a lot more likely to be sitting in the library on a Saturday night instead of the local bars, right? No good participation. The cool thing about this project is at least at our university, it's IRB exempted because it's unobtrusive observation of public behavior. So you can literally show up in a country, show up in a place and watch people and count and come back with a sense of where there's actual participation. These are the kinds of ideas that become tools that you can take to your partners overseas, validate what they're doing, making them locally famous and you'll get your Nobel Prize too, I guess. Chapter two, where do you wanna go? Well, it kind of goes like that, where do you wanna go? So I'm gonna kind of briefly give you the silliest snapshot of countries around the world. The point is that I know this cause I've been showing up. Oh, do you know how you get world famous? Did you know that like to be a professor, full professor at Michigan and Harvard and the big schools, you have to be world famous, right? Nationally famous, you can be associate professor, full professor, world famous. You know how you get world famous? You show up around the world. You know, all of a sudden somebody in Bangladesh and China thinks you're kind of cool. So I encourage you show up at ISPRM, show up at global meetings. And as a result, you begin to connect with people and go, oh, that's what it's like over here. So here's my snapshot thing, right? In the Americas, rural United States is at the bottom, right, because it's true. You come up to rural Vermont, you come up to my Appalachia sometime and see what's happening, where we can use the help, right? Native American reservations, all kinds of other places that need the help. In Latin America, you find that every country has a pretty well-established academic program. The national university has a national hospital, has a residency program. So you're not walking into a vacuum, you're walking into a place with a lack of resources across the country. So you go to the second city in the country or you go to a rural area and there's huge needs, but it's most cool if you hang out with the professors that are gonna teach the next generation, right? Lauren's more an expert on the Caribbean. I've done a lot of work in some ocean places. And these are interesting because you can just take one on, you can find a fun little island and say, I'll help, and just keep showing up until they got what you need. It's neat, it really is cool. Excuse me, and you can build like Lauren has done, build, and Dr. Leroy has also, you can build networks of people around the Caribbean or around some Pacific islands or something like that. And of course, telemedicine makes it so you can really be super helpful, even if you're not there. So many smaller isolated places need this kind of help. Sub-Saharan Africa, ain't nobody there, nobody's answering the phone, right? Any hospital you show up, unless it's one of ours, is gonna have an orthopedic surgeon who thinks they know or a physical therapist who yells at people to make them less depressed or the visiting American who comes by every once in a while, nothing happening except for Ghana, Ethiopia, Cameroon, which have our graduates now, South Africa is gonna have to start training 15 more doctors and they've got legitimate hospitals. They tell us that none of their doctors are legitimately board certified. And so there's stuff happening, there's rehab hospitals, but the rehab doctor sophistication you would bring is needed every place. I really encourage you to join up with us or expand from what we're doing with our help rather than to just say, gosh, I like Mozambique, okay? The reason is because I'm trying to pull the Africans together. We need the African Society of Rehab Medicine, we need them to lead us and us to be their servants, okay? And so when these people from the different countries I've worked with, they've already started to form these African things. They're gonna spin loose from us and have it work in Africa like it does in Europe. So if you got your favorite country, go with it, but contact with us and see if you can work with us and if we can't help you. You also don't have to go there, right? Tomorrow morning at seven o'clock, I'm teaching electromyography of carpal tunnel syndrome to the African team. Every week we're teaching somebody. You can join in our teaching sessions, right? You can help us to organize that. You can decide you wanna glom onto our stuff and go visit Ghana and hang out with some of these kids and teach or just hang out with them and learn because we have faculty in these places, right? You can come up with a cockamamie research idea and execute it with us. And especially as we get past COVID, they do need to come to the States. Imagine being the end of your three-year family practice residency and your two-year PM&R fellowship and never having physically met a rehab doctor or seen a rehab hospital, right? It's pretty sketchy. And they show up and they go home saying, damn it, that's not how it's done. We need a rec therapist there, right? They get so much sophistication. So if you or your institution can either host visitors or raise funds to bring visitors back in the context of not training the whole person, but somebody who's already trained getting a little bit of a snapshot, good things happen. So Sub-Saharan Africa, you can do your own thing, but join us, help us out. Asia's a really big mixed bag. Back in the day, Howard Rusk, the father of our field had the World Rehab Fund, which was in 120 countries around the world. And maybe 20 years ago, I was in Korea as the Rusk fellows, these tottering old men, came up and got there. They were the fathers of rehab in South Korea because Howard Rusk taught them. And if you take a look at the Philippines, if you take a look at all kinds of countries in Asia, they have very sophisticated programs launched by Howard Rusk in the 1940s and 50s. So when you get to Japan, Korea, Taiwan, the Han portion of China, the part that's more main culture, China, you're gonna see programs that are better than where you're training. You're gonna see outstanding scientists, clinicians, hanging out with them is a blast, doing things with them is a blast. It's really a very cool thing to do. So your job there is to partner up with them. You get to Western China, you get to Tibet, you get to some of these areas. They're Chinese, but they're politically like a mess and the people that are not well-served. And so these other Chinese areas need a lot of help. Politics of getting there and working with the Chinese is complex, but there are people who have that kind of an interest. Then there are other countries which are lower or middle-income Asia. And the places I list there all have academic PM&R, but it's kind of like Latin America where they've got it, but it's not in every city and they could use the help and they could use the sophistication. The people that are, the faculty are as good as you and me, but they just have a great need to expand, right? South Asia is a whole nother beast, right? India has a billion people and kind of officially only 700 rehab doctors, right? Bangladesh is probably the best model of a low-resource country having its own rehab that you'll ever see. My friend Taslim Uddin and his friends, there are probably eight residencies and programs all over the country. There's still a huge need. It's a poor, poor country, but you're dealing with people who know how to do it and still make a living in a low-resource country. So they're pretty cool. Cuba, the same way, by the way. And Pakistan, it's all in the military right now and coming to the private side because my friend Farouk, who is a military PM and our resident and his friends are now cycling out of being in the military and they're showing us professors' universities. So a weird, interesting model is to work with the local military, build something that they need because the most value you could ever get is rehab for military. That's why we have the VA system. It's not just healthcare costs, it's lost wages and lost productivity and it's politically sensitive stuff. And in any country, if you partner with the military to build something, eventually those doctors retire. That's a patient way to go forward. We've done, Tom, my brother here especially, has done a lot of work with the Tibetan government in exile in India. Lots of need there. Raju in Nepal, lots of need there. There are these other South Asian countries that are pretty empty of rehab that could use help and yet we know who to talk to, right? The Middle East and North Africa is also very interesting. Most of the Arabic speaking countries have, again, sophisticated rehab. They often have like oil driven, high quality rehab hospitals. And I kind of laugh because a lot of richer countries say, I would like you to build a program. What kind of equipment should we buy? And of course the answer is people, right? And so what you'll see in a lot of the countries where it looks affluent and the hospital looks great and they got the 50 meter swimming pool with the 10 meter diving platform for the rehab center, whatever, right? Yeah, but they don't have a nurse that knows what they're doing. They didn't hire the people. So you show up, if at all, to help them train. But there are strong, smart rehab leaders in each of these countries. So you're not walking into a vacuum by any means. Iran, you can't go there if you're an American. They trained in a very American model. And among the other rehab doctors in the world, I can talk EMG with an Iranian, like a really great American EMG, right? They really got it. But again, as things loosen up and our countries become friends, I hope the partnerships would be quite real and quite easy. And Iraq had a whole bunch, the head of the national hospital, one of my friends contacted me and said, Andy, what is the Dr. Haig Rehab Hospital for which this man apparently worked? He's trying to get out of the war and escaped, right? It's getting better, but it's tough. Europe. Western Europe is a mixed bag of many different kinds of rehab. So in Austria, they look a lot like us. In Germany, they don't do EMGs. In different places in Western Europe, but high-level sophistication, big academic departments, very, very smart people. Eastern Europe also has a lot of programs, but what's interesting is they're kind of old Soviet in its physical modalities. Of course, as American rehab doctors, you laugh at shake-and-bake therapy for the backache. You can learn some stuff because they got some sophistication. They don't have the two visits and you're out of physical therapy. They have time, they have the spas, they have a lot of other ways of doing things. So on one hand, you learn a lot from them. On the other hand, a lot of times, they're what you'll call inpatient rehab. Sophistication isn't quite there. How does the team work, et cetera, et cetera, et cetera. I raise a flag over Albania because it's like a third world country. My Italian friends are working with them. My brother Tom's worked with them. And it's an interesting place to try to put energy. This is a picture of me in Ukraine, right before the war with my bowl of borscht and my stomach is sick because every place I've been has been bombed. And my friends, the neurologists and the trauma surgeons are on the front line and showing us pictures of dead babies and crap. It's just not okay. It's pretty disgusting. Brings me to this, which is there are nasty places, okay? And they have major, major needs, right? And they have big barriers to getting stuff done. And there's a reason why you might show up, but you better know what you're doing, right? So there's an American Syrian born rehab doctor who went back to the refugee camps in Syria, did a whole bunch of really good work, but I don't think I could show up there, right? There are other places where you know what you're doing, you know the place and you can help out and plug yourself into the system. But the biggest lesson is when you're going to a nasty place, whether it's war or disaster, don't you dare go with a team that you form in the United States. Don't you dare do that. If you aren't plugged into somebody who's there on the ground doing stuff, you are just getting in the way of everybody, screwing things up and they're gonna get really mad. And the locals are gonna see that you're stealing their business. That local ophthalmologist, yeah, he's left dealing with the complications of the ophthalmologists work from America and he doesn't get paid. And the people think he's an idiot because the American did the surgery, right? Be very sensitive to sustaining the careers of the people that are living there. The problem with the nasty places is that all these people like Doctors Without Rehab, wait, Doctors Without Border, but I think they're also called Doctors Without Rehab. They show up, they do the heroic early work and they skip out and anybody who knows amputees knows that there's a need for a new prosthetic leg five years later, right? Nobody's advocating for the long-term rehab needs and most often nobody's triaging these people early on to say like, this one needs an amputation, this one can go home, right? So with disasters, I formed this disaster rehab group with IRF and we handed off to ISPRM, the committee, I've got a bunch of my names on some of these papers, but there's a disaster rehab committee that's gone far beyond my expertise. They've got a dozen papers on how to do it. They've got processes for doing it. You don't have to be part of them, but they know what they're doing. So if you're interested in a disaster, read first before you jump in. If you're gonna go follow a disaster, you gotta put together your team, your resources and your funding and hey, if you're kind of interested in doing it, get it together ahead of time. My Australian friends, Dr. Ferry has a team that's ready to scramble and it's pretty cool. It helps really a lot. You got attached to big people, but the aid agencies themselves, the Red Cross, the Doctors Without Borders are really weak in rehab. They have some PT sitting on their committee, but they don't understand the breadth and scope of what's going on. So if you show up there, it's all about, remember the crutches, remember the depression, right? War zones, all kinds of them. They have a huge need and an even bigger need for rehab advocacy, but you get killed. And that's the other thing is there are places where you know they need the