All right, we will go ahead and get started. Thank you everyone for joining tonight's member community session. Before we get started, we'll just review a few housekeeping notes. As a reminder, this session is being recorded and will be available along with the ability to claim your CME through the Academy's online learning portal. For the best attendee experience, please mute your microphone when you're not speaking. You're invited and encouraged to keep your camera on and to select hide non-video participants. This will ensure that speakers are prominent on the screen. To ask a question, please use the raise your hand feature and unmute yourself if you're called upon. Alternately, you can use the chat feature to type your question. Please note that time may not permit the panel to field every question, but we will do our best. Just a quick note about the Zoom platform, the microphone and video controls are located in the bottom left hand of your taskbar and are controlled by the caret to the right of your icon. Red line through the icon indicates those functions are off. Click them to turn them back on. Participants in the chat function are found in the middle of the bottom taskbar and you can bring those both up by clicking on each of the icons. The raise your hand function is located in the reaction section of the right bottom taskbar. To hide the non-video participants, you click on the three dots at the top and then hide non-video participants. Thank you, and I'm going to turn this over to our community director, Dr. France. Thanks, and Megan, I appreciate it and everything you guys do at the Academy. It's really exciting to be able to do this virtual event this year, hopefully to make it fun for everyone. It'll be interactive for those who are here live. It'll be informative for everyone who's going to watch the recording, and we've got some pre-submitted questions. We'll take live questions. We'll have some breakout rooms. And I guess the main disclosure here is we're all really enthusiastic about neuromuscular and electrodiagnostic medicine. So you're going to get maybe some honesty, of course, but also maybe a bit of a bias towards encouraging people to pursue this career. I think a lot of us love it for different reasons and you'll hear about some of the good things and some of the challenges. With that said, I'd like to have the faculty actually introduce themselves. And why don't we start off with our most junior person, Dr. Allen from Queen's. Thanks, Dr. Franz. Hi, everyone. It's a pleasure to be here. My name is Matty Allen. I'm actually a fifth year resident in physiatry at Queen's University in Kingston, Ontario, Canada. And I'll be really excited to be starting my neuromuscular fellowship in July next year at The Ohio State University. Prior to medical school, I did my master's and PhD at University of Western Ontario in neuromuscular physiology. And my research centered on using some specialized EMG techniques like quantitative EMG to study people with polyneuropathy. With that background in mind, I kind of started medical school knowing I wanted to end up in neuromuscular medicine and nothing's really changed my mind in that time. During fellowship next year, I'm keen to build on my clinical skills and continue to build my research portfolio. And at the end of the day, I'm hoping to stay working academically as a clinician scientist if everything works out. So anyway, thanks for having me here on the panel and looking forward to all the questions. Great, thanks, Dr. Allen. Dr. Allen's about to start a neuromuscular fellowship. Dr. Attaway is currently a neuromuscular fellow. It just occurred to me that you don't need to have a PhD to pursue this career, but Dr. Attaway shares that in common with Dr. Allen. So Dr. Attaway, why don't you tell us a little bit about what got you down this path? Yeah, so I go by Nike. Nice to meet everyone. So I'm a currently fellow at Northwestern through the neurology department. I did my MD-PhD at Northwestern University. My PhD was actually on using EMG to control partial hemiprosthesis sort of using advanced pattern recognition algorithms. And I did my MD-PhD at Northwestern University using advanced pattern recognition algorithms. My advisor was not only a clinician scientist, but he was also a physiatrist. And that was sort of actually part of my very first exposure to PM&R, was going to clinic with him and seeing him manage amputees. And sort of because of that, and my background had been in engineering, that's sort of what got me down the PM&R path. And while in residency, I was actually thinking about doing stroke and maybe TBI because I liked the brain and then really did my EMG rotations and I worked with Dr. Friends. And I was like, I love this. I was like, I realized if I do stroke and TBI, I may not be doing EMGs. And I realized that I wanted EMGs to be a part of my life. And here I am doing a neuromuscular fellowship with the goal of sort of being a clinician scientist. But like Dr. Friends said, you do not have to have a PhD or want to be a clinician scientist to go into neuromuscular medicine. That's true. And at this point, I'll introduce the kind of co-director, the person who helped me plan this from the get-go. First person to sign up when I reached out to all my friends in neuromuscular medicine, Dr. Rad. Dr. Rad, do you want to tell us a little bit about yourself? Yes, thank you. So I had the pleasure of being co-resident with Dr. Franz. So I completed my rehab residency at the then Rehab Institute of Chicago, now Shirley Ryan. I really was drawn to neuromuscular for the patient population. So I loved working with ALS patients, muscular dystrophy patients, in addition to performing EMGs. But what I really wanted from a fellowship was to gain the knowledge about diagnosis and management so I would have full spectrum care of patients and also a better understanding of when I was in rehab, managing these patients, what it was that they had gone through and what the expectations were. So for me, I was really driven to this field by knowing the patient population that I wanted to work with and knowing what my gaps would be. So that led me to applying. I completed my fellowship at the University of Michigan Neuromuscular Neurology Program and I'm now at the University of Washington co-directing the MPA and ALS Center there. Thank you. And we'll keep going around introducing the rest of the faculty. You get a flavor for where everyone's coming from. So why don't we go to Dr. Moser? Hi, I am unique a little bit in this crowd because I'm pediatric neuromuscular medicine. I did my combined residency program at Thomas Jefferson University in Philadelphia. And I was very blessed and privileged to have Dr. Gerald Herbison as my primary mentor in EMG. And a little known fact about Dr. Herbison is that he started out his career actually doing pediatrics and maintained that love for it even when he became primarily an adult electromyographer. So I was fortunate in that he was really an inspiration to me and he also connected me to some fabulous people in the world of neuromuscular medicine such as Royden Jones who helped to write the book on pediatric neuromuscular disorders. So I'm not fellowship trained in neuromuscular. Most pediatric people