and welcome everybody to our Latinx session. This is gonna be like a informal engagement about, you know, things that we like to do and new hot topics. I think the sun is still not helping too much. Let me move my chair. Maybe that's a little bit better. So once again, thank you for joining us. We heard through Mona that we will have about 25 members. So I'm super excited about the turnout. This is the first time I think we have this many attendees. I think last year we were maybe 12, maybe 15. So the point is that I wanna get to know each other, wanna collaborate and network so that everybody in this community understands, you know, where we are, how we can continue to collaborate together and all the cool and fun things that we're doing throughout the nation. And we chose the topic of MSK without borders because physiatry or physiatrists were at the forefront of MSK care. We do understand that our colleagues from primary care as well as, you know, orthopedic doctors perhaps and rheumatologists are also involved with MSK issues or treat patients that have MSK issues. But, you know, as a physiatrist, we kind of understand MSK issues in a different level, right? We all are in different levels of our training. Some are attending, some are residents. And we do know that we are the experts, right, of treating any conditions that will affect the bone, the muscle, tendons, ligaments, and nerves. And throughout talking to Marcos and Mariana, they are both part of, or two of my speakers today, we decided that it was time to discuss, you know, how we can approach MSK care truly without borders, only with the caveat that to do a good job, we need to start doing things locally. And then perhaps we can expand to the international realm, right, or the global community. So without further ado, I wanna introduce my speakers. I have, ladies first, Dr. Mariana Velazquez Cano. She is, and I'm gonna read from here, Mariana, because she sent me a pretty detailed list and I don't wanna miss anything. She is a primary care physician with outpatient experience and a strong commitment to patient-centered care. She's currently working as a professor in Colombia and she's from Medellin. She's passionate about education, mentorship and supporting the next generation of physicians. Dr. Velazquez will be starting her venture in the PM&R world with us in Rush University Medical Center, Chicago, Illinois, now in July 1st. So we're so excited that she will be joining us because we know she's gonna combine all her experience throughout the years as a primary care physician and now also working with the global health community in the PM&R and continue to engage with patients, peers and expand her knowledge about improving quality of life for patients. So thank you, Mariana, for joining us tonight. And I also have Dr. Marcos Enriquez Corporan. He is a current PGY-3 at our program at Rush University Medical Center. And Dr. Enriquez is the lead PM&R resident for the Department of Global Health. He's also the lead resident for our community health clinic where we do MSK care here in Chicago. And he's an aspiring sports medicine doctor. And I know he will do a fantastic job with that. So he's gonna be busy in the next couple of months just doing auditioning rotations and charming everybody the way he knows how to do. And I'm Dr. Abreu Sosa. I am a fellow member of the APM&R since the year 2012. I am a current assistant professor at Rush University Medical Center, the Department of PM&R. And I'm the medical director for the inpatient rehab unit at Rush Specialty Hospital at Rush. And also the lead attending for the Department of Global Health with Rush University Medical Center. And my job today is basically just to do like a general overview. And then I will pass the torch to Dr. Enriquez so that he can talk about his experience between community health in Chicago and then how we expanded that globally with the Global Health Department at Rush. And then I will pass the platoon again to Dr. Velasquez-Cano so that she can give us her experience working abroad in Colombia. And we can talk about the challenges that she has seen and how that compares to how we treat MSK issues in the United States. So MSK issues, like I said, we all kind of know a little bit about that, right? There are about 1.71 billion people in the world that live with MSK issues. And this is the leading cause of disability around the world. And any type of musculoskeletal conditions will limit our ability to move, our ability to complete our activities of daily living, our ability to work and can also affect our disparity. We understand that as the population increase because just us as doctors, we're getting better at diagnosing medical conditions and people live longer, right? So it is expected that there's gonna be a trend of the population growth with having MSK or musculoskeletal conditions. And just in general, working force, right? People that work tend to take about 14 days a year from work just because they have an MSK condition. And this could co-exist with non-communicable diseases. And by that, I mean that a lot of the times patients, right? And any person that will have a musculoskeletal condition could also have things, comorbid things, chronic conditions like asthma, hypertension, COPD, diabetes, right? And in musculoskeletal conditions, especially pain can lead to a high increase in mental health, right? Mental health issues like depression, anxiety, and other things. Neck pain and lower back pain are the most commonly reported musculoskeletal conditions. And out of those two, lower back pain, I think takes the win. And, but there's still a disparity. We all know this because this is data that has been published by the World Health Organization, by the CDC, by the NIH and different studies. But we do know that the cost, right? Of this healthcare, right? For those patients that can't afford it, right? Patients that have insurance, it's about $2.4 million a year, whether you have a private insurance or Medicare, Medicaid. But when we talk about those people or patients, excuse me, that are uninsured, it's about $923. And you're probably thinking, well, that number is lower, right? It's lower than 2.4 million. But if you think about it, it might be a lot for patients that are uninsured. Why? Because they have low income, low income, right? The type of work that they have is not sufficient, right? To have a high earning and maybe $900 in a year, right? It's a lot of money that they cannot afford. So the lack of knowledge, lack of understanding, you know, where to go, you know, what kind of doctor should I go? Most of those patients don't have a primary care doctor and they turn into urgent care. They can go to the ERs. And sometimes it's just fear. Fear of maybe hearing a bad news and thinking it's, you know, it's some ambiguity. Fear that they're just gonna have a lot of money to pay. And that money, they need to have it in their pockets, right? They have a family that they need to support. They need food on their tables, right? They need to make sure maybe families living abroad, right? If they are uninsured and undocumented, that they send