Welcome everyone to our Member May session tonight. A few housekeeping notes before we get started. The views expressed during this session are those of individual presenters and participants and do not necessarily reflect the positions of AAPMNR. AAPMNR is committed to maintaining a respectful, inclusive and safe environment in accordance with our code of conduct and anti-harassment policy available at aapmnr.org. And all participants are expected to engage professionally and constructively. This activity is being recorded and will be made available on the Academy's online learning portal. And an email will be sent after this activity with a link to bring you to the recording and evaluation. For the best attendee experience during this activity, please mute your microphone when you're not speaking. And to ask a question, we specifically are requesting you to raise your hand to be called on and then unmute yourself when you're called on to get your question asked and answered. And time permitting, we may not be able to field every question. So it is my pleasure to now introduce our speaker tonight, Dr. Tamayo. I will be sharing her slides. And I hope that you enjoy her presentation. Let me get her deck up. Give me one second. Jordan, I'm actually just gonna talk about the housekeeping items first, and then I'm gonna let Dr. Eisen go, and then afterwards I'll go. So we have two separate topics tonight. Okay, so do you just want me to share this screen? Yeah, just this screen first so that I can introduce everybody to some of our projects. So I guess I'll introduce myself again. Hi, everybody. I'm Dr. Tamayo. I'm the current chair for the International Rehab and Global Health Community for AAPMNR. It's actually my last year and my last time hosting member May as your chair. We will have a new leadership coming up and we're looking forward to a new chapter of the IRGH community. So anyway, I just wanted to let everybody know, these are actually all links. And Gina, if you can actually, if you are able to share those links that we have, it was in our last newsletter. Yeah, she'll put that all on the chat, but we'll also be sharing these slides in the forum. So we will first talk about the Listserv contact info form. And I know we have this forum, but we actually had a few requests for a separate Listserv. And so we created a Google form. And what's nice about that too, is that since we've been trying to collaborate with other organizations who have an international arm or committee, it's been nice to kind of see everybody, sort of outside also Fizz Forum, but it's there if you would prefer to use that as a contact. So if you could fill out the Google form, if you'd like to use that instead, or if you're not necessarily, although everybody here is part of AAP MNR, but we also use the Listserv for those who are not part of AAP MNR to let them know about our projects. The second thing I wanted to bring up was the State of PMNR series. And this actually was born out of this community, but it's kind of expanded and grown. I'm actually gonna be the one sharing that slide or that link. Give me one second. So the idea here is to expand on Dr. Walter Frontera's work in 2019 as part of ISPRM. He actually wrote a scope book discussing sort of how PMNR is being practiced in different regions of the world. We're taking that one step further and hopefully describing the scope of PMNR as it is right now in different countries. So we have, I think about one, two, three, four, five, six, seven, eight, nine, 10, 11, 12, 13 countries on the list. And the goal here is to match students or residents or even attendings who would like to publish about the scope of PMNR in a country of interest with physiatrists who practice in that country. And so we have a little bit of a task force working on this because it just became too big for me to do it myself with my small executive committee. So we're inviting everybody who's interested in being part of this to just email us and let us know. So I'm gonna put the description of the State of PMNR series there, and then you can all feel free to email me if you would like to be part of it. This is actually a joint collaboration with AAP GAPS, the Global Academic Physiatrists and also ISPRM. So it's truly breaking down the silos, which we're really, really excited about. So it's a really big production, but we're really hopeful that it can turn into something great. The last couple of things are just, things that this community decided to take on in terms of a medical mission directory. We introduced this last year. We don't have that many people sign up yet, but basically we wanted to have a directory for students and residents and attendings who are interested in doing medical missions abroad. And so the link is already in the chat, thanks to Dr. Libby. But if you are part of a medical mission or if you've been to a medical mission that consistently goes to a particular place around the world, please let us know. And if you could fill out the information for students and residents to contact that organization or whoever the contact person is, it'll be very helpful for those who are interested in doing some kind of international rehab. The last thing I'm gonna mention is we've also had a lot of international and foreign medical grads join our community. And one of the questions that we got asked was if there was an observership directory. And I don't think it really exists, formally at least. It exists sort of personally for a lot of students, they've kind of done their own research, but we wanted to sort of get a little bit more information for these students who are interested in rotating here in the U.S. There is a directory that's available through ISPRM if you wanted to go abroad, but these specific links are for U.S. based institutions or for private practice docs. So if you are an institution that takes on observers, please fill out the institution form. And then if you are a private practice doc, please fill out the second link. So that is all that I have. So I'm gonna hand it over to the illustrious Dr. Eisen, who's gonna be talking about a very, very interesting topic tonight. I would not be surprised if we take most of the time to discuss her topic. My topic's not as important or as interesting, but if we do have time, we'll talk about AI and sort of the role of AI in education after Dr. Eisen's talk. All right. Thank you. Thank you, Nina. I would not say that yours is less important at all. I mean, they were both really important. So I appreciate the credit, but I don't really want to take it all. So I'm gonna go ahead and share my slides here. Are you able to see that? We see it, but it's loading. Interesting. We saw a slide and then it says now it's just black and loading. Weird. Hold on, let me stop sharing and see if I can start it again. able to see that? Yes. Okay, now let's see if I put it into presenter mode, if it will do the same. Otherwise, you're just gonna have to bear with me in in non presenter mode. It says pause, doesn't it? Weird. I don't know what's going on with that. Okay, so we're gonna do it. Exit full screen. I wonder if we can do it like just as a PDF. Okay, can you guys see that? I don't think you're sharing. Take two, take four. There we go. We're going to do it this way. Everyone okay with that? Great. Okay. All right. So, just to give you a little bit by way of background, my name is Kaylee Eisen, and for the purposes of accessibility, I'm a cis white woman with a green and white shirt sitting on a green couch in an apartment in New York City. As some of you may know, I'm an attending physician at New York Presbyterian at Columbia, which is in the Washington Heights neighborhood of