probably would not go for that we were just discussing because that's an extra fellowship. So I'm living proof that you don't necessarily have to be fellowship trained if you have a passion for it. And I was tasked when I started my job at Akron Children's 16 years ago to start a neuromuscular program which was like my dream come true. And so I also have experience with how to start a multidisciplinary neuromuscular program from the ground up if anybody has interest in that conversation. Excellent. And Dr. Boone, why don't you go next and then we'll finish with Dr. Arnold. Hi there, I'm Andrea Boone. I'm a physiatrist at the Mayo Clinic in Rochester. I kind of randomly got into this because I decided to do a PM&R residency at Mayo from New Zealand where I went to med school and I wanted to do sports medicine but we do six months of EMG as part of our PM&R residency. And I really loved EMG. I'd never heard of it actually before that. And then our program director or our fellowship director encouraged me to apply for the fellowship. So I ended up doing an EMG fellowship instead of a sports medicine fellowship. And I just was kind of drawn to it because I love how it's a puzzle basically. And each patient is a challenge. You're trying to figure out where the problem is along the axis from the spinal cord out kind of thing. So I then came on staff again, not planning to stay, planning to go back to New Zealand but now I've been there for 26 years and I do half of my time in the neurology department because that's where our EMG lab is. And then half of my time in kind of musculoskeletal and neuro PM&R outpatient. And I've kind of developed a little research niche in EMG using ultrasound in conjunction with EMG to kind of improve the information we can get for our referring physicians. So that's where I'm at. Excellent. And I'll finish up. Dave Arnold, I'm currently a professor at the University of Missouri. So I did my fellowship at the Ohio State University now a little over 14 years ago. So when I was growing up, I was growing up in a very rural place and I had a family friend that said, oh, you should go to medical school and consider physical medicine rehabilitation. And so I just kind of locked that into my head and I have always been an athlete, not a very good athlete, but I like being active in endurance sports. And so my plan all along was actually to do sports medicine but then I got into residency and while I liked it, I didn't find it as exciting as neurological disorders. And I actually thought about a lot of different paths. So I thought about spinal cord injury. I thought about movement disorders and I thought about neuromuscular medicine. Actually, the first fellowship that I had was a movement disorder fellowship. But then I decided I really also really loved EMG. I love single fiber EMG is one of my favorite tests to do. So I thought neuromuscular kind of made more sense. And so I had very little exposure in medical school to neuromuscular medicine. In fact, like I think the only way I found out about it really was I read a book by one of my mentors. So when I went to OSU, I trained with a group of people that were kind of the trainees of Jerry Mandel who some people may know that name, people that he's a leader in the gene therapy field. And it was amazing because I was part of a study team that worked under the leadership of Jerry Mandel to deliver the first gene therapy to SMA babies. And so it was kind of a cool story. His book that he wrote with Birch Griggs like decades ago kind of sparked this interest. And it was again, like Dr. Boone was saying, the patterns and figuring out the puzzles. And I really wanted to know how to take care of the patient from diagnosis to rehab. Really the whole continuum was my goal. And I didn't plan on staying at OSU either, but then I stayed there 14 years, just moved, so. Awesome, yeah. And I guess we have a bunch of questions that were pre-submitted. And one of the things that we wanted to kind of tackle right off the top is a little bit about the specialty match. So there's, well, of course, we're gonna talk about some different ways you can go into neuromuscular and electrodiagnostic medicine as a physiatrist. But I thought I'd open this up to Drs. Allen and Dr. Attaway. Tell us a little bit about the current, which is the new match process to apply if you wanna do a fellowship in neuromuscular medicine. And Dr. Allen, it's probably freshest for you since you just successfully completed the match. Maybe you could tell us a little bit about how that portal works and where it's located and whether or not, what your experience was with it. Sure, yeah, no problem. So yes, all of the fellowships through the states are all available through the AANEM website. I mean, it's probably easiest if you literally Google AANEM fellowships. It'll take you to a handy portal there where you can see all of the different programs offered across the country. With the name of the program director, the program description, and then also access to the program website. So really it's kind of a really handy place to go even when you're just exploring the various different programs and places you might consider ending up. But basically the same website is also where you create your account. And when the sort of the application process opens, which isn't until like February, simply just upload your CV, your letters of reference, your cover letter, and then basically you're off to the races. It's the same, it's very simple system where you tick off which programs you're interested in applying to. All of the communication is done through the portal. And basically after you've done all of your interviews, you use the exact same system to just enter in your rank, which is the same as what you would have done for residency. So all in all, I found it pretty intuitive, pretty straightforward, and it was really easy to contact anyone if you had any questions. Yeah, I don't know, Nikkei, if you had any different experience or different thoughts. So the year I applied was the year they started the program and it was at that time not a match, but kind of, yeah, I'm gonna say pseudo match, but similar idea where you went to that same portal, you applied, you click whichever programs you wanted to apply to. However, like in a match system, you rank, right, and then you get matched. But at that time, ranking wasn't an option. You interviewed and then they would let you know if a program had accepted you and then you would either accept or not accept. And if you didn't accept, then you would wait till another program accepted you. So it was, if you think about it, that was more of like thing like applying for a job. So it was a little different. And then the next year, your year, they decided to actually make it a full match experience. And I'll add, one of the things I've noticed on the website and we've given the feedback is it doesn't indicate, some of the programs don't consider physiatry applicants actually, and that you would have to find out by going to the specific websites for the different programs. However, I've been assured that this year, and I haven't checked today, but last week or two, that they're gonna actually add a line, whether or not they consider neurology or