This is Mona Artani, AAPMNR staff. Welcome to your Member May session. I'm just gonna go briefly over the housekeeping notes before you guys get started. Just to let everybody know, this activity is being recorded. We will have a link available to this recording after the session has been completed and it will be made available in your member community. We usually ask everyone to please stay muted and if you wanna contribute or say anything or ask a question, just use the raise your hand feature. Also, all the views in this... The view shared in this... Here it is. The view shared in this session don't necessarily reflect those of AAPMNR. We are committed to maintaining a respectful and safe environment according to our code of conduct and the anti-harassment policy, which are both available on the website if you are interested in looking at that. And of course, since you guys are all professionals, we just ask everybody, stay engaged in a professional and constructive way. So without further ado, I will stop sharing and the floor is yours. Hi, my name is Bruce Hsu. I'm a physiatrist at Lancaster Orthopaedic Group in Pennsylvania. I'm current chair of the Alternative Medicine Pain Group. And I just wanted to host this November, May networking event. I know I met some of you, probably not anyone in this current room, but we had a side meeting at the Academy meeting in San Diego last year. And so this is kind of our midway point to see if there's any areas of interest that you might wanna pursue between now and the next Academy meeting, which I believe is in Salt Lake City. I know that a lot of you do go to the meetings and just wanted to see if we could stir the pot a little bit and see what's out there and what are of interest for you in the alternative medicine pain realm. So with that, if anyone has any ideas or any areas that they'd like to expand upon in our little forum, I'm all open to new ideas. I just have a question. Do any members have presentations that they're already scheduled to do with the meeting? And is there some topics that have been accepted for presentations that we should put on our to-do list for the meeting? That's a really good question. I mean, I'd have to look into it to see if there's any specific presentations or sessions that have been submitted and approved. I'd probably have to reach out to the Academy staff for that specific piece of information. I'm not privy to that at the moment. Did you all talk about that when you were, because I, the meeting, where were we? San Diego? Were we in San Diego? Yeah, we had an offsite meeting in one of the conference areas in San Diego. We had a meeting that was collaborative with some of the other similar groups at that point in time. Oh, okay. I didn't make it to that meeting. So that's why I'm sort of wondering. Was there any planning to do anything collaboratively on pain with any of the other groups? Well, in San Diego, we did collaborate with some of the other similar groups, including the Interventional Pain Group. And we had a, not a huge meeting, but maybe about a dozen people at the meeting that we scheduled at the separate area at that meeting. So perhaps we could do something in the next meeting, if any of you are planning to go. I know it's a little bit early and a lot can change between now and then. But if you wanted to do some kind of discussion in person, if you are planning on going to Salt Lake City, I think that would be a good idea. And maybe we could follow up in the forum or if you have any specific ideas, we could chat about it now. Thank you. Well, my name's Deborah Burnell. I work for WellSpan. So I'm here in York, Pennsylvania. And I do, in addition to PM&R Lifestyle Medicine, and I do some shared medical appointments for chronic spine pain. And I use Lifestyle Medicine pillars to help patients modify conditions that perpetuate their chronic pain. So, and I also engage them in other alternative pain medicine things like acupuncture, massage, myofascial relief, and I also do some other things like acupuncture, massage, myofascial release. I do trigger point injections in the classical way of Trevelle and Simon. That's how I was trained. And I do Reiki and color puncture, color puncture, aromatherapy, herbal medicine. I do African herbology. So I'm in a training program for that that I do in Nigeria every year with traditional healers. So those are the things I'm interested in. Just to give a little idea, I was just wondering what everybody else was interested in and maybe that will come up with something to present at maybe the following year's meeting. Wow, that sounds amazing. You seem like you're, you have your hand in so many different areas and maybe I'll refer you some patients and some just practicing the next county over. So maybe I'll send some folks your way. I've been practicing for 38 years. So I had a lot of time to accumulate those different pockets of things to use in my arsenal for my patients. Yes, I agree. It's amazing that you have so many different areas that you are able to explore and develop. And I see that Dr. Patel has mentioned