Hi everybody. Welcome and thank you for coming to the session today. In planning this, Rose and I, like our number one goal was to just get a group together and have a conversation that was pertinent to things that we were discussing around last year when the session proposals would come together. It also happens that it's way easier to talk here than at a bar out on Frenchman Street. While this conversation has already taken place in a few pockets over the weekend, I think it will be nice to sit together with everybody and not only have the privilege of having a lot of close friends and mentors over the last couple of years join the panel today, but also meeting new colleagues too. My name is Charlie Kenyon. I'm currently an early career representative on the membership committee. Our session today is navigating diversity, equity, and inclusion through early career and mid-career transitions in musculoskeletal and pain medicine. Certainly, that seems like kind of a narrow scope, but I just want to give everybody a little bit of history on how this came to be. Last year, I had the opportunity to be involved with one of the medical student and resident ultrasound teaching sessions. Afterwards, I was having a conversation with one of the academy leaders about how homogenous that teaching panel was looking like. It was a combination of factors that led to that, but I felt like we needed to take that opportunity to broaden that discussion and kind of turn that into a positive and kind of carve out some time to talk about the challenges that we all face in our different settings from different experiences and kind of look at that through this diversity inclusion lens as a core goal for the academy. Then, that kind of got combined with other conversations I was having as a fellow that was going through my second year and seeing my peers go into their early careers and just seeing how these intersections were taking place. Pretty focused topic, but I do think that some of these things manifest a little bit differently in the realm of pain, musculoskeletal medicine. While we've done a good job of having these conversations in different settings, I just felt like it was worthwhile to carve out some time and, again, invite some great friends and mentors to have an open and honest conversation. Certainly, while all of us up here are in that musculoskeletal pain sports medicine realm, definitely invite people from all backgrounds to join the conversation and go from there. Rose Paschule, Dr. Paschule, is going to join me in helping moderate the session. Then, like I said, I have the privilege of introducing both friends, mentors, and new colleagues here today. We have Dr. Eves, who's joining us at Vanderbilt University. He's currently practicing pain medicine over there. Dr. Sharma, over at Thomas Jefferson and Rothman, also practicing pain and interventional spine medicine. Dr. Duarte, who's practicing pain medicine over at UMass, and a very close mentor of mine over the last couple of years, Dr. Stafford, who's joined from Emory University. I've had the tremendous privilege through sport and now medicine to be exposed to a lot of unique opportunities I wouldn't do otherwise. Specifically, I just wanted to thank Dr. Stafford for having the faith in me a couple of years ago to throw me in the fire as the team physician over at Morehouse University. While I may have stood out in the locker room, it was a great learning experience. I'll remember all that for many years. Our session objectives today are to discuss the impact of diversity, equity, and inclusion on early and mid-career transitions, and reflect on the impact of diversity, equity, and inclusion on the future of our field. Also, most importantly, provide peer-to-peer support. We have an intimate group today, but again, I'm not afraid of that. I think if each of us walks away with one more core relationship, then that's a huge win from the conference. I'll go back for those who might be watching this recording, just so you can see everybody's face here. We'll leave that up on the screen. Just some other reminders for those that are in the audience live today. Cell phones. Please silence your cell phones for all sessions except workshops. This will be an audio-only recording today. Also, as attendees, you're going to get evaluation forms. I encourage everybody to complete individual session evaluations as a help with future planning of the assembly. Without further ado, we'll get into some personal introductions. I'm going to let each panelist talk a little bit more specifically about where they are currently, what their training history and background is, and what your big-picture career goals are moving forward at this point. Whether you're in your early career or early career looking to transition into that next phase, what are the things that are top of mind for you? I guess that's close enough. I can lean in. Hi, everybody who's here and virtually watching this in the future. My name is Andrew Duarte. I'm a physician, physiatrist, and subspecialty in pain medicine. I practice currently at the UMass T.H. Chan School of Medicine, UMass Memorial Health Care, which is in Worcester, Massachusetts. I guess just my background, so I went to medical school at University of Connecticut. I did my residency training at NYU and then a pain fellowship at University of South Florida in Tampa. I guess kind of my unique kind of perspective coming into medicine as both a first-generation American, first-generation who graduated from college and advanced professional school, also being someone who identifies as gay. I think it's important to kind of foster mentorship in our space. I think everyone brings unique identities and pathways to their experience and how they relate to patients and colleagues, and so I think that's something that's very important. I've gotten involved at UMass both in the department as well as in the medical school. I'm on the admissions committee, which I think is a lot of fun. So I interview potential medical students, and then we have our committee meetings. So participating in that has been, I guess, an early way for me to kind of get involved as admissions. It's kind of been a strong passion of mine and kind of fostering a more heterogeneous medical school population to serve our patients and our community as well as nationally. So I'm excited to join the panel with these other great panelists. I'm not cool enough to be a panelist. I'm just the moderator today, but I'm really excited to be very honored to be with this group. So I'm Rosa Pasculli. I'm lucky enough to know Charlie from our fellowship together, but I have people from kind of all walks of my career here, and I feel very thankful for that. So I'm actually from New York originally. I did medical school at NYU and then stayed for residency for PM&R and then came down to Atlanta and did sports medicine fellowship at Emory and actually really fell in love with the city, and we made the transition down south. So that's been really fun. For me, I identify as a woman. I'm also Latinx. Part of my family is from Cuba, so it's been very important for me to have representation in that space as well as just feeling like a minority as a woman in where I work but also in our space. I think, you know, Charlie and I talked about this in musculoskeletal and in sports, especially when you are more straddling PM&R and orthopedics. I feel challenges being a woman there every day. We were joking earlier today about even just being called nurse. It's something that I think all of us women have experienced. It's something that I feel passionate about, trying to make sure we reach people as early as college and high school, people who are going into medicine. And so I do a lot of community outreach in the Atlanta area with high school students who are interested in going into medicine, especially women. And just really honored to be here with you all. I do a pretty diverse sports medicine practice. I'm in my second career as an attending and going well so far. Pass it on. Hi there. I'm also really glad to be part of this panel. Thank you, Charles and Rosa. My name is Saloni Sharma, and I am at Rothman Orthopedics, part of Thomas Jefferson in Philadelphia. It is a large multi-specialty orthopedic group. There are 300 physicians, 20 are female. So there's lots of dynamics that are interesting there. And like Rosa mentioned, I'm interventional spine, so there's a lot of dynamics with that too. There's not as much female representation. In terms of background, I went to Penn State Hershey for med school. I went to Jeff for residency. And then I went back to Penn State Hershey for anesthesia-based pain fellowship. I recently completed integrative fellowship through Andrew Weil. I'm also an acupuncturist, and I am very much mid-career. I feel like I'm maybe the oldest person up here possibly. And I think there's transitions that happen too, so I'm glad we're talking about that. Sometimes, you know, interventional pain doesn't make your heart sing the way it used to. And you want to open your toolbox and broaden it. And so I think there's important things to think about too, is not just diversity in terms of how we appear or how we identify ourselves, but in terms of our career path. And there's a lot of options with the MSK pain world. So thank you. All right. I'll just leave it like that. All right. I'm Ashley Eves. I'm excited to be here as well. I'm at Vanderbilt, and I do interventional pain there. I did my residency at the University of Washington in Seattle, and I did a fellowship