physiatry applicants, something to that effect to make it so that you can actually pull that information off the website itself without having to do as much digging. And as I've heard from different sources, it's worth checking with programs because some programs send mixed messages about this very important issue to our field. And in fact, raises the question for the future, maybe I'll throw this at the panel, is where are we at for having PM&R based neuromuscular fellowship programs at our different institutions? And maybe I'll throw that out, Dr. Arnold already unmuted, but I think that this is a crucial thing for the future of our program is to have our own training options. Yeah, that's a goal of ours. I had similar experiences. So I was, when I did my fellowship, it was 2008. So that was the second accredited year, and I applied all over the country. A lot of places didn't interview me. I have one place, and I won't say where, I got there and I'm meeting with the, I think it was director of the division or the chair, I can't remember, he's like, oh, you didn't do neurology. Like that was the first time they figured it out when I was there, but they offered me the spot even though I didn't take it. So, I think the key is our reputation is growing, and I've been really welcomed like wholeheartedly with neurologists in my group. So I think that's what this is about is growing and making that more prominent. And it is a goal of mine to start a fellowship at my new institution. So we don't currently have a fellowship. So stay tuned. Excellent. Dr. Rad, you were not that long ago either, the two of us, but looking, do you have anything else to add about your experiences around that issue in terms of tips for applicants, since we're much of a sort of feed into that narrative there about being a PMNR? Absolutely. Yeah, and so I would say again, not new to the match, but not that long ago. And so there was no match process. And back then definitely had to reach out to programs to figure out, would you accept physiatry? Would you not? The caveat back then was many programs didn't even know that physiatry could apply to them. So it wasn't just that they weren't interested or interested, they, to be honest, were a little confused why I was applying. And so I think now what I've seen, or as we have residents that have also matched into neuromuscular, it seems that they're more aware of our skillset. But unfortunately, I think even with physiatrists matching into these fellowships, I'm still getting feedback that they're not aware of everything that we're capable of doing. So I think making sure on interviews that you stress not only why it is that you wanna pursue neuromuscular, but what skillsets make us really valuable for that. And so the specifics of, after diagnosing these diseases, most of their management is in the rehab world. And I think putting that out there point blank is very helpful. Most MDA centers, ALS centers are sponsored or have their funding and grants through the rehab departments. And I don't know necessarily that that's really talked about but I think as applicants really honing in on what the skills are, I've been very fortunate in my current position to how it's kind of viewed is not even like neurology or rehab, it's essentially neuromuscular. So we are that group. So it's not like, oh, which one of us are neurologists and which one of us is a rehab medicine? But what we all have in common is neuromuscular. And I try to reassure residents, rehab residents that are going into the field that your counterparts applying most, and this is kind of general, but in my experience, most neurology residents have to seek out the experience in neuromuscular. So they're not coming in with a breadth of these medication knowledge or whether it's immunotherapy or gene therapy, we're on similar fields. So to also have that confidence as well. I could speak about this forever, so I'm gonna pause there. Awesome, and if any of the panel wants to add as we go along, it just occurred to me, you could raise your hand. Also in a second, we'll start taking questions, working questions in from the audience that are live. In addition, we still have a long list of pre-submitted questions as well. It just occurred to me as we're going on about doing the fellowship year, there's also a Pediatric Neuromuscular Fellowship and also a Pediatric Rehabilitation Fellowship, which is in itself two years. And I was thinking about Dr. Mosher's experience as one of the pioneers and one of the few who sort of built it from the ground up at her hospital to tell us a little bit about the sort of what it's like post-graduation from a Pediatric Fellowship taking on the responsibility of running a neuromuscular clinic and what skills that you brought into it and what you had to learn. Sure, so as you said, I'm not fellowship trained. I'm not fellowship trained in PEDS either. I did a combined residency in pediatrics and PMR that was five years total. Some people do end up doing a extra year fellowship from the combined program. Other people will do the straight PMR residency and then two years of pediatric fellowship. I don't personally know anybody who has done the pediatric neuromuscular fellowship. At the time that I graduated, it was not an option available to me or I may have considered it actually. But, you know, I think you can do it no matter what. And honestly, pediatrics is a great field because you can really kind of go in whatever direction you want because there's a lot fewer of us, there's a lot more demand and there's a lot more flexibility. I am very fortunate that I happen to work in a center called the neuromuscular, or not neuromuscular, sorry, the Neurodevelopmental Science Center. And so our collective center includes physiatry, neurology, developmental pediatrics, psychology, neuropsychology and neurosurgery. And so, you know, we do a lot of multidisciplinary work in all the different patient types that we see. We host a number of multidisciplinary clinics in our center. And, you know, when I started, honestly, there were no neurologists who were interested in neuromuscular and there were no neurologists who did EMG. So I really had the, you know, sort of a blank slate to kind of create things around what I thought would be most meaningful. And so when I started the program, I really looked at the MDA model and tried to collect a group of individuals from all the different specialties who had some interest and willingness to, you know, join this endeavor with me. The wonderful thing about pediatrics is that everybody's incredibly nice. And so you typically can find somebody in each department who is actually, you know, if not really enthusiastic, at least, you know, willing to go ahead and dedicate themselves to be a resource for you. So we currently have a neuromuscular clinic that serves about 200 patients. And we have in our staff neurology. I have two neurologists now who work with me. One is neuromuscular trained and we have PT, OT, nutrition, social work, nurse coordinator, palliative care, orthopedics, pulmonary, cardiology, and genetics as a part of our crew. Yeah, and it strikes me actually, for anyone who's started in neuromuscular, you know, more than five or 10 years ago, that the genetics part of