help and you're not gonna be very effective, right? And so when you're dealing with these places where you're gonna get kidnapped, you're getting in the way, you're hurting people, okay? You deal with places that don't want Americans, find other ways to help or find another place to help. You're not abandoning them, you're helping somebody else because you can just make a mess of things. You can really get in the way and injured hostages and heroes really, really are no good. Write them a check. So the real question is, find a cool place, enjoy this work, find someplace that is really a delight to say, I did it, whether it's from the adventure or the warm weather or the snow or the people or your family's background, find a friend there that is your anchor. Your job is to stick with them in the long term. The first time you show up, they completely will not bank on you being back and they'll give you what my friend Noel calls a shit eating grin. Yeah, yeah, we could use your help. You show up again and all of a sudden they get real because they're like, you really are not a medical tourist. Your job is completely to be a tool for them, okay? It's not to take care of the baby, it's to take care of the African doctor who's taking care of the baby, help them with politics, help them with money, help them with resources, praise them, help them build their careers. That's really what we can do unless you wanna live there, right? So you're validating them, bringing outside brains and anytime you decide you're gonna bring something in your suitcase beside your toothbrush, say, is this something sustainable? Are they really gonna use it? And when they've used up what I got, what happens next? Is this a smart idea or do I have to come up with a more sustainable plan? So where do they want you most? Just keep listening. Finally, really, there are not enough of us and there's not a single institution in America that makes this the academic strength of the university department. You folks who have an interest around the country, stick together, work together, build the specialty of global rehab as a academic pursuit together so that when I'm retired and demented, I can travel and be okay. My email is andyhagadumich.edu, rehabforum.org is our gang and we'll help you stick together. We're gonna back up everything happening with the academy as well. That's the end of my slides. Thank you. Wow, what a presentation, Dr. Haag. Thank you so much for that. I think we're gonna keep moving with the presentation. So we'll save all of your questions until the very end during our Q&A. Jenna, go ahead. All right, let me pull up what we have here. All right, next we have the wonderful Dr. Stephanie Rand. Dr. Stephanie Rand is the residency program director of the PM&R residency at Montefiore Health Systems slash Albert Einstein College of Medicine in the Bronx, New York. She has overseen sending residents on physiatric medical missions to Jamaica, El Salvador, Iraq, and the Dominican Republic. Thank you, Dr. Rand. I just said I was trying to share my screen, but not actually unmute myself. Let's see, do you all see my presentation? Yes, we can see it. Perfect. Sorry, too late. Okay, I'm Dr. Rand, sorry for the slight mishap before we started. I'm going to talk about bringing residents on missions. So, the considerations really are quite similar, for the most part, to starting up a medical mission at an institutional level. Often people are concerned with the cost of bringing supplies, bringing people internationally. And also, if we're looking at it from an institutional level, the cost of lost productivity. As Dr. Shapiro mentioned, she goes on her vacation time because if she were to go during her clinical time, that would be time lost. There's often few people willing to do this, and not everyone, by any means, is trained to travel internationally. As Dr. Haig mentioned, you're really going there to help the country and the people there, not to just do medicine. It's easy for us to do medicine in a place where we're comfortable, but it's a totally different experience to practice medicine in a very low resource environment. As Dr. Shapiro said, she does a lot of botulinum toxin injections in Miami, but when she travels to the Caribbean, that's no longer an option. She has to rethink her resources, right? So, you have to think about what you're actually going to be able to do. So, in our institution, we like to really focus on the teach a man to fish and he will eat forever mentality, and not just going there to practice a little bit of medicine. So, what do we really worry about when we are sending residents? So, the main issue comes down to time and what residents need in order to meet the ABPM&R requirements to graduate in a timely manner. Most people are aware you need 12 months of inpatient, 12 months of outpatient. You also need two months of peds, a bit of consults is required, but is not specifically delineated in the RC guidelines, and two months of peds. So, you add all of this up, and you still end up usually with anywhere from three to six months of additional extra training. Now, there is a requirement written down that you can't spend more than six months of elective. I don't know a single institution giving anyone six months of elective, although that would be lovely, and no more than six months of research. Again, I don't know anyone who really makes that as part of their formal plan, but it is written into the requirements. So, in our institution, most of our residents end up with three, four months beyond the minimal requirements to be board eligible upon graduation, and we have some flexibility there. Most residents spend the time in outpatient because that's the bulk of where residents seem to want to practice, but there is flexibility. And because there is this flexibility, we've been able to actually send residents on medical missions with our faculty and call it AC jamming time. We are really lucky that we have a lot of faculty interested in medical mission work, and so as long as our residents are with a teaching faculty, that can count towards teaching time and towards their ACGME required time. So for our program, we aren't taking it out of elective or vacation time. Certainly this has not been feasible in the last two years with the pandemic, but thankfully we are slated to start this up again shortly in July. So one of the missions that we've been doing the longest was to El Salvador. El Salvador is a mission that was started by one of our sports doctors, Dr. Maurice, through her church with her ex-husband, who is a family practice doctor. And they were running to El Salvador, and this was one of our residents' favorite missions. You had to be extremely physically fit in order to go on this mission because there was a plane to a train to a bus to a donkey to a several mile hike up the dormant volcano to the very top where this village was. So this was our only international effort that was really just about service. There really was no infrastructure at the top of this mountain, and in the rainy season, which is almost half of the year, it turns out there is no way to get off the mountain. So a lot of the people living in this village really only had each other. So there was a lot of bringing resources. I don't have a picture here of the dozens upon dozens of shoes that were also brought by our team up the mountain, but also they had to bring all their medical supplies. And it was a lot of teaching the people who lived there. Exercise is medicine. Nutrition is medicine, and teaching them little things that they could do. Also, the benefits of just good footwear to help prevent worsening of arthritis, and the occasion as is pictured here of injections. Starting in 2016, we started doing twice a year missions to Jamaica with the rehabilitation hospital there, which is the John Golding Rehabilitation Center. It's the only acute rehab institution for the island of Jamaica. The island has a slew of physical therapists, no occupational therapists, and one speech therapist who is in her 80s. So we would go there with a team that included rehab nursing, physical therapists, occupational therapists, speech therapists, residents, physicians, and even some research mentors to try to help build a team. And so we built their center. They have really excellent prosthetic care for lower extremity amputees, but the Jamaican insurance doesn't cover upper extremity amputees or upper extremity prostheses. We delivered a 3D printer, which you can see as one of those photos, and helped design a myoelectric prosthesis for them, and trained their staff on using the 3D printer, which they used for a number of different activities. Also really, really liked using it for splinting. In general, plastics are not readily available. The thermoplastic sheets used in traditional occupational therapy are not readily available on the island. So having the small shipments of 3D printing plastic material that could be printed and in the exact shape for the splints was very much appreciated by the nursing staff in that institution. And this is a mission that we will be starting up again in July. It's a really good example also of some of the barriers. There are a lot of visa requirements in order to practice medicine in another country. You can't just go and walk in and decide to start doing medicine. So we have a really great champion through Zion Care International. Dr. Bishop Craig Brown is a health minister for the country of Jamaica, and he really helps us to navigate the landscape and navigate the political requirements, such as delivering the printer, where Jamaica has a 100% tariff. So they tried to charge us to deliver a printer, but thanks to our connections, we were able to get that waived, which of course you think you're donating equipment, but if you're trying to do this without having actual connections in that country, you could be charged and could be doing something illegal. So it's very important to think of who is going to be helping you on the ground in a country with need. Iraq is a country that we went to in 2016 with the help of Amamiya, Amamiya Medics International. In the light brown, that's Dr. Anakfi, who led this mission. We sent one resident there at that time, though we had a second doing the work, doing a lot of remote work with them, and both residents and Dr. Anakfi presented at the UN, at the United Nations that year about the work they were doing. As Dr. Haig mentioned, a lot of these countries in the Middle East have the resources, but they may not be always delegating them in the right or in useful ways. A lot of patients in Iraq were still in significant need of medical attention. There was still a lot of negative connotation around persons living with disabilities, and yet still a lot of persons with amputations and other disabilities as a result of of mines from the Iraq-Iran war just sort of being left out in fields. So we were seeing a lot of patients in need. From 2016 to about 2019, we did a lot of remote work helping them to build their PM&R residency and making e-modules and doing e-lectures. We were gearing up for another mission in 2019. The political climate did not allow it at that time. This was one of those, this is a region where things change rapidly. So even though the visas were all in order and the staff was in order, it's about three weeks in advance that all of a sudden it just kind of had to be shut down because of international political requirements. And then the pandemic hit and we're waiting for our next foray back into that country. So where do you want to go? You know, if you're a resident and you want to get involved, I think that's amazing. I think that you know, I know that I have two residents right now looking to start a mission to India. They have our full support. We've given them a list of contacts they're working with. Something that we've always required for our medical missions that are department sponsored is funding. A lot of this funding comes from private donors, some from organizations. But for the residents that we send on missions that are not going as part of their elective or vacation time, they're just going as part of their learning and their education time, we don't want them to have the burden of cost. So we do a lot of fundraising. So that's one thing that's very important to consider who's paying for you to go, because not only are there costs associated with your travel, but there are costs associated with your absence. And those are things that have to be dealt with. It's imperative to develop relationships on the ground. No mission work can be done without really having a group in that country to be working with. And as Dr. Haig said, nothing should be done without knowing what they actually need. When we go to Jamaica, we work with the University of the West Indies doing CME presentations, medical school level presentations, working with the hospitals there, both Kingston Public Hospital, as well as the Golden Rehab Center, doing in-services for nurses. It's imperative to be training people and to be asking what they need to know. It's easy for our trainees who are very excited about regenerative medicine and ultrasound to be looking and saying, oh, I want to go teach them this, but if they don't have the access to that technology, then it's really not useful. So often what we're going and training is about wound care and neurogenic bladder and neurogenic bowel and splinting and things that are accessible and make humongous differences from a quality improvement and quality of life standpoint. I think that's about all from my slide deck. All right. Thank you so much, Dr. Rand. We'll keep just moving along here and I'll have Jenna introduce our next speaker. Okay, next we have Dr. Amy Matthews. Dr. Matthews is an assistant professor in the Department of PM&R at the University of Texas Southwestern Medical Center in Dallas, Texas. Dr. Matthews is board certified in PM&R and brain injury medicine. Her clinical interests include brain injury and spasticity management. She's been involved in global health resident curriculum development and is involved in rehabilitation efforts in Bahir Dar, Ethiopia. This presentation that she'll be giving will discuss global health rotations for residents, including pre and post departure recommendations for rotation structure. This talk will also briefly review regulatory requirements from governing bodies. Thank you, Dr. Matthews. All right, let's see if I can share my screen. While Dr. Matthews