at Wake Forest in Winston-Salem, North Carolina. And I just completed my first year of being and attending at Vanderbilt. And I would say I'm just now starting to integrate more DEI things outside of my clinical practice, given that I just recently started. But it's been really interesting just having conversations with patients in pain, talking to them, and we know, like, that they have different outcomes for people who are women, people who are women of color. So it's interesting having conversations with them about this. So I'm really passionate about that. As well as interacting with medical students, residents, fellows, sitting interviewing fellows currently, that's been interesting, and having conversations with other attendings about diversity in that space as well. So I'm excited to be here. Good evening, everyone. Thank you once again, Charlie. Thank you, Rosa, for putting this panel together, and thank you for inviting me. I'm Cleo Stafford. I'm originally from Miami, Florida. I went to medical school at Howard University, did my physiology training at Emory, went away to do my fellowship in angiosports medicine and primary care sports medicine, and then came back on to faculty at Emory. My clinical practice consists of the bulk of my time at Grady Memorial Hospital, where I work with Rosa. It's the largest state-owned hospital, definitely in the southeast, and probably rivaling a lot of the nation as well. I also spend a portion of my time at the Emory Clinic as well, which is more of an academic type of practice. You know, I was the first non-op or primary care sports medicine physician to start in a Grady ortho, so that was an interesting experience, but I also identify as a black male. My trials and tribulations in going through medicine of a lot of imposter syndrome sometimes, sometimes some inherent biases that I always didn't have to say it out loud, but definitely the temperature in the room, definitely my detail towards that. My goal, particularly now in my roles of attending, is that I try to empower all of my trainees so that they do not have to worry about some of the biases that I had to worry about, number one. Number two, my goal is to hopefully create a musculoskeletal network so to be able to treat patients from all backgrounds and paths of life. One of the things that I've continued to push at Grady, and Rosa's been a great advocate as well, is to bring high-quality techniques to our patients. We see a lot of individuals who either, A, don't have insurance, or B, are underinsured, or even if they do have insurance, their socioeconomic status are probably on the lower end when we start to look at that standpoint. To allow them to have access to these things, high-level techniques, that most places wouldn't even attempt to try on them because of their social status or unfortunately sometimes their ethnicity. My goal, and I know the rest of this panel's goal as well, is to try to combat a lot of these things. Thank you once again for having me. Awesome. Thank you guys. We have this mobile mic too. Maybe I'll take that one. If that's easier than the wired mics. I'm going to back up. I think a nice place to start. Again, we're going to ebb and flow between just career issues and as they apply to your individual identity and advocacy efforts too. Just high-level, looking at Andrew, Ashley, and Rosa, as you've started your career now a year into your practice, what's the number one challenge that you face? That can be whether it's just getting documentation done or anything. Yeah. I think certainly a big challenge is, Cleo mentioned imposter syndrome. I feel like as a first-year attending, stepping on your own to do procedures or even just making decisions in the clinic about medications or things that you know you've done 10,000 times already, but you just question yourself in that regard. I feel like that was an early career thing that, to me, was a little bit of a struggle that I am continuing to evolve and improve in that regard. One thing that I was looking for in my first job was to be able to join a department that had other physiatrists, although I'm the only pain board of physiatrists in my department. We also are very collegially integrated with the anesthesia pain department, and so being able to leverage their experience and their knowledge has, I think, been very instrumental in helping fend off those concerns. I think that's all I have to say about that. Yeah. I'll go next. I agree. The challenge sort of changes with every year I'm finding, so I agree that the first year out was complete imposter syndrome every single day for about six months and second-guessing every clinical decision I make and really finding my footing in terms of the way I want to manage the clinic flow. Then I think once you become more established and people start to trust your clinical acumen, then it's sort of establishing your personality among the team. I am someone who has a really strong personality, and there's been moments where I kind of flare and get caught up in the heat of the moment and I have to sort of pull myself back and reevaluate because it's easy to get lost in the we don't have staffing today or my patients show up an hour late and they get checked in, even though that's not our policy and just those sort of things that add up and multiply so quickly. I think my challenge has been just sort of maintaining my clinic and then now sort of making sure that there's a really good flow and there's a really good team in place. Now I think people sort of have respect for what I do and now just trying to broaden that reach, I think. In terms of the DEI challenge, though, I will say we talked about sort of being one of the few women. I've already had comments made to me this year about things that, in my opinion, probably wouldn't be said to a man, so things like tone, that magic word. When you give that feedback, it's like, well, what were the words specifically? And they're like, well, no, it wasn't the words, it was the tone. So you get words like that given back to you, and I think it, for me, prompted a lot of introspection and a lot of conversation with colleagues about how to navigate conversations like that. We actually have a female chair where we are, and so I kind of bounced that back to her, and she was like, well, let's sit down and talk about that. It's interesting that the two women, me and a female surgeon, were the two who got that comment. So, you know, just I think trying to take those tidbits and then the challenge is how do you respond and sort of change and grow from that. So I would say I echo the imposter syndrome for sure. During the first year, I think I'm now starting to come out of that a little bit, which is nice. I wanted to join a group that had a lot of people, a lot of other doctors that I could lean on for advice, and luckily that's been the case, so that's been great. I would say now the challenges that I'm facing are, from a patient care perspective, just advocating for them. Now I know what they want, what they need, but whether it's insurance or some other socioeconomic factor that isn't allowing them to get the care that they need, that's really, you have to put so much effort into it, and I want to, I want to help them, but it's like at what point do you stop, and asking other colleagues, and they're kind of like, oh, you do what you can, and then that's the end. But this is pain clinic, they have nowhere else to go. They've seen 10 other people, so I think that's been a challenge, navigating that. And then I would also say, so I'm in a mainly anesthesia pain clinic coming from a PM&R background, and so being integrated in our PM&R department from a DEI perspective, that's been a challenge to make sure I'm going back there, doing all these things, staying with the department. So I would say that I'm now navigating how to do that, and they're great, and our department's growing, so I think that's been things that we're learning. And then for Sloney and Cleo, are those things, hearing some of those things from people who are just starting a year out, are those similar experiences to what you guys had, and now reflecting back on those first couple years out of practice, how's your perspective, or how would you advocate differently for yourself, if you had the opportunity to kind of rewind a little bit. Yeah, I definitely echo the sentiments that everyone said. I think imposter syndrome, it doesn't really go away. It just sort of changes what you feel an imposter in, right? So maybe you guys will move up higher in career, and you'll be a chair, and you'll feel like an imposter chair. So I think the imposter syndrome lives sort of forever. I also do not like that term, because I think it blames the person. And it is our culture and society and the setup that makes you feel like that. So it's not a syndrome that you have. It's a problem that's a systemic problem. So sorry, that was a little aside. But yeah, I agree. I think that the challenges remain the same as you move along in your career, but they just sort of evolve a little bit. I think advocating for patients, you sort of, over the years, sort of develop a line about what you can and can't do and what you can take home and what you can't take home. I think advocating for yourself within your practice, whether you're in a multi-specialty practice, whether there's gender issues or other issues, I think you find a community, and you create a community. And I think that's one key piece, creating a community of people who are similar to you in whatever way, whether