in the chat that the biggest thing is getting people off of opioids. I'm pretty fortunate that I don't currently really prescribe many opioids in my current practice other than a few short term here and there. But I think that some of us do practice in environments where there is a lot of quote unquote opioid use and it's variable from, I think region to region, practice to practice. But I think it's amazing that you have discussed so many different areas that you are exploring and developing. And I'd also like to hear what anyone else has been up to in the terms of the area. I'm sad to hear about people complaining about getting patients off of opioids. When I came to WellSpan 17 years ago, I worked with a group at WellSpan for the system to try to decrease opioid utilization and then have it in the hands of the primary care physicians. So none of the physiatrists in, I'm a site director in physiatry, none of the physiatrists in WellSpan treat with any long-term opioids, very short term or maybe procedures, that's it. Yes, that's a wonderful way of looking at things. I know it's quite difficult and quite dependent. I was wondering if anyone else had any areas that they wanted to explore further or discuss what they're doing in their current practice? I know there's quite a few of you out there. So if anyone wants to chat, don't be shy. All right, I guess there's no one that's willing to chat at the moment. So I'll just talk a little bit of what I've been into in terms of my practice. I mean, most of my practice is currently procedural, but there's quite a few people that are recalcitrant to traditional methods of physical therapy and the occasional injection for your typical radicular pain or whatnot. And then we have more complicated patients that have things like CRPS and the like that are even more recalcitrant to traditional treatments. I did do the Joe Audet's acupuncture class a long time ago, not currently doing acupuncture myself, but I did went to kind of re-explore that in the future potentially. I know Dr. Bernal talked about lifestyle medicine and I'm sure some of you have gone to academy meetings. You've heard some discussion about that from some of our more esteemed colleagues like Dr. Heidi Prather and about her lifestyle medicine that she discussed at her practice at HSS in New York City. So I think that there's a wide variety of different things that you can do in terms of this space. And I think one of the challenges of this space is a lot of it is not really mainstream and it's frequently not covered by insurance, for example. And so you need to think outside of the box in terms of how you could build a center or be a part of a center to introduce some of these techniques that are novel or not necessarily mainstream into our practice, especially since a lot of our patients are recalcitrant to some of the things that are more traditionally used. So there's, I think Dr. Heather Galgan is in the waiting room. I'm gonna meet you. Hello there. Welcome to the Alternative Pain Medicine Mid-Year Meetup. Let's see, let me check the chat to see what's going on. So I see from Dr. Cardanui that he says he does OMT and trigger point injections for myofascial pain. Yep, I do quite a bit of myofascial release techniques as well and traditional trigger point injections. In my previous practice, when I was working in the New England, I also did quite a bit of botulinum toxin injections for recalcitrant pain, which is a little bit quote unquote off label and difficult to get coverage for, but seemed to be effective for some folks. I was wondering if anyone is using neurotoxins in their practice or anything like that. And then I see that you also mentioned you do OMT. Yes, that's an area that I wish I was more versed in. So I've had to refer out for osteopathic manual manipulation and treatments for that. It's also difficult sometimes to find, you know, local practitioners that are able to spend the time that's necessary, that's, you know, rather hands-on and labor and time intensive. All right, is there anything else that people might be interested in discussing between now and our next meeting in Sandy, I'm not saying you're in Salt Lake City. I'd be interested to know, do people want to meet and present something from this alternative perspective or would they like to work with other groups to do some kind of presentation in that way that includes the spectrum of pain medicine and not just alternatives? Just as far as opioids are concerned, it's something I feel you have to have some communication with your colleagues as to what you are and are not willing to offer because you could offer them options like, oh, post-surgical, you've been on opioids, you refer to me, I'm going to help you wean off of opioids, not that you're going to take over and continue those opioids for the rest of people's lives, which you know is not helpful. The literature has definitely shown that, so maybe you should sort of rebrand yourself and market yourself as somebody that would do that for a patient population. Is anyone else using medical marijuana as options