it's really, you know, no matter what you're gonna have to learn as you go along, I would imagine as you're probably now in charge of a lot of your kids' gene therapy. Yes, yeah. So I have learned a lot about genetics and I've really, really enjoyed it. It's so fascinating and it's very exciting to be a part of gene therapy. And there's gonna be more and more gene therapies becoming available in the pipeline. So I think this is a really exciting time to be a pediatric neuromuscular specialist. And actually, speaking of gene therapy, I might make a plug for this AANEM monograph that Dr. Rad just put out, if I'm not mistaken. It covers a lot about managing patients with SMA, including the breakthroughs in gene therapy. Is that correct, Dr. Rad? Yes, it is. Thank you for mentioning that. Although I do wanna circle back to Dr. Arnold, who before this has published a previous review, just a lot has come out. So my review is specific to adult SMA patient population, but Dr. Arnold has worked at the forefront of that gene therapy on pediatric patients with SMA. Yes, and Dr. Arnold, feel free to chime in if you want about, of course, he was involved in some of the discovery of gene therapy for gene replacement for SMA. Yeah, he's nodding. Yeah, and we're just getting started. I see myotonic dystrophy coming next and so forth. So I think it's a cool area to be in because these therapies will have major impact, but there still will be a lot of gaps that I think our skillset is very well suited to address. And so it's a very exciting area to be in. Yeah, and I would just, I can't help myself when I think of our colleagues, and I'm a member of the regenerative medicine community as well, but I tend to think that we underplay how much these gene therapies are actually really kind of at the forefront of regenerative medicine more so than some of the other orthobiologics that you'll often hear about at these meetings. So just to, and they may do more than just treat a single mutation like SMA disease, but have relevance for other diseases and other aspects of muscle function. As if you follow Dr. Arnold's work, you can kind of see where that might lead. I have a question. Oh, no, add it in Dr. Rad. I was just going to put another plug because I also, sometimes I've had people interested in neuromuscular say, well, what if I'm not interested in whether it's bench research or clinical research, because I'll participate in clinical drug trials and talked about Dr. Arnold's research a little bit. And I just, even if that's not your interest, some of these things are changing the phenotype. So even if you're not, you don't want to do the clinical or you don't want to do the bench science research, understanding the disease process, we're introducing therapies that'll make SMA, SMA is not a pediatric disease anymore. And so we're going to need providers, specifically rehab providers, because the diagnosis portion is done, that know how to care for this changing phenotype. So I just wanted to take a plug for those of you considering the field, but maybe research isn't your forte. To still consider it based on EMG and patient population. We have a lot of very intelligent people on this panel. So I just don't want you to shy away if you're like, I don't want to do any research. So sorry to interrupt Dr. Frans, just wanted to get- No problem, no problem. Everybody excited. Dr. Red, you brought up EMGs, it's a perfect segue. I was gonna bring up this 200 studies is what PM&R residents are required to do. And there's this question of being competent to do EMGs and then feeling ready to really take on real world EMG practice, electrodiagnostic practice. And I can't think of a better person to sort of talk about this issue than Dr. Boone, who probably does more teaching and has been publishing in this area more than maybe anyone on the panel. She's at the forefront of it. Could you maybe talk a little bit about that in your experience of the program at Mayo, but also what you've seen across the country with the EMG competencies for PM&R residents with and without fellowship? Sure. Yeah, so I would say that our residents, our PM&R residents get a phenomenal EMG training. They're lucky in that our lab is fully integrated neurology and PM&R. So they do get to see a wider variety, I think, than they would if they were just in a purely PM&R lab. But they, so after they do six months straight with two months of what we call the C&P course, and then just four months of doing EMGs. But so they get out with very good skills to do routine EMGs. But in order to work in our lab, you have to be fellowship trained to be on staff. And the reason for that is, you know, you see so many complex patients with very, I mean, tons of CIDP, things like multifocal motor neuropathy with conduction block, myasthenia gravis, you know, Lambert-Eaton, and their residents really don't get exposed to much of those more complex things. And then all the cranial neuropathies, you know, needling facial muscles, the diaphragm, the residents don't needle the diaphragm, the fellows do all that. Single fiber, we don't train them in that. You do that in fellowship. And like Dr. Arnold was saying, you know, single fiber is super fun once you get the skillset. And so with some of these, like diaphragm, I think it's pretty fun to needle. Most people shy away from it because they haven't been trained in it, they haven't been exposed to it. But because now we have ultrasound to use without EMG, it makes some of these things easier to do and to do well, and it's just more fun. We're getting all new EMG machines at Mayo that have a really pretty nice ultrasound machine integrated into it so that you can do ultrasound and EMG simultaneously, or I often switch back and forth. So if I've got an ALS patient and I can't find anything in the cranial muscles to kind of clinch the diagnosis, I can use ultrasound and quickly look at the fasciculations that I might've missed or something. So it's kind of a fun, the fellowship training for EMG is, I think you get so many extra skills that you won't get in regular residency training. If you wanna have EMG as a good part of your practice, it will give you the best side of it by having that extra training. Yeah, actually, I feel like there's a lot we could say about ultrasound. Dr. Mosher, did you have another point you wanted to make before we get back? I was gonna follow up on that ultrasound comment in terms of what you can learn in training. Oh, yeah, I just wanted to sort of piggyback on Dr. Rad's comments about SMA to let the group know that after the networking opportunity for neuromuscular medicine, apparently that day, there will be a talk from two to 3.15 on Friday about decision-making using FDA approved treatments for SMA. So I wanted to highlight that for those who might have interest. Excellent, and actually one of the things I wanted to, I appreciate you pointing that out. And one of the things I was just thinking that came up from that comment about using ultrasound for EMG was bringing up the possibility of where would you learn a skill like that and how people might pick that up with or without a fellowship training. For example, I kind of picked up on neuromuscular ultrasound a little bit as a resident, but really focused