that's identifying a certain way or even just a certain subspecialty. And then you sort of form that community, but then you also find ways to connect with people in other communities, right? So it's sort of making those communities fit together. I think finding mentors can be helpful. So I think there's ways that, as you move along in your career, you sort of figure out to navigate some of the challenging aspects. I guess I could say retweet, but I guess as a panelist, I guess I'm going to say more than that. You know, an imposter syndrome, I mean, it's just a day-to-day thing. Doesn't really matter how high you go, how low you go. You know, it's going to be there. I continue to combat that. Like I said, as being an African-American male, there's a lot of times when I step in a room where there might be a certain notion about me. Sometimes they can think I can be intimidating, even though I might be speaking very passionately about a subject. There are times where they say, well, I'm young. Well, are you experienced enough to be doing this procedure? When I first arrived at my job, I was the first non out there. So, you know, at first they thought, though, I didn't know how to manage a lot of things because all I think I did was stick a needle in someone. And so there was a lot of combating with that. What I had to learn along the way was that the environment may not change, but I can. I had to change my lens from consistently worried about the negative attributes and try to figure out the positive attributes. Why do I say that? I used to come home and complain to my wife, you know, I keep seeing these same kind of injuries in these young kids, and we're not getting better. Like, what are we doing? Like, what am I missing? And she said, aren't you a physician scientist? I said, well, I don't know about the sciences part, but I am a physician. She said, why don't you go like do some papers about it? Why don't you go do some research about it? My wife's OBGYN, so she clearly understands it. So I got together with a couple of my friends and we wrote a health disparities paper looking at ACL outcomes compared to care because they have Medicare or they might have Medicaid. My point in saying that is that all of us, we will continue to have various trials or various obstacles placed in our way from various facets of our lives. And one of the biggest things I've seen to be able to at least help me so far is that change of mindset for myself, even if my environment itself may not change. Awesome, thank you guys. And do wanna encourage everybody to make this as interactive as possible. So feel free at any time, step up to the mic, panelists, if you have any point, counterpoints, just kind of jump in there. But one thing that you've been alluded to is kind of creating pipelines and pathways and it's different settings are more set up to be able to recruit people from different backgrounds. Ashley, I know you made a big point when we're in residency to get out there and go to schools and host events. What are some ways that you guys have found to be most effective to get people engaged whether it's in medicine or specifically in physiatry? So yeah, in residency, I did a lot of this. And we always tried to start with the youngest people we could get because otherwise we're all just fighting over the same candidates. So we would go out to elementary schools and get people, get students interested in science. We did a lot of advertising on social media for those events as well as for college students, medical students, residents, fellows, everybody in between. Did a lot of that. Word of mouth would just take time to have conversations with people. I was probably talking to someone like every week on the phone just while I'm driving or whatever. Just introducing them to what I do and how they can get more involved. And then I would also say speaking to other clinical faculty as well about the challenges that we're facing and how we can be supportive. And we did a lot of interdepartmental things amongst the University of Washington, knowing that each department is facing similar challenges, bring everybody together. That's one way to help with that. To echo some of the things you said, in a city of Atlanta, it's a very diverse city. I've had the opportunity to go out to elementary schools and actually speak to so many kids who are career day to someone that looks like them that can actually become a physician or become a scientist, become a lawyer and do these various things. So that's one way to outreach there. Two, when I have an athlete encounter, the first question that I always ask my athletes is never about the injury. I'm asking something about them as a person. Sometimes I ask them what's their favorite subject at school and PE and lunchtime are both options as well. Or I used to be a sneakerhead, so anytime someone comes in a certain kind of sneakers, I ask them about their sneakers. And the reason why I start that conversation off that way is because I went to the military, so we're people. I understand I'm a physician right now and right now you're a patient, but we're still individuals, collectively trying to move things forward. My point is saying is that each one of my patient encounters then becomes potential mentorship opportunity. Even if they don't go into medicine, where the facet of life, hey, let's try to get you to go to college. Hey, you have a little brother, a little sister, how about you read to your little brother and sister and let's continue to advocate and do things going forward. Because all these little small connections that we do at large events, also small events, I think make a big difference. I would also just say yes to everything early on. I think that's the best way to pay it forward. I think the imposter syndrome for me carried into that. Like I would get asked to speak at things and I was like, well, I just graduated medical school or I just finished fellowship. You don't want me, you should ask somebody else. But people do wanna hear your story and they wanna hear where you come from and something you say has the potential to resonate and connect with so many other people who may have a very similar story. And so for me right now, like that looks like Angie is here and she's from Morehouse and we just did an event just talking about on Zoom, what does it look like going into sports medicine? And for me, I'm a year out. I don't know how much wisdom I have to offer yet. That's that, again, that horrible term imposter syndrome that we feel, but she gave me feedback and we got feedback after that. It was a great event and people really, they wanna hear your story. And so I think just say yes, even when you feel doubts about it and just get out there and share your story with people. And I would also just give kudos to Angie and all the other medical students in the crowd of being brave to show up today or to send that email. And it's really fun to get you guys out, whether it's an adaptive sports event and getting exposed to that. So, just send the email. Like it's a small tight-knit group and we're all here to help. So it's awesome to see those relationships grow. On the flip side, have you guys ever had a particular mentor that's really encouraged you to kind of embrace or express your identity in a certain way, specifically in the workplace? Hard no. I wouldn't say it was a particular mentor, but it was a interesting experience. So when I was at UConn in medical school, one of the things that we do, and I think this has been done at a lot of other medical schools early on in your preclinical training, spending a half day a week in a clinic and you're interacting with patients, honing your patient skills, practicing that lung exam that you just learned. So I remember a patient that I interacted with was just making some very derogatory LGBT kind of comments without kind of knowing, I guess, outwardly that I identify as part of that community. And then I remember talking to the doctor that I was working with and he kind of was supportive of me, but kind of dismissed it as that patient's kind of their age and then I remember talking about this with actually our dean and the dean kind of challenged me. Why didn't you kind of push back more firmly and kind of shut down those comments because if you don't address it, they might continue to kind of repeat those things. And so I feel like that was something that I still kind of continue to remember. So like on my kind of faculty bio, I kind of mentioned as one of my interests as LGBTQ medicine and I'm kind of astonished the number of patients that I get, whether they're transgender or they're someone who identifies as gay or lesbian and compared to like my other colleagues, like when you think of like the population on average, the population might be five to 8%, I think, depending on what you look at various studies, but I feel like I get like several a day and I'm really surprised just by putting that kind of on my bio, like that kind of opens that door for patients to approach me and maybe be more willing to kind of discuss their concerns, even though it's not related to LGBTQ health. That's more obviously a lot of stuff related to primary care, endocrinology, some of those things, not so much pain management, but it's interesting just if you kind of put yourself out there, that patients will want to kind of make that connection with you and how that can help kind of enhance their care. So not a mentor, but something that still sticks with me and I think about at least once a week. Yeah. I wouldn't say