for pain management, sleep management, stress management? I don't use any Botox for trigger points. All I use is a local anesthetic. I don't use steroids either, like has become more popular. Yeah, those are really good points that you've brought up. I have been, you know, referring out for medical marijuana. I don't currently do it myself. There's some local, you know, providers that, you know, devil more than area. It's interesting, you know, practicing in Pennsylvania how every neighboring state has legalized marijuana except the Commonwealth, which is a little unusual. No, the Commonwealth is a late adapter of everything. I worked 15 years ago on trying to get the Pennsylvania Department of Health to monitor opioids and other controlled substances. And that took forever. We were the 49th of 50 states to have a state registry. So we Pennsylvania's late adopter of almost everything. Yeah, that's probably true. I guess they even made such a big deal about the real ID deadline, how I think only 20% of Pennsylvanians had a real ID as of the deadline or something like that. So I guess that goes to your late adapter point. Anyway, I hope all of you have real IDs if you're planning to fly. So yeah, I think, you know, those are interesting areas. And obviously, we don't want to over promise to our patients. I think it's a, you know, quite a balance in there. I think that, you know, in this space, I don't want to become the. So I mean, my current practice, but I felt like, you know, if you're in this realm, you kind of get patients that everyone else has tried everything else on and then you're kind of like the last train stop on the railway. And then it's kind of like you're our last hope kind of thing. And it's a difficult spot to be put into because the expectations are kind of high sometimes. And we've tried a lot of different things and they feel like, oh, there's this alternative management system. And it's, you know, quite a varied area of management. And it's, you know, not necessarily just one thing. But I think if you're right, if you wanted to have a discussion or a mini presentation, if we had a meet up at the meeting, I don't know who's planning to go. As you said, it's quite a ways away. I think that would be interesting if you wanted to collaborate on that. I know they always ask for proposals or the mini proposals for the meeting. Should we have a get together at the Academy meeting? I know there's a lot of forums that do get together at the Academy meeting as well as other special interest groups. And I'm going to take a moment to admit Dr. Ramos. So just give me a second. In the chat. Who is this that was talking about medical marijuana? Then they want opioids and medical marijuana. Yeah. Anybody can want anything. But, you know, it's your license that allows them to to get it. So basically, I work with PCPs offering medical marijuana and other lifestyle and alternatives to help wean people off of opioids and use medical marijuana. And I don't encourage anything that they take in through their lungs because it can cause side effects, lung side effects. But I have had a lot of success in that. And I guess maybe it's just my colleagues knowing my thoughts on opioids so that when people come to me, they have that understanding. So they either go somewhere else. But pain is such. I only do spine pain, neck, mid back and low back. I mean, that's the second highest behind headaches. Why people come to the doctor. So I don't have any lack of patient population. So I don't know if it's too late to change your message that you sent out to your patients and your referring providers, but it's your practice. So if you wanted to change, you're going to have to do something different. Just my thoughts. Yeah, I agree. I think it's always a tricky balance because, you know, there's always different warnings, you know, that patient that's on benzodiazepines who wants an opiate. And then, you know, you try to explain to them how that's such a bad mix and black box warnings. And there's a but I've been on it forever. And so, yeah, I think it's, you know, it's difficult. And we work in a difficult space, you know, especially, you know, since you also share a panels of the panel of spine related pain patients. And I think, you know, some of them are even more recalcitrant, you know, especially they've, you know, they've tried everything they've tried, they've had a laminectomy, they had a spinal cord stimulator, the spinal cord stimulator didn't work, they had it explanted, they're still in pain, and nobody can help them. And, you know, it's a quite difficult space. Well, I think, because I've done this for so many years, I have sort of a different attitude that I have certain tools to help patients. And they're, if they're interested in my tools, I'll share the things I can share with them. I'll share the things I think that can help them and I make them aware of the fact that I believe they should wean off of opioids for chronic pain. And sort of let the chips fall where they may, and end up still with a full patient panel, and a lot of time to get