it in from more general MSK application to neuromuscular specific stuff with the help of my fellowship and some of the training I got exposed to as a neuromuscular fellow. But does anyone want to maybe comment a bit about what skills you can pick up related to ultrasound during training and whether or not that's a consistent feature of programs across the country? I guess I could speak to that first. I agree that as coming in as a physiatrist where a lot of the programs are providing pretty good training now in musculoskeletal ultrasound. So you have some really good fundamentals. A lot of the time at this point, our residency, they get phenomenal training in MSK ultrasound. And so then it's, once you get good training in EMG, it's kind of an easy step to almost self-train yourself. And then there's quite a few different courses available now. There's a good Wake Forest course every year. There's this iSpiny conference we put on usually every year that alternates between Europe and the United States where there's quite a few hands-on workshops. AANEM and I'm sure AAPMNR all have quite a few ultrasound workshops. AANEM, they tend to focus on neuromuscular ultrasound more so than musculoskeletal ultrasound. There's also some pretty good online resources. There's some great books out there. And the beauty of ultrasound is that you can just train. Actually, I'll duck away in a minute. I'll show you guys this handheld ultrasound. I just thought it's literally this big and it has no cord and you can take it home and practice on yourself, your family members, and that you can find nerves. You can really, you can look at your diaphragm. It's quite easy to get basic training just by hands-on and then finding some mentor that has some skills in it and you can really go from there. So I think, and that's one other thing I didn't, I omitted to say with the, from the point of view of residency versus fellowship, we also do, the fellows get exposure to pediatric EMGs, which we do under sedation. So my, you know, congenital myasthenics, where we do a lot of extra testing. The ICU cases are much more challenging. Residents, I'm definitely not trained to deal with those. You need that extra training, I think, to be confident at these really challenging cases of EMGs. And even interruptive monitoring, you might get exposed to that. I do that as part of my, as part of my EMG role. About a fifth of the time, I'm doing interruptive monitoring with spine cases and brain tumors and stuff. So there's lots of, it just allows you to have a much richer, I think, job in EMG if you have that extra training, instead of just doing radiculopathies and carpal tunnel all day. Great. Well, and I know you've been also at the forefront of the certificate of the, sorry, the- Added qualification. The added qualification certificate to the, Yeah. Could you tell us a little bit about that program for people trying to get certification or credential to do neuromuscular ultrasound? Yeah, so we kind of try, because there's not a lot of certifications out there. And, you know, sometimes hospitals want to see some kind of proof of that you should be doing something if you want a privilege for it. There is something through the AIUM, but it's a really, it's much more musculoskeletal based and really very in depth. So we tried to come up with a kind of more focused neuromuscular ultrasound added qualification. It's just a straight off exam. I think there's maybe a hundred questions and it covers, you know, some basic physics, it covers anatomy, and then it covers kind of the things you'd expect to, you know, you'd want to be able to recognize like tumors and transections of nerves, and then, you know, all the neuropathy, carpal tunnel on EMG, on ultrasound, sorry. And so we are trying to develop a resource currently to give people a curriculum, but we're sort of in, we'll be going back and forth because Jeff Strakowski from the Ohio State is, you know, has a lot of good resources out there and he's currently in the process of doing another, doing a kind of a video series, I think. And so we don't want to double up, there's a lot of work involved for us to get those resources together. So it's evolving constantly, but there's enough out there and good textbooks and these different courses to get the training you need in order to pass that qualification. So this strikes me as we've focused a lot on these two skills, the electrodiagnostic and the ultrasound. So, you know, I wanted to maybe bring it back to first a little bit about the skills you can get from training. And I thought Dr. Attaway, who's currently a fellow, could tell us a little bit about her experience going from, you know, a PM&R residency into a neuromuscular fellow in a neurology division, a department about, you know, what skills are you learning this year and things that you wouldn't have been able to do without the fellowship? Great. I think we had touched up on this a little bit, but from the EMG perspective, I mean, yes, we do 200, but I think as a resident, you don't get as much exposure to a broader range of diagnosis in more complicated cases or even needling more obscure muscles, you know, doing the facial muscles and with every EMG, you certainly see a lot more ALS cases. I think I had, you know, like one to four, right? Doing residency. Actually, no, that's not true. I did some extra electives, but I think a typical resident doesn't see as many. So I think certainly having that exposure is important, right, because if you haven't seen certain pictures and it's harder for you to realize it. So I think even though we do get a lot of EMGs, I think you definitely gain from the experience during fellowship. Two, there are other things besides EMGs. So you don't typically do autonomic studies or at least read autonomic studies during your residency. So we get exposure to that as well. Three, you don't typically read muscle biopsies. I think different programs or some have, I don't know, like at Hopkins, some of the fellows will actually read it and then read it with their attendings. My current fellowship will have like a weekly session where we go through slides and that's also part of our boards. That's something you definitely get no exposure to during residency. Four, right, is the clinical management of these patients. Right, and so as physiatrists, you see the patient when they need rehab, right? You're focusing on their functional deficits of their CIDP, of their polymyositis, right? And so, but in neuromuscular pain, if the patient comes to you with weakness, right, how do you work that up, right? What's important, like what is the differential? What labs do you need? Once you figure the diagnosis, how do you treat them? Right, and so you don't really do that during a residency, right? And I think that's a really big part of it. And there's so many disorders. And then we also touched up upon the genetics aspect, which has sort of been new in the last couple of years. And that's something that's totally new, right? When we're coming into fellowships, learning about the genetic basis of all these things and the new therapies and treatments and how these genetic syndromes can present clinically, right, I think those are all very unique things about the fellowship that