panel and we have this awesome lineup this morning on niche rehab and we have different physiatrists on this panel, six different ones, talking about their special niches. So we'll get started. I'm going to introduce the session organizers, myself and we have the FIT board members, Alpha Anders, Chris Lewis, Kamaria Coleman, and Kevin DeJesus and we're all part of the FIT council and organize this panel. No disclosures for us. Go ahead and scan this QR code. We just want to know what stage of training you all are at. Okay, we have medical students, residents, fellows, attendings. Okay, awesome. We have a great spread. Looks like 45% med students, 22% attendings, 24% fellows, 10% or yeah, 25% residents, 10% fellows. Cool. So we have a good spread today. Our session goal is we want to develop an understanding of the breadth of practices within PM&R and we're here to learn from the perspectives of our panelists today about unique niche careers within physiatry and establish opportunities to network if you're interested in any of these fields. Alright, we have some background slides. This was published in the American Journal of Physical Medicine Rehabilitation, Dr. Yang, its factors influencing fellowship decision making during the residency. So there's about 393 fellows in this 2020 or residents in this 2020 class and there's a hundred and seventy-five people who responded to this survey and so this is the fellowships that they were considering upon entering residency and the predominance of sports medicine followed by spine and pain and then this is the current fellowship plan at the end of residency for those same respondents and you'll see that seventy three point seven percent of the responders plan to enter fellowship so in this day and age people want to subspecialize which is great it's not necessary but it's an option and then of those people eighty percent of them are entering that MSK pain spine sports world and so just a little food for thought you know there's a lot of people in that boat and we're going to talk about that but first Kevin's going to talk to us about the fellowships that are out there. Good morning everyone. For the half of the room that's medical students and for lower level residents he are the fellowships that are created by the Accreditation Council of Guided Medical Education in the field of PM&R. The most sought-after I guess is pain medicine, sports medicine but we also have brain injury, neuromuscular medicine, spinal cord injury, and periodic rehabilitation. Nonetheless we have other specialties that you can go from the PM&R field and residency which include cancer rehab, interventional sports and spine which is combined sports and spine, spasticity, multiple sclerosis, amputation, neurorehab, headache, occupational environmental fellowship, research, and regenerative medicine which is a growing field right now. Alright so I had a little bit of fun so humor me as somebody himself entering pain I entered residency and this was me that's the path that's already there it's very deep and ingrained and I wanted to follow that path but I also didn't know as much about the rest of PM&R. Luckily I'm gonna introduce Dr. Eastman but she helped me see the bigger picture and learn a little bit more about some things earlier on in my career but the point is that there's other paths and there's so much opportunity for people to go ahead and stake out some claim in areas that are less trodden and then here's a little cartoon a little adaptation for PM&R. It's a crowded field saturation is a thing especially in the major cities and so I'm happy to jump in I'm excited to be a pain doctor but there's also other options there's other things to explore and medicine is a giant field there's so much opportunity for post-acute care across the spectrum of medicine. Okay so we have an awesome lineup of panelists we have six different panelists and you can see all their specialties we have Dr. Yogita Taylor, Dr. Maria Reese, Dr. Amelia Eastman, Dr. Brian Fricke, Dr. Chris Lewis and Dr. Deborah Bernal and so we will go through and have each of them present their story and save questions for the end and we'll have a lot of time at the end to do a little Q&A session. So I'm going to go ahead and introduce our first presenter Dr. Yogita Taylor who practices pelvic rehabilitation medicine in Atlanta Georgia and she is board-certified physiatrist and completed her medical training at University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine now called Rowan and her internship at Christiana Medical Center in Delaware. She did her PM&R residency at Sinai Hospital in Baltimore where she served as chief resident. She's skilled in the treatment of pelvic dysfunction and resulting pain disorders. Prior to her current role she was on faculty and assistant professor of rehab medicine at Emory University and served as staff physician at the Atlanta VA Hospital from 2013 to 2020 where she practiced general physiatry as well as wound care hyperbarics. All right so Dr. Yogita Taylor you can come up here. All right thank you so much Farah and it's so great to see many young faces and wonderful excited faces today. I remember being in your shoes almost more than a decade ago now so I'm just gonna talk a little bit about my journey to where how it led me to where I am today. So I graduated from medical school in 2009 and then my residency was done at Sinai