scheduled with me. I even trained a PA to help me. So I think we should put some things out there. The first presentation I made when I got to WellSpan was on the topic, and there's plenty of literature to document for chronic pain, that opioids are not beneficial and harmful. And I had providers get up and yell and scream and argue, but all these years later, I get patients who go all around the mulberry bush looking for answers and end up coming back to me because I still have opioids. And I have options for them that they haven't tried, and everything else has failed. So I feel like if you just stick to your guns of what you think is right for patients, offer it, and stay consistent, the funnel will bring you patients that hopefully can benefit. But I also do lifestyle medicine, so I have a lot to offer. And since chronic pain is a chronic condition, the nutrition, the sleep management, stress management, avoiding risky substances, including opioids, and physical activity and social connections, are all avenues to explore with patients. And I see you all are hiding, but if anybody wants... Yeah, I do. I mean, I agree with you. I think that lifestyle medicine is quite important and can be quite useful. Last year, at the same time for Member May, I did a very short presentation on lifestyle medicine. But I thought I'd keep it a little bit more informal this time around. But I think that goes back to common sense things that systems are trying to work on, like the social determinants of health and those things as well. Nutrition is the fundamental basis of health and living conditions and things like that. I think that's important. I think we discussed that it could be worthwhile for some of us to get more information about lifestyle medicine. I believe there's even a certification that some of us have done in it as well. But I think it's definitely an area that you can grow into. You can make a whole practice out of it. And I think if you're able to be in a more concierge-type practice, where you are not limited by the amount of time you spend with patients, I think it could be quite worthwhile. Though it's challenging to practice that way in certain systems or communities or environments. But I think that's all worthwhile, for sure. I am board certified in lifestyle medicine, but I started practicing alternative and lifestyle medicine before it even was a specialty back in the 80s, late 80s and early 90s. There was one of my mentors, Dr. John Chasell, he wrote a book called Pyramids of Power that outlined his pillars of optimal health, which turned out to be about the same as lifestyle medicine, but he had a spiritual pillar. And I'm actually on a committee or an interest group on meaning, purpose and spirituality as components of lifestyle medicine. So my work started, and I have been practicing this way before lifestyle medicine. But when I became aware of lifestyle medicine at the academy, I said, well, I'm doing that work anyway, so I might as well get boarded. And I got boarded the next year. And I find it helpful, even though I was in that space already. Lifestyle medicine has a lot of resources for patients and providers. And although I've done shared medical appointments before now since the pandemic, and because of my access to lifestyle medicine, I have gotten a lot of support in doing virtual shared medical appointments for my chronic spine pain patients. And that is lucrative. You're seeing multiple patients that you're billing at the same time. But I don't know what people's schedules are like. I see new patients for an hour, follow ups for a half an hour, procedures for 15 minutes. And that's how my schedule is organized. Are you all seeing patients rapid fire like the family medicine physicians? What's going on out there in the, I guess it's the real world because I sort of created my little hub the way I wanted it. Yeah, I think that it's pretty common to see, you know, patients at a little bit faster pace. But, I mean, I know that some people are seeing three or four patients an hour as being typical or some even more, but, you know, I think it's difficult to do some of the education that you talked about and, you know, the quote-unquote, you know, four or five patients an hour at CLEP that is not that atypical in some practices where there's some pressures in terms of seeing a number of patients or, you know, billables or work-hard views or whatnot. I don't know what other people's experiences are out there. Yeah, I'll speak. I work in an orthopedic practice and I apologize for getting here a little bit late. I missed all of the introductions and what you were talking about. I do have some questions about that, but I am doing chronic pain. I would probably say more than 50% of my practice is chronic pain, which then kind of what you're alluding to, I'm like a primary care doctor. I have to see these patients every three to four months. My current state states I should see people in three months. Again, it's a guideline, not a law, but I'm sure since we're talking about opioids as one of the things, it's just very frustrating because