is figuring out her, her computer screen, I just want to take like 10 seconds for everybody to just show us their faces and, you know, say hello. Can everybody? Yeah, turn on their videos. I love to see your faces. Yay. Hi, guys. Thank you so much for joining. Okay. All right. Dr. Matthews, you okay? Yep. All right. Is it working? Am I sharing? Yes. Okay, I see it. We can see a screen. You can see a screen. We can see a document. There we go. Okay. And it's your it's your I forget what these things are called the speaker. Oh, yeah. Yeah, I can change that. That better. There we go. Perfect. Excellent. Sorry about the technical difficulties. I just got a new Mac. So any new Mac users might be commiserating with me. So I will be on the same kind of lines as Dr. Rand in talking about some of the residency rotations and considerations. So I'll talk about some of the compliance, compliance considerations, and then some thoughts about how to structure rotations if you're a trainee, or maybe if you're a program director, and then a little bit about what our experience in Dallas has been. So this might be just a little bit dry. But I want to make sure that if we're going on these global health rotations that we're, you know, playing by the rules. And the last thing I want is for our programs or our residents to, you know, get in any kind of trouble. So there's three governing bodies that we have to appease the ACGME, the AUPMNR, and then whatever your sponsoring institutions, GME is. So the first thing is, in terms of the GME is that typically, there's some type of like program letter of agreement or PLA between the participating sites. And that happens whether it's domestic or abroad. And the things that need to be included in this, and it doesn't have to be anything very formal. And a lot of times, it includes things that you should already be figuring out for these rotations, like who's going to supervise our residents? What kind of supervision are they going to have? What will the residents be expected to do? Do they have formal teaching? What kind of evaluations are they going to get? How long is the rotation? What kind of patients are they going to be seeing? So, you know, none of this is really onerous, but it does help us kind of dot our I's and cross our T's for the ACGME. When it comes to who can supervise, if you look at the common program requirements from the ACGME, they're pretty vague. And I think this is helpful from a global health rotation standpoint, because they basically say that any of the providers that are supervising our residents just have to have qualifications that are judged acceptable by the review committee and are approved by the program director. So, it doesn't necessarily mean that if we're going to other countries that it has to be a PM&R US board certified physician that's supervising our residents. So, that does open up more opportunities for our residents. The next governing body that we need to know about is the ADPM&R, which is the governing body for like our certifications. And they basically say, you know, if it's okay with your GME and it's okay with your program director, it's okay with us. And then the last instance, like the last governing body is your sponsoring institutions requirements. And that's going to vary by the GME. All rotations are going to require some type of approval from the program director and the designated institutional official. My piece of advice here, if you're building a residency rotation is really to start early. At both institutions, I've done this. It's been like a three to six month approval period. There's a lot of forms and kind of check boxes to get through just to make sure that our trainees are getting, you know, one, a safe experience, but two, like an educational experience. So, now I'll talk a little bit about kind of a suggested structure for these global health rotations. I think it's really easy to think about global health experiences as these kind of like isolated drop-in and drop-out experiences. And the speakers that are, you know, in this panel are going to talk about a lot of the benefits and complexities of global health experiences from a lot of different perspectives. And as someone who's here to talk about this from the resident education standpoint, the complexity I want to highlight is that we kind of need to do some prep work before we have our residents go. And then there's also this part of, this part of the rotation that's important to follow up. So, on the front end, before residents leave, we want to make sure that they have kind of adequate medical knowledge, like first do no harm, right? So, we don't want to send our residents into another country to see a lot of musculoskeletal complaints if they've never seen MSK patients or pathology. So, you know, we might not be able to have full MSK knowledge, but having some type of introductory knowledge, working knowledge that makes them clinically safe is important. And then they should have, you know, ideally completed some type of global health education, learning about kind of general global health principles, ethical practice abroad, sustainability, you know, if they can, ideally starting to learn about some of the cultural differences or, you know, local infrastructure as much as they can before they leave. And then when they come back, that shouldn't necessarily, back stateside, it doesn't necessarily mean it's the end of the rotation or learning. So, just like our rotations here, there should be some type of evaluation process for the resident. And then in addition, some type of debrief. So, sometimes it takes a while for those lessons learned to sink in, but they are, those lessons really are longer lasting if we kind of formalize it, either through having our residents give a presentation or write something up, or at least just, you know, talk about their experience with their mentor. All those things can help make that, you know, two week experience or four week or six week experience, really a lifelong educational opportunity. So, as we've been learning through these sessions, there's a lot of benefits to global experiences, but it can really be overwhelming. The good thing is you don't have to completely reinvent the wheel. So, I think the big question is like, how do we get started if our program doesn't have something established? And there's lots of different ways. You know, there's programs that are residencies that I think are very traditionally known in the global health kind of landscape, like emergency medicine and internal medicine and OBGYN. So, you know, connect with leaders in those departments. They may have something that's already established or a site that they have a partnership with. Your institution or your GME at large might have a global health office or an office of international affairs that has some opportunities. Lots of medical schools have opportunities for their students that don't necessarily translate to their residents yet, but you might be able to connect with some of the partners that they use for the medical students. And that might be like you're in for your PM&R residency. And then obviously one of the points of this community is to connect with colleagues. And this is another great chance to find opportunities as a resident to do those global health rotations. So, in terms of our experience at UT Southwestern, it was kind of serendipitous. We partnered with the neurology department that had a fledgling program that was led by a stroke neurologist, an Ethiopian stroke neurologist, Dr. Gabrielle Hans. And we started to go to Bahargar, Ethiopia back in 2017. We went there twice before the pandemic and we hope to go again in the future. Our team kind of grew as we got our boots on the ground and we learned what they needed and what would be beneficial to them. So, the second time we went, we brought an ER physician. We actually also partnered with a local Ethiopian student interest group and they had a lot of family in the area and that I think really helped with the sustainability of the program. And these initial visits, a lot of them were like facts finding missions and kind of talking to the people there and hearing what they needed and what their approach to rehab is. And the neurology program has been rolling out a new stroke unit and building a curriculum for their physicians there. And from a rehab standpoint, we've been partnering with them to develop some of their post-stroke rehab protocols. So, our goal once we're allowed to go back again is to continue to work with the providers there on developing kind of feasible post-stroke mobilization and dysphagia screening protocols. And ideally, one of the things that we heard was they really need kind of nursing partners that might, that'll help train some of their nursing staff in some of these ideas. And they've really expressed an interest in learning things like bracing and dysphagia evaluations and phenol for spasticity. So, I think that's kind of over the next five to ten years, things that we're hoping we'll be able to partner with them on. So, that's it for me. Obviously, if there's any questions, I am happy to take them now or at the end. All right. Thank you so much, Dr. Matthews. Can I get everybody to put a hands up emoji in the chat to say awesome job to all of our speakers so far? Let me see those emojis. Emojis, everybody. Anybody want to start the emojis? Maybe I'll start. Here's one. Put in the right skin tone, too. No? There's my emoji. Can I see everybody else's emojis? Oh, there it is. That's awesome. Yay. Okay. All right. So, Jenna, our next speaker. Yes. Yes. All right. All right. Next on our schedule today, we have Dr. Clarice Sin. Dr. Sin, MHA, is a double board certified physiatrist who practices in Dallas, Texas, also at UT Southwestern Medical Center. She specializes in pediatric acute rehabilitation care with a focus on neurotrauma. She also has interest in policy and reimbursement as she serves on the AMA, Relative Value Scale Update Committee, representing the AAPMR. She has done medical mission work in Ghana, Ecuador, and the Dominican Republic. Thank you, Dr. Sin. All right. Can you see my slides? Yes. They look great. Thank you. All right. Perfect. So, I'm also at UT Southwestern, like Amy Matthews, and I'm going to talk about the work I've done there with our therapist. Oops. Hold on. I have no relevant disclosures. So, I really want to talk about what is Propel DR and how did I get involved and where is it going? So, if you don't know where the Dominican Republic is, it's in the Caribbean. It shares the island with Haiti. It is the second largest Caribbean country. So, back in 2009, there were three therapists from Dallas, Texas, who went to Cielo, a small town in the Dominican Republic outside of Santo Domingo, and they put together for them a therapy gym at Mission Emmanuel. So, that is a Christian ministry. At that ministry, they have two campuses. There's two schools, a medical center with a physical therapy clinic, a dental office, a water filtration plant, a women's co-op, a screen printing room, and multiple storage facilities. And throughout the year, Mission Emmanuel will host multiple short-term mission teams from all over the US. Most of them are church groups. However, there are a few medical teams. Those three therapists who went for the first time back in 2009, not only did they set up a physical therapy gym, but they spoke with the current therapists there and helped them set up home exercise programs for the children they were treating, and they also set up a few wheelchairs. Since 2009, the therapists had continued to go every single year. I did not join the team until through 2017 when I started working in Dallas. Each year, they brought more resources and more team members. The group eventually became called Propel DR. It makes up a team of physicians, both pediatric PM&R, myself, a pediatric neurologist, a therapist, PTOT speech, some ATPs for both national seating and mobility, as well as New Motion, and we take a team of interpreters as well. So what is Propel DR? It's rehab professionals providing educational seminars and clinics to support our Dominican colleagues in serving their community. It's dedicating to raising the quality of life in the Dominican Republic through providing education and rehabilitation. Okay, so the lecture series, it's the annual lecture series where we match the knowledge of the American health care providers to the need of the Dominican health care providers and their families. So we will ask ahead of time before we go, are there certain topics you guys want to learn about? What are you wanting to do when we're here? What do you want to accomplish? And so usually the therapy clinics are hands-on, as well as some are minor with the residents that I will get to. So here's pictures of some of our therapists working with the children there. So they will actually bring in some of the patients from the facility to work with the kids as they're explaining different techniques that they can do with these patients. So I just listed some of the lectures that our therapists have given. So this was back in 2015. This just names a couple of them. Also prior to me joining in 2017, one year they brought one of the PM&R residents from the DR over to Dallas to Shadow, as well as five physical therapists. So one thing that makes the Dominican Republic very unique is that they actually have two PM&R residency programs on the island, and there are over 100 physiatrists on the island. So these are some lectures they gave in 2016. Like I said, just a couple that we do while we're there. Lectures given in 2017. So all different breaths, you know, different techniques, different type of patient populations they're going to be taking care of. Here's 2018. 