that money so that they can help out their family. So there's many factors that come into play. And that brings me to, you know, something that we've all been hearing over the past maybe three to four years, which is a social determinants of health, maybe a little bit more, which is how do we integrate, you know, community, society? We think about economic risk factors. We talk about food insecurity, things like that, and how we can provide an equitable healthcare, right? There was a picture that I had recently, and I said had, because unfortunately 20 minutes before this presentation, my nice presentation disappeared. So I couldn't find it. But it's not the same, you know, in this picture that I had showed it, having, you know, three different people, right? A mom, a dad, I think of a child, standing watching a baseball game, all in three different stools. The stools are the same size. So you might think this is actually equal, right? Because the three of them have the same size stool, right? That's so they can watch over the fence to look at a game, but it's not equitable, right? Just because the fence is high. So the only one that is able to see is the tallest. So just because you're providing someone with the same tools it doesn't necessarily mean that you're being equal, if you get my point. So I just saw that a name that popped up and it's Dr. Gerard DeCicco. Dr. Gerard DeCicco, and I would love for him to talk to us a little bit whenever he wants. It could be at the end, it could be now about, you know, his initiation about community healthcare and an MSK clinic in this community health. So community health is a free clinic run by volunteers and established in 1993. And by this, it's a physician actually called Serafino Garella. And this physician noticed that there was a big disparity about the patients that he was seeing. He was seeing a lot of patients in the hospital that had no primary care, no follow-ups, and then a lot of conditions that were either misdiagnosed or diagnosed late. So a lot of his, he got together with some of his colleagues and decided to open this free community clinic. And I have to say that I've been fortunate to train at Rush University Medical Center. And I know Dr. DeCicco did too when he was a resident. And Rush is very, part of their mission is just to be very equitable, right? And engage the community. And we're located in the West side of Chicago. So we provide care in the location that we are. We also foster different, oh my God, what is the word I'm looking for? Partnerships. Partnerships with our community, right? We employ people from the same area. We provide care for them. And we take care of patients regardless of their status, whether they have insurance or not, whether they can pay or not. And Rush also has a medical college. And Dr. DeCicco was able to attend Rush Medical College. And through the family medicine rotation, he was able to start going to the community health clinic. So he saw for a fan, asked the students what the community health clinic could provide. So then years later as an attending, approximately the year 2009, he said, you know what? Our residents don't know or don't have that experience of having community care or continuity care and he pitched the idea. And all of the Pima residents started going to community health with him. I was a second year resident when that happened. And I was fortunate enough to be one of the pioneers in that year along with Dr. DeCicco to attend the clinic. And why is this important? Well, it is important because it teaches all of us what it is to give care with low resources, right? All of us at one point, we work in academic centers, right? And the patients that we're exposed to the majority of the time have insurance, right? And they can get DMEs, we can prescribe medications, we can perhaps write an order for PT and LT. And we take things for granted, right? Because everything is done like, we go through the motions. If we can call it like that. But in community health clinic, we needed to think outside the box, right? We needed to provide the same level of care that we were providing at the academic center, but with less and our supplies were donated. We were writing exercise programs for the patients because they had no access to PT and LT. It just created also mentorship, right? We had a second year resident that was me in 2009, partnering up with a third year resident or a fourth year resident and also being mentored by an attending. So with patients, with time, with just understanding of the level of, I guess of expertise that we were all at one point, we were able to not only engage with the patient, but communicate with them. And the end point was the same, right? Providing good healthcare and a much needed healthcare. 16 years, I believe we've been going strong with this clinic. And we did take a pause for COVID during the years 2020 to 2022. But roughly, I think we were able to see about 30 new patients a year. Nobody knew what PM&R was doing in that clinic. But as soon as the word started spreading, all other specialties in that clinic were referring patients to us. OB-GYN, primary care, internal medicine, urology. So everybody now wanted to get us involved. And I believe, and Dr. DiCicco, correct me if I'm wrong, in the year 2010, we won the clinic of the year. Yes, yes, yes. Which is amazing. And we still have medical students coming and learning and getting passionate about MSK care and community involvement. And it was around the year 2022 that I was talking to now one of our former residents, Dr. Paul Pobian. And he said, why don't we do this abroad? Why don't we expand and go somewhere? And that was something that I always wanted to do. My first experience traveling abroad was in the year 2011. I was a third year resident, third to fourth year. And we went to Guatemala and I loved it. And I said, sure, let's do it. I told boss, like we call him. And we partnered up with the Global Health Department of Rush. And in the year 2023, it was our first year traveling to Santo Domingo. And before I lead off to, or pass it between to Marcos or Dr. Enrique Corporan, because he's gonna expand a little bit on that. I wanted to see if Dr. DeCicco had anything else to add about this amazing opportunity and the value of providing community healthcare in locally first in Chicago where we're at. Hi, everybody. Can you hear me? Yes. Great. Thanks for letting me speak a little bit tonight. So it's a real honor to be able to talk a little bit about our experience at Community Health. I've always found Community Health to be an extension of where I work as well at Struture Hospital, Cook County, which is a safety net hospital for many different populations that may not be able to provide or may not be able to obtain healthcare regardless of the ability to pay. That is the mission statement of the county. And while this hospital that I work at has resources the way that Dr. Barrios-Sosa mentioned PT, for example. Again, when we went to Community Health, that was yet another step where there wasn't as many resources. Teaching residents about being resourceful and knowing the best way to not