Hospital of Baltimore where we had a wonderful very broad learning where I was enthralled in everything so between inpatient outpatient got a little bit of wound care under my belt. Great experience and at that time at the time of residency I also got married and so lots of professional as well as personal achievements and from Maryland I moved down to Atlanta where I was at Emory for seven years and in my practice was a very general practice. While I had great interest in inpatient outpatient musculoskeletal I didn't find a great compelling reason to specialize and coming right out of residency I was it was wonderful to be able to do as much broad practice as possible. So part of it included EMGs and while I don't have a picture of myself doing an EMG, there I am in that bottom right corner, I also did some inpatient work seeing stroke, brain injury, spinal cord injured patients. I worked with the residency team and then part of my practice was also including wound care and hyperbarics which in itself is a niche not where I am at right now and again if any specific questions about that but that's something that also came into my lap during my time at Emory. And while I was there my interest in pelvic pain started not only from my outpatient practice where sometimes I would see patients with presenting with hip pain, groin pain or even pregnant women who had issues that were deemed to be normal or common, but I was like from a physiatry approach this is something that we can be we can treat and sometimes that pregnancy state leaves people in kind of this limbo spot where the OBGYN is like you're healthy, the baby's healthy, let's just let this pass and there's not much we can do about it and then from a physiatric perspective it's kind of like well okay if you're pregnant there's not much that we can do from medication or injection or procedure perspective but actually there is a lot we can do. So just a little quick definition of what pelvic pain is. It's any pain from the lower abdomen, pelvic bone area, lumbosacral region, tailbone to the buttock area. Similar to the way we describe any type of pain there's different stages of it. Acute pain which can be from zero to three months, that's typically our pregnant postpartum patient, patient that may have had a recent trauma or injury or someone with an underlying infection that has resulted in pain. That's subacute from three to six month duration and then chronic pelvic pain which has been over six month duration can be which can be continuous or intermittent and again the type of patient that we see has enough pain that causes any functional disability or seeking any type of medical care. Pain can originate from different organs from uterus, ovaries, prostate, penis, testicles, intestines, bladders and then don't forget the nerves, muscles, ligaments, joints of the pelvic floor and so that's where as a physiatrist that's the role that we play. So looking at the muscles, nerves, joints and kind of the dynamics behind all of that. So initially when I started treating pelvic pain it was at Emory and my practice was primarily pregnant in the postpartum patient. So looking at pelvic girdle pain, low back pain, radiculopathy, SI joint dysfunction which again something that we see very commonly as part of a lot of outpatient physiatric practices but then there's also pubic osteitis and stress fractures which may be more unique to a pregnant patient than non-pregnant patients. So a lot of that can include things of education and making sure that they're being seen by the right person. Pelvic floor physical therapy is a very unique niche even in the physical therapy world where a lot of biomechanics education can be done. A lot of exercise modifications can be taught from our perspective and sometimes in certain situations medications may be warranted and so again collaborating with the OB it's something that our practice can entail. So and then there's the postpartum patient. So with someone with ongoing pain after delivery of a baby and so thinking outside of our typical physiatry type of approach we want to think about things like what type of delivery did they have. Was it a vaginal versus a c-section? Even with a c-section were they pushing and how long were they pushing? Were there more was there more than one baby involved? Was there instrumentation that was used? Was there any tears or episiotomy done? And then again the fetal birth weight, head circumference, all of those things are important to think about in that postpartum period. So again working with the OBGYN department at Emory this was a great aspect of what I included in my practice. However you know five six years into me doing what I'm doing I really wanted to expand this aspect of my my career and so in the last four years I've expanded my scope to treat chronic pelvic pain. And so at this point now pelvic pain is kind of what I do all day every day. And outside of the pregnant postpartum patients this is a lot of what I see on an ongoing basis and oftentimes there's multiple things going on. So again there can be pain with menstrual, severe pain with menstrual cycles, vaginal pain, rectal pain, pain with sitting, pain with bowel movement, a lot of functional issues. Again bowel bladder, whether urgency, frequency, and then going back into sacral pain, tailbone pain, pubic symphysis pain, SI joint pain, syndrome called persistent genital arousal