2019, our last year, we went before COVID hit. Of note, when Propel DR started, they were teaching at only one to two locations. Now we teach at six to seven different locations. So we lecture to parents, therapists, other physicians, the residents, as well as the practicing physicians. That could be PM&R, neurologists, surgeons, ER residents, or some of the groups that I have spoken to. So this is at Caid, which I'll talk about a little bit later. So how I got involved was I had just started my job at the beginning of 2017 in Dallas and found out that our therapist went, asked my boss, hey, can I go check it out? And he was like, sure. So I went, met with the PM&R program director residency there in Santa Domingo, and we kind of set up what, you know, what can we do? How can we collaborate together, you know, and work with one another? These are a couple of lectures I've given. Several of them I've done multiple times going. I've been three times now. Last two years, we weren't able to go due to COVID. I am going back next month. I also do clinics. I've done combined clinics with the residents where they'll present a patient. Then the patient comes in, the family, the therapist, and I have a therapist with me. We'll assess the kid, go over what their treatment plan is, and then if I have anything to change. And one thing that's been nice, I then get to see these kids the next year I come, and I've gotten to see the progress they made. And then my therapist will touch base with their therapist to see like, okay, what are you working on? And is there any, you know, next steps, what should we be working on from there? So one of the big things is there's nearly 100,000 people, mostly children in the Dominican Republic alone, who are in need of specialized wheelchairs to improve their quality of life and mobility. Children born with disabilities in impoverished countries, they're often carried throughout their adolescent years. Void of proper positioning can lack potential development in their muscles, affect their nutrition and learning. So Propel DR, that's kind of where it got the name from, is for the wheelchair. So they help raise the quality of life for these children by providing them with customized wheelchairs. They are donated wheelchairs and equipment that we collect throughout the year and then ship them to the Dominican Republic. Once they're there, therapists and our ATPs will work with the Dominican teams to help come up with a custom, the best that we can wheelchair for these children. And they work together with these donations to try to meet the needs of the kids. And what's cool is the following year, those kids may come back and if they have outgrown their chair, they will donate the chair they had previously and get a new upgraded chair, or they may need some parts switched out on the chairs. Oh, also, so in 2019, right before COVID hit, when we were there, they were able to set up the first Caribbean vendor to actually go to the Dominican Republic and they ordered the first chair while we were there. So for kids with insurance, they were able to actually order a custom wheelchair like we do in the U.S. and deliver it. I don't know if things slowed down to COVID or not. I guess we'll find out next month when we go. And also now that we have trained the Dominican wheelchair technicians over there, they are running a clinic at ADR, which I'll explain a little bit later, year round and able to do these repairs on wheelchairs and able to assemble wheelchairs out of the donations that we have sent to help these kids. So it's not just a once a year we're here to help. It's really training them and how can we make their program more sustainable and make them more successful. So here's some pictures. It starts out with us getting donations of these chairs. They get broken down, put in big cargo boxes or boxes and get shipped in cargo over to the Dominican. Once they arrive, they get unloaded, the chairs get taken apart. You can see the front, we got some frames, we got some backs, you'll see headrests, and they basically get broken down throughout the whole room, just piles of wheelchair parts. The kids come in, here's our therapists working with them to kind of get the right positioning and how you're going to want them for seating. Then the therapists, our volunteers, the ATPs, both the Dominicans and Americans are working together to assemble these chairs, and it's literally done all in one day. These kids come, get their eval, they see if we have parts that fit them, and they basically leave several hours later with the wheelchair. Here's just some pictures. This is the before picture, a teenage girl who her mom has to carry everywhere, like you see in that picture, with her first ever wheelchair. Here's another picture of a kid who'd never had a wheelchair in his wheelchair afterwards. Now the kid on the left, two pictures, this is a little boy with spina bifida. He was in a special needs school because he couldn't walk and didn't have a mobility device. We gave him a wheelchair that first year. He was so excited when he came back the second year to get his new big boy chair, as he called it. We found out that he was now in a quote, you know, normal school because he had this wheelchair and he was independent getting around. The girl in the middle is in her 20s. We're not really sure what her diagnosis is. It changes every time we see her, but she comes back every year and gets different tweaks to her wheelchair. The kids on the right are first time wheelchair users. We have some really complicated cases, and you can see this girl is like basically contracted in this position, so very difficult for family to pick her up and move her. This is the wheelchair they came up with her or device for transporting her. Another one, this was just a wheelchair the hospital there had, and now you can see in the wheelchair that she was provided. It's a lot easier and she can be more independent by propelling it herself. In 2019, this was the biggest case. These are three adult males with a genetic condition unknown who are non-ambulatory and basically homebound because they're large and the family couldn't take them anywhere. These are their first ever wheelchairs. You can see the kid on the right how excited he was for them. They also go through, you know, teaching the families how do we now break down these chairs? How do you get them in your cars? All the same stuff that they would do in the U.S. and that they can come get their repairs or anything that they might need with the technicians here in the Dominican. There's also Chariots of Cielo, and that's at Mission Emmanuel. They actually do have a place where they can come and get wheelchairs. I've personally not been to that site. I've only been to ADR, which is all the other pictures. To date, well, as of 2019, the last time we went, Propel DR has had 2,500 participants. We've given 87 lectures, 402 wheelchairs delivered. Now, like I said, those are the wheelchairs we deliver the weeks we're there. They have been, the last like five, six years, they have been actually assembling chairs while we're not there, and so a lot more chairs have been given out. So the places that we go to, ADR, so it is the Dominican Rehabilitation Association. It is actually a school for special needs, and it's a rehab facility outpatient, so adult and kids. This is where our wheelchair clinic takes place. It's in Santa Domingo, but they actually have these locations throughout the country, multiple ADRs. CAID, it is the Comprehensive Care Center for Children with Disabilities. This place is gorgeous. They only take three diagnoses, CP, Down syndrome, and autism. As far as I know, it's still up and running. When we were there in 2019, they were about to have a political upset. A new group was taking power, whereas CAID was the previous president's wife's like pet project, the First Lady. She's the one who created it and started it, but as far as I know, it's still up and running. Here's just some pretty pictures of this place. Another thing I want to point out, when they started going back in 2009, a lot of these gyms were donated these amazing equipment, really high-tech, fancy, but none of them knew how to use any of the equipment they're donated, which is kind of pointless. When our therapists started going, they said they'd walk into a gym, see 10 kids laying on a mat, and they were just doing range of motion exercises. Now they're doing gait training, kinesiotaping, just so much more that they can provide for these kids. Here's when I've given lectures and seen children at CAID with some of the therapists. The residents, like I said, there are two PM&R residencies on the island in Santa Domingo, and I think the other one's Santa Ana, but I could be wrong. There are over 100 physiatrists on the island. When I've gone the last two times, they've held a rehab symposium where I was the guest lecturer at, but they also spoke as well. Right before the 2019 was there, before COVID hit, they came to me and said, we were wanting to do a fellowship, our first ever, and we decided, what is the biggest need for a fellowship here? They decided it was pediatrics, because there's so many kids with disabilities there. They wanted me to help set that up for them, help them get the ball rolling. However, COVID hit, so I will kind of see what we can do, and I'm also working with our GME now, trying to bring some of the senior residents over to do rotations with us in the U.S., so they can kind of see the differences of how we do things versus how they do them. Here's just some pictures of me seeing the kids with the residents in clinic. They also see a lot of adult patients, but because I do PEDs, they saw PEDs with me. So, since we've been there, the wheelchair clinic, it's become a pretty well-oiled program at ADR. So, when we return next month, we're not really sure what they're going to need from that standpoint, so we're going to kind of check out what the resources are, and if there's another need we can fill, because our goal is that they will not need us. We want them to be completely sustainable, and we're about there on the wheelchair front. However, they do use the donations that we get, but my plan for my part of the team is to keep working with the residents and try to build a collaboration between our department and the department in DR, and that's just a cute girl in the town of Cielo who stole my sunglasses. Thank you. Thank you so much, Dr. Sin. That's a great segue into our last two speakers for the evening. Jenna? Yes. All right. Next, we have Dr. D. So, Dr. D is a full-time pediatric physiatrist and clinic chief for PM&R at the Texas Children's Hospital in Houston, Texas. She is an associate professor at Baylor College of Medicine and serves as the vice chair of education and director of the PM&R residency program. Dr. D received her undergrad degree in BS physical therapy and then medical degree from the University of Santa Tomas, Philippines. She completed a combined PEDS slash PMR residency program at the Albert Einstein Medical Center and Temple University Hospital in Philadelphia in a pediatric rehabilitation fellowship at AI DuPont Hospital for Children in Delaware. She is triple board certified in pediatrics, PM&R, and pediatric rehabilitation. Dr. D is an active member of several organizations, such as the AAPM&R, American Academy of Cerebral Palsy and Developmental Medicine, Association of Academic Physiatrists, and serves as the chair of the education committee of the ISPRM. She has participated and served in several short-term medical slash rehabilitation outreach programs internationally, such as the Philippines, China, and northern Iraq. Thank you, Dr. D. All right, so let me see this place. Is it, are you seeing my slides now? I see like it says AAPM&R, COMDE, and then it's like white. I think I probably see like the top. Anything? No, not yet. No, no. I am, sorry, let's see. Yeah, it's weird. I'm getting some feedback blank. Let me see. I don't know why. Let me see. Let me try this again. There you go. Okay, better. Okay, let's see. Looks great. All right. Is this a better way to do this slideshow or sometimes? Let me see. Let's try. Oh, it went back to the previous screen. Yeah, so I think if I use that to do a slideshow, it just doesn't go. Let me see. Sorry. I'm having some delays here. I don't know what's happening. Sorry. Sorry. Well, Dr. D is figuring out her technical difficulties. Let me see everybody's faces again. I think we had two additional. Yes. Is this better? We haven't seen anything yet, Dr. D. I think you're frozen. Yeah, for some reason. Let me bring up the deck that you had sent me via email earlier. I can just throw the next slide here and there. Thank you, Michael. Okay, is it my network as well? We can hear you, but I think you're freezing in certain cases, but we can hear you. All right. Okay. Is this better? Okay. Do you hear any background noise? Just let me know. Okay. Okay. All right. Thank you so much for having me and for this opportunity to share some of my experiences in global rehab as well. I'm just grateful for the opportunity to be able to have been participated in some of these mission work. My goal is to just share some of these stories with you and some setups. I couldn't agree more with my colleagues, all the speakers who gave principles and just takeaways of their experiences. I couldn't agree more with all those that they've shared. I know in the interest of time, I will just probably give stories of different areas or different scenarios that anybody could also participate in international work as well. Okay. Next slide, please. I think we already know by this time. Okay. I just wanted to show you that the first one that I had the opportunity of actually helping to organize as well is the one that we had a medical mission in the Philippines. As a disclosure, I'm from the Philippines, so it's my native country. That's where I grew up. We had then, we actually in the US, we have a group of Philippine American physiatrists that we just do this at a social basis. We thought about like, hey, we wanted to give back to the community and to our mother country. We thought of ways to try to provide some of our physiatric services to the Philippines. We partnered with the National Society in the Philippines, the Philippine Academy of Rehab Medicine, because we wanted to make sure that there would be some sustainability to see some of our patients. We know, especially in rehab, this is not a one-time thing. We wanted to make sure that there would be a process for an opportunity and an ability for these patients to be followed longitudinally. We partnered also with a local nonprofit organization to serve the urban poor, so they already have the patient population. They were the ones who helped us with screening patients. We just provided them with a list of patients that would potentially benefit from our services. This happened in February 6th. If we could go to the next slide, please. This is just a one-day, almost like a three-quarter-of-a-day medical mission, but the preparation that went on along with this is, of course, pretty huge as well. There came some coordination of services and coordination of supplies. We said definitely