Manhattan, which is in sort of the most northern point of the city. In our department, I wear a number of different hats. I primarily work clinically on the inpatient rehab unit, which is culturally diverse with a Latinx predominance, and it's a combination of neuro rehab, medically complex rehab. I also work on the consult service, and in the outpatient setting, I staff the resident amputee and spinal cord clinics, and then my own clinic is embedded into the HIV clinic at Columbia, where I see patients with neurologic and musculoskeletal sequelae of living with HIV. So, a lot of different hats, but one of the hats that I am most passionate about is the director of global health for our department, and in that capacity, I run the global health track for our residency program, which I will talk a little bit more about in a second. My journey with global health began long before I was a physician. Growing up, I was fortunate as a child to have parents, both physicians, who decided that they were going to homeschool their kids, and so that the world could be our classroom, and we traveled all over the world learning the history and the culture and the language, the folklore of the places that we went, and as we got older, they started to combine our travel with their global health work, and they still work extensively in the global health realm, but I didn't pursue global health in sort of a professional capacity until I was in residency, really, and at that point, it was after my first year of residency, I went to rural Uganda with my mom, who is a palliative care physician, and our first trip there started out as all things that I now say you shouldn't do. It was a medical mission of sorts, and it was filled with well-intentioned medical tourism, and I'm going to talk about a little bit why that's not really okay to do, but as with many people's global health beginnings, that is where my global health journey began, and I knew when I applied for residency that I really wanted global health to be a part of my career, and so that was why I chose to go to New York Presbyterian for residency, because they had a global health experience of sorts already in their residency program. These pictures here are two. These are in Uganda, and then this one by the water there is in Madagascar, so the experience that New York Presbyterian had at that point, as it existed then, was a six-week trip to Mwanza, Tanzania. That experience has been going on for the past 10 years or so, and at that point in time, the trainees who participated in it universally loved it, but it was a very isolated experience in that there was little to no education or preparation going into the six weeks. They did a thing, and then there was really no follow-up afterwards, and so when I was hired to stay on at Columbia, it was with the caveat that I would be able to take over that global health experience. I apologize for dogs popping in and out of the screen if you see them. They're very passionate about global health as well. So at that point in time, I created this global health curriculum that I now run, and I'm not going to get into the details of it here. It's sort of its own conversation, but essentially, it emphasizes the critical importance of global health, and it's the creation of bilateral sustainable projects and exchange of information and education, because I truly believe that education is our greatest renewable resource. Hold on. Sorry. Excuse me. Can you come out? I just want to make sure that I'm seeing everything. Great. Thank you. Okay. So the first year of the curriculum is all didactic space. It's all virtual didactics. The second year of the curriculum, should they choose to travel, again, culminates in six weeks of travel to Tanzania, but this time based solely on educational topics. The other curriculum that I run, that I developed and run with a group of physiatrists from around the country is called the BRITE curriculum, or Building Rehab Initiatives in Global Health Training, and this is a similarly created curriculum, but it is for any resident in any ACGME physiatry program that doesn't have their own global health curriculum, so we are now heading into our second year of that curriculum. My own personal global health work, I work in two places mostly. One of them is in rural Uganda still, and then the other one where I do most of my work is in Tanzania, in Wanza, Tanzania, which is a large city in, well, moderately sized city in Tanzania. But why do I do it? I don't get paid for it. I don't get protected time for it. Why do I spend so much of my time on global health and global health education? Why do I think that it's an essential and important part of a trainee's education, and why do I think that rehab deserves a place at the table and needs to have a voice in the world of global health? And so to answer this, we're going to go a little bit back in time. So our story actually begins in 19th century Scotland with a man named David Livingstone, whose picture you can see here. And David grew up in a tenement in Blantyre, Scotland, and he worked in a cotton mill for 14 hours a day while still going to school and being heavily involved in his church. And when he was 21, he saw a pamphlet calling for missionaries to China, touting this novel concept of missionaries as doctors. They were going to be trained as physicians and then go to whatever country they were going to go to, and they were going to, you know, proselytize, but also they were going to treat people. And so this motivated him to go to university in Glasgow, and he went on to become a physician and also an ordained minister. And when he originally applied to do missionary work, it was in China, and they said, well, that's full. And then it was later to the West Indies, and they said, no, we don't really have spots there. So instead, he was sent to sub-Saharan Africa with the instructions to preach the gospel to as many natives as possible, and north of South Africa, which is essentially the whole continent. So what he found was that he was actually less interested in trying to convert people and more interested in becoming an explorer. And he spent months and months learning the Tswana language. He made trips to different countries within Africa, and conceptually, he found that his goal as a missionary was less about converting and more about finding ways in which to integrate Christianity into the already existing beliefs of the cultures he encountered. And he wrote extensively on the need to improve commerce in Africa in order to facilitate national and continental independence. He also purportedly performed surgeries and obstetric procedures on villagers throughout the continent, likely without informed consent. So his work there is highly problematic in multiple ways. His exploratory goal was actually to find the head of the Nile River, which today we now know is in Uganda. But at that point in time, no one or at least no white guy had found the head of the Nile, and so that was his goal. So during his travels, Livingston contracted cholera, and he had to rely on Arab slave traders to take him out of the jungle and bring him somewhere where he could get treatment for this cholera. And it was at that point in time that he witnessed the treatment of slaves by the slave traders and became an adamant oppositionist or abolitionist. And so he eventually died in Zambia, at his home in Zambia, of malaria. And he's credited in history as being both a very problematic figure historically, but also as a figure of sort of reverence. And he's considered in some ways to be a father of African nationalism in a sort of strange way. But his story is also at the roots of what we now consider to be