disorder, and penile and testicular pain. So again as a physiatrist we are trained to grab a very comprehensive history and that looks at function, bowel, bladder, intercourse, activities, how their pain affects their work schedule. And we want to do a good thorough physical exam and that includes the back, the hips, the abdomen, and then a pelvic floor exam which typically is not something as part of our training but that includes an external exam feeling kind of the bony areas from pubic symphysis, ischial tuberosity, and then the peripheral nerves that come through, as well as an internal exam examining the neuromuscular aspect of the pelvic floor. So we have the levator ani muscles, the obturator muscles, and deep nerves including the pudendal nerve, and furicloneal nerves. So that's a big part of that aspect and we want to treat chronic and severe pain from that musculoskeletal approach. So oftentimes with patients with chronic pelvic pain there's over activity of the pelvic floor so we want to use our physiatry practices to help down train. That can include a guided non-operative procedure such as trigger point injections, nerve blocks, joint injections. And again we are used to working in a multidisciplinary team so collaborating with gynecologists, urologists, GI, physical therapy, mental health professionals, and potentially helping avoid unnecessary surgeries and treating the patient as a whole person and focusing on the function. Again love this kind of diagram how we are working as an integrated team approach. So a lot of my practice does involve collaborating with multiple other specialties and for something like this for a practice like this to grow a lot of networking marketing needs to be done. So between visiting other practice to explain like how can a physiatrist help with pelvic pain. That is that was that is and continues to be a huge part of growing our field. So meeting with different gynecologists, surgeons, OBGYNs, speaking in podcasts, zoom meetings, grand rounds. So again making yourself known to the community is really important to making your practice grow. And then again obviously incorporating more of the academics. So publications. So this this study that we have here is kind of collecting about one years of data of how our approach of physiatry approach can improve quality of life and decrease pelvic pain. Having a social media presence can also be helpful to spread awareness through the community is also important. So I'm going to step down and let the next person, Dr. Maria Reiss, present what she does. Hello everyone. I have the pleasure of introducing Dr. Maria Reiss. She served as the medical director of the Shirley Ryan Ability Lab Performing Arts Medicine Program. In this role Dr. Reiss cares for a variety of performing artists from dancers to actors to instrumentalists and crew members from the amateur to the professional with a variety of injuries and ailments. She currently provides care to several theaters in Chicago in the Chicago area including Lookingglass, Chicago Shakespeare, Goodman, Steppenwolf, and Ravinia. She previously served as the medical director for the Joffrey Ballet and the Blue Band Group as well. Her current area of research is in medical education regarding how to best train residents and fellows to perform dancer specific physical examinations. Her unique approach to caring for performing artists was featured in JAMA's 2019 Day in the Life series, Performing Arts Physicians Saves Careers by Fine-Tuning Physicians Form. When caring for patients, Dr. Reiss is able to extend her physical examination by offering dynamic ultrasound assessments. She strives for the least invasive treatment options yet is it trained in lumbar spine, peripheral joints, soft tissue, and perineural injections performed under fluoroscopic or ultrasound guidance. Dr. Reiss earned her BA in human biology and MA in sociology from Stanford University and her MD from University of Southern California Keck School of Medicine. She completed her physical medicine rehabilitation residency at Northwestern Shirley Ryan Ability Lab where she served as chief resident. She completed her sports medicine fellowship there as well and was asked to join on as faculty thereafter. She's board-certified and PM&R in sports medicine and she is an assistant professor of PM&R at Northwestern University Feinberg School of Medicine. She thoroughly enjoys teaching medical students, residents, and fellows, of course, helping patients get back on the stage. So join me in welcoming Dr. Reiss. Good morning. Thank you, Chris, for that introduction. So as he mentioned, I'll be talking a little bit about performing arts medicine and sort of my path, my current practice. A lot of my points can actually be expanded to another area that you may have if you want to start a niche practice in maybe cancer rehabilitation or otherwise. So while this is geared towards performing arts, do feel free to make the leap to the lily pond of your choice. So a little bit of what we're going to be doing is talking about how to start or grow a performing arts medicine program and aspects of that PAMP or performing arts medicine program. So from a clinician side, how do you start or grow a program? Well, obviously, you have to be interested in it. If you have passion, passion can go a long way, especially in the early phases when you may not be seeing a lot of the maybe