funding. We were the ones who tried to do a fundraising campaign on this. You could see here in the slide. We wanted to make sure that we were also well-rounded. We had some residents who helped us, local residents, and also some attendings who were there locally to be able to prescribe some medications just for internal medicine like blood pressure meds and all that that they have to supply. Then we also wanted to tackle the rehab part. One is providing some of the equipment, the gate aids. As you could see here, walkers, gate canes. Then one other thing that was also very expensive or that was cost-prohibitive for them are braces like all these custom-molded orthoses as well as prosthetic legs. This is where we asked for donations from some of our colleagues here. They're orthotists and prosthetists, so they donated boxes of these used braces. You could see AFOs in there. The main thing that's very useful for Third World countries are actually the joints and the parts. That's where they usually just take that out and they can create their own mold. Sometimes if we are able to find a good, closer fit AFO and all that, then it can be reused or remolded somehow. Also, we wanted to of course make sure we are able to provide physical therapy services as you could see there in the picture. Next slide, please. As we said here, our objective is we wanted to give back and provide rehabilitation-specific consultations because there's a lot of medical missions already that's happening. We know this is not a one-time. We want it to be sustainable. We also wanted to connect our patients with the local rehab doctors. We identified that through the PARM people. Also, we wanted to foster relationships with our partners in the Philippines for future endeavors. The outcome is on the other side of the slide. We know that it was even the fabrication of the AFOs and even the prosthetic legs that we funded, at least for PAPA that we funded. It took a while, so we actually got reports a couple weeks later. The nice thing is that the patients also, as you could see, perhaps there was stroke patients or amputees. They were able to get therapy services not just during the medical mission itself, but they also had subsequent visits in the local clinics. Next slide, please. As a segue to that, now looking back, we had another one, a follow-up partnership with the PARM people, Philippine Academy of Rehab, when a big storm hit the Philippines. This is now where we went into the disaster relief realm of medical mission. We didn't necessarily even expect this, but since there was a need for it, we wanted to respond to the call for help. This became even more like a bigger endeavor, including ISPRMs through their disaster relief committee. This was in 2013, actually. It happened in 2013 with a big Haiyan storm. Next slide, please. This was a Category 5 storm that hit the Philippines, the southern part of the Philippines that really left a huge devastation in the island of Leyte. With this one, they were, PARM as rehab professionals, also did not just sit back on the sidelines, even though we're not necessarily acute care, but there were also a lot of injuries. Of course, there was a high death toll, but there was also a lot of injuries, including spinal cord injury and brain injury as a result of this. When we came in, this was towards basically the third month already post-Haiyan. They wanted to still continue their ongoing projects and community service to the people in this disaster-stricken area in the province of Leyte. Can you hit enter, please? I think there's another. This is just how devastating the area is. Basically, they were still cleaning up months after the typhoon. Next slide, please. The PARM, the local national society, they were already doing medical mission work. We asked them, what are their needs and how can we help from the Philippine American Physiatry Association? They told us we wanted to do a follow-up medical mission to do a 100-day post-Haiyan relief because they're still needing to provide even basic hygiene kits to the people who are still living in tents. That's what we said, okay, we will be able to help and sponsor that. We did a fundraising campaign here in the U.S. and we formed a team to partner with them. Next slide, please. These are some of their pictures of their ongoing medical mission work leading up to. You can see there's definitely two areas where the physiatrists rolled in disaster responses. We actually tried to do both. Even though for this mission itself, it's not necessarily as a first responder, but I guess to some other people, it could still be because there's still a lot of people who did not have access to care because people had to walk hours to even get or pick up some of their relief goods. Next slide, please. what happened was, this was in February of 2014. So we had a team, you can hit return as well. There's another, maybe, okay. Another one, please. There you go. So from PAPA, Philippine American Physiology Association, there were three of us. So there's two who are attendings, and one was one of my residents here at Baylor. So he's also Filipino. So this was, we all did this out of our vacation. This was not something that is part of our residency program. But this was just something that we wanted to give back and help out. And so we, as I said, did a fundraising campaign. We did two clinics throughout that day, as well as distributed relief goods, or relief hygiene kits to the patients. And then what we did was we also did some research and data gathering in terms of what are 100 days post-typhoon disaster, what are still the most common medical problems that can be seen? And lo and behold, MSK injuries, arthritis, or even acute MSK injuries were pretty much high up on the list. So in this, we actually wrote it up as an abstract that we presented at the ISPRM. Next slide, please. So I'm gonna turn the page a little bit into a different kind of model. So this was something that, as most of my colleagues have said too, if you wanted to really make an impact, it really has to be something that you wanted to, you foresee as possibly doing a long-term, because it takes a while to really develop that relationships. They don't know you, you don't know them. Even your teammates may not know what you can potentially provide or what you can help out. So this was my experience in China. So I, how I got into this, I was actually just asking people around in terms of where can I order wheelchairs that my plan was to send them to the Philippines and to order them in bulk and to send them to the Philippines. And lo and behold, I sat next to one of my friends at church and he said, oh, my father actually goes with a team who distributes hundreds and hundreds of wheelchairs to the people in the provinces of the remote areas in China. So I was like, oh, what was this about? And later on, I got connected with the, with the chair of the foundation who's an orthopedic surgeon who happened to be a pediatric orthopedic surgeon who's doing work in China, treating patients with cerebral palsy and helping them with their deformities. So I said, well, that's pretty much, I think that's right up my alley. So how can I help? So this is where I started to venture out and go with a team. So this is just particularly in Dali. The team goes to, I went to like other places in China, but I just committed to one place. Dali is in Yunnan province, so it's a mountainous area in China. It's still fairly, the capital is Kunming, but the rest of the province is still pretty rural. And so they do, in this area, they do have a lot of people, minority groups. And so the first year I went there, it's almost like there are patients that have never seen a physician in years. And so access was still very, very difficult for them. So the goal of the foundation was really to reach people who are very indigent people and to provide the services. Next slide, please. And so this was, of course, that there was coordination as well. Our team members were coming from many different countries and also filling in the different roles. We had ward nurses, OR nurses, orthopedic surgeons. So I was a PM&R. Some of them never even heard about PM&R as a specialty. We had PT or OT, orthotists, and some of the admin team was very, very important. They kept us fed well and kept us safe and with all our transportation and all the logistics. And then this was a partnership as well with the Dali People's Hospital, number two. So it was a contract as well. They provided us with the OR, the beds, and also the facilities to use. And also we partnered with some local workers to help with follow-ups, especially with post-surgical needs, as well as rehabilitation. When I started here, they really didn't even have much of a concept of rehabilitation. And over the years, they were starting to evolve. Same thing, there was one of our colleagues who was asking, they have the money. So it's like, okay, let's build a gym. But again, they don't really have the people. So you could see the same kind of string of the theme. You could see the theme here. So that's really quite still very deficient in a lot of places in the world. Next slide, please. So here we did outpatient clinics to assess the patients. Before this though, there was already screening ahead of time, just at least to make sure that we are a little bit more, that's appropriate for the clinic that we're holding. So basically these are lower extremity deformities that patients who had those, who could potentially benefit from our services. And then without of those outpatient clinics, assessing what their needs and what their goals and all that, then they were scheduled either for surgery that year, or if not, then potentially the year after. Next slide, please. And then we all kind of just helped with post-op care. So I saw myself like I was wearing multiple hats. So I was a pediatrician, I was an internist, and also sometimes helping out with physical therapy. We were assembling wheelchairs as well to provide for our patients, but it was a lot of fun. And so the concept of therapy right after surgery is totally new as well in Asia. And so we said, yes, we got to get up. We got to do all these to move. So next slide, please. And then as we evolved over time, as I said, they knew what we could bring to the table, each of us, and we were more comfortable as a team and also the local partners. Then we evolved into having multidisciplinary rounds to make sure that we are all on the same page. The orthopedic surgeon somehow relied on me to say, oh no, this is dystonia. Oh no, they are too weak. So in terms of prognosis or really potential as a, you know, are they a good rehab candidate post-operatively or not? And then over time, again, we didn't have botulinum toxin. It was expensive. They didn't have phenol. And then we discovered we could use somehow alcohol for focal spasticity management. So we were able to implement that as well, which was very, very helpful for some of our patients who were not needing surgical intervention. Next slide, please. So I would have to say, I mean, I actually learned more from them over these years. And so we also had these programs that, you know, we got together as a farewell, during farewells with patients and family. This is always a very moving time and everybody has a tissue on their side just because we, you know, just the heartfelt thanks and gratitude from the families, you know, after all these. And then of course we also, you know, try to, you know, keep our, just keep our camaraderie as well going on with our hospital staff. Because even we have the nurses to help with the services for post-op care and all that. It's also their local nurses as well. And some doctors who help to translate that and put that in their medical record and put the orders in the hospital. So it really is a teamwork and a partnership. So unfortunately it had to stop just because of the political climate that was in China. They were pretty strict and not allowing external nonprofit organizations to come into China. So we had to close that program. And I've started going, and they started going into Northern Iraq and established that to serve the Yezidi refugees. So just for some takeaways, as I said, lessons learned. Could you please hit enter? So just be flexible and humble. And a lot of the times it is, as you said, your first time, you might be more of an observer. Just watch and see and learn, ask questions. You might be asked to do more than, or other things that might be outside of your scope, I guess, just be careful before you say yes. But sometimes any menial jobs can seem to be like, hey, this is not what I'm here. I'm a doctor and I'm not supposed to lift all these cargo and all that. But in that kind of setting, you just need to be flexible and be humble. Whatever help is needed, just be willing to help out. Next. Remember, it's also bi-directional and collaborative. Because a lot of times, sometimes for us, coming in from the first world country, we feel like it's us that we are able to, we are the ones providing them with something. We wanna think of it as them, that we're also learning from them. What can they contribute? It is gonna be a collaborative project and not just a one-sided giving. Sometimes you never know what you actually learn and what you get out of it. Next. Other things is, one thing too is do no harm. As it is in the Hippocratic Oath, right? And so sometimes we think that we practice medicine here, that would be the best for them. But what about who's gonna follow up with some of these? Are they able to sustain this kind of treatment? Is this the best thing for them? Next slide, please. I mean, yeah. And also we started learning this as well, that sometimes we think that we're helping, that we may be hurting. So the one thing I realized here is that we wanna make sure when we provide these services, that we are not competing with the local doctors, because that becomes a negative connotation and it provides a negative atmosphere as well with colleagues, because they are a fee-for-service most of the time, even though they do work in the government, most of the doctors, but they also have technically their private practice on the side. So that's why we stuck with services that we provide wherein perhaps most of the local doctors are not able to provide us a service, just making sure that we don't compromise their livelihood as well. And of course, not to mention the other cultural, political and the economic situation of the