global health, and we'll talk about that. So it wasn't that long after that, that the International Committee for the Red Cross and Red Crescent was established, and that was the first large-scale, non-faith-based approach to population health in a global setting. And it's the model that Médecins Sans Frontières, or Doctors Without Borders, still uses today. Global health was transformed in the mid-20th century by the founding of the WHO, which obviously continues today to have a large focus on large-scale population-based health and development of programs. With increasing ease of travel and accessibility with air travel, the invention of air travel, medical missions became increasingly popular and also increasingly unregulated in the 1970s and 80s. And then, of course, with the advent of the internet and sort of the accessibility of the internet, global health work became sort of ubiquitous. And medical tourism, as this is often referred to, is problematic on several fronts. You know, imagine for a moment that you're a doctor in the U.S. and that a doctor from Nicaragua or Nepal comes to your floor on the hospital and just randomly starts treating people or starts doing procedures on someone without being accredited at the hospital. They'd get arrested and probably deported at this point. So, you know, entirely regardless of their skill set. Unfortunately, many low and middle-income countries don't have the same regulatory processes that we have in higher-income countries, although that is changing. But, you know, it becomes problematic when you have these patients who undergo these interventions who, you know, may not have a doctor that knows how to follow up on their procedural complications or doesn't want a doctor in their community to follow up on their complications, or will wait for years for that person to come back after having done it, or other people in the community may wait for years for someone to come back, rather than pursuing treatments that are available for them. So it's near, if not impossible, to fully comprehend the culture in the course of a short-term medical mission, and that cultural understanding becomes essential when you're doing work of any kind, not even just interventional work in another country. So this is exemplified when we talk about the concept of decolonization of global health. What does that mean? So it's a controversial topic and term, and it's one that not everyone believes exists. But in very brief, it means acknowledging that the roots of what we typically think of or historically think of as global health are based historically and largely in colonialism, in the concept of the Western world going on a mission to help or save the poor underprivileged people of a country by showing them the right way to do things. It's this dangerously toxic and largely outdated paternalistic way of looking at things, but one that still occurs with alarming frequency, and one for which there is an impetus to change. And one of the things that we talk about in both of my global health curricula is that the words that we use when we talk about the world matter. And so when we say things like first world versus third world, we're implying that a third world is somehow less than or inferior to a first world country. If we talk about a developing world that we're talking about somewhere that is underdeveloped, it's something that's childlike or doesn't have the same capabilities as something that is fully developed. And so we can think about things like high resource versus low resource country, which is great until you start to think about what those resources actually are. There's this concept and this idea that was developed by Mitra and Majid Sadegh at the University of Vermont, that countries are not inherently poor. There are inequitable policies, power disparities, or activities that are sustained by wealthy elites, systemic issues that keep people in poverty. There are countries in which the power to choose the fate of their resources has been taken away, whether that's by environmental causes or by war or by economic privilege. But if you're thinking about resources like intelligent, creative, hardworking people, then no country is truly poor in those things. So for the time being, we've settled on high income versus low to middle income countries, which is a really important concept because for the first time, we're using language that takes the onus off of the people, off of the country itself, and placing the burden on the system, on the government. And that is really important. I'm not going to talk too much about this. You guys all know about Rehab 2030, and I'm actually not going to spend a lot of time on this, but just know that the need for rehab is being acknowledged at a global level at this point. These are some pictures from where I work in both Uganda and Tanzania. And the reason I have these here is to really talk about Rehab 2030 as this call to action. And it highlights this need for more robust rehab services worldwide. And it's really the first time that rehab has been recognized in this way internationally. But when we start to think about... And for example, in Africa, where I work, it's estimated that about 2% of individuals who actually need a wheelchair have one. So if we're thinking about resources from that perspective. In Tanzania, where I do most of my work, there are about 2,000 documented wheelchair users in the country to the estimated 30,000 who need wheelchairs, and the roughly 3.3 million individuals with documented disabilities, which is about 8% of their population. And I suspect that that's a gross underestimation. But what if they had wheelchairs? These are pictures, like I said, from Uganda, Tanzania. This picture, this third picture over of this woman jumping over the ditch, this is the road to get to the hospital. So you have to be able to jump over a two-foot-wide ditch in order to get to the hospital. This picture of the building up here is the hospital itself. It's in an area of Mwanza called Bugondo Hill, which is literally on the top of a very steep hill that you have to be able to get up in order to get to the hospital. So when you're talking about availability of rehab resources, where do you begin? And while the perception of disability — excuse me, I don't want a doggie hitting me — while the perception of disability changes from country to country, in a lot of the world, and in particular in sub-Saharan Africa, where I am, where I work, there's still a tremendous amount of stigma attached to it. So where do you start? Do you start with the roads, the equipment, the governmental infrastructure, the people? It's complicated, and it's multifaceted. So where does it leave us? Should we all be jumping on planes? Probably. I mean, I personally feel strongly that the more you see of the world, the better. But there need to be guidelines and regulations when we're thinking about how we're going about these types of things. And not unlike the work of Dr. Livingstone that we talked about, the ethical boundaries of medical mission trips are often virtually non-existent. And so this poses problems on multiple levels. There's medical tourism and the risk that poses on patients, like what I talked about with undergoing or deferring interventions. But there's also larger implications, too. The questions of who has a voice and who has a seat at the table for decision-making, and what those voices are saying and not being asked is really, really important. And this is true at the level of the STAG, the short-term experience in global health, and at the governmental and non-governmental policy level. Even today, more leaders in global health are graduates of Harvard than