the majority of things that I'm doing is I'm practicing defensive medicine and it's really frustrating. Certainly since I've been practicing, this is my 24th year, even my prescribing pattern habits have definitely changed because of the CDC guidelines. I now will, if patients are referred to me just because I don't really have a lot of space, kind of what Dr. Bernal was talking about, she is busy. If someone doesn't want to see her, there's other people who will see us, especially in my town, we don't really have a lot of quote unquote pain doctors. I see about 17 patients in a half day. That's a lot, but when I was younger and crazier, I would see 22, 23, but I got burned out. I think the rules that we have to follow now are much more strict and half the time when I'm seeing these med checks, I'm just making sure I tick the boxes and I'm compliant with pain agreements and urine drug screens, et cetera, et cetera. If I were to just be doing that day in, day out, I would definitely burn out and wouldn't probably continue to practice. But I do think pain management with opioids, again, just like everything in medicine, if you find the right patient and prescribe for the right patient, and the patient is a compliant patient, I think it can work. I would say less than 5% of my patients are the problem patients, always early refills, coming up with excuses, et cetera, et cetera. Fortunately, and that's just a guesstimate, it's not as common as you think. The problem is, if you're a new doctor and you're trying to build a practice, I'm almost at the point where I'm kind of saying, I really can't see more people because I'm now not going back to seeing 22 plus patients. That wasn't, in my opinion, good medicine. I could see 30 patients in a day or in a half clinic, but I also don't want to leave at eight o'clock at night. You can do that. The way you cut corners is you see patients for two, three minutes and you walk out, but that's not medicine. One of the comments I wanted to say about the opioids and marijuana is, because I told you I'm risk averse, I really don't recommend the combination. I tell my patients they really have to do one or the other. Some of that is based on going to a talk several years ago, maybe things have changed. Here's a guru, Gerald Aronoff out of Charlotte, and he's done reviews for physicians like us. When you have a guru like him saying, he didn't say it's illegal, he just said, I wouldn't recommend it. In my practice, I'm not against marijuana, but I'm not going to continue doing your opioids. One last thing, I will say I'm mildly a hypocrite, because even though I just said that, I have a few patients who are on benzodiazepines and opioids now. They're on benzodiazepines from someone else. They're not really being prescribed by me. I go through almost at least once a year talking about the risk and benefits of that combination, but just sometimes someone is always going to show a study that everything we do is worthless and we shouldn't be doing it. That's what's frustrating. We're trying to do the best thing for their patient. Of course, some expert or attorney can show us a study that shows that procedure doesn't work, that medicine doesn't work. What are we supposed to do for half of our patients? I struggle with that because, of course, I want to do the right thing for the patient, but I'm also equally risk averse and always worried about someone pointing the finger at me saying, you caused this problem. Why do you have your patients on benzodiazepines and opioids? No wonder the person overdosed. All I can do is, number one, I know this isn't a good plan, hope that doesn't happen, but I've also documented multiple times in my chart that there is a risk and they understand the risk, et cetera. That's why I was drawn into this community was to say, what are the other things other than lifestyle medicine, which I'm not boarded in, and I'm too old to try to do that at this point, but are there other things like, are people doing acupuncture? Is it effective? I like the idea of root telemedicine. I never even thought about that, but that would allow us to see more people in a shorter period of time. Those are discussions or topics I would like to hear in the future because that, to me, is totally outside of the box that I've never heard of prior to tonight. Thank you. I've been practicing for 38 years and I just got my board in lifestyle medicine in 2023, so two years ago. I hadn't taken a board since 1987 because I was grandmothered into PM&R and never had to take boards. I find it interesting that you, as such a young buck, would call yourself too old to do lifestyle medicine. That's cute, but I have been practicing these tenets of lifestyle medicine before the specialty even existed. I was telling them before you arrived that I had a mentor, Dr. John Chassel, who wrote a book, Pyramids of Power, and it talked about these pillars for optimal health. That had been my practice all along. I see new patients in an hour and follow-ups in a half an hour and procedures in 15 minutes. That's how my schedule is built. It has