only provide quality care but to meet patients where they're at, whether their medical literacy is not where we would hope it would be is still a very important mission. I'm so proud of how we've evolved over the years and the amount of mentorship as Dr. Barrios-Sosa mentioned, we've developed over time. And the many populations that we've served in this clinic, a lot of Latino, Latina patients, Southeast Asian, Polish. It is a lot like what we deal with at county. And so you can imagine trying to meet everybody culturally at where they can understand what it is that is going on is very important. And it's just really exciting to see how they've extended this now into the international realm as well too. So thank you. Thank you, Gerard. I do want to point out that everything that I know about MSK, I learned from this guy. And I know all of our residents are more than grateful to have him around just because you're truly valuable, Dr. DeCicco. So thank you so much for joining us tonight and for just dedicating a few minutes about, just discuss your experience with all of us. So without further ado, I just want Dr. Marcos Enriquez, Corporate Oncologist to take it away. Thank you, Dr. Abreu-Sousa. I can say that it's a pleasure to be here and to have two of my mentors here, Dr. DeCicco and Dr. Abreu-Sousa. I think that I get pretty involved with their interview season when we're interviewing candidates at Rush. And I always say that I have two babies in residency. Those two babies are Community Health Clinic and our Global Health Program. And I come here just to share my experience, the privilege and the luxury, I say that I have, of being involved with two of these scenarios. So let me go ahead and share this presentation with you and I'll run you through, it's gonna be a bunch of pictures, but I just wanna give a graphic description of what is it that we're experiencing at Rush and how we're taking that somewhere else. So Community Health Clinic here in Chicago, it's on the West side, just like Dr. Abreu-Sousa mentioned, she was mentioning Dr. Povine, which is here. I think I consider him as a brother, but also as a mentor and that I had the pleasure to work with in residency. And here's our chair, Dr. Dugan. This is one of the days that we were, we were talking about the COVID-19 pandemic and this is one of the days that we were officially handing off the leadership in terms of the resident that was taking over Community Health and Dr. Povine was passing over the lead to me. Just to get a little bit of context, I think that physiatry, they do this very elegantly. Oh, we have to understand where Community Health Clinic is. And if we look at closer to the map, it's in the West side of Chicago. But then if we point out specifically the villages, the areas that are nearby, the Ukrainian village, the Pilsen is localized, it's more South to it. That's where most of the Mexican population is located. And then Humboldt Park, where a lot of the Puerto Ricans are localized, but it's not limited to Puerto Ricans. There's a lot of Latinos around that area. And we get the luxury to see them all here in Community Health Clinic. And then again, as I mentioned that day, I had the pleasure to have the torch. This was our very last day of Dr. Povine in Community Health Clinic. And then I took the lead, that was two years ago. And then again, Dr. Abrozos has already mentioned Community Health Clinic, but I wanna focus on my second baby, which is Global Health Trip to the Dominican Republic. As a little bit of a context, I'm from the Dominican Republic, I grew up there. So joining the program, as Dr. Abrozos had mentioned, Dr. Povine was trying to figure out a way to go to the Dominican Republic. Perfect opportunity, I just matched into Rush and I was practicing in the Dominican Republic. I knew people that maybe could help us out, that we could contact. So we started reaching out to everyone to see how we could make this happen. And up until January 27th, it's the first day that we were able to make this possible. We joined forces with Rush Orthopedics. So we had two arms, a surgical arm and a non-surgical arm, and we flew to the Dominican Republic. Imagine, we got there, people in the Dominican Republic were friendly. We'll receive you with open arms and food. The community is pretty involved in this program. And then we headed the second day to Aswa. So Aswa is a place closer to the Dominican-Haitian border. It's an hour and 50 away from the capital. I was born and raised in the capital. And we went to this hospital there. It's a regional hospital. But I wanna give a shout out to this lady right here, this is Dr. Crane. She's the head of the Global Health Department at Rush. And she has been pretty open on the ideas that we have been presenting to the program, just having us and getting whatever we pitch, we'll get the full support by her. And then again, understanding the context, understanding where we're going, I think that is key to find out why we need PM&R going to this community in Aswa. So Aswa is one of the 31 provinces in the Dominican Republic. And then as I mentioned before, it's like 100 kilometers from the capital. There's only one regional hospital in this area. There's no PM&R service in this area. Shocking, I know. But if we look closer and we see, let's take a closer look at the map. You can see how there's water nearby, there's mountains nearby and there's the center and there's like a city over there. So what the people do that's important in our specialty, what they do is a lot of physical work. They have their coffee farms, they have plantain farms, coconuts, they do fishing, they have their own animals farming and some of them they work in industry. So there's a lot of heavy work in order to sustain themselves. So with that heavy work, there's a lot of MSK pathologies, but then there's no PM&R, there's no physiatrists in the area. So who gets to see that? The answer is very simple, almost no one. So there's a high chance of running with chronic MSK pathologies and they're unseen for ages. But now the question is, what had PM&R to offer in this trip? So I wanna bring this image. And previously in the global health program, orthopedic surgery was going to the Dominican Republic specifically to ASWA. And the question was very simple. If they were seeing a patient, are you surgical or not? If you're surgical, you get surgery. If you're not surgical, there's nothing to do, you go home. So there's this, if we have our physiatric lens, we can see how there's a bridge and now we can meet whatever is in the middle. So we can bring all this home exercise program, we have MSK ultrasound that we can utilize to support and make a diagnosis. But on top of that, we can treat the patient and guide a needle. And if we need to do an injection, an interticular injection, we can do it with ultrasound. We also had orthotics provided by partners that we made here in Chicago. And we took those orthotics and we were able to give it to the community as well. But then if we do this rundown, I do remember getting there the first day on our first trip. On day one, we only saw 21 patients. We were saying