they are women from low- and middle-income countries. So it becomes really important to identify the grassroots the grassroots causes that are actually important to people on the ground. So thinking about whose voice is at the table is important. For the purposes of time, I'm going to go kind of quickly through this. But one of the reasons that I bring all of this up is that as rehab professionals, our connection and understanding of topics in global health and the topics of partnership in global health go deeper than I think other specialties do in a lot of ways. And one of the ways in which they do that is our understanding of disability and ableism in medicine. The concepts in global health can be applied to the understanding of the model of disability and of ableism. So ableism as a concept intuits that there is something wrong, that disability is somehow a mistake or a failing, rather than an inherent effect of human diversity, much like gender or race. And it implies that people living with disabilities are in some way less than those who are not. But what if we thought about disability like a low- or middle-income country? Not a failing of the people, but rather a failing of the system. That people with disabilities are not inherently disadvantaged, but rather they are subjugated by a government or by a medical system in which they are not advantaged. And much of this when talking about both global health and disability comes down to privilege. And this is from an article by Stephanie Nixon in the BMC Public Health Journal. And I really encourage you to read the article because it's fascinating. But in the article, she talks about the coin model of privilege. On the bottom of the coin, that's literally the coin that you're looking at here, on the bottom of the coin, the coin being a societal structure is a concept that produces or maintains inequality. So like ableism. On the bottom of the coin, it's our people who have disadvantaged because of that. And then on the top of the coin, are individuals who are advantaged for the same reason. So physicians, the majority of whom are in this country, are white men are advantaged by being white men. But there is also, and that's an unearned privilege, but there is also an earned privilege. And I think that the healthcare privilege, having learned those, having spent most of our lives in school and learning, affords us a position of power and of leadership. But it's really important that we use that leadership position thoughtfully. And just in the same way that I said the words that we use when we talk about the world matter, obviously the words we use when we talk about disability matter as well. And this is something that I'm sure you as physiatrists all know, but obviously we wouldn't refer to, Stephen Hawking is that crippled guy, or we wouldn't call Beethoven that deaf guy. But how many times do you still see in a chart things like wheelchair bound or suffers from a disability? And so when you're thinking about using those words, thinking about what terms subjugate people in different positions, because it comes back to those topics in global health. And so this brings me to some things that we can do as professionals to hold a space for sensitivity when we're thinking about this population. And the first thing is to question, and this is right now I'm talking about people with disabilities. The first thing is to question yourself. Am I doing or saying something harmful? And if I am, how do I become less harmful? How do I demonstrate humility with a population that may make me uncomfortable because I lack an understanding of their experience? How am I complicit in the system in which ableism and disadvantage are inherently embedded and in which we are often relegated to a role of helping the oppressed third world? How can I critically explore my role both as a guide through the system and also as an ally? These are all concepts that we as physiatrists think about all the time and grapple with on a daily basis when we're working with patients with disabilities. But I want you to look at what I just said. Am I doing or saying something harmful? If I am, how do I become less harmful? How do I demonstrate humility with a population that may make me uncomfortable because I lack an understanding of their experiences? How am I complicit in a system in which disadvantage is inherently embedded? How can I critically explore my role? All of these things apply to you in global health as well as you as a physiatrist. Systems of oppression cross boundaries and these rules hold true for creating sustainable global health partnerships. So we can begin to create a construct for the evolution of global health. And I wanna go back to Dr. Sadeg that I spoke about earlier and some of his rules for developing sustainable partnerships in global health. His number one is identify the right partners. They need to be equal. The relationship needs to be equal, bi-directional, but also equitable. Minimize transactional costs. When the money runs out, education is forever. Determine governments. Who makes the decisions? Who's in charge? Delve into projects based not in short-term interventional procedural experiences but in equal, bi-directional, sustainable concepts. We can empower host countries and transition away from that savior complex by giving back to one of learning and sharing knowledge and sharing information. And we can partner with grassroots organizations. Who knows what's best for the community because they are the community. And one place to start with this is with a needs assessment. So don't just assume that a community needs something or a hospital needs something or that just because we do things a certain way in the US that that's how they should be doing things in another country. Ask the questions first. So, so much of what a rehab professional is in this country and all over the world is an advocate. So particularly for patients with disabilities but really for all patients. And this becomes magnified when you're working in a place where physiatry doesn't exist which is much of the world but especially in Sub-Saharan Africa where I work or where disability is stigmatized because that is something that exists truly everywhere in the world. So here it is. This is my call to action, my own call to action. My advice to you is this. Take advantage of the skills that you have and you are already developing as physiatrists. In rehab more than in almost any other specialty we have the opportunity to create relationships with our patients over a long period of time. We're so lucky in that. And we're experts in partnerships. Patients with disability often know their disability extremely well, often more so than most other populations. So we may be able to explain the path of physiology of something, but they have the lived experience of it. And in the same way we can talk about that, in the same way that we can talk about relationships with patients that we see on a daily basis we can also talk about that in terms of how we develop partnerships between a high income country or between how we work in a high income country. And for those in low and middle income countries know that they know what's best for their communities and partner with them to share that knowledge. Rehab 2030 is a global initiative. And don't forget that we're part of the globe here in the U.S. So the work begins here, being advocates and leaders here, being an ally here. And while Dr. Livingston never actually found the mouth of the Nile River, his journeys led him to change his ideals and beliefs and brought a different view of the world to him and to his world. So go explore, go educate yourself, go educate other people