been that way for years because it takes time to educate patients. Generally, I bill by time, which allows me to get RVUs for the time I'm spending. I also do shared medical appointments, which allows me to bill for group visits, but those aren't based on time. I do have to bill on what I've been able to provide for each patient for those shared medical appointments. I was just mentioning how I do those virtually now since the pandemic. Before the pandemic, I would do those in person with a lot of variable success, and having them virtual has been helpful to me, so I'm hopeful that the government does not shut down virtual visits like they always seem to, okay, we'll extend it, we'll extend it, so I'm crossing my fingers that they keep extending it or make it permanent finally. I don't know how many other people do virtual visits, but I would say about 50% of my practice is virtual because once I've seen you, made the diagnosis, come up with a plan, I might need to see you for labs or x-rays or whatever, but I'm just going over your lifestyle medicine tenant and getting you assistance, coaching, or into some program to help move you along in the pillars. I do prescribe or certify, in the state of Pennsylvania, you certify for medical marijuana. I don't prescribe any opioids, and I work with the patient's primary care physician or pain physician to wean them from their opioids and use marijuana to help them with stress management, pain management, improve their physical activity, sleep management, and I find it helpful as something that they can use to help them with those pillars to be more engaged. Just my, I'm just sharing my experience. Yeah, I think in that instance, then again, that's because I came late and I didn't hear all of that. I would totally support that type of a practice in using medical marijuana, but I would never, again, in the perfect world, recommend it with opioids, just from us worrying about our license and someone pointing the finger at us saying that we're doing something wrong. I mean, I'm human. Tomorrow you could just randomly pick a chart and somehow I didn't follow the guidelines to a T. Does that mean we're a bad physician? Of course it doesn't, but in a court of law and in front of the medical board, depending on who's reviewing your case could throw the book at us. That was the only thing that I thought you were okay with both of them. Again, I am a hypocrite because I don't have a lot of patients, but I know it isn't zero. I do have a few patients because when I check the PDMP profile, the database, controlled substance database, I see that they're on it and I'm like, oh, good grief. Of course, like I said, as you heard me say, I do a bunch of education. Definitely those patients have Narcan on hand and I have a discussion and I document, hey, you know there's a risk of what you're on. I know you've been on it a while. Things are stable, but have you ever thought about trying to get off of the pain medicines? You know where that discussion goes. 99% are no way, no way. I'm not going to force them. I just say I did what I could and certainly if I had other arrows to give them as an option, I certainly would want those patients to do it, but again, the other thing is whether this is wrong or right, we live in an era where patients want things done to them instead of them doing things for them, which again is obviously the opposite mantra for us who take care of chronic pain patients. When they come and see us, they're obviously at the point, yeah, I'm writing some prescriptions, but just like you said, your lifestyle is what now you need to work on because no one has discussed this until you come and see us. We're the last bastion of hope usually when we see these patients and so you hit it right on the head talking about the things that we really should have been talking about 20, 30 years ago, the lifestyle, the food choices, the exercise, your sleep, et cetera. You're absolutely right. We didn't get any of that in med school. I think things are slowly changing, but for now, those are definitely things I could see that helping. Obviously I'm a little bit more constrained for time. I again could see less patients than I'm currently seeing, but I do try to intermittently ... The one thing I harp definitely most on my patients coming from physiatry is discussing the term exercise. I actually, I don't even call it exercise anymore. I call it physical activity and I try to discuss with the patients how important that is and what is the definition. In my mind, there's three components of physical fitness, which is cardio strength and stretching flexibility. I tell them if they could at least do one of the three, I would be happy, but really we should be doing all three, at least one or two times a week within the American College of Sports Medicine guidelines. From a lifestyle medicine standpoint, that's about the only thing I feel I'm somewhat knowledgeable about and I will spend time discussing with my patients about really their activity and how important it is. Yes, I was one of the doctors earlier in my career, PT