area. Next. And then also the local medical practices. So we've learned to really understand, okay, what other services can we refer to afterwards? What resources are available? Because we know that we're not gonna be there for, you know, this is so, even though this is a, you wanted to try to at least provide something that they could, you know, continue on with. Next, even though we try to stay connected through some local partners, it's still different if you have somebody on the ground locally. Next slide, please. And as I said, the follow-up and the continuity. So usually for this one in China, there would be a smaller group of a follow-up team who would go back, you know, like two months after the, two months after the big surgery because they needed to remove the cast and then also provide the braces, the AFOs and all that aftercare and then some physical therapy sessions for these patients. And then it was nice over time, I've actually developed rapport with like, I see these patients every year and so yeah, so seeing how they progress, what has happened through their lives, some of them have gotten married and all that. Next, please. And as I said too, we tried to do some training, but it didn't necessarily happen in Dali, but I was able to have some medical students come with me from China who came to the U.S. and wanted to serve in their country as well. So they have the language, they know the local area, so it was really helpful. They served as our interpreters as well, but they learned along the process. My goal here was to also be able to train therapists and some potentially physiatrists, but they really did not have the infrastructure in this area. Next slide, please. Next, okay, as I said, make sure you have fun, cherish the bonds that we make and also next slide, please, the relationships that you're able to keep. All right, next slide. And I think that's my final slide. I wanted to thank you for your attention. I'd be happy to answer some questions. And this is the one that, as I said, now I'm kind of committing to, which is the Kurdistan medical mission in Northern Iraq. All right, thank you so much for your attention. Thank you so much, Dr. D. I had just put in the chat that if there are any questions if there's PAPA, which is the group that Dr. D and I are part of, both part of, this is the Philippine American Physiatrist Association, it's also another way for you to serve in an international level. And I think we're picking up a lot of themes from the talks tonight. So one of the things that we were able to do during COVID was actually provide webinars or lecture series for a couple of international conferences. So I'm spinal cord injury trained. So I helped put together the Ask Khan Conference. And then we also did a work with University of Santa Tomas for their 100, is it 100, I think, or 200 year something celebration. So again, you don't have to leave the U.S. to do international rehab and global health. And there's various ways to help other people in other countries. So for our last presentation, I'm gonna hand it over to Jenna. All right, thank you, Dr. Tamayo. And I am very excited to introduce Dr. Leroy. She is both a Harvard trained medical doctor and a medical intuitive. She is an expert in lifestyle, functional, integrative and rehabilitation medicine. She comes from a long lineage of Western medicine trained physicians and holistic healers, which has shaped her unique and science-based approach to integrative and individualized care. She completed her residency in PMNR at Harvard Medical School in 2010 and Durant Fellowship in Global Health and Refugee Medicine from Massachusetts General Hospital in 2011. While working at Massachusetts General Hospital, she spent her time working as an inpatient physiatrist and as the medical director of the Haiti Rehabilitation Program with Partners in Health, a Harvard-based nonprofit dedicated to healthcare delivery in resource limited settings. She remained on faculty at Harvard Medical School for eight years, completed her master's degree in spiritual psychology with an emphasis in consciousness, health and healing from the University of Santa Monica in 2016. She currently serves as co-chairman of the Lifestyle Medicine Interest Group with ACRN and has launched Lifestyle Medicine Track for the PMNR residents at Spalding Rehabilitation. All right, thank you, Dr. Leroy. Oh, you're still muted. Hello, hello, everybody. Let's take a big stretch, home stretch, you know? I know this is- Let's see everybody. But we will have time for some discussion and I'm just so excited to be sharing this with you. So my presentation's a little bit different in that I'll be sharing some lessons learned. In addition to all of that work, I'm also a coach. So I hope to coach you through, for those of you who are looking for international experiences, wherever you are in the range, whether a student, resident, attending, you know, retired, these are just some lessons that I learned from my six years working in Haiti. So I want to go through an introduction of who I am and then we'll get into some drawbacks of traditional medical missions and why I feel so strongly about really doing your homework and understanding, you know, how can I make my contribution sustainable? How can I leave that legacy beyond my time there on the ground, which for many of you will be limited because you have other obligations to family, to work, et cetera. And so we'll go through the lessons of how this can be achieved briefly. And I created this framework of five different lessons that I'll get into in a little bit more detail, but one being clear intention. Like, what are my intentions? What am I hoping to gain from doing this sort of work? The beginner's mind, coming with an open mind. And the more you prepare, the better you'll be able to be of service and to learn how to provide culturally relevant care. I'm also an officer with our diversity, equity, and inclusion. And this also applies to international settings. Task shifting, which has been mentioned, but not formally by name and definition. And then the follow-through and handoff. I always say that the fortune is in the follow-up and whether it's you doing the follow-up, whether it's the people on the ground doing the follow-up or a subsequent team, this is what is going to carry the legacy forward and ensure that we're not just reinventing the wheel every time we participate in things like this. So this is who I am. I am Haitian and Jamaican. Mother is Jamaican and Cuban. Father is Haitian and French. I always wanted international experiences. I started out doing mission trips in medical school, went to Cuba and the Dominican Republic for brief stints. And then during residency, my first couple of years did a few mission trips to Haiti. I think my influence, so my mother's side, the Jamaican side, many natural healers in that side of the family, as well as my father's side, there's 19 physicians actually on my dad's side of the family. I never thought that they competed against each other, but I understood this contextual framework very well and could apply it to my work in Haiti. As many people in rural communities in resource-limited settings rely on natural medicines. And so I first began the really in-depth work during my last year of residency at Harvard, the 2010 earthquake. My chairman was not able to travel, had other obligations. He asked since he knew I was both Haitian-American and had been on prior trips, if I could take a trip down. And so 10 days after the earthquake, I was on a plane and was on the ground. I realized that the earthquake itself shattered an already weak health care system. You know, Haiti is the poorest country in the Western Hemisphere. There were multiple disaster responses from different countries, different organizations here in the United States, some of which went really well, and some of which did not. And we were dealing with a lot of the complications from those that did not go well. And then I worked with Partners in Health. It's a Harvard-affiliated program. Some of you may have heard of Paul Farmer, the founder of the organization. But it was a sustainable program, nonprofit that partners with local ministries of health. And the catchment area that I served was 1.5 million people. For those of you who are familiar with Haiti, I was mainly in Plateau Central, and then Artibonite, which is just a little bit west of where I was located. So Plateau Central is like due north of Port-au-Prince. And then St. Mark was the major town that I spent a lot of time in, in Artibonite, which is just about a two-hour drive away. So let me just, I'm not trying to rain on anyone's parade here, but I do want to mention that there are many drawbacks to what we know to be traditional mission work. One thing, this has been well-studied, well-documented, published in the literature, and talked about within international communities, is that when you decide to go on a traditional mission, which is like, okay, I'm gonna bring all my supplies, I'm gonna go down someplace for a short period of time, do the work that I do, and then leave, it creates what's called a parallel health system. So what that does, in turn, is it can destabilize what's already existing, because as people have mentioned before, it impacts the business and livelihood of the local providers, the hospitals, and the health systems. Another thing about it is, this is not our place of origin or where we plan to reside. I happened to be able to do that at the time. And so it's not really sustainable for both the country and for us to be continually going down on short stints without thinking about the long game. Traditional missions rely heavily on foreigners, and when that disappears, so does the system. And we saw this pretty clearly during COVID. When a lot of people were not able to travel, those systems became even more disrupted and destabilized, because they began to rely so heavily on foreign aid. There were medical consequences, there are cultural consequences. Every time I prescribe a medication, I think about, is this something that's going to be available again locally? What are the complications that could occur as a consequence? Do they have the means to get the proper testing that's necessary to deal with the consequence or identify the consequence? And do they have the materials, the tools, and the resources readily available? If the answer to that is no, I question whether or not it's something that I need to do. And then sometimes we can drain the resources that already exist to resolve the complications that we create on these missions. And like I said, it disables health systems when it's not well thought out and well done. However, there's tremendous opportunity to create sustainability. We've talked about this, but it really requires partnership with the local community, creativity, flexibility, and intention. Like you have to have that intention that you want whatever you do to have the impact that lasts well beyond your time on the ground. So I was the medical director of the Haiti Rehabilitation Program for Partners in Health. And we talked a little bit about community-based rehab. We too also realized very quickly that it was very limited in what it could provide in these resource-limited settings, but we didn't wanna throw the baby out with the bath water. And what we realized was because of the rugged terrain of Haiti, access to hospital care is next to impossible for people with disabilities. In fact, most people who are able to make it to you in a center in a resource-limited country have means, have some form of affluence that allows them. Because if you think about where most people are coming from, even having the ability to get a wheelchair or spending a lot of money because gasoline is in the Caribbean, it's one of the most expensive places, to get a ride to get to you is sometimes just such a huge barrier that it limits care. So we have these rehab educators. They're like our rehab community health workers that we trained to be the eyes and the ears. They would provide primary prevention to the family members of the people with disabilities, secondary prevention, checking blood pressures, checking blood sugars. They did a lot of disability advocacy, learned how to do home-based exercises. And then the biggest thing was red flags, recognizing the signs of when people need to come into the hospital. So we really wanted to create a system. And so they were our eyes and ears in the community, but they would interface with the hospital. So they would be the ones to link community, to clinic, to hospital. And then the rehab techs, which are, it's like a one-year training that you can get right now, kind of like a physical therapy, occupational therapy assistant. They used to, so rehab educators were daily in the communities that, and they were from the community. So they were familiar with terrain. They were familiar with who in this area has a disability, who's been discharged from the hospital, who has this, who has that, very familiar with that. And then the rehab techs who were mainly in the hospital and part-time in the community, would weekly survey their daily work. So they did a lot of quality improvement. They did fitting of equipments, and they were the interface between hospital and home. We linked the community-based rehab and the rehab techs to our hospital system. Every Friday, everyone would be in the hospital for morning rounds. Everybody would round together. And this is where the rehab techs and what we call an accompanateur model came into play. So every expat, so to speak, was never working on their own, but was partnered with a Haitian counterpart. So the physical therapist had a U.S. on-the-ground full-time U.S. counterpart. There was no physiatry in Haiti. In fact, there was one other physiatrist in the country full-time, Jesse Pierre, who trained in China, and then there was myself. So, and then intermittent people coming through. But what we decided to do was we trained a general practitioner who had an interest in disability advocacy, musculoskeletal medicine, rehabilitation, and she became my accompanateur. We created an inpatient unit that had 10 spinal cord injury beds, and then 10 general rehab, TBI, stroke, amputees, general rehab. We also had a PEDS unit that was in the pediatric area. They did, we did outpatient visits with the physical therapist three days per week, the physician two days per week. We also did some group sessions. And also we're in charge of wellness