you can't find sort of doing your PM&R residency. Yeah, and I think this is like a real intersectional point between where, you know, you come in with certain skills in physiatry, ultrasound, exposure, probably to a greater extent, more EMGs and some of the rehabilitation management of neuromuscular patients that you would be a little more familiar with, but you're picking up these new skills, the clinical, managing new medications, getting exposed to these really rare diseases and genetic diseases that you just don't see in training. And so there's this sort of kind of back and forth, like, you know, things that physiatrists can bring into the fellowship training and things that, for example, someone from the neurology background bring into the training that are different. And then you're learning kind of a little bit of how to kind of blend the two specialties together, I feel like, as we sort of talk about these things. And it makes me, inspires me to, you know, to think about what got me going in this. And one of the people who pulled me into the specialty, Dr. Drist joined us here, and she's actually a fellowship director for the neuromuscular program at Northwestern and has taken a few physiatry residents into the fellowship program now over the years. And maybe you could talk a little bit about what you're looking for in an applicant and, you know, how you size up someone who comes from a PM&R background versus neurology background or what your thought process is on that, because it's still an issue that I think some of the physiatry-based applicants run into as they apply to programs across the country. Right. Well, thank you, Colin, for inviting me and sorry for joining late. Well, hello, everybody. This is a trick question. Our setup is a little bit different. So we do work very closely with the Shuri Ryan Ability Lab and the resident to rotate through our EMG lab. So we get to know them a little bit and we can steal the best one and attract them to our program somehow. But I think, as you said, PMNR resident have a lot to bring to a neuromuscular fellowship. True, they will have to kind of see patient differently and they have to take their PMNR hat and put in neurologist hat sometimes. But really, there is a set of skills that is very important. Personally, what I look for, I think that there is a need with the advancement in these genetic therapy that we're having, we're gonna have patient who before used to die that now are gonna live. And then unfortunately, they're gonna live with some deficit, right? They will have some impairment and it's really important to have a pipeline of physician that will be able to address this and think about it outside the box anyway. I think the rehabilitation of chronic neuromuscular patient is important and there is a huge need there. So the ideal candidate would be somebody who's really interested in neuromuscular medicine beyond just neurophysiology, right? Beyond just EMG, because as Nikki said, you do get a lot of EMG training already, but really interested in the rehabilitation of the chronic neuromuscular patient and thinking of ways of making that a career choice. And usually that will come when somebody is interested in staying in academia somehow. Does not have to be necessarily that. I mean, we have one person who joined a private practice so it can happen as well. But that would be the thing that I will look for. Somebody who's really trying to think about this outside the box a little bit and taking the rehabilitation of the neuromuscular patient to the second level where that person would be involved really with a neurologist in the diagnosis, the evaluation, the treatment of the neuromuscular patient with the addition of really, how can we make the patient life the best we could from everywhere, kind of. We are limited as neurologists. I mean, we can use treatment because when it comes to rehabilitation, we're not very good there. So we need your help. Yeah, I think it's not really an opportunity for collaboration and there's different ways that that collaboration could unfold in terms of how you're... But every setting can be a bit different in terms of how the departments interact. And maybe thinking of someone, I believe Dr. Arnold, and this may be true for Dr. Boone to some degree as well, I'm not sure everyone's fully. But Dr. Arnold, you were in a department, you were hired by the Department of Neurology, your first job, is that correct? Yes, correct. For 14 years, I was in the neurology department. That's right. So tell us how that worked as a physiatrist when you're looking for a job and actually your job is not coming from a division of physical medicine and rehabilitation, but rather one of neurology and how that... Because that can complicate things, can it not? Yeah, so when I was looking for fellowships, there were no human are sponsored ACGME programs. And so actually the director of the neuromuscular division, his brother was a physiatrist, actually won the Elkins Award. So he knew what physical medicine rehab was. So I think that's the reason they took a chance on me. They didn't know what they were getting at that point. Now, of course, Dr. Allen's gonna be there next year or so. So they've changed their mind maybe. But so I was doing my fellowship. I actually initially had planned on learning neuromuscular and then going back to the University of Louisville and kind of building a neuromuscular program there with the children's hospital there, with the neurology department, which I was familiar with and collaborated with before. And that was a plan. But then as I was coming up to the end of my fellowship, somebody mentioned that you don't have to do research to go into neuromuscular. Well, I can tell you, I do research now mostly, but I didn't even publish a single paper until I was faculty for two years. So you don't have to be in research to do neuromuscular. You may get swayed to the dark side over time, but you don't have to start out that way. So basically they offered me the position and I did over time have a joint appointment in physical medicine, but OSU is weird that you only really have one home department. So I kind of stayed there the whole time I was there. Now I am for the first time in my career in a physical medicine rehab department, very excited about that. But I was very like supported and welcomed. And I think like having a hybrid relationship and interaction actually is a good thing. I really wanted to learn how to be a neurologist when I did my fellowship. I wanted to learn the neuro side and bring my skillset with the rehab side. So kind of together it's synergistic. So I think the key is to kind of dive in, learn skillsets that may feel a little scary at first. And so you can be the well-rounded neuromuscular specialist. And I really don't think there should be any difference between a neuro trained or a physical medicine trained at the end of the day. There probably is, but my goal is that there shouldn't be. So that was my goal as a fellowship. So I think for the majority of my time at OSU, most people didn't know that I wasn't a neurologist actually, but not because I hid it, it's just because they treated me like their own. So it was a great opportunity. Yeah, and actually you and I had that in