to ourselves, well, it's gonna go very slow then. Those patients, I think that they did like a marketing campaign for us. So they started spreading out the words that there was new doctors that could do something different with a different view. So the second day it doubled and then it stays to sustain. And over five days, we were able to see 207 patients. It was incredible. It was only three of us, Dr. Povian, Dr. Abreu-Sosai and myself. I cannot tell you how long those days were, but it was so refreshing just to see that first we were helpful and we were thinking outside of the box. I think that this place is, when people say that medicine is an art, I think that this is the perfect scenario to practice this art because you got to think outside the box. And then as we move forward, we can see all the MSK complaints that the patients had, a lot of knee pain, low back pain, shoulder pain, you name it, any pain all over their body. And we were able to diagnose them and treat them. So looking closely, it was a security guard. He was saying that he had a lot of atrio-medial knee pain, did a knee X-ray. It was negative. So there was nothing else to do. Fortunately enough, we had an ultrasound machine. We were able to scan it. We were able to find a bigger cyst. On top of that, we have another patient just complaining. Interestingly enough, she was able to go down to the Capitol. She had a diagnosis of carpal tunnel syndrome, but she didn't get treatment. So we had the diagnosis and Dr. Povine was- No, thanks. What I want to highlight is, here in the States, we try to provide care. If we have a tool like ultrasound machine, we say, we're going to use it. That way we can provide a better care. And I think that the elegant portion of this, we were able to take that quality to the community as well. And on top of that, we were diagnosing patients, treating a lot of patients, but all of that was followed by quality. It's the same. Nothing is changing in the recipe. And then moving forward, another thing that we had into our toolbox, this is more of ultrasound. As Dr. Roberto Sosa mentioned, I look forward to getting to Swartz Medicine. So you're going to see a lot of ultrasound pictures because I consider myself someone very passionate and I like using ultrasound as part of my treatment. This is for another patient who had a lot of posterior medial knee pain. I don't know what happened in this trip. There was a lot of patients just with Baker's cyst. And she was complaining of a lot of pain. She had a small farm and she was super distressed because she couldn't walk due to the pain. And we were able to find the Baker's cyst. We aspirated it. And then she was able to walk as we can see here in this video. The pain went away. She's scratching her head. She's like, where's the pain? It just went away. Which is, to me, it's very reassuring. I think that it comes with a sense of, I felt very happy at the end. It's very, because you can see in their eyes that you were doing something different for them. And I think that this is the perfect scenario to fully grasp the impact that we had as physiatrists. And then moving a little bit forward. This is a picture of one of my patients who had a lot of posterior medial knee pain. Which is landed by us by one of the... One of... She had a lot of posterior medial knee pain. One of my mentors in the Dominican Republic, I have been fortunate enough to be exposed to shockwaves. And we were able to borrow a machine and use it with some of the patients that had some of the MSK complaints as well. So we were also able to treat the ones that were taking care of us. So this is Wendy. She's one of the, from the community. She's one of the lead person organizing this trips. And she was stating that she had a lot of neck pain. We treated her. We can see her... How long has it been since you've had a neck pain? Yeah, exactly. Last month. How long has it been since you've had a neck pain? Since we have a medial pump off. Since when was that? Two. And then as something that I wanted to highlight, our intention was not to replace the traditional methods. We just wanted to enhance them and compliment them. That's why we were bringing all these machines and into this trip. Because I think that it had an added value to our trip. But I just want to pause here. I'm just mentioning all the things that we were doing for the community. And I just want to take the time to highlight the things that the community were doing for us. At times I was wondering if we were treating the community or the community were treating us. Because every morning we woke up and I just wanted to share the things, the fulfilling moments that we had in the ER. We woke up to this beautiful sunrise, had some coffee early in the morning from the mountains, probably from some of the patients that we were treating. And then just local food that everyone was making for us. It was so... That's why I keep saying that it felt at some time that they were taking care of us instead of the other way around. And then every afternoon we try to catch the sunset and just spend some time. Interestingly enough, Dr. Poving, he was very... I think that he mentioned that the last time that he had some sugar cane was like back in his childhood. And he had the opportunity to try it again in a ground public. And then we spent hours just talking to this man. We had such a pleasant conversation. But then the patients, as the day went by, patients came back and they were bringing food from their farms because their pain was getting better. The first day, there was like a Dominican version of a pumpkin. There's a bunch of plantains inside this bag, mangoes, just a lot of things. It was like 50 pounds. At the end, imagine me trying to take this back to Chicago. There's no way. So the lucky one was my mom because she had the opportunity to keep it all in the Dominican Republic. But guess what? We just came back from our second trip, which is in February. We just did another trip and let's see what happened during that trip. So remember that the first day on the first trip, we saw only 21 patients. This time we saw 32, but look at the following days. This was insane. I honestly, I think that the patients did the best marketing campaign for us because they were trying to get everyone and have them see us. And we saw 280 patients at the end of the trip. This time we had a cancer machine, so we came back and... So now of our experience with companies here in Chicago, and they were able to lend one of the ultrasound machines, we're detecting... What we want to have... And then there's more interventions with ultrasound machines, patients is having things that we might call here in Chicago or here in the States, very simple stuff. But the thing is, they don't have the luxury of having that in the community. And the other thing is that I want to bring up, when you go to those communities, we are threshold to do something interventional. It might be lower because we don't get the chance to see them as often as we see them here in the States. So we want to treat them. And maybe sometimes we might think if they do PT, it might get better. But