on why the differences matter and educate yourself on the fact that no matter where you are, people are more the same than they are different. And remember that education is our greatest renewable resource. And that is it. Thank you guys. Any questions? Firstly, does anybody else have chills? Because I have chills after hearing that. So I wanted to just open the forum to everybody who's here. And yeah, please turn on your cameras. Love to see everybody's faces. Always nice to see you all. And I just wanted to open the forum to like discussion about this, because this is some pretty heavy, this is a pretty heavy topic that has multiple subtopics underneath it. And I guess my first question is to everybody, have you guys experienced personal experience doing sort of global health and in this context of sort of decolonizing global health, like what have your experiences been like? And sort of what lessons have you learned? Because for me, after hearing Dr. Eisen speak, it makes me really reflect on the couple of experiences I've already had. And it really starts with self-reflection and kind of checking your own biases at the door. And sometimes that's really hard. It's really hard to do that. And it's also really hard to do when, let's say you haven't even been to that country and you don't know what you're gonna walk into. And I think part of my question to Dr. Eisen after our mini discussion is, how do you even educate yourself about the potential biases you might have going to a country you haven't been to? You know, I think that's really hard. It is really hard. Some of it comes from sort of the prep work. Like before you're gonna go step into another country, learn something about it, learn about their culture, learn about what disability is like there, learn about what physiatry is like there if it exists. So don't go in blind, learn about who their president is or learn about their religion, whatever it happens to be, get a basis of understanding of where you're going to. And then when you get there, it's all gonna go out the window because it's totally different than what you expected. And so there's a lot of on the ground learning. I remember the first time I was in Tanzania, I'd been there for six weeks and one of the physical therapists I was working with said to me, do you know what our president's name is? And I said, no. And I'm just like, it was this moment of like, that's crazy. I've been here for six weeks and I don't know who your president is. And it was sort of just a wake up call to my own ignorance of like how little I knew, even just going into that experience where I thought I was really prepared. And then once you're there, it's a lot about asking questions because you kind of don't know what you don't know. And I think some of your biases, anyone's biases often come from ignorance. They often come from just not knowing. So making sure that you educate yourself on what it is that they have to share with you. I think that's really important. Nina, you're muted. Do we have anybody who'd like to like speak up and talk about their experiences and give us some insight on things that you've gone through? No. Oh, it looks like we have somebody in the chat. Okay. Holly, do you wanna say something? Since nobody wants to speak. I can read it if you don't wanna say it out loud. Yeah. So she says, I worked in global health a decade ago, Tanzania and Kenya prior to switching careers and attending medical school. I was very disillusioned by the lack of sustainability and paternalistic approach our organization and many others used. It's great to hear that there's an increased emphasis on education and empowering people, the communities themselves to lead these initiatives. Yeah. I had a question for you, Dr. Eisen. It kind of like tails off this question here. One of the things I really liked what you said was like how we can obviously do this, but like not be harmful in doing this. One of the things you mentioned was doing needs assessment. I was wondering if you could talk about what you meant by that and maybe like what your version of it is. Yeah, for sure. Is that something that I'm also very passionate about, interested in and definitely try to do before going, but would love to hear more about what you meant by that and like what you do. Totally, yeah. So I think that there's this maybe impetus or expectation maybe that when we think of a problem here, we assume it's a problem there. So we're like, there's no rehab there. Let's make rehab, which is really like a very obtuse way to think about it, but it's kind of how I went into it. And before doing something like that, before doing anything like that, start at the basis, ask the question first, go to the people for whom this is gonna make the difference or this is gonna matter, who are the invested parties and ask them the question. Do a needs assessment say, what are the available rehab resources that you already have? Do you think you need more resources? Do you need rehab in this country? It's easy for us to say, yes, we think you need rehab, but like maybe that's not a priority for them. So I think it's just worth the time. It's a lot of effort. Doing research in another country is hard if you're not on the ground. It takes time. It often takes money. It is a pain to actually do it, but I also think it's the right way to do it is ask the question first. Yeah. Sorry. Oh, no, I was just gonna post a link here from the World Health Organization. The example is not for rehab, but specifically for somebody with like a psych issue, but the five main questions that they ask, I think are still very relevant to rehab. And so, you know, like firstly, like, cause we treat a lot of disorders. So the first question is like, how many people in the region or community need treatment for, you know, a particular disorder? So for us, maybe we want to focus on like stroke or like spinal cord injuries. Any of the 13 diagnoses we usually see in inpatient rehab is usually a very good place to start. And then, you know, sort of asking like, what is the relative need for the treatment services across these different areas or communities? I think these are very like basic questions, but it's gonna give you a lot. And then what types of the services are needed? Like, is it inpatient? Is it outpatient, you know? And do we even have the capacity to do it? Because Dr. Eisen was talking about infrastructure and she was like, I just remember, you know, the picture of the hospital on the hill, like how are we gonna take care of people with disabilities if they have to get up the hill and they have no way to do it, right? And, you know, I'm gonna share the link, you know, but the other thing is, really talking to like the community leaders and because they're the ones who have, they're the boots on the ground, you know, they're the ones who have their ear on the ground, like really knowing what's happening in the community. And I think they're also, it kind of leads to the next question is sort of asking, what are sort of the existing services? You know, like for us, it would be like finding out, are there disability organizations? Like are there like, you know, are there disability organizations? Like, are there people who are kind of working in this space already? And, you know, what sort of needed to improve that overall level of, you know, functioning for their system. So I think these are all really, really important things to kind of consider. And I like the way that this link actually walks through a needs assessment, but those would be, those were actually the questions I asked when I went to Namibia or when we went to Namibia last year. So, you know, my job was to be the one kind of listening