common that we stayed on with connections where we trained and I have a cross appointment in neurology at Northwestern, but Dr. Rad did it a little differently because she went somewhere else to train, which like you did, but then when she hit the job market, she went really far away from where she trained. Maybe this would be a good time for you, Dr. Rad to chime in a little bit about how you hit the job market after your fellowship and what you thought of that experience. Absolutely. So after RIC, I went to University of Michigan in neurology and then I switched coasts. So I'm at the University of Washington. And when I went to the job market, I kind of knew what I wanted. And so even before fellowship, and I think Dr. Drift had kind of mentioned what they were looking at in fellows and essentially what I wanted was very similar. I went back to neuro, I did a neuromuscular fellowship because I wanted to know how to diagnose, but ultimately I wanted to follow patients through the continuum. So I wanted to be there with diagnosis through the chronic management and I wanted to be part of multidisciplinary disease management. So certainly I was open in the job market. I actually interviewed for a lot of private practice jobs. They were enticing because the pay was a lot more than academic salaries and they offered a lot of EMG. It was my experience, like come in, build your EMG practice. But truly what I wanted was found in academic centers. And for me personally, it was finding a center that had great collaboration of neurology and rehab and also availability and a need. And so I think because this is a little bit of a niche, you may need, a lot of it is about networking. So the University of Washington reached out to me knowing that they were gonna have faculty that were moving on. And I was interviewed by both neurology and rehab, but my position was in rehab. It was initially to do the neuromuscular management and run their EMG lab. And within a year or two, it was co-directing with neurology, the MDA and ALS center. And as Dr. Arnold mentioned, I do think that there are differences in having either a long training background in neurology or physiatry, but at the end of the day, our group is just neuromuscular, right? And so we all kind of sit in the same dictation area. We forget that on MDA day, all of them are housed through rehab because that's where all our funding comes from through the MDA grant. On certain days, I'm staffing the neuromuscular fellows and my billing is through neurology, but we don't really see it that way. It's just neuromuscular. It does complicate things. So when I'm doing clinical research, that's when all of a sudden it's, okay, well, who's paying my salary? So how do you become a PI in another person's department? Where does that money funnel through? And so there's a lot of nuances that I could get into. I will say that it's all manageable. I think you'd find that in any academic career that there's going to be hurdles and things you need to navigate in an academic career, but if your goal is academics, you want to find a place where, or you want to establish a relationship that's very strong between neurology, neuromuscular and your rehab department. I will say that. I think I would have probably early on shied away from places that didn't have that just because as a junior faculty, as you get more experience, you're probably less intimidated, but having that relationship is really key. Yeah, that's great insight. And I guess we've got to the point since we're talking a little bit about jobs, I guess the thing that kind of goes with it is kind of income and generating revenue and some question that has come up in pre-submission is what sort of salary expectations that you might be facing and if you go down this career path. And I think it's a reasonable question and it may also sort of play at, at least from what I've learned as a young attending about like how much, for example, I break up my practice into procedures like electrodiagnostics versus clinics, because there's this sort of, I think still a kind of myth or maybe not a myth, but a legacy of there being a cut in reimbursements for EMG that people don't get paid well for that. But it seems to actually be one of my biggest revenue generating things I do. I don't worry often about just those things when I make my decision about what to do, but maybe some of the more experienced faculty to comment a little bit about that in terms of how you break down your practice so that in terms of what you're doing, electrodiagnostics, other procedures, call and clinics. I could pick on someone there, but maybe Dr. Mosher, Dr. Boone. Yeah, I'm happy to speak. I mean, obviously every job is gonna be unique, but I tell all my residents if I'm mentoring any of them and, or if they're coming on staff, like we've started a new program where we are mentors to new staff and that you have to carve out niches. You have to carve out areas that are less prone to burnout. So, you know, patient care is for me is easily the most intensive and most demanding. And then I have, so I have a real combination. I have my EMG time, which is 50% actually of what I do. And then I have, I do ultrasound guided injections and I do Botox injections for spasticity. So I have procedure time there too. And then I have a little bit of research and then, you know, some neuro rehab clinics. So it's a real hodgepodge. And I, for me, that spells a job that I love and also sanity. Those procedure slots are just so much less demanding from a point of view of you just do, you do the procedure and then it's somebody else's patient. So you don't have all the extra work with it, but you still have, but it's a really fun part of your practice. So I think it's super important to make sure you give some thought to that when you're starting out in a job and really try to compartmentalize it and make sure you're getting some time that's either gonna be protected for research or a little bit of admin time combined with the procedures that you like doing the best. From a revenue point of view, I would agree. I mean, I have a joint appointment in neurology and PM&R and it's kind of weird. Neurology pays my salary when I'm there and PM&R pays it when I'm in PM&R. But I know that I am, my billing, we're on salary, so it doesn't matter, but my billing is absolutely massive compared to the rest of the PM&R and that's all from EMG. And I do do some interruptive monitoring too, which at the moment is quite, I think quite lucrative for, from the point of view of what it brings in for the institution. So yeah, even though it kind of EMG took a hit and was, everybody thought it was not gonna be generating any revenue, we, it's still a big revenue generator for neurology, for our department. It may, it's easily what keeps us in the right side of the budget from the institution's point of view. So it seems to bring in money, no problem at all. And Dr. Mosher, did you wanna comment or Dr. Driss? Yeah, Dr. Mosher. Yeah, it's a little bit different in pediatrics because there are rare people who can develop a full career in just neuromuscular and we do a lot less EMGs on children than we do on adults. So it becomes a smaller portion of your full practice than it does in the adult