then you question yourself, what if it doesn't get better? The impact that it might have in their life might be so much. Just remember, this people do a lot of physical work. So that's the beauty of our specialty. We try to design a plan. It's like being a tailor. You tailor the plan according to the patient. So depending on the pathology that they have, we design a plan for them. Depending on what they do, just more pictures. So we were using our ultrasound machine a lot. While we were using ultrasound machine, I just mentioned that before, it provided us the opportunity to extend our physical exam, to diagnose, to provide real-time guidance and ensure that we were delivering the treatment in a safe manner. First of all, we don't want to do harm. And this is one of the ways that we were able to feel that we were doing interventional stuff in a safe manner. And now that technology is advancing, things are getting more portable and these are things that you can definitely incorporate when reaching out to the community. And then another thing, the imaging studies and types of imaging that we're doing, and then another thing, the imaging studies in Taiwan Hospital, which is the hospital in Asheville, it's only limited to x-rays. So you can see soft tissue with MSK ultrasound. And then for shockwaves, we were using shockwaves so much, more than half of the patients that we saw were able to get some treatment with shockwaves. And then why? It's a non-invasive treatment. You can treat tendinopathies, trigger points, just these fused myofascial pain syndrome. And it doesn't take that much time for treatment. And then again, oh, I don't know why this is repeating. But then again, I just wanted to highlight how the community was so warm to us while we were there. Just a lot of gratifying moments as I as I clicked through this. There's after the first trip, I asked Dr. Povian to give me his perspective of the trip. And he sent me a video. And this is what he's Hey, guys, this is boss, I had the great privilege to accompany Dr. Brasosa and Marcos on our trip to the Dominican Republic, where we serve the people of Oswa. This trip was so many different things. And even though it was so much fun, above all, it was very humbling. I'm just left with a great sense of gratitude for the opportunity to go to Oswa, learn about such a caring and kind people, and learn about the disparities that they face there. More so, I'm just left with a huge sense of importance for the work that we do as physiatrists, not only in terms of the medications and procedures we provide, but also the education that we provide as well. I'm just left with this sense that this is the beginning of a very beautiful and powerful movement in rehabilitation care that's going to be happening in Oswa in the Dominican Republic. And I'm really excited to see where it heads from here. And then again, I was doing some, trying to get more information of how many programs we're doing, like global health trips. I wanted to get some specifically to the Dominican Republic. It seems that at some point, physical therapists were going to the Dominican Republic without physiatrists. And there was even a suggestion of including PM&R residents and maybe having them going to those trips to get some information to provide a better care for that community. And I think that that's what we're doing at Rush right now. This is the opportunity that I've had so far. And then one of the goals that when we were designing the global health program is to create partnerships to make sure that we can sustain this over time. And we have been able to accomplish that. We have been able to get some support by GE, Hangar, Bayer in the Dominican Republic. And this is my mentor. He's the CEO of Rehabilitate. He's one of the individuals that brought me into the physiatric world in the Dominican Republic. And that's why I came here to the US just because I just wanted to dive in and get more of that experience to eventually go back and maybe and treat the community and keep the community work that we're doing. I don't know if you remember, if you remember Wendy's, but this is another video that she sent a couple of months after the first trip. And I just want to share this one because it came with a, it just came with so many gratifying memories and I just want to play it and that way you can listen to what she had to say. I'm a Community Empowerment Servant and I want to thank the Physical Medicine and Rehabilitation Program at the Ross University Hospital in the city of Chicago and especially Drs. Marco, Sol, and Voss, who were instruments of blessing for my community, ASWA. En nombre de ASWA, en nombre de Community Empowerment, en nombre del Hospital Taiwan, queremos agradecer por el trabajo maravilloso que hicieron durante toda esa semana que nos sirvieron a más de 200 pacientes con dificultades, con dolores, que necesitaban un servicio de terapia física. Servicio que es muy difícil tenerlo y servicio nunca antes recibido en la provincia de ASWA. Así que muchas gracias por tomar de su tiempo y de su profesionalismo para servirnos con entrega, con amor y dedicación. Le invitamos a todos los miembros del programa que se unan con Sol, con Marco, y con Voss y puedan venir a nuestra querida ASWA a seguir sirviendo a nuestra gente que lo esperamos con los brazos abiertos. Well, after we saw that, going back to the original question, so what's the role in PM&R and medical mission trips? And when I came back, I tried to answer that question in so many ways, so many answers came to my mind, and I just wanted to share this experience at AAPM&R. And I was fortunate enough to be, I presented this as a first talk, and I was fortunate enough to be one of the finalists. And I just wanted to give you a recap of what I said. One of the things about PM&R that is meaningful for the specialty, we try to understand where the patients come from. We try to understand their surroundings. If they have a disability, we can truly understand how this disability is impacting in their function. What do people in ASWA do for a living? They rely on farming. They have coffee farms, plantain farms, fishing. It's a lot of physical work. So any physical disability, it's going to tremendously impact their function. If they're not able to take care of their crops, that's going to compromise the way they're going to sustain economically. We had home exercise programs in Spanish and ultrasound machines. So we reached out to one of the companies that I used to work at in the Dominican Republic. The very first day that we got there, we only saw 21 patients. Those patients, they're starting spreading out the words of something new, new specialty of doctors doing something different. So that doubled the following day. And it stayed sustained in about 40 to 50 patients per day. And then again, just stay tuned. Just after this, I think that there should be a part three. And it makes me, I'm so excited to, first of all, introduce the following speaker that we have now, which is Dr. Velasquez Cano. And I, things that I, when I joined the program, I was, when I was visualizing this, I wanted to figure out a way how we