to see like, what is rehab like here, right? And so those were the questions I started. It's a really, they're very basic questions, but anybody who's doing a needs assessment would, you know, probably learn a lot more than they bargained for just by asking those questions. And you're like, oh, wait, there's so much more that I don't know, you know? And I think that's the beauty of medicine, right? It's the more you know, the more you realize you don't know. And I think global health kind of, global rehab specifically, because, you know, we don't have a lot of rehab. You know, it's very much focused in areas that are more densely populated. And so like places like Africa, parts of Asia, you know, don't have it. So even here in the US, you know, not all inpatient rehabs are created equally. So, and I've certainly discovered that as a locum stock. So I think it offers me the opportunity to travel and to really understand like the rehab scope and rehab scape of, you know, here in the United States, but it also allows me to understand how rehab is practiced elsewhere. So, but yeah, I thought that might be helpful, you know, for anybody going to a country looking to do a needs assessment. Yeah. Anybody else? There was a question in the chat that says, what are three tricks you've, excuse me, what are three tricks you've found to increase the sustainability of educational programming after you leave the country or exit the project? I think the number one thing is developing relationships. You know, I work at a hospital that I've worked at for the past six or seven years now. And so the people I work with are my friends. They're the people that I've worked with for six or seven years. We've kind of grown up together. And so developing those relationships longitudinally has helped have, it's helped the sustainability of it because they're invested and they know that you're invested. You know, there's a lot of people out there who say, if you're gonna do global health work, you gotta do global health work. Like you gotta be feet on the ground. You gotta move to the country that you're gonna be working in. And I think that's amazing. And I would love to do that. And also I have a physician husband and two kids and two dogs and like the idea of moving to Tanzania is not sustainable. It's not practical. So having that recurrence of going back, of being in, I mean, I text with them every day. So developing those relationships over time. And then the other piece of that is having people who are invested on the ground. So having them care about what it is that we're doing because it matters to them, not because you said you should care about this. It's another way to continue that sustainability because if they don't want it, why do it? But if they do want it, you're the one that's gonna be there to help facilitate it. That was probably two things. I don't know what my third thing is. Yeah, I definitely agree with that. I think for, that's something I've also learned just from my own experiences in both Namibia and the Philippines. I've been very lucky to help run a nonprofit organization called the Philippine American Physiatrist Association. And so I had a history, we had a history as an organization with the Philippine Academy of Rehab Medicine. And so because of that relationship and because we've nurtured that relationship over the years, we were able to go on medical missions with them. We had people on the ground to really understand how rehab is being practiced in different islands. And the Philippines is a massive archipelago. So you can imagine not every place is gonna have rehab. And if they do, it's not gonna look the same in other places, but still having that connection was so important for us because it gave us the chance to mobilize our troops in the appropriate way with their help. I think you said something really important in your talk, Dr. Eisen, about like how you're not like the savior, you're an ally and an enabler. You're the one behind the scenes. You're letting them lead, right? And then right now, I think in some of the work that we're doing in Namibia, we purposely stayed in contact with them after we left because we were only there for like, what? Seven, 10 days, something like that. And we purposely stayed in contact with the physician who is taking Dr. Haig's course, the International Rehab Forum's certification course. And so, you know, we connected her and then we connected another physician to him. So, in the same country, so now they're going to have two rehab doctors there for the first time. So, we stayed in contact with them and we promised, you know, essentially that we would, you know, be their mentors. And, you know, we're still talking now a year, more than a year later, you know, and hoping to potentially go back to help them really build like their inpatient rehab and maybe later outpatient facilities as well. So, yeah, I think definitely connection, like just being purposeful with your connection too. And continuously asking them, like, where are you guys? Like, with respect to your program, like, what do you need? Like, how can we help? But never really like stepping on their toes. You wait for them, you know, to kind of come to you. And not just like forcing your way in there, like, you know. And so, that kind of goes back to the whole like decolonizing idea that it's, as much as we want to help, you know, them, we have to let them, you know, take sort of ownership and empower them to find the help that they need to. So, yeah. And I think also understanding that expectations may be different depending on where you are. When I go to Tanzania, whenever I get upset about something, like a patient not looking the way I want them to look or, you know, like discharging a patient with a spinal cord injury who still has a Foley in and also like doesn't get physical therapy and has no adaptive equipment, and I'm just like, what are you doing? And the therapists always say to me, Dr. Kaley, something is better than nothing and walking is walking. And I have to like stop and say, all right, you're right. Like, my expectations of what something looks like doesn't apply to this situation. So, not necessarily literally and not like that, but even in sort of theoretical concepts, it's important to check yourself. I had another question for you, Dr. Eisen. Like, so, you know, it sounds like, you know, you went in and really tried to work on like your own biases to try to create a project that is sustainable and hopefully as much as possible. Like, right, trying to be unbiased and to make a sustainable change. In what ways do you think that like you've been able to change the program and adjust the program to reach those goals? And second question, was there anything maybe like recently that you didn't realize was a bias that you had to learn like maybe in the last like three years? That's a good question. What changes have I seen? So, my biggest project over there in Tanzania is creating an inpatient rehab unit at this hospital. It is a massive undertaking. It is like what I'm considering a 10 to 15 year project. We're in year three or something. So, we've done a tremendous amount of work on this, but it's all been groundwork. And it's only just now in the last few months that we've like, you know, gotten a donor for things and gotten a space for things and gotten like starting to look at equipment costs, things like that. But this is like years in the making. So, a lot of it is sort of this labor of love. I think my bigger accomplishment in that capacity is emphasizing the importance of rehab, why it even needs to happen. And that's true, you know, when I first got there, you talk to the therapists, the PTs and