three times a week per therapist. I remember in our training, we couldn't write that. We had to write down everything we wanted to do. Then you get in the real world and you just go per PT or whatever, spine protocol. I do agree with what you're saying. The lifestyle medicine aspects is very important for our chronic pain patients because probably until they see physicians like us, no one has really discussed that. Everyone is talking about what procedure, what MRI, what medicine, myself included, what medicine can I give you? Even the medicines I give them don't solve all their problems, so then that's when we, like you said, we have to talk about these other things that they've probably never heard about. Right. Everybody comes, I tell them if they're breathing, they can do breathing exercises. I expect them to be breathing in my office and after they leave. Everybody starts with breathing exercises because that can help with their lung volume. It can help with stress management, but really I think it has to do with how you set your parameters of practice. I've been practicing, like I said, 38 years, so I have put these things in place. I have set an expectation of this is how I practice. This is what I'm offering. I also know that benzodiazepines don't work with opioids. They don't work with medical marijuana either. I work with patient psychiatrists to decide how they want to manage that. If they still want to do the benzodiazepines after we've had this discussion, I don't interfere with that and I still work with medical marijuana with those patients because I figure we've had a discussion, we're working as a team. If you can feel that they'll be safe, then I'm fine with us collaborating and moving forward, but I don't put anyone on opioids and I help patients get off of the opioids that they're on. People know that when they come to my practice and when they're not willing to go that route, they might go somewhere else. I have some patients that are on opioids with a quote unquote pain provider and then they come to me for what I have to offer because they know that the opioids themselves aren't enough to get them out of the trouble that they're in. I feel like if more people beat the same drum and make patients feel responsible for their care and their management instead of a doctor's responsibility to fix it or take care of them, that they are empowered in their healing process to take care of themselves, that they have opportunities to move forward. That's probably why I have gray hair because I'm always beating that same drum and trying to convince people to take the reins of their lives. You do not look like you've been practicing almost 40 years. I am going to be 70 next May, but I just want you to know I practice all the tenets of lifestyle medicine and I have heat on my shoulders because my personal trainer kicked my butt this morning. I don't have any problems with Lyrica and medical marijuana or gabapentin in medical marijuana. I haven't found that those, I haven't seen anything in the literature against it and I haven't found any side effects. I could have lied instead 40 to 50 I don't need to lie about my age I'm just trying well first of all all those tenants of lifestyle medicine I practice those I've been practicing yoga for over 42 years I do strength training I've taken it to the next level with this personal trainer because I'm trying to get baby strong for my first grandchild that's on the way I avoid risky substances I I'm a pescatarian but a plant I have a plant predominant diet I do stress management and I do all the work that I'm asking my patients to do is all I'm saying and that makes it a lot more authentic when you're speaking to them about them making their changes I don't know the income potential and trajectory for lifestyle medicine. I'm hired as physical medicine as the site director of the spine program here at WellSpan Health in York, Pennsylvania. We just hired another physiatrist to come in. She's interested in lifestyle medicine and shared medical appointments as well. She is making a good salary, I think. I would ask you to just go to the WellSpan.org website and see how much they're offering physiatrists there. Yes, I love meditation definitely is something I I start all my shared medical appointments with breathing exercises and relaxation and a brief minute meditation before we go into the topic of the day But I don't know where our moderator is, but anyone. Sorry, I was just stepping away. I was trying to find some more information about our question about lifestyle medicine. And I believe the, I was just looking at another device. The American College of Lifestyle Medicine would probably be a good resource for just general information about salaries and the like, if your money matters to you, which I'm sure it does to everybody to some degree, even those people that claim it doesn't. I put the six pillars in the chat when they asked that question, but I also don't know what a lifestyle medicine physician, you can be in any specialty. So I don't know if they have any real data on that. Yeah, I