could pass on the torch. And just having Dr. Velasquez Cano joining the program, I can see how this can be alive over time. And maybe she can experience the things that I was able to experience in the Dominican Republic. And I just want to thank all the individuals that I've been able to meet in my, in my life. They have been making, they have been friends, colleagues, and even like family at this point. And I just wanted to give a big shout out to the team for our most recent trip to the Dominican Republic. I'm just going to stop right there. Thank you, Marco. Yeah. Let's just pass it on to Mariana because I think, you know, at 7.15, oh, there's a question from Glendalee Vazquez. Are you training local clinicians to be able to provide these services? What's the future for local resources? Yeah, great question, Glendalee. We are actually right now partnering up with medical students that are interested in PM&R. In our medical trip, unfortunately, there's no one around us. This is a funny thing that happened anecdotally. People thought that I was a doctor working in the hospital in Taiwan and Marco too. And I was the one writing scripts, you know, doing just the primary care work for them. So I was doing a little bit more than, than PM&R work. The goal is to partner with local PT, maybe OT clinics or other, maybe PTAs. We did have one PTA that came to shadow us. And in the future, we will hope that this organization called Community Empowerment identifies key members in the community that we can train so that the exercises that we provide or maybe the non-pharmacological interventions, right, or non-injectable interventions can be continued. So yeah, it's a work in progress. And hopefully this week, I'll be able to meet with our global health partners to kind of discuss a little bit more about what are the next steps. So Mariana, the floor is yours. Thank you. I can't wait to be a part of the next MECO mission. Okay. Let's see. So I'm going to talk about the rehabilitation through a primary care lens in Colombia. My name, as I said, is Mariana, and I'm an incoming resident for Roche Medical, Roche University Medical Center. So the objectives that we're going to have today are to describe the scope of physiatry in Colombia, to explain the responsibilities of primary care physician in musculoskeletal conditions, to explore the difference of health accessibility in rural versus urban areas, and to expose the opportunities for improvement in PM&R. So let's start with the general information. Colombia is located in South America. Let me... In South America, the population is 51 million people. 99% of the population have health insurance, but it doesn't mean that they have access to every single service that we have here. And 75% of the population lives in urban areas versus the 25% that resides in the rural areas. So how is PM&R practiced in Colombia? So in terms of education, there are only six medical schools that have one or two spots for PM&R. These are the different names of the medical schools, and there is no fellowships. And there is a huge difference because the sports medicine and pain management are other... are a different specialty, different to physiatry. So there are 300 physiatrists in Colombia, and 54% of them are located in two cities, which are Bogotá and Medellín, the most important cities in the country. And the services where they work are mostly outpatient consultation, hospitalizations, and they teach, but there is no acute rehabilitation centers. There is no LTACs, no skilled nursing programs. So acute rehabilitation centers, there is no LTACs, no skilled nursing facilities, and no hospice care. So they say, for example, if a patient needs these kind of services, they go to their house if they are stable, or they stay in the hospital if they are unstable for the amount of time that they need. So what are the responsibilities of primary care physicians in Colombia? Knowing that there is a small amount of physiatrists in the country. So in my experience, I worked as a primary care physician in an outpatient facility and in a home health care. So I'm going to tell you a little bit of my experience. And I'm going to give you an overview of the MSK diseases that we have in our country and the percentage that is very similar to what we have worldwide. So the prevalence of MSK diseases are between 13% and 47%, and male are the most common patients with 64%. The musculoskeletal disorders account for 51% for occupational diseases injuries, including conditions such as rotator cuff injury, spondylitis, carpal tunnel syndrome, ulnar nerve injury, or calcaneal tunnel syndrome. And the conditions that we usually see in the outpatient facilities, as a doctor said, that the low back pain, the prevalence is of 27%, carpal tunnel syndrome, 13%, intebral disorder is 12%, and rotator cuff syndrome is 6%. So what we used to do if the patient comes into the office, we do the medical history, we do the physical exam, we do the diagnosis, we order images if we need to. We couldn't order ultrasound if the patient needed an ultrasound that needed to come from a physiatrist, but we could order an x-ray. And this is in the urban area. And we will order the physical therapies or the occupational therapies if they needed to. But there were a lot of challenges during that recovery and during that accessibility for those services for those patients. For example, the limited accessibility of physiatrists, as I said, there is a lot of millions of people for only 300 physiatrists. They require multiple steps and approvals for them to have a physiatry consult. And the access to the consult was for two to three months ahead. And for the physical therapies or the occupational therapies, the consults and the therapy needed to be like group therapy. So there was an individualized therapy, and if they needed one, they needed to pay out of pocket. There is limited transportation costs, lack of local services, and limited awareness of what physiatry really is. Because here and as a state, sometimes they don't even know the difference of what a physical therapist and what a physiatry does. So we're going to talk about the difference between how we take care of patients in rural versus urban areas. So this is Medellin. This is where I come from when I'm leaving. And these are the communes. So there is approximately two healthcare facilities. There is healthcare infrastructure because we have outpatient settings. We have clinics. There is healthcare workforce because we have physiatrists and we have every single kind of therapies, OT, PT, and speech therapies. We have accessibility of specialized services, and we have access to transportation, buses, taxis, and the metro. And we have two different kinds of services. We have the home healthcare and the outpatient settings. So for the home healthcare, we use this service for those patients that had a lot of chronic comorbidities and they had limited mobility. So they were able to go from their houses to their clinic or to the outpatient settings. So I show these pictures because when I was in home healthcare, my car, my Chevy, and I used to put stickers around