world. But definitely I agree with what Dr. Boone was saying. I love doing procedures. I find it much less taxing, I think cerebrally and emotionally, not that they're not cerebral, but it's just, it's easier because it's fun and you're enjoying yourself and there's not all the other responsibility and drama around it. And when you're working in an environment where your reimbursement is really closely linked to your RVU generation, you know, procedures always bring in more RVUs. Maybe kind of related to this, and this is maybe one of the, where we're gonna be kind of finishing up and then we can do a little bit of networking in small groups at the end here. Dr. Driss, Dr. Arnold, maybe you could start us off on like what either what's the best or what's the worst part of this or the most challenging part of this subspecialty. I think that it may be linked to some of these topics that are coming up about income, but yeah, Dr. Driss, why don't you take the lead on that? Not sure I understand your question. So what's the best part of what we're doing as neuromuscular specialists and maybe the most challenging parts of your practice? I think the best part is really where the field is going. I mean, it's, I feel like we're leaving the science, leaving in the world of science fiction that you were thinking of like a few years back about the genetic therapies and all that. I think it's just amazing. And we are lucky to be in it during this really time. We understand ALS a little bit better. Again, we're gonna have a treatment for genetic form of ALS. We're gonna have the same treatment for even sporadic. We have many gene therapy for many of these obscure diseases. So it's like, it's really very exciting. What is, what I hate about it is really dealing with administration and having people in my way who won't let me do what I wanna do that I know exactly what I need to do. So dealing with that is a little bit hard. I mean, yeah, I don't know if I can think of anything else. It's a lot of fun. It's, and the patient are rewarding in themselves, right? I mean, it's, you do a little bit and it feels like you're doing a lot. I mean, not all the diseases are chronic and incurable. Of course, there are inflammatory diseases that are very fun to treat. Certain patients really like them and you make difference very quickly. So you could do it whatever you want. If you want treatment, you can go the inflammatory route. If you're interested in really weird genetic diseases, you can go that route and you make it, I mean, you build it the way you want it actually and what you want about it. Yeah, I think along those lines, I think the variety of the types of diseases and the variety of things that we can do, we can do procedures for diagnosis. You can do interventions for therapies. You can do biopsies and read or interpret morphology. You can design treatment plans, rehabilitation approaches. I think it's very exciting to have all these new therapies, but that's also kind of scary and challenging because like for instance, this therapy that I was involved in, it was the most expensive drug in the world when it was first approved. And so the lack of access and in some countries it still isn't approved and some of these treatments are approved. And so you have these diseases that are seeing great successes, other diseases that are not. And some of the therapies are relevant for some patients, some patients are kind of past the window in the impact. So I think it's the dynamic nature of the field that I think is one of the best things about it, but it's also very challenging and trying to meet the patients where they are for that is kind of tough. But that's the reason I like research because we're trying to work on that. Great. Yeah, maybe I'll add one thing on this too, is I find there's a double edged sword when you're a physiatrist with a neuromuscular subspecialization because there's so many issues that, at least in our freestanding hospital that come up that could use some input from me. And there's very little redundancy in terms of I'm the only person carrying that certification in the hospital. So I do feel like it wasn't something that they were necessarily before, when they hired me, I don't think that they necessarily needed, realized they needed a person with this training, but now that they have me, I feel like it would be very hard not to have access to like some of the inpatient consults I'm asked to do. And so there's this feeling of, I guess, being incredibly valued by my colleagues, my partners at the hospital, for when I can help them out of a situation on an inpatient consult or something that comes up and they can make a referral to me. And then there's this also, this aspect that kind of cuts the other way, where every now and then you take a vacation and it just can be a little bit frightening when you're not around to help out. I see a hand up there, Dr. Arnold, I hit a nerve here with this, but so my hope to fix that problem, it's a good problem is that, there's gonna be more of us and multiples of us at different freestanding rehab hospital, different PM and R departments across the country, so that there is a little bit more capacity, not so much as a competition to the department that's based on a neurology, but more partnership and just, there's just so many patients, it comes up all the time, our wait lists in the neuromuscular division, Dr. Driskin attests to, there's just a huge demand for the subspecialty and the patients are there. Dr. Arnold, did you wanna? I was just gonna say, it is fun to be an expert too, and doing the subspecialty training to really get to see that high numbers of patients have these rare disorders. When you see lots of patients with a certain disorder, it's no longer rare to you, so you can really handle problems that other people are very challenging. And that's, for me, that was rewarding to become an expert in a specific area. Great, anyone else wanna add to that? Because we're gonna, otherwise, we're gonna wind it down here and then do some breakouts for some networking. All right, well, thanks everyone. This is gonna be the end of our recorded portion of the session. There'll be a little bit of extra time that won't show up online, but we expect this to live a long life and be hopefully useful resources for people considering a career in neuromuscular and electrodiagnostic medicine. And thanks so much to the faculty for giving up their time this evening, their free time, their family time to contribute. And we're all passionate about it. Clearly, you could tell, enthusiastic about the field. And it's actually hard to find someone in this field if you go to the subspecialty meetings, like AANEM or to our meetings, our little breakouts at the AAPM and our work together to find someone who's really cynical or not happy with the career choice. So I think that also is something to keep in mind if you're thinking about it. And with that, I'm gonna hit the pause button. Thanks for signing off.

neuromuscular and electrodiagnostic medicine

fellowships application process

clinical skills

research experience

collaboration with other specialties

advancements in genetics

diagnostic process

EMG revenue generation

career prospects

treatments and therapies development