OTs, and they're like, of course, rehab is important. And then nobody else in the hospital has ever heard of rehab or understands why. And so, a lot of what we've done there has been education around like what is rehab and why is it important and why would it matter to have an inpatient unit there at all? So, that's something that we're like still in process, still working on. And then your second question was about biases, about like, are there still things that I have biases about? Yes, of course. Every single time I'm there, I am surprised by something. Every single time I'm there, I learn something new about the culture or learn something new about myself, you know, that I need to check myself. Like I said, Tanzania is a very religious country. Religion impacts a huge amount of the medical care that happens there. There's a very different sort of separation of church and state in healthcare than it is here. And so, when I'm working, depending on where you are in the U.S., but when I'm working there, I need to sort of step back and say, this is what I think you should do. And also, this is what I know you're not going to do because this goes against your belief system. So, that can be really tricky. And of course, that exists in the U.S. also. And especially, you know, here I am in New York where we have a gazillion people from a gazillion places. But it happens there quite a lot. And then you mentioned that you have buy-in from like the therapist, but you're trying to get buy-in from like maybe more at the admin level. And you said you tried some education. Did you do that with like meetings, a lecture? How did you do that or how are you doing it? Yeah. So, some of it was sort of right place at the right time in the sense that I was starting all of this as Rehab 2030 was coming out and also as the Tanzanian government started an initiative for rehab in Tanzania. And so, there was like a guy that they put in the Ministry of Health that was like the rehab guy. Has it come to any sort of fruition? Not really. But like they're at least sort of like aware that it exists and think it's important. And so, I was coming to the hospital leadership at a time when their government was saying to them, you should do more rehab. And I was saying, here's how you should do more rehab. So, that was a huge sort of, I mean, somewhat a coincidence, but it really was helpful. So, a lot of it is, some of it is being in the right place at the right time. A lot of it is, what's the word? Attrition, I want to say. Like it's being really stubborn and being like, all right, it's 10 a.m. and you told me I was going to meet with the Director General of the hospital at 11. It's 4 p.m. and I still haven't met with the Director General of the hospital. Am I going to meet with him today or should I come back tomorrow? And it's that every single day. And it's sending email after email after email, WhatsApp chat after WhatsApp chat to try and get to the right year. It is challenging, especially when you're not on the ground. Yeah, I think just to kind of jump off that question, because that's one thing I get asked oftentimes, especially early career sendings or residents who are going off to another country where they want to establish something that is sustainable. And sure, they might have the buy-in from their local organizations, but it's really like the Ministry of Health. How do you even get your foot in the door? I think that's what questions, not even just questions, but what do you present to them? And I think that's sort of what Gina is also asking in the sense that like, okay, fine, maybe you're there day in and day out. How long should we expect that process to continue? It's almost like it's an act of persuasion. There's something to that. There's an art to it and there's definitely a science to it. But what has been sort of your strategy to kind of get in there and explain to them this is your point? Yeah. There's also a formality to it. Especially where I work, everything is done very formally. So it's like you have to have an introduction from someone else to talk to this person. The first time that I met with the hospital board in Tanzania, I walked into a conference room and it was 30 men sitting at a table and each person went around and introduced themselves. And it was like the director of the hospital was in a military uniform, though he's not in the military. And it was like very formal. And so you kind of have to play by their rules too. Depending on where you are, it's going to be different. So yeah, a lot of it is sort of like multi-level education and multi-level conversation. There's the conversations that happen on the ground. There's the conversations that are happening to educate the people that need to know about it. And then there's the conversations at the leadership level to actually get things to happen. Right. All right. Any other questions or suggestions? I have two. So first one, I'm Fiona by the way. I'm a med student from LECOM. I just saw this in my email. I'm like, I gotta go. But do you recommend any sort of research journals that kind of has data to either dive into the assessment of each country or just like overall physiatry in global health? And my second question is, I recognize that the program that you're with has an attention focused on global health. Do you have any other residencies that kind of have similar programs? Because I would love to incorporate global health within my residency. I think that's like the best time to potentially travel without having a family. That's like you said. Journals, the Lancet Global Health is probably my favorite global health journal. It's not physiatry specific, but it is a really great global health journal, BMC public health journal as well. The Journal of ISPRM is probably the biggest, I would say, global health physiatry journal. And that I, to their credit, they really get publications from all over the world, which I think is wonderful. I don't know if anyone else has other suggestions on that end. Yeah, those would be my suggestions too. Yeah. In terms of programs in the US, there are a number of, there's a number of residencies that have global health programs that are not necessarily physiatry specific. Like a lot of residents do global health travel while they're in residency through internal medicine or through peds or through emergency medicine, whatever it actually is. To my knowledge, there's not, and I could be wrong about this, that there aren't any other rehab specific global health tracks and trips in other residency programs. Although I know a number of them that are starting. So I know somebody at Mary Free Bed that's starting one. I know someone at Pitt that's starting one. And then also there's the Bright curriculum, which we're working with residents at 12 different residency programs. So I'll keep an eye out for that one. And there's, and Dr. Eisen, correct me if I'm wrong, in terms of the actual educational curriculum, you're right. I don't think there's any other residency that does something this specific like yours does. But I do know like Monty has a very strong presence in Jamaica, University of Miami. Well, Lauren Shapiro left, I think. So she might be, I think she's at Brooks sales, Brooks something, Brooks, Brooks rehab. But I do know that they have, you know, a global health component. Rush also has a very strong global health component. Dr. Saul, who works with Dr. Ravi Kasi, who's the program director. Baylor College of Medicine in Houston. They do have, they have attendings who go to, I like the last I heard they were supposed to go to Ukraine, but because of what's happening over there kind of got stalled. But I do know that they had a resident