for the employees at Mirabalay Hospital. It's actually the largest hospital in the Caribbean. So I'll move from there. My experience of hosting several volunteers who would come down and provide some education, we made sure we had very clear and specific goals for what we wanted them to support us with. One of the things that I think is so important before you decide to pursue international work is to really get clear on what your intentions are. So it's not a cure for burnout. Although the work can feel so fulfilling, if you are in a state of burnout and you are coming to a resource-limited setting, it's likely to exacerbate that. It can be very mentally taxing and challenging and realizing you're working in a very different culture. You know, Americans, because, you know, our health system flows and works at a certain pace, but you have to understand in an area where there's limitations, you may not be able to see your 15 to 20 patients per day. You may be seeing eight or nine just because of translation, because of equipment, because of supply chain, and you're willing to do whatever it takes and be flexible. So partnership is so important with shared and open communication. And in realizing, you know, a lot of people go down on these trips with the intention of, I'm gonna teach them, I'm gonna show them, they're gonna learn from me. But what ultimately ends up happening is because we have so much technology, especially in the United States, your clinical skills are probably a lot weaker than your counterparts that you're working with, because they're required to make diagnoses just based on, you know, an exam and some limited diagnostics. And so you often end up learning and taking away more from the experience than you actually give. So getting clear on your intentions is important. Number two, prepare, prepare, prepare. So expand to general skills. Doesn't mean you're gonna be, you know, trying to do, I met many people who were like, oh my gosh, I'm in this country and there's this need, so let me just try to do these procedures that I would never do at home. That is not an appropriate use of your skillset. It destabilizes the system, and you have to ask yourself, if I move forward and do this and a complication occurs, what resources do I have that can help support me with that complication? Doesn't mean you can't expand beyond your range of expertise, but a lot of people come down to developing countries and think that they can just like, oh, let me experiment with this. And that's not really an appropriate use of your time, nor is it supportive to the people who are there. In a way, when you decide to become international and participate in these experiences, you become not only the clinician, but also a medical anthropologist, because understanding the context from which you practice is essential. So being open, being flexible, being willing to change course, being willing to look at the supply chain and consider like what is really essential, what could have a high output or value in what I do that could sustain, and then what is available locally, like what resources? Do your research. It's really in realizing like, oh my gosh, this other organization down the road actually fits people for prostheses or learning about what else is available in country is essential because otherwise, again, you're creating a parallel system that can't be sustained. Lesson three, culturally relevant care. So according to the National Institutes of Health, the combination of a body of knowledge, a body of belief, and a body of behavior is how culture is defined. It includes the personal identification, language, thoughts, customs, all of these different things. And so health, what I had to realize is rural health is very different than urban health in Haiti. And people's perceptions of health, people's perceptions of healthcare providers differ even depending on, you may be in the same country, but if you're in the countryside versus in the city, perceptions of health or in healthcare providers differ. And so the more understanding that you can gain to prepare yourself, the better. Seek first to understand. There's a lot of lessons in humility and we have to have some respect for the lay of the land. A lot of times people will come, especially in Haiti, there's what's called the explanatory model for what occurred. So because there's limitation in resources in rural areas, a lot of people will come up with stories about, you know, oh, so-and-so put a curse on such-and-such and then he woke up one day and then he fell and then half of his body didn't work anymore. And this is the explanatory model that they are utilizing to make sense of a situation. And it's not meant for us to judge it, but support them in whatever way we can. I remember I saw a physician, he was visiting and trying to explain to this family, like, no, this was actually a stroke and this is how it occurs in this vessel in the brain and he was getting all complicated. And it's like, okay, let's just simplify and just look at like what this person needs. And if we can try to explain it to that vantage point, it might be better. And really also looking at what is their intention in coming to see you? What is the intention behind the intention? Sometimes you have to dig a little bit deeper and there's a lot of somatization that goes on, especially in cultures where mental health has been stigmatized. I've seen plenty of functional neurologic disorders, not only here in the United States, but also in Haiti as a result of major traumas that occur. So any training that you have along those lines will only support you. This is a quote from my mentor. In this increasingly interconnected world, we must understand that what happens to poor people is never divorced from the actions of the powerful. And that's Paul Farmer, my mentor, my boss. He passed away this last year, but had basically started in Haiti, the largest nonprofit healthcare delivery organization for the poor operating in several countries around the world. So task shifting, and this was spoken about a little bit. This is in Tigua, this is the Southern part of Haiti, beautiful beaches. So really looking at who can I teach? What kind of legacy can I leave behind? And it may not be another physician, depending on where you're going. It might be a patriarch or matriarch of the community you're serving. It might be a leader in that community, but really looking at what is in place already that I can support, enhance, or grow. And task shifting is really about the delegation whereby the tasks are moved, where appropriate to less specialized healthcare workers. So some of my tasks as a physiatrist were shifted to the GP. Some of the PT's tasks were shifted to the community health workers. Sometimes I found myself when we were short, helping and supporting home exercise. You do whatever it takes. It doesn't mean that it's taking away from your degree. It doesn't mean it's taking away from what you're doing as long as it's serving the greater good. And by modeling this behavior, it opens up the way for others to do that as well. And lesson number five, the follow-through and the handoff. So the fortune really is in the follow-up. So what resources are available after I leave? Is there opportunity for any telemedicine? Ongoing communication? Who's coming after me? What do I wish they knew? What did I wish somebody told me before I came here? And so really it's looking at your clinical skills, your knowledge, your compassion, your understanding, and follow-up that you can offer and give as a way of service. So for, he says, another quote for me, an area of moral clarity is, you're in front of someone who's suffering. You have the tools at your disposal to alleviate that suffering or even eradicate it, and you act. So with rare exceptions, all of your most important achievements on this planet will come from working with others or in a word, partnership. So in closing, building a sustainable program in least resource-limited settings, I have a lot of experience with this. I've also consulted other groups in China, in Ukraine, in Russia, in the Dominican Republic, in, there's one other country I'm forgetting. Anyway, there are some drawbacks to traditional missions. And so if you're really interested in sustainability, it's important to think outside of the box. And maybe you go on a traditional mission and you create some sustainability within that mission. Really getting clear on your intentions is important. Why do I wanna do this? If you're looking for the antidote to burnout, this may not be it for you, especially if you're going into an emergent or disaster situation. Prepare, prepare, prepare, prepare, prepare, understanding that you're only gonna get a tiny sliver in comparison to the preparation of repeated experience. Culturally relevant care is essential and looking at it from the vantage point of that culture's healthcare delivery and the individuals you are serving will really serve you in providing value on the ground. Task shifting, it's something that we all have to consider and do. And then the follow-through, the fortune is in the follow-up. Lessons learned, maybe it's an annual trip. What would you want someone else to know? Maybe it's a phone call. Maybe it's keeping in touch. So thank you so much for your time. Thank you for the opportunity. Thank you for your patience. And I guess now it's time for the Q and A. Yes, thank you so much, Dr. Leroy. That was wonderful, very deep and appropriate messages for us, and especially for the trainees. I'm loving seeing the emojis. Yes, can I see more emojis? Clapping for all of our speakers tonight. If everybody can turn on their cameras, we would really love to see all of you. Michael, that might include you too, AAP MNR over there. And we can start the Q&A session. We had some questions. I mean, I know I posted some questions. Jenna, I think you had some questions, but let's open it up to the floors if anybody has any questions for our speakers. Now, Dr. Rand had to run. She had a slight child emergency, so she is wishing everybody her best regards. And if you have any specific questions for her, I can certainly forward them to her. And I have one comment to add. I thought about after I finished, and then it kind of goes along with what she says. We're not going there to tell them, like, we do it right. This is how it's done. So since I do a lot of lecturing, when I go there, I make sure, one, know my audience, who I'm talking to. And two, I lead. Like, when I give my spina bifida talk, it's, yeah, in the U.S., we want them to have surgery to have their spine closed in the first 48 hours. That does not happen in a lot of other countries. And I let them know. I say, hey, everything I'm about to present, this is a perfect world. If I could have every patient with, you know, unlimited resources, they have great insurance, I can order whatever I want. If this was, like, the textbook, this is what they'd look like. I go, but I live in the real world. My patients don't all have insurance. They don't have resources. And I feel like I win over the audience a little better that way if you don't walk in just saying, like, this is how it's done. And you're doing it wrong, you know, so you have to really, one, build their trust, because they're like, who are you? And do you think you know better than I do? You know, so I tell stories. I go, I have families who make equipment out of PCP piping, walkers, you know, and I'll even use pictures. But yeah, you want to try to relate to them and not come in and act like you're just doing it for them. Great point. Yes, Dr. Patel. You're muted. Yep. Well, first of all, great presentations. Really good to see everybody. I have a real quick question. Maybe any one of you who have traveled can answer this. What about issues regarding malpractice as well as health care insurance or travel insurance? Have you, and especially if you're sending residents, do you have questions about that? To get that through the institution? Or how do you do that? That's a great question. I can speak to that a little bit. I know for Harvard's medical malpractice, it actually covers you all over the world. And so it offers coverage to our residents as well. However, a lot of organizations have additional plans for additional layers of support. But as somebody else mentioned, you know, you want to make sure you do research on, especially if you're going to be the only physician on this team, that you've done your research on what are the legalities and what are the guidelines for practicing in that particular country? Because they vary. And usually in disaster situations, it actually opens up where the licensing is liberated. But it's definitely varies from country to country. So doing your research is important. Thank you. I believe there was a question from Dr. Brandenburg. Would you like to just ask your question live? Sure, happy to. Thank you so much for your presentations. And I'm just wondering, I don't know if I came on just a smidge late, but if someone's interested in traveling with an organization or with a group, how do you find one? And how do you know what's a good one or it's reputable? Well, I can say, I was going to just say one of the things that we're trying to do with this community is to pull together, you know, the various organizations that people have worked with. So I know there's been posts on the women's physiatry group. I'm so sorry for the gentleman in the group. But, you know, they have, we've had quite a few fantastic colleagues who've gone on missions. So we're trying to pull that into like an actual directory. So my goal is just to be a resource for all of you. So then that way we know it's been vetted because they've gone to it. And then obviously tonight, there's been such a wealth of information. So we're going to have to go through all of the slides to make sure that that's also on our directory. But to speak to, you know, what makes it a reputable organization. I've found, I have not gone on a mission. But I think what I look for is if they've gone to the places multiple times, like a lot of the themes that we heard tonight were about sustainability. So I think that I equate sustainability with a reputable program. If they come, they go every year, if they have, you know, dedicated. Another theme that I heard was commitment. This is not medical tourism, if this is what you're going to pursue, you have to commit as an individual, as a physician, you have to learn what's, you