the car for them to be able to know that I was a healthcare practitioner. And I wrote this picture for you to be able to see if a patient with a wheelchair or if a patient with limited functionality, they had to come up and down if they needed to go to a consult. So it's very hard for them to even transport to these clinics or to these outpatient settings, as well as here too. So in the outpatient settings, they had all the services for the patients to be able to recover. But remember that these services are mostly in the urban area. But now in the rural area, when the patient lives up in the mountain, there is geographical barriers. There is limited healthcare infrastructure. The patient barely have like only one hospital. And in the hospital, there is only primary care physicians and there is no other specialty. The healthcare workforce shortage because in these kinds of places, there was no physical therapist or occupational therapist, no therapist at all. There is limited access to specialized services and there is transportation challenges too. Let's say, for example, if the patient lives in the mountain, for them to go to a consult in the hospital or in the city, they needed to walk or needed to go by car. I mean, by horses or by donkey or walking two or three hours for them to get to where they were supposed to. And we have different kinds of patients. We have patients using wheelchairs, patients that wear bedbugs, patients with walkers, you can barely see a walker here, and patients with amputation, as well as we can see those patients in the urban areas that maybe they have more accessibility. We can see these patients in the rural areas too and in the condition, as you can see, that they live here. Patients in rural areas, when they don't have access to the hospital, they are visited by a primary care physician every three or every four months just to see them. But there is no therapies or nothing like that related to rehab. So these doctors, what they do is manage their chronic condition most of the time. So the challenges in rural areas, so the challenges in rural areas were mostly economic. The patients weren't able to afford healthcare services, transportation, medication, or utilities. And there is cultural and social factors too, such as discourage from people to seek medical attention due to their cultural beliefs, stigmas, and mistrust to healthcare practitioners. There are a lot of opportunities for improvement in terms of accessibility for skilled, personal, and specialist rehabilitation centers, which there is none here in the country. Education to improve knowledge of what PM&R is and to increase the numbers of physiatrists that we really need. Public awareness to support research initiatives for PM&R. And telemedicines for those patients with chronic conditions and telemedicines for those patients where they have difficulty accessing these specialists physically. I hope next of the mission trip is here. Right, we should plan one over there. Thank you, Dr. Velazquez for a great presentation. Clearly shows that, you know, the common thing is that there is a lot of multiple conditions that we are the experts that are treated, and, but then there's lack of access, there is lack of perhaps funding, people are uninsured, there is fear about and mistrust right about the physicians about the process. The unknown basically. And before I open up for any questions I wanted to also go back to Dr. Velazquez's question. We, when we were our first time in Dominican Republic. Just talking to the local leaders, we said, is there anybody you'd like any PM and our doctor around here or closer to us that is willing to dedicate a little bit of time so that we can partner. And then the answer was where they're about two hours and a half away. And we need to make sure they're able to close the day in clinic because they are in private practice. Which is another thing right we are in the streets right at least the one that I did with Marcos to the Dominican Republic. We're going out it's a rural area even though the Taiwan hospital is in a it's a it's a regional hospital so basically it's a main hospital in the area. There is still a lack of access right and for for services. I always said that it's always great to start locally right in our own community so that we can understand, you know how to deal with this issues and and get the experience of what it is to serve your community. And do it well and do it with limited resources. I think that's why, at least here in Chicago and through our department just understanding the value of community health right and how that opened the door to now allowing us to travel internationally. Hopefully with Mariana and we can meet other, you know, services, not services like community of powers of empowerment entities, that's what we're looking for that are not for profit, that are willing and able to allow us to come in and share. But I always said that in those trips I noticed and even in our community, a lot of people just want to be heard. They just, they just want to have a time to just communicate their needs, and just by paying attention, listening, and extending a hand right there they're grateful. 90% of the time, with just that communication, you know what is going on, right, and patients provide the history they have the key to what their ailment is and maybe with guidance, just a little bit of exercise, non-surgical management, you're able to treat them. Common theme also in both in, I guess, and I'm going to speak on Dr. Velasquez behalf and but that I've noticed with her and also with our trips to Santo Domingo, the ones that I did with Dr. Enriquez and even here in the United States. This theme, right, of MSK issues, that's what we see in the community, right, and the underserved and the uninsured. But there's so many things that we're not being exposed to, right, your spinal cord injuries, you know, the amputees, stroke patients. Dr. Velasquez did it as a primary care doctor traveling, right, as a traveling doctor primary care going to the houses and seeing those patients. So that is something that I think we thought about doing, going abroad in the Dominican Republic, but we truly got really busy in those trips. And if you remember when I first started presentation, I said that through the statistics that we were able to get from community health, we were seeing about 30 new patients at year 30, right? We only go once, is it twice? Once a month, right, Marcos? Yeah, I think when we started. Third Wednesday of the month. Yeah, and I think when we started and Dr. DeSigo can correct me if I'm wrong, maybe it was like that and then we expanded. But it seems, it seems slow, right, when we compare those numbers we saw in our second trip to the Dominican Republic 286 patients in only five days. Right, Marcos? Was it 286, something like that. And the day that we saw the most patients, we saw 75 patients in one day. That day, we were not using any ultrasound, we were not indexing because we run out of medication. And we were just providing, just doing a history of physical and providing home exercise program with oral medications that we