potentially going. So I may be wrong, but you know, I, at least from the last that I heard from the grapevine, you know, that's still a very strong possibility in the future. What other Colorado, Colorado. That's right. Yeah. Colorado. And then I'm missing one. I'm, I'm missing another program. Again, I'm blanking on the last program I was thinking about, but those are all, I mean, you've got a good, there's a lot to pick from. Yeah, that was a good list. Thank you. Yeah. The other tip I'll give you if you want to, is like, even if like, you know, for some reason, some of these residencies that they mentioned, you know, don't work out for you, or it's not quite a good fit, just like on your interview trail, I would just ask like, Hey, if I wanted to do medical mission, could I, because not all residencies would even let you leave. To go on something like this, or not all of them will even let you leave for more than a week at a time. So just like wherever you interview, I would just ask, like, say you have an interest in it, and just ask if the opportunity would be there for you, whether with that program or something you make on your own, so that either way, whatever residency you end up at, the door is still open for you. That's great advice. Thank you so much. Yeah, I absolutely agree with Jenna on that one. I think her and I may have had similar experiences where, you know, our programs knew we had interest during residency in global health, and although there wasn't a structure for it, they allowed us to unfortunately, use our vacation time. Unfortunately, unfortunately, in terms of, yeah, there's time that you could use towards it. And they were super supportive of it. I mean, we had fundraisers going for, for being able to go and that kind of stuff. And you know, it took time out of vacation, but it was worth it. And there was support of like, being able to change like, you know, our call schedules and that kind of stuff. Personally, so there are some options to do it. But also, it sounds like there's programs that are starting to create those opportunities for you, especially with what Dr. Essin's mentioning. That's awesome. I'm glad that they're able to work with like residents like that. Because, I mean, that's such prime time to get your, you know, feet wet in a sense. Yeah. And that's one of the reasons. Oh, go ahead. Go ahead, Dr. Essin. I just, I think it's going to become more ubiquitous too. Like as more and more people are interested in this and want to do it. So I think people will, even if it doesn't exist in particular programs, people will be more open to the idea of it. And it's one of the reasons why this community got started to begin with was because there was sort of a growing interest amongst like residents, especially, and med students is one of the questions that got asked oftentimes during the interview trail the last, you know, few years. And it's kind of just exploded now, you know, so. And that's one of the reasons why we wanted to create that medical directory, a medical mission directory, you know, to make sure that the programs that are on there are also vetted. So, you know, there are physiatrists who have gone to those, you know, medical missions. It's sustainable. So it's a lot of the things that, you know, we want to make sure are good experiences for you. And so, you know, we're really hoping that, you know, we can grow that directory and have you guys like, you know, go on these missions, hopefully for, you know, multiple years, not just like a one and done thing, because obviously, you know, that's not the sustainable part, right? We don't want it to be a medical tourism kind of thing. I am, I just talked to my attending, I'm on my geriatrics rotation, but we had a patient come in and he said that there was a program he was involved with that, you know, like Habitat for Humanity gets a bad rep, but in his program, they created wheelchair ramps. And I was like, Whoa, that's kind of cool. And so my attending goes annually to his home country in Bangladesh, every December to just do like work there. And he's like, Okay, let me know, because I'm retiring next year, I want to go and do whatever program you're a part of. And just hearing that and like, hearing accessibility being implemented was really unique. I hadn't heard of it from like a random patient before. Yeah, well, if you're ever interested in going to the Philippines for an observership, you know, just contact me, I put my, you know, email up at the beginning of the chat. And I'll put it in here. Anybody else who wants to go to the Philippines, let me know, because they're very happy to have you guys. And and so, you know, we have we still have our connection with them. And they're very, very excited when other people are coming to, you know, you know, Filipinos, we all love visitors. So and especially if you're there to learn about physiatry there, because they're very proud of it. So but yeah, I know, we're probably I knew we were gonna run out of time. And so and I knew that we're gonna have a lot of questions afterwards. So Jordan, what I'd like to do maybe is I'm going to save my lecture for like a another session, because I think it's also a very big topic, but it we're not going to have time tonight to do it. So everybody who's here, you know, we want to thank you. I don't know how much more time we have. But we have three minutes. But yes, we can definitely talk about. Yeah, I had a feeling. So but anyway, my talk was supposed to be on, you know, trends in rehab education. And it kind of goes really well with Dr. Eisen's talk, because as she said, you know, it's education is something that you really can't take away from anybody. So my goal was to kind of look at, you know, where the trends are right now in terms of rehab education, and then kind of focus on the AI component of it, like who's, who's using AI for education, where, and you know, what can we do in terms of like, the context of global rehab? And how we can, how can we utilize AI to create these, you know, opportunities for sustaining sustainability, and also to share knowledge? Because again, you know, if push comes to shove, if that's the one thing that we can do, you know, then I think that's, that's the strongest thing we can do, if there's technology that we can use to help out with that, then, and it's something that's accessible. I think that's another thing that is, is a feather in our cap. Certainly during the pandemic, for example, you know, we, we really focused on a lot of like educational initiatives, because nobody could travel. So a lot of the organizations I was part of, you know, were trying to do more educational lectures across, you know, the internet, essentially. And that's some of the ways that we stay connected with different countries, or even built relationships. You know, certainly now, even, we had our speaker from AAP Manara last year, Dr. Amanda Mayo, she kept her, you know, connections in Ukraine, you know, through like tele-rehab. And, you know, that was, that's one way to kind of, it's not quite AI, but something to think about. But yeah, so that that'll be our next topic, I guess, we'll save it for another, not Member May, but another session, you know, for the summer, potentially. And if you have a particular interest in AI, please come join us. So thank you again, everybody. Thank you, and Nina, thank you for asking me to be here tonight. Yes, you're awesome. We love you, Dr. Eisen. Thanks, everyone. All right. Bye.

global health

rehabilitation

sustainable education

Sub-Saharan Africa

decolonize practices

local expertise

low-resource settings

partnerships

AI in education

project sustainability

international collaboration