necessarily a mentor, but where I was for fellowship, I was in Birmingham, Alabama. It's a pretty rural state, except for the city of Birmingham. They have a lot more, more outdated ways of addressing folks and thinking about that. And so I remember like, you know, my first couple weeks there, you know, one of the attendings, he's a pretty brash guy. And he comes to me, he's like, it looks like you're kind of cowering down sometimes. And I kind of look at him like, okay, this is a kind of weird comment. And he goes like, no, you have to understand, you have a very high intellect. I don't care what you look like. You should not walk into a room and cower down just because you're a large black man. You should just go in a room and be positioned. And here I am in Alabama, and I don't know if a lot of folks know about a lot of the civil rights things that happen in Alabama. Every day when I went to work, the 16th Street church bomb, I had to drive past that church every day when I went to this job. And so even then that, every day playing it back in my mind as I'm going to work to hear this man then say, hey, you need to be able to celebrate your blackness when you're at work, to me was kind of a slight turning point to me where I could just focus on just being in the best position possible. Because in a lot of spaces, even though it's not said out loud, there are certain terms that like you said, toned, or brashness, or other little things that seem like they're really antidotes and not serious adjectives. But after a while, you will continue to play those in your head even when you're sitting up there giving a speech to one of your patients. So not necessarily a mentor, but more of an entire environment and kind of forcing me to kind of get to that place. I would agree with that. I initially thought that patients might not want to see someone who looks like me depending on where I am. Like I work in rural Tennessee sometimes. And it's been so surprising and refreshing actually that a lot of them say, no, I saw your picture online and I chose to come see you because of that. So, and just having these other discussions with them too. So I think it's better than what I thought it would be. For sure. And yeah, and I don't have to change myself, which is great. Cleo, something that you mentioned when you're introducing yourself and has been very pertinent in my setting right now is, so two days a week, I'm at our Grady Equivalent County Hospital at Harborview. Two days a week, I'm in our like, quote unquote sports medicine clinic under the football stadium. Very different patient populations at times. And just trying to develop those like checks. Like you walk out of a room, you're like, did I treat that patient the same way that it would have at Montlake just because we're at this other practice setting. So if you don't mind just kind of expanding on how you accomplish that mission on a daily basis. Great question. I don't know if I have the best answer, but this is what I try to do. So I walk in a room and I just offer the patient all the options. Even though they might be fully well based on the, you know, it's a homeless patient. They may not be able to do some of the things I'm asking them to do, but I still want to give them the opportunity. If they tell me yes, then I'm going to figure out a way in order to help navigate some of those processes. I would say probably when I first got out of practice, I was always concerned that, well, I can't do this advanced procedure because this person's not gonna be able to do the rehab. I have to worry about a complication because they just can't, they don't have access to it. And for like the first 18 months, that's the way I was thinking. And then one day I had to just wake up and say, okay, but I got into medicine because I wanted to give people hope. I want to give people opportunities that I didn't have access to. So I'm essentially cutting out access, even though I say I want to expand the access. And so now I just walk in a room, I offer the patient all the options. If they say no, we can still tweak the plan, but now it makes it a little easier. It doesn't matter what office I walk into, here are the potential options available, and here's how we're gonna try to get it done. Some days it works to be completely transparent, some days it doesn't. But I just try to take that mindset now of trying to treat everyone, give them equal opportunity, even though their resources are obviously not equal. I think I'm just gonna expand on that because Cleo said it all and said it perfectly. And I think the second part of that is education, like outside of our clinic. And I think we can do everything in our power to treat all patients the same, but then you're gonna refer them to a physical therapist who may not do that. Or send them to another specialty clinic that may not do that. And so for where we work, I see a lot of high school athletes that don't have access to an athletic trainer, which makes things really challenging. Like for a concussion, having them do a return to play, who's managing that, the coach? No way, they're gonna have them go back the next day. And so really taking those opportunities to educate the parents or whoever the care is, coordination of care for the patient that you're seeing. But also all of the people that you're referring them to and just how important it is to kind of maybe go that extra mile for certain patients. Like we had a athlete who, again, a complex concussion. We actually sent him up to Shepherd Center to see like the neurologist who actually put him on amantadine, put a 15 year old on amantadine because he was having such cognitive issues after his concussion. But then he couldn't afford the medication. And so we had to take a few extra steps to make sure, and we had to educate everybody in that clinic. Okay, well, you prescribed it, but he actually didn't get it because he couldn't afford it. And so maybe just ask those questions when you're seeing the patient, like I'm gonna prescribe this to you, things like even just medication coupons. And I think just being able to constantly educate ourselves, but also everyone involved in the care team and sort of taking those extra steps for these patients and doing it for every patient. I mean, it doesn't matter who, but we have to trust that like when they leave our doors, we've done everything we can to make it easier for them. For the pain folks, how does that manifest in some more of these chronic issues in terms of trying to sometimes be more effective and do more with less resources? How do you empower your patients in your setting? Yeah, I take a similar approach where I offer, give them all the options, and then we go from there. But that way, at least I know that I've set all the options. I will say I have had some conversations with some of the fellows when we do chronic pain consults, and they're mainly running the show. I'm there to help them out. And I'll say, okay, what did you offer this person? And why did you do that? Do you think there's anything more you could have given them? And I have them go back and talk to the person, and they're like, oh, yeah, maybe I did treat them a little differently. So I think just going that extra step and really thinking about what you did. Because sometimes with chronic pain consults, you're not gonna offer them every single thing. They'll get confused, but you're like, okay, let's go the extra step. So I would say that's been just thinking about it. It's been good. Yeah, and I don't think this is just unique to pain in our field as physiatrists, but physical therapy and the barrier, whether it's getting a ride to the place or a language barrier or just the actual financial barrier of a high copay, and just taking some time to, well, A, educate the patient about what's kind of contributing to what they're experiencing in terms of their pain, but also giving them the exercises. And I was actually texting Rosa about a patient, and she kind of introduced me to the UCSF kind of different protocols that they have for some of the basic things, whether it's knee pain or hip pain or back pain. And I think finding those resources, and even if it's not your institution, there are validated kind of things that can be done online, and introducing those to patients, particularly in those kind of more resource-sparse areas, I think can be very helpful in empowering patients to kind of take a more active role in treating their pain as opposed to identifying that this is bothering them and this is just another barrier why I can't get treatment. So it just is kind of a negative feedback loop. So even if they're able to, A, understand what's going on by taking that time to educate them, and even giving them something active to do, I think, is a good way to kind of put the locus of control for them. Instead of feeling like there's nothing that they can do about it. They can't afford the treatment. I definitely agree with that. Just like everyone said, definitely give everyone the same options. But with chronic pain, especially, giving them some empowerment. So going through the lifestyle medicine pillars, for example, which are daily choices that you can make. And having handouts, which in lifestyle medicine, the pillars, I'm sure you're familiar with them. So it's like sleep, stress, exercise, positive relationships, stress management. Those kinds of things don't have to be an expense. So you could have a handout about how canned and frozen foods that are plant-based are just as nutritious and healthy as things that are