mean, there is some general information on their website, but I think it would probably be variable about how, obviously how many patients you're willing to see how hard you're willing to work. If you're doing more procedures or less procedures, if you're having large amounts of group sessions, I just think there's too many variables. I think you could definitely make a decent living in most of the country, but I don't know that I would tag any specific number. Oh, I'm just getting a message from Ramona, I believe, that we're at the 15 minute mark. So does anyone else have any, not last minute, but end of the session areas that they wanted to touch upon as we are in our last quarter hour or so? I can't believe the time has just flown by so quickly. It's so nice to see all of you out here today. All right, I'm just going to type in the chat the website, I believe, for Lifestyle Medicine, lifestylemedicine.org, but I wanted to put it to everyone, sorry, not just to Mona, but I do see that people are starting to... Drop off. Drop off, as I'm sure everyone has, you know, it's a school night and you guys have obligations to your loved ones and children and whatnot. So, you know, I'll be happy to stay on as long as people want to chat. But if everyone wants to, you know, cut out at an hour or so, I think that's quite reasonable as well. So I will, I put that little link in the jobs.lifestylemedicine.org, I believe that's the American Academy or American College of Lifestyle Medicine. But I think it's, you know, quite variable, as I mentioned, though I'm not hardly an expert on that. So, anybody else have anything else to do? I wanted to thank, you know, Dr. Bernal, thank you so much for all your contributions. I know you've been amazing and congratulations on being 70 and still, what's the right word? Getting up every day to make the donuts, so to speak. There's the Dunkin' Donuts analogy. Well, the most important part is getting up every day to go to a job you love and enjoy that's not burning you out. Yeah, that's really important. And I think it's difficult. I mean, you could have a whole session about burnout and how to combat it. I work on that too, at WellSpan. Oh, yeah, I do. I do go to one of the WellSpan hospitals in Ephrata, Pennsylvania. So you're a solo practitioner? No, I'm in an orthopedic group. Oh, an orthopedic group, right. Okay, does anyone else have anything they wanted to bring up before we might call it a wrap? Maybe I can end 10 minutes early unless Mona has objections. I did want to say that we are going to be releasing forms for meetups at the Annual Assembly this year. Pretty soon. We also have a meeting coming up for the chairs for all the member communities to talk about opportunities to get together at the Annual Assembly. It seemed like there was a lot of interest in terms of just like what's next and where to. You can definitely sign up for a meetup where folks can get together at the Annual Assembly. We have some lunchtime sessions available. We have some morning sessions available if you wanted to get together in person. Yeah, we had a small meetup at the last Academy meeting in California. If there's an interest, maybe I'll post something in the forum to see if anyone wanted to have a meetup or co-sponsor a meetup. Or if they wanted to do a mini presentation at the meetup, I think it would be less structured than a bona fide Academy presentation. No, you don't need that. You can just get together. It's just a space and grab your lunch and hang out. I missed your meetup because it conflicted with some other meetups I was meeting up with. As you see, I have a lot of things that I'm interested in, so it was hard to get to everywhere. Oh yeah, that's understandable. You're a popular person. But yeah, I would be interested in this meetup. And I think I talked about lifestyle medicine at the last meeting. Yeah, I talked about lifestyle medicine at this presentation last year in 2024. I also did go to Heidi Prather's presentation. I can't remember if that was last meeting or two meetings ago. Sometimes as you get older, your memory just kind of washes together. But I think she gives lots of excellent talks on lifestyle medicine. And Beth Frady, who was the president of lifestyle medicine at the time, gave a talk at the last meeting. I went to that presentation right before. I had to run to another presentation that I would give. So yeah, it was a busy meeting for me. Well, it's good to do this. It keeps you younger. It must be working. All right. Very good. So I wish you all a very pleasant evening. And I will circle back with you on the forum to see if there's an interested meeting in Salt Lake City later this year, actually, not next year. I'll time flies. I think you should just plan it. And I'll see you there, hopefully. All right. Thank you, everyone. And all of you who came to the meeting tonight, thank you so much for coming. And thank you once again to Mona for her excellent hosting of the session. And I wish you all a pleasant evening. All right. Take care. Bye now.

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