had available. So, because we were not using technology, right, that is something that we have in our toolbox, right, of our doctor's bag. We went to bread and butter, history and physical taking and using our hands, right? As a psychiatrist, we diagnosed a lot of things with sensation, right, with feeling, palpating, especially if it's coming, if it's an MSK condition. So, I think that combining both has been eye-opening for me. It's something that I would love to continue to do throughout the year. And maybe, you know, reach out to the global health community and PM&R or other, I don't know, entities in Chicago, globally. See, you know, how we can make things work and get that experience one more time. So, I'm just going to, you know, stay quiet for a little bit and open up the forum to any questions or comments that any of the members of the press have. Hey, my name is Lauren. I'm a I'm finishing up my third year at MSU. Oh, sorry. My dog is very enthusiastic about saying hi right now. But I am really interested in PM&R and super excited to hear all the cool stuff that you guys have going on at Rush. I just wanted to say that it made me super, super excited that this is the area that I feel most comfortable going into. And I'm excited to continue this journey, learning more about stuff and definitely like how I can apply it in a global aspect, because I have enjoyed like my experiences so far going abroad. I have been to the Dominican Republic for a study abroad and and I went to Peru two years ago with my medical school. And so it was just it's just super fun that there are still opportunities to continue doing that in residency. Definitely. Thank you for your kind words. I again, I think that traveling abroad provides you with a wider view, and that's where where you train how to be an artist. Again, just navigating with the tools that you have and thinking outside the box. So, yeah. Thank you again for your kind words. I appreciate that. And just one thing, I thought that this was very rushed site again in Chicago, but I'm pretty sure or maybe I don't know about any other programs across the nation that are doing that. And they reach out before, you know, putting together this networking event to see if anybody wanted to share their experience. And and it happened to be that Dr. Velasquez, you know, now is going to be part of the Rush medical group or medical team, right? For a residency program. And and we're so thrilled that she's going to join us and she's going to bring that bring over that, you know, experience just working, working abroad. Michael, Michael, too, he was also practicing that I'm going to go public before he joined us for for him in our residency. So. So thank you. Thank you both for doing what you do and doing it with passion. Dr. Walker says there are other problems, but you may. Yeah. Correct. She says that there are other programs that we need to ask about them when they interview. In that in different purposes, probably for you, Lauren. So yeah, I will highly look, look for those programs. If this is something that you're passionate about, just ask about any opportunities during your interview trail. I will definitely add that to my list of questions. Awesome. Yeah. I think that the other thing that was a little bit inspiring what we did our trip. There was one of the medical students he was working as a translator. He was figuring, trying to figure out his career path in terms of what specialty he wanted to dive into just by working with us at the end he made his mind and got interested into PM&R. Maybe we don't have the clinicians and the Dominican Republic just joining us, but we're maybe reaching out and touching base with the future clinicians and just influencing those that are going to be our colleagues in the future. So to me that was very inspiring I try to stay in touch with them and try to mentor them along the way and into the physiatric world to. So yeah. So there's a question in the chat, saying, or asking from Arabia. Thank you for sharing what you're doing and through your experiences, how was the travel paid lodging, etc. So with this organization that we plan community empowerment. There's a fee right donation that that we paid and that will pay for lodging transportation and all your meals for your there. Also, water. You know, at all times, the other. We I did pay right and my, my case for my plane ticket right. And so it was, you know, that donation and my plane ticket but I know as residents or the residents in this case, Dr. Enriquez and Dr. Povian and also Dr. That was the one that went with us this year. Some part of that risk, funded by the department of team and our, and in another part of funded by the general medical DMV general medical education group. So at the end of the day, Michael's cost was a third of what I pay attending. And most recently, we have been able to get people involved and supporting our cause and we have like a go fund me now. So we're trying to collect funds to eventually figure out the destination of those funds if the, the opportunity is to make it more during the strips, because we know that cost is an issue, it's a reality. And if we do want to expand if we want to expand, we should ask, we should answer that question, or if we want to do a more frequent we have to answer that question too. So that's another that's a way that we're acting and trying to answer that question. If it's feasible to either expand or make it more frequent, depending on how much we're able to raise. We only have two minutes left. But I wanted to see if there were any last minute questions or comments. Oh, yeah, from Dr. Bosque. Are there any other opportunities to train family physicians or the type of physicians that may be accessible in the area? Yes, there is a huge opportunity to do all this again is the ability to get those sometimes so that they can take a little bit of their work right or time off from their busy schedule as private doctors. I do want to say that there were a lot of doctors that we treated in our clinic that work in the same hospital and they were general practitioners. And, yeah, I think they were all general general practitioners and they came over and they saw what we did we treated them and then they asked questions and when we were there. We just provided education about the things that we were doing and they were pretty surprised about the things that we did that they were not exposed to in their medical field right when they were training. So, yes. Thank you for that question Dr. Bosque. So it's 714. So I do appreciate everybody's time and in actually all of you guys joining us and allowing us to share a part of us right a part of our life as doctors, not only as a cypress right but also doing things that we're passionate about, which is caring for the community and doing it locally and also internationally. So thank you all one more time and hope to see everybody around. Have a great night.

Latinx session

Rush University Medical Center

physiatrists

musculoskeletal care

networking

community health

uninsured populations

Dominican Republic

healthcare disparities

Colombia

global outreach