fresh. You don't have to have the $20 salad to eat well. And so I think having handouts, it sounds so cheesy, but having handouts. Because if you just say, hey, eat healthy. That helps with inflammation. That's not really going to change anyone. And so when my surgical colleagues say, this person needs to lose 30 pounds to get a hip replacement. Go lose 30 pounds and come back. Those people aren't coming back. They're not coming back. And so I think if you can't have a full integrated lifestyle medicine center, you could have the handout. You could have the therapy handouts or online resources. There are online resources for free mindfulness exercises as well. So there's definitely free apps. Insight Timer is a great one. And Common Headspace have free versions. So I think doing that, sometimes with a patient, I'll have them download the app in the room with me if they have a capability. Or just write out the website that they can even go to a library and listen to the website if they don't have a computer at home. And so I think empowering that and showing them. And having a physician say, these things make a difference for your pain is huge. Because most people, most physicians don't really tell them that. And so saying that you can have this locus of control and you can have this power and not be such a passive experience can really help people in pain. I'm going to see if anyone has any questions. I'm happy to come run the mic over. But I want to make sure that this is interactive. Hello, Karam. I'm MS4 from University of Kansas. I wanted to ask, within rehab around the country, especially around the area where I grew up, it doesn't have as established of a presence. And especially when you work within academics, if you're trying to advance, progress change in your workplace, or provide education to staff or stuff like that, you're going to have to go through a lot of hoops, obviously. If you're working under another department, let's say your PM&R is under ortho or under sports med or anything like that, I just want to know, does that make it harder? What are the challenges that you've had to go through when maybe you're a subsection of another department or when you're in an area that is already established and you're having to go against the grain? So I guess it depends on what their attitude is towards PM&R. I think previously, not all specialties liked PM&R. I think they're now realizing the value of it. I'm mainly with all anesthesiologists. There's a neurologist myself. They love PM&R. They see the value in things that I can do that they can't and vice versa. And we learn from each other. So that's really nice. And my fellowship is also an anesthesia-based fellowship. They did not have a PM&R. They had two PM&R physicians there, but not really a robust department in general. And so they saw the value because we had all these patients that would come to the pain clinic. And I was like, they need a PM&R physician. And they were like, yeah, this would be good. So I think it's been great, because I think that that was already established for me. But there's a lot of education that goes into about what you do and what you don't. But most of the time, I think they've been coming around. I would just echo a lot of education and not. So when I first arrived, I did a little five-minute elevator talk about things that I could offer to the department, not just things I did. I changed the things I can offer to be able to assist with patient care and to be able to potentially offload some patients, optimize patients. That was one of the first things I did. And then any time I had an interesting case, I would just go talk to one of my partners. And it wasn't really always to get the answer to the question, but just for them to feel more comfortable with the way that I wanted to practice medicine, the way they practice medicine, so that we can find somewhere in the middle to meet. Once I started doing that, I was able to get a little more access. But that's where it kind of started a lot of education for the staff, having educated staff on what I do. And then luckily now, I have two great women physicians that work with me who are really spearheading taking that even more forward. So a lot of things when I come in now, Rose is coming in and starting an acupuncture clinic. That's something, another facet that we didn't have before. But it's been a lot of education, not just from the staff, but from administrators, the whole entire system to kind of help them understand, this is why we should be able to offer these type of treatments. So if you hear nothing else, I guess from this is education. The Academy has a lot of resources, too, the BOLD initiative. If you're working with administrators, they have a whole language behind it. And a lot of it's showing value, right? So we're talking to administrators. It's all about money. And so showing that you can save money and be cost-effective, but still provide good care, maybe prevent someone from having a big surgery, or manage their pain in a different way, I think that's something that's important. And there are Academy resources for that, too. Yeah, I think being in an orthopedic department and being the first pain board of physiatrists that they've had, once it did the first genicular block and genicular RFA, the knee surgeons send me all these patients now. Like, they're like, oh, we've, like, even the anesthesia pain, I don't know why. They don't do the procedure. I think part of it is billing and their time. And then expanding that in the future towards neuromodulation, I think there's a lot of avenues for that for patients that either are too sick to undergo surgery, or their BMI is the main barrier, or for whatever reason, they just don't want surgery. So I think advocating your skill set, and all it takes is one good patient to a referral source, and then they're going to think you're the best physician ever. It's pretty remarkable. That's one thing that I didn't really understand as the importance of those relationships or your referral sources. And if you set that expectation, or a patient goes back with a good word, oh, Dr. so-and-so did this for me. They sat down. They explained the imaging. It just really opens doors, and then you become very valued. Thank you. Hi, my name is Angie. I just want to say thank you all for coming here and talking with us. My question is, I'm currently a second year medical student, and I was wondering, moving forward in a medical student's career, perhaps as a woman, or as a minority, or even an underrepresented individual, what might be some things to look out for, and how would you approach them? For example, negotiating salary, or even just standing up for yourself and speaking up for yourself, if you have any examples of that. I'll start. That was a great question, and probably the hardest one we'll get today. So one thing I found to be extraordinarily helpful in my personal experience and from talking with people is to have conversations with everybody around you. I think, in terms of, I'll take the salary one, a lot of times you will get a number, and you don't know what the person next to you has offered. And you don't know if the number you got is because you're new. You're a woman. You're Asian. You're X. You're Y. You're Z. So it's what I found, and we were just talking about this in the example where one of our co-residents from NYU got an offer, found out that offer was lower than a male's offer, who was also fellowship trained and was going to the same institution. And because they're friends, they had that conversation, and she went back and renegotiated a better offer. But a lot of the times, you're walking in blind and you just don't know. And so I think there are some people who don't want transparency, and they don't want that for a reason. And so I think the best thing to do is just to ask questions and to try and meet people and try to have that conversation. And then once you build that trust, then there's an open door to talk about actual numbers, which is a really scary thing. And again, we're just using the compensation one. But for me, I think that's something I've tried to get braver with and not really worry what people are going to think of me and just say, OK, I'm doing this because I want to push for my own skill set and push for my own value and be brave enough to ask my colleagues about these conversations and have those talks. And then I think once you get through that door, it becomes a little bit easier. And I would say the second part of that is just knowing your worth and knowing your skill set and then being able to prove it. So I can say I do all these things, but at the end of the day, I'll say, these are my RVUs. This is what I'm worth to this practice, and that's what I'm going to show you. But you can't just, you know, everyone wants a hard number and they want to show you, they want you to show them that you're going to make them money. That's when you become our age. That's all they care about, unfortunately. And if you can go in and you can do that, then you're proving your worth. And then when you, for example, with compensation, you give a number, then you have a reason to stand by that number. And just data collect in every way. Have those conversations, and it just gives you more blocks to be able to stand on. But that's a really great question. I think, too, given where you are in your training as a medical student, on your horizon is going to be residency application. And a lot of that has moved to more of a virtual platform. But then there's