know, there, what's not there, and to really modify your practices. So if I see a physician who goes like every year with an organization, then yes, I would find that reputable. So anybody else can answer as well. Hey, Jolene. So for me, like, I think my experience was, I think it was kind of some commonality, right? I think for mine, how I got into mine was basically, it's a faith based organization. And also basically a lot of meetings with the, the, the, the, the head of the committee or the head of the mission, just a lot of prep work. Just even to find out like, what, what can I bring, especially if they don't even know that, you know, there's such a thing as rehabilitation doctors before, as I said, he's an orthopedic surgeon in the US already. But he, this was the first time he's been working, he would be working with a pediatric rehab. So he wasn't sure really what he couldn't tell me exactly. So I had to go somehow, you know, first time to kind of just, just survey the scene and see, okay, what can I bring? Or how can we work together? So it is a slow process. But yeah, I agree. From first of all, safety, and also perhaps how they cover all these with regards to, you know, like your travel insurance, all the other stuff, they should also take care of your licensing. So as everybody has said to like, you know, how is a local practices? What's required? So, you know, so yeah, I guess it's a track record as well, if they have been going somewhere, then those are those are one, something website, you could tour it, you could see how extensive they are. The one thing is also shared values, I believe, I think that's one thing, because what are they really for? You know, a lot of times, there might be some political flavor to it, like what is what is the priority? So those things, it might not always come up at the surface first few meetings, but, you know, so, but as it is something that probably it may take some time to really feel comfortable and safe. But as I said, there might be some other ways to kind of, you know, ask around and see other people and their track record. So go ahead. Yeah, just very briefly, it's okay to work with small charitable organizations, if someone is very familiar with the area and has good resources and contacts, even if you haven't heard of them. And the key is, are they part, you know, if you're going in that scenario, are they partnered with the Ministry of Health or otherwise the local government? Do you have an invitation to actually come? Is there work for you to do? And I personally, because I live in Miami, and everyone around me is from all sorts of different countries, I get invited to go all the time on things that people call medical missions. And what I've learned, and it always sounds great. And I always, you know, sit them down and say, now tell me what I'm doing. And who are our partners on the ground? And 99 times out of 100, they can't tell me and then I know, like, I'll just say, well, I think it's fantastic that you want to do something. Let's talk again in a few years when when there's something there, some sort of structure, and they want us there. I think that's extraordinarily helpful. But don't be scared away from working with small organizations. So long as that invitation and those partnerships are there. Great advice. Jin, I know you had some questions you want to ask. I think we just have maybe time for one or two. Oh, you're muted. Now I have the pressure of choosing only one or two. Here's, here's one that I really love to hear possibly multiple people's opinion on is, what are some of the best ways that we can prepare ourselves to be culturally competent prior to doing a medical missions trip? Go ahead, Dr. Hay. Yeah, there, we've got a bunch of different pathways on this. And the really basic thing is to get to the CIA factbook on a place just to understand the very basics, and get on Wikipedia, okay? Almost any place you go, you're going to find people from the diaspora from that country in your community. So for instance, when we started with Ghana, I kind of said Ghana, Ghana, where's that place? And by the time I was done, we had 20 Ghanaians meeting once a month with me for pizza, talking about their country and their culture for a year before we dropped into Ghana, which was a blast. I mean, right? It wasn't onerous. Like, this is so cool. So if there's a country, you're going to know somebody who came from there and take a look at that and talk to them and have a few meetings. And just have like, over a cup of coffee, occasionally get to social enough that they begin to start spinning stories about how it works and what's going on over there. Once you're in country, of course, your hosts often aren't so great at introducing you to the important things. You know, if you're going as an American rehab doc in another country, and this is where communicating with the disabled people's organizations and others can be really helpful to really get the lay of the land in terms of disability in the country. That's great. Yeah, go ahead. Yeah, just to add, I would also say, if you can meet somebody who's worked in that context before, if you can meet, you know, former healthcare worker who worked in and you want to ask them simple questions, like, even like, what do people wear at the hospital? So like in the DR, it's socially acceptable to wear jeans and your white coat. I met many expats who would come to Haiti and thought that they were like, you know, auditioning for, you know, mash, I'm dating myself, but they would come in cargo pants and fatigues and tank tops. And that's like, it's like, totally culturally inappropriate to be showing your arms in a hospital setting. So you just want to make sure that it's the simple things that go a long way. In addition to like, not only like, what is healthcare delivery like, but how should I dress? How do I conduct myself? You know, little simple things like, oh, chewing gum in this culture is just not appropriate, but in this one it is, because you just, the last thing you want to do is offend people. And those kinds of bridges go a long way. So I would agree with everything Dr. Haid said as well. Can I comment on that? Yeah. I think living in several different countries, I would just say, of course, know as much as you can before you go somewhere, but when you go get anywhere or you're dealing with people from different cultures, always just be observant. See what other people are doing and always think twice before you do something. I mean, some cultures, it's okay to hug people. Some cultures, you can't even touch the opposite sex. You've got to be, even when you're taking photos, make sure, you know, see what other people are doing. Keep your hands in your pocket or to your side. Don't, don't put them around because in America, we're so used to touching. You got to be careful about those things. And, and if, and like Dr. Haid said, if you're coming from America, they're going to let you get away with a lot of those things, but you might be offending people. So just be very observant and find a couple of people that you can trust and ask questions before you do something like that. Simple things, even eating habits, how they eat, what they use, do they eat with their hands? Do they eat with their right hand, left hand? Do they burp? Do they not burp? All kinds of things. That's great. Well, are there any other questions? Jenna, did you have one more? I think we can ask one more. Yeah, unless anybody else from the crowd has a pressing, pressing question, obviously we're here for you too. So, okay. A few times there tonight, you know, funding was a big topic and many people had multiple different sources of funding, but a lot of what I heard too, not only from like the time, like a lot of this time giving back to different communities is their vacation time, but a lot of this was like self-funded and also like private funded. And I think a lot of people here are really interested in joining medical missions, but I think funding could be a barrier. Could anyone speak to like maybe how they've been able to find funding through like a private or a non-profit organization? Funding through like a private group or maybe through funding through their own organization? I paid for my own way because it's not that expensive for me to go because they make it fairly cheap for us, but we did work out if the fellows, my pediatric rehab fellows want to go with us, that they can use their education funds and it's been approved by, you know, the program chair. So that's been kind of a nice resource. If I wanted to, I probably could go the route of getting assistance. I just haven't, but it's fairly, at least my trip, it's fairly inexpensive because they kind of wrap it up all nice for us. But I think the biggest, if you're at an institution, another thing that's nice is I have a very supportive boss. So it doesn't count as vacation time when I'm off because I go teach, you know, I'm going there and teaching. And so it counts like I'm going to a conference. So I get that time away and then same with if the fellows were to go with me, it's not, it's part of their rotation. It's not vacation. Dr. Haig? Yeah. If you're inside of a university, there are all kinds of hidden funny grants and funny ways of doing things. One of my most productive trip was where I had to take a group of 16 undergraduates to Ghana for four weeks. Oh my God. And actually it was great because they got a lot of things done except for the one that got drunk and passed out. But anyhow, maybe three or four different projects where we just looked around the university and found, oh, here's a cultural exchange program. Oh, what do you call it? The Fulbright scholarships are not outside of your realm either. If you kind of get involved in something like Fulbright. The international rehab forum, we formed as a not-for-profit to be a tool for people. So for instance, there were some nursing students at Madison who wanted to go someplace and the university wasn't going to support them. So they raised funds through us as a not-for-profit organization. So we're very much a tool for that. I didn't say it's a tool. I said, a tool, my friend. We're very much a tool for you to use if you want to raise, you have to get our approval. If you like want to do the bake sales and raise funds and have the movie night or something like that, that we become a not-for-profit thing, people can donate to them. We just turn it back off to you. So we've developed some of those platforms for you to use if you need to use them. I know that Dr. Sin is an amazing baker. So, you know, we might just do our own little fundraiser here. Dr. Patel, go ahead. Yeah, I was just going to comment. Yeah, if you beg enough, I'll help out. But I'm in private practice and what I've done is I pay for my way to go, but also somebody in one of the presentations, man, you know, it's a calling. If you're going to do it, you just have to donate your time and money. You just have to do it that way. And most of you who have done it and most of you who have done this, you know, you get more back than you put in. So it's very rewarding. The one thing I have done is and you may want to consider this. So if you're going to a particular area of the world, look for the sister city in America and the sister city fund. So I've used the sister city fund and community here in Kansas City to help me fund residents from Guadalajara to come and spend time with me. The other thing is, if you do end up talking to people, if you're going to go to Tanzania or something like that, find the local people, find the local business people and say, look, I'm doing this for your country and your people, help me. And they will, a lot of them will put up money and you'll get money that way. That's another way to do it. That's how I've done it, being outside of an institution. Yes, I'd have to agree with that. As I said, you know, Russel and I are part of PAPA. So Melissa, I'm looking at you. We're going to see you at AAPNR. I'm going to try to recruit you. We're actually going through kind of a change right now and sort of revamping how we run our organization. And I think one of the things that we thought about in terms of fundraising is going to like little Filipino town, like in L.A., we have our treasurer is actually from L.A. So and really going to, you know, our local Filipino stores and telling them, hey, we're doing this. So that's kind of I agree. I think that's a really great way of fundraising. Like for PAPA, we really just fundraise. We fundraise within our organization. So, you know, and I think that's part of the reason we became a nonprofit, because a lot of the funding came from internal, you know, people. So but I think, you know, money is tight and it's always tight. So it's we have to find ways to be really creative, you know, to fund these trips. So I think, yeah, going to your local communities is a really great option. Yeah. Do we have any other questions? Otherwise, we're going to wrap it up tonight. I just want to remind everybody, Dr. D is actually going to speak again, for those of you who didn't catch my little introduction earlier. She has a talk on Friday, October 21st. We did not have like our own, you know, networking session for that Thursday. So we're kind of using this session as our networking time. So she is going to be part of a panel. I already forgot the title. Sorry, it's a little late, but it's global opportunities as well. I think there's something about disparities and opportunities, and sort of the future directions for it. And it is from 2.15 to 3.30pm on Friday, October 21st. We will have everybody who's going to APM and we're going to try to be there support Dr. D. And then afterwards, if there's anybody who wants to just talk to us and talk about what we talked about tonight, sign up and, you know, continue the conversations about this. We will all be there to support you. So thank you so much for everybody who came. This is great. We really enjoyed everything. So thank you to the speakers. I've really appreciated all of your hard work and just, you know, being very patient with me and all my emails. So let me see all those emojis again. Yay. Thanks, guys. We'll see you at AAPMNR. Thank you.

Dr. Andy Haig

International Rehabilitation Forum

global rehab

partnering with established teams

investing in local careers

conducting research

rural areas

Latin America

Caribbean

Sub-Saharan Africa

Asia

Middle East and North Africa

collaboration

wheelchair project

China