these great events like AAP Menorah, where you can meet programs, program directors, residents, and engaging, and kind of like Rosa said, engaging in those conversations. And so you never know by bringing up whether it's hobbies related to your identity or something else, that's a good, I think, segue to kind of get a pulse, a sense of the pulse of that program and their willingness to kind of incorporate that in terms of the resident body or even the faculty. So for me, I always kind of start with, oh, my partner. And I don't say it's a he in the beginning, because just kind of leaving it vague and kind of testing those waters. And because certainly in different settings, whether it's been in training, as a medical student, you're the lowest person on the neurology service. And you're just like, oh, I'm here. And there's residents doing all these things. And even, I think, as an attending now, like meeting a nurse for the first time, and they're asking, oh, what did you do this weekend? And I still kind of keep it vague in the beginning. But I think as you kind of engage with people and you understand that a lot of people kind of share the same values as you, and then you're more willing to kind of guide yourself towards that residency program or that part of the country or whatever else it might be. I think, like Rosa said, just being open and engaging in those conversations goes a long way. I'll just add something real quick, because they did an eloquent job explaining it. Bravery, like they said, being able to reach out. When you reach out, you make those connections. When you make those connections, you now have data points. The last thing is that you have to become a very good storyteller. Whether it's on residency applications, fellowship applications, or where you're trying to prove your worth, you have to tell a great story. Now your great story needs to have the data points. You need to have those connections so the individuals listening to your story are now still connected to those data points, but you're still being brave at the end of the day. A lot of time in medicine, administrators have figured out we would just rather see patients than worry about the rest of the stuff. As long as we continue to not worry about the rest of the stuff, we will continuously have issues where our worth is not being truly valued. But it's because we have to start doing these things that my two other panelists just spoke about. Sometimes, in truth, you're not gonna stand up for yourself, right? Okay, so sometimes you're in a hierarchy and there's a hierarchy setting, and he mentioned that maybe you're the lowest person on the totem pole, and I think you kind of pick and choose your battles because there's only so much you can take home and only so much you can carry. And so when there's some, quote unquote, microaggressions, I think you have to sort of decide which ones you're gonna sort of speak up and sort of bring to the forefront and which not. And I think that's very individual because it does take a toll on you. And so I think it's important to not feel bad if you don't speak up. If you're not in that frame of mind or in that place, I think that's okay and that's not your burden to carry. Ashley, I'm gonna put you on the spot here real quick. Something that we never talked about was the summer of 2021 or 2020. And I just will always remember the two of us sitting in the workroom at Harborview, it was probably about the same size as this table, would you say? Yes. COVID, like everyone trying to be masked and they're like distance, but sit in this closet together. So it's been locked down and it's a very stressful place. You're taking on the NERF leadership, and then the George Floyd episode happens and there's riots outside of the hospital. You're just trying to survive a very challenging residency position in a normal setting. And then I was always very impressed by how you handle yourself being asked to navigate a leadership role in response to what was going on in the world that was above and beyond, what would put anybody else at their normal capacity? So I've always wondered and what was actually going through your head at that time? Yeah, I would say that, like he said, the setting, at first I was like, oh my God, why did I do this? But it was actually, it was great. And I think like you were saying, you have to pick and choose what you're gonna worry about and what you're not. So some things I just, I could not be worried about while I focused my energy on other things, just because otherwise you'll wear yourself out. And I did get worn out, like for sure, but I was also happy that I thought I was helping people doing things. But yeah, it was, I don't know, looking back, yeah, focusing on the things that you can fix and not on the things that you can't. Thanks a lot for talking, everyone. I have a question for the females on the panel specifically. As we all know, the split between men and women in physiatry is about 65-35, 70-30. 70 men, 30 women, more or less. What is your institution doing to fix that? And if you can, just speak about your experience about probably being 20 of 300 physicians who are women, or I don't know what the ratio is for the rest of you. But I'm wondering what your institutions are doing to ameliorate that issue. Well, I guess the 20-300 comment was sort of piggybacking on what I said at the beginning, because that is the dynamic where I work. There is a DEI council, I believe we call ourselves, that I am on. I don't, I think it's, sometimes, to be frank, because I think we're being an open group, and you're frank, so. I think, you know, sometimes people do things for show, and I think that's something you have to be ready, right? They want to look good on paper. We have this committee, checkbox. We're doing the right thing. And so I think that's a really hard thing to navigate. I think it's hard to be a minority in whatever form, and then, you know, people talk about this a lot, right? So it gets put on you to fix that problem, right? Because you're the minority, so you should somehow, it's your problem to fix, which of course it's not. But I think that's hard, and I think it's hard to, you know, be in places, sometimes, where you feel like they're just saying the right things on paper, but not taking action. And so it's struggling to find, for example, in my workplace, even though I'm not being super positive right now, there are some older, there are not older, but more senior mentors who I'm sort of aligning myself with. They're not physicians. So I think sometimes looking outside the box, and even finding, like, administrators you can click with, or who have the same priorities as you do, I think that can be a helpful way. So I think aligning yourself with mentors, and sort of compounding your voices together, and having concrete events. So it's not just, like, we meet once a month, and we have a conversation about DEI. What are the events we're doing? What is the change? What is the data we're tracking, right? So I took the Stanford Wellbeing Physician Director course, and we talked about don't get sad, get data, right? And so really collecting data, doing, like, surveys, and seeing how people's attitudes are, seeing if that changes with some of the events you do. So I think that's some of the things you can do, is sort of align yourself with people who are like-minded, and try to record what the current, sort of, thought processes are, the current attitudes, whether that's surveys or other ways, and then actually have events, and sort of advocate for events and outreach programs. We do, now, these sort of employee resource groups, they're called, so we're trying to have funding for people to get together in their individual, the way they identify themselves, based on that. Purely, they get to make the groups, sort of like our community groups here at IAPNR, and give them some funding to, sort of, put something together, to have an event, or to do some public service as a group. So I think that's it, sort of, taking action and finding mentors. I would say there's not a lot being done, where we are. Unfortunately, like, speaking the truth, we have, what is it, 20 non-op sports medicine physicians, more or less, four women, we had five, one left, because of how women were treated. And I think the thing that I'm trying to do is use her leaving as a gift, and she and I had a conversation about that, and she said, okay, take this now, and try to run with it. So I think, like, to identify opportunities, where now you say, okay, there's been a change, how can we move forward from that? And so, for me, what that's looked like, is since she's left, is having the same conversation, on repeat, in writing, and in person. So that, at least now, the conversation is being had, from multiple ends, and it's not something that they can ignore. So it's, we lost a faculty member, how are we gonna replace that faculty member, and now, how are we gonna use that as an opportunity to grow? And so for me, what that's looked like is okay, I'm gonna come with some ideas, put them in writing, so they're not, at least they're documented somewhere. But then also just having that conversation with the people in charge and making those decisions. But to be honest, I wish that our department was doing a lot more. I don't know if Cleo has insight on that. But it's been sad. I know we can't be all sunshine and rainbows here. And so speaking very honestly, I don't think they're doing a lot. And I also think that's the nature of we're in an orthopedic department. We're not in a PM&R department. And so the ratio is a little more harsh. And I don't know if it's something that necessarily they want to fix, to be honest. I will say from another perspective where we take a lot of people that we've trained in fellowship and keep them on if they wanna work at Vanderbilt. And so when we're interviewing fellowship candidates, we have conversations about this person is a woman. We need to move them up. We just ranked 10 men. Move up the women. Or this person is a minority. Move them up. Things like that. And so I think that. And then from being at fellowship there, then they can get a job there. So I think that's one way that we're increasing female presence. So that is something we're doing in my workplace too. I think the difference is I feel like a lot of DI initiatives end up being very external. Go to the high schools or go to the colleges and talk about diversity and talk about different pathways or recruit these wonderful candidates. But then when they get there, the work environment or culture is terrible. And so I think there's different paths to DEI. And I think it depends on. And I think no one group obviously can achieve them all with perfection. That's not realistic. But I think it depends on what your priorities are. So for me, I think we have a lot of the outreach and we have a lot of the recruitment stuff in the last couple years. But I don't know that when you get there then, it's like where do you land again? And what's that culture? What you're talking about? And I think that's a hard thing to change. Hi, I am not within the medical industry at all. I'm not a student, resident or anything like that. So my question is kind of as someone who's outside the box, what can we do as patients or friends or partners to support minorities or underrepresented communities within the medical industry, either through, well, I guess anything really, big or small, larger movements or just stuff at home to ease the burden that comes with, as you've all kind of pointed out, the struggles that can come with being underrepresented. How much time do we have left? Yeah. So it's a very important question that you asked. I'm not gonna give you a perfect answer though, because one, just if we look at United States of America, there's so many different pockets, so many different cultures there where you want to meet individuals. I even try to stop myself from saying I wanna reach them because it almost seems like there's a hierarchy. So I try to meet them in whatever space we can potentially find. Some of that starts at the very earliest school levels, elementary school level. Yourself, you're not a medical fair, however, just putting on career fair so that these kids are able to see folks that look like them in so many different facets of life. So that's number one, okay? Number two, partnering with community organizations. A lot of times there's folks giving federal dollars to the American Red Cross and other areas, but they tend to sit in the same parts of town, probably where it's probably not as needed. And so be able to get those resources to other areas that definitely need it, number two. Number three, and we got 10 minutes left, all right. Starting to look at your political leaders. There's a lot of things that comes from funding just from the fact that who's actually on these various boards, where's funding's gonna go for hospitals, where's funding gonna go for schools, all these various initiatives, whether it's new housing projects, whether it's new building permits being given. All those things matter, and the reason why they matter, if I got another 30 seconds, is that, for instance, the amount of money that a school might have for athletic department typically comes from the taxes being paid for the houses in that area. Well, the houses in that area being appraised at a much lower rate, that means you can't raise as much tax money to be able to help those students. Instead of those students being able to participate in school sports, now they have to go play in travel ball, which takes another $10,000 away from that family who already doesn't have it. So now we have a kid that thinks that the only way I can get out is that if I play basketball or football, because my mom, who barely has enough money, wants to send me out. Well, some of this stuff could be avoided if we actually had more equitable use of these funds to be able to help folks. So, thank you. There's no way to follow that, but, because that was incredible, and I think that was very big picture. If you want very little picture, I wrote a book and I call things micro-boosts, like little steps that add up to big change. And so, if you want little micro-boosts, it's gonna sound really cheesy, writing health grade reviews, sharing good experiences on social media, Instagram, LinkedIn, Facebook. And like he said, sort of having that representation and showing people that these people may not look like you, but this is a great experience I've had with them, this is a great care they've given me. I think those are really easy steps, and then doing all the wonderful big picture things that Cleo talked about. Hello, so, in pain, sports, spine in general, a big thing that we deal with when we deal with populations of all kinds of different backgrounds, I myself, I come from a family completely of refugees, and I got the privilege recently of getting to work in indigenous communities and reservations and stuff like that. And what I've kind of like seen and observed in my upbringing and recently, is there's so much in the care of these patients of like complimentary, integrative, alternative medicine, Eastern medicine. And I've always seen it throughout my medical training where a provider will either go like, do whatever you want, or just like, I don't believe in that stuff. And it's always like shunned away, and I feel like that leads to a big distrust with the community. I wanna know just in general from your practices, what are your experiences when you have patients bring these up? And what have you done to better educate yourself on the stuff that they do and stuff like that? I think two of us are probably pretty biased, if not all of us, so take it with a grain of salt. But, you know, for me, I practice acupuncture. I was really lucky enough to have a mentor during residency who built that into his practice and offered it to us. And I just have found that I don't know who I am to tell someone that something doesn't work. I've never thought like that, and it makes me sad when physicians think like that. So for me, you know, if someone asks me about something, I'm just completely honest with them. I say, either I haven't heard of it, but I will look it up and do some research on it, or I will find someone who knows more about it and get back to them. This comes up with a lot, a lot of supplements. I mean, medical marijuana now, which I don't prescribe, but there are people in our community who do, and so I'm trying to get patients resources. You know, a lot of different tools. So I practice acupuncture, and people ask me about that all the time. And a lot of that has been educating our partners at work about that. But I think what you can do is just say, if you don't know anything about it, say, I'm gonna look into it for you and get back to you. And if you do know something, you can tell them what you know. So a lot of people ask me about, you know, for OA, turmeric, glucosamine chondroitin, and I say, okay, you know, the data is mixed, and I talk through it with them, but I have patients who swear by it, and they say, this is what fixed my knee OA, or I have a dancer who said, this, you know, turmeric fixed my patellar tendinopathy. Great, okay, so I'm not gonna question it. I'm gonna accept it and, you know, and then tell that story to somebody else and say it may help you, but it may not. And if you're interested in trying it, I think it's worth it. But, you know, for me, I just like to stay as open as possible because we are fallible and we don't know everything and just try to keep learning. I think that's what we all love about medicine. Yeah, I think too, I think that's a great question. I think one thing that I personally try to do, and I don't know if this is the correct approach or not, is I'll share, oh yeah, I had another patient who referenced this and they found this to be beneficial, but like Rosa mentioned, this is what I know about the data. And I also always try to be cognizant of like the financial implications of them going to get this treatment or buy this pill and just being upfront with them and saying, yeah, if you find this to be beneficial and it's doing no harm, it's not interacting with anything, I think that's reasonable. But if you feel like it's not doing much, then you might be able to spend those financial resources somewhere else that might benefit you. This supplement has, like so for instance, like alpha-lipoic acid in patients with peripheral neuropathy I talked to them about that and how that does have some evidence behind it and we could try that maybe. And so, but that's a great question. Yeah, I agree. I think being open, like everyone has said, and the do no harm thing. So if it's not hurting them, if it's not dangerous, I think a big thing also is it's not instead of, right? So it's not like I'm gonna put all my eggs in that basket, Reiki's gonna cure my disc herniation, right? So I don't have any problem with Reiki, I just don't think it's gonna cure the disc herniation, but I think it can help with pain control for Reiki. I think Reiki can help with pain control possibly, maybe, I think so. I think it can help. I think there's a placebo and a nocebo effect and there's things that can happen and I think can be helpful. But I think it's sort of saying it is, yes, we're open to that and if we don't know, we'll look it up. But this is also should be part of a big treatment plan, not the only treatment. I think it can also be hard in some of those situations where you're not as familiar with the patient's background to sometimes put yourself in their shoes and I found tremendous power just stepping back, just what are your goals, what are your values, what's most important to you in this visit and find that that can really open up the conversation. Time for one more question. Hi, I'm Anna. I'm two years out of residency. I'm practicing at a small kind of rural community hospital. We're high public payer so I do have a lot of patients who have poor access to medical care and poor medical literacy and kind of wondering for the patients, you're offering, obviously you're offering the same treatments to everyone but for the patients who aren't going to be able to access them or aren't, they don't have a cell phone so they can't get the reminders about their appointments or they have a language barrier, how do you avoid getting burnt out when you're trying to go above and beyond but the system just isn't working? Daily struggle over here. It's an excellent question and being completely transparent, like 24 months into my current job, I was reaching a point of why am I into medicine? You know, I'm doing my best but I clearly don't have enough to be able to make a difference and then I started doing little things so instead of giving them a handout, I would start doing the exercises from the handout and so then I would literally show them how to do the exercises. Now we start to give them resistance bands so they leave knowing now, okay, well, my doctor can get up on the table and do it. Maybe I might be able to do it. That's the first thing that I do. Two, and I think someone already mentioned or there's other websites that sometimes we use and if they don't have access to a website, sometimes I'm just trying to get them to couch and get them to exercise. A lot of them have cable. Well, a lot of these Comcasts and Spectrum, they have exercise videos on cable so that's already something that they're paying for that could be potentially being utilized and I get it about the physical therapy part because Rosa and I can probably tell you about 25,000 stories where we're trying to do things. We do partner with a physical therapy company that actually provides rides for patients. So there are companies that are willing to do it. We have another company that donates hyaluronic acid to our clinic so that we're able to do physical supplementation injections for patients if they don't have any money. It does require some more thinking outside the box but there are opportunities to be had in between the burnouts. Yeah, I would echo on that, that I think the planning upfront requires more brain power and more investment and that can have the potential to burn you out while you're still practicing but for me, I know the handouts have come up a bunch so I made a whole folder box and I have everything in there. I have orthotics but I don't just have what is an orthotic, I literally have the Amazon page with the picture and everything and I do that for the metatarsal pads and everything because if I say, okay, just buy these on Amazon, then they go home and they're like, there's 4,000 options on Amazon but so I'll take an actual screenshot of it and if they want to, if they have a phone in the clinic, I'll actually have them order it in clinic with me and so I think just as many steps as possible trying to eliminate it but being cognizant of, okay, if we plan ahead and do all of these things earlier, then you're not sitting in clinic. Let me go to my computer, let me find it, let me print it, let me give it, you know, if it's already done and made, I think it makes such a difference and like the EuFlexa and MonoVis that we use, we've learned that we only use MonoVis effort and then we talked to a medication coordinator and she's like, oh, do you know, EuFlexa has a patient assist program that you can apply for and we were like, we had no idea so all the patients that had gotten denied now we have another option for them and so I think part of it's luck and timing but I think part of it is, okay, let's like do a dive and find these resources and then pool them and bring them into clinic and try to have it sort of lined up for yourself because, yeah, I mean, when I first started, I was spending like an hour with a patient in clinic and then you're like, okay, well, thank God I just started. I only have six people on my schedule today. I think it's starting out to you feel a lot of pressure to solve the world in one visit too, right? So I think taking a step back and taking a breath and giving yourself some grace but also realizing that we just need to pick out one or two wins at a time and those can stack up as we build relationships. Also, I think that's where like the wellness stuff comes in in terms of like sleep, diet, like you're already doing those things, like you can improve that and it's free so or like the cost is the same. So I think that's where like insurance will deny every procedure I do. The patient can't go to physical therapy, the medications are too expensive, what do we have left? Then those are the things and those actually like can make a difference so that's what I'm typically working on then. Do we have one second? So I also think that the goal that came up too, like what's the patient's goal? Because your goal might be to cure their something and that's not their goal. Their goal is to be able to walk to the mailbox and they're very happy if they can walk to the mailbox and so I think that helps you not take it home but also a lot of people, we don't solve their problems, especially in pain and a lot of them just are happy to be heard and I think you maybe underestimate the difference you make by being present and listening to them in a way that no one else does in their life. So I think just keeping that in mind that you are making a difference if you're not solving the problem per se. So we're coming up on time but we're finally getting the gloves off a little bit so I think with that energy that we have going right now, I do wanna, before we kind of take off on our own ways, having the privilege of having this recorded, someone from the Board of Governors, when they go and listen to this session on their flight home or whatever, what would be something that you'd wanna communicate to the Academy about what we can think of as next steps and keep the conversation going? I think we need to have more sessions like this, more conversations. I think there should be an annual, we were talking about this in D&I this morning, an annual session dedicated to D&I issues and it could rotate what the topic is but if we don't talk about it, we can't improve it. And taking it a step further to just prioritize this, we're at a session right now, 3 p.m. we're competing with six other sessions. If this is a priority, let's put it on the main stage and let's get a lot more people in the room and have this conversation over and over. And just talking to colleagues, like this has come up so many times, but just having those conversations. Every conversation is an opportunity for some of us to learn something about the other person and so I hope if they're hearing this, they take that moment now to maybe look at a patient a little differently or their colleague and maybe ask themselves, what do I wanna do with this? Funding, continue to have funding for various advocacies that we're trying to complete. The academy right now is focused on a whole lot about health equity and disparities. We continue to provide funding for potential research projects in those areas or community service projects for a lot of our patients that definitely need it in addition to making something like this on the main stage like my colleagues have said. So we're gonna continue to do that. In addition to making something like this on the main stage like my colleagues have greatly pointed out. I completely agree. Put your money where your mouth is and yeah, funding is good. Maybe also incorporating this with trainees as part of the medical student program or putting resources to connect residents or people who are transitioning into their early careers as part of that mentorship program. I think could also go a long way to making those personal connections and getting those anecdotes and knowing that it's helpful to know that someone who's done this and navigated this successfully or maybe give you the pearls and pitfalls of how they would have maybe done it differently. All right, well, thank you all. It's been a privilege and I'm glad we were able to have this opportunity and like I said, making new relationships and hanging out with old friends is always a privilege in annual assembly. So for the medical students out there, you guys got your reception downstairs now, go there, meet everybody. Those are gonna be your friends, colleagues and mentors for a long time. So like I said, send that email, reach out. A lot of us have social media or email presences and we're happy to continue this conversation.

diversity

equity

inclusion

musculoskeletal

pain medicine

imposter syndrome

representation

mentorship

chronic pain

patient empowerment

resource-scarce areas