reimbursement aspects of your care. And of course, having the applicable knowledge and skills and then networking really helps to grow your practice. So a couple of ideas is thinking about starting a journal club or a monthly meeting for like an interest group within your practice or even within your small hospital or your larger city. Thinking about shadowing colleagues or therapists. So in the performing arts world, there's quite a few performing arts physical therapists, but there's also ENTs who specialize in vocal cord rehabilitation. So those folks also serve as not only your network, but obviously colleagues that you may need to seek care from down the line. And then thinking about referring your patients to those individuals, and obviously this becomes a growing relationship. When you're on the patient side of things, you want to make sure that your clinician is speaking a language that they understand. I've had countless times that a patient will seek out my care because they've seen somebody that says, just get a different hobby. You don't need to play violin anymore. Which obviously that's not what they are going to listen to and nor should they. And so also being at least able to start to understand, you don't need to necessarily know all the fingering and tuning that's required for various types of music, but at least being open to hearing and listening and seeking out. And then also understanding that this is literally their life, right? A lot of the folks that we see, it's maybe kind of what keeps them sane, but it also keeps bread on the table. So telling them, oh, just take a rest or just take a break, that's not an option. And so being able to understand how can we change your choreography or what you need to be doing in order to keep you literally on stage. A lot of times, obviously, we all like to keep our expenses low. And being that I can do bedside ultrasound and do that immediately, not only is that helpful for the patient to say, oh yeah, we can look here and see what the problem is, but I sort of use that when I'm working with theaters because, hey, I'm going to keep your expenses low. We're going to do bedside ultrasound. We're not going to have to send everyone for an MRI of their shoulder. So obviously, theaters want to hear that too, keep their workers' costs low. And then thinking about how to connect them to the next step of care. A lot of times when you're growing your practice, you're going to want to have that sort of what I call like the white glove handoff, right? I have the specific therapist for you, I email that therapist, I text that therapist, I make sure that therapist calls that patient. So there's a lot of handholding, but that helps make sure that that patient feels heard, feels cared for, and then can continue to do what they want to do. Having a clear follow-up plan when they're going to see you, obviously have an easy way to connect with you, and then a lot of times those patients become your referral base. I can't tell you how many of my patients say, oh, so-and-so sent me here because you cared for them, or my teacher sent me here, and that's great, right? That's exactly what we kind of want is that sort of small grassroots efforts to become bigger efforts. When we look at the team side, obviously we're interdisciplinary as physiatrists, and the clinical team that we work with at the Ability Lab, all of us who do see performing arts patients are dual-boarded in physiatry and sports medicine. We learn how to do dynamic evaluations of the patients, so not only your sort of typical neuromuscular exam, but having the patients play their instrument and looking to see how they're playing, what's changing in their body. Obviously sometimes it's not possible to bring your piano into the clinic, so we do have a portable keyboard, or you just try to sort of make fit with something, the keyboard itself or pretending, and having the patient adapt in their different positions, right? So a violinist may sometimes practice standing up, they may play sitting down, so making sure that you're looking at them as they're playing. And I always have patients, I tell my patients obviously what I'm going to do, but I have them in a gown. I'm seeing their back, I'm seeing everything as they're playing, and I let them know, I'm going to be walking around you here while you're playing, try not to be distracted, but it gives me a great sense of what's actually happening. We're able to do x-rays, MRIs, and EMGs on site, and again, having those colleagues that I can talk with about what we're specifically looking for is helpful, and as I mentioned the bedside ultrasounds, this is an example of a guitarist who I had, who had a snapping ulnar nerve, and you can tell on the top photo, the medial epicondyle, and that's the ulnar nerve circled in kind of blue and red, and then when the guitarist would flex, it would hop over that medial epicondyle. But again, that was a very good example of the use of a dynamic ultrasound, and I didn't need to get an MRI and extension, and then an MRI inflection, we could just see it literally right there. And as was previously mentioned, we can of course always do procedures, but not typically indicated. And then as other aspects of our team, I have a group of physical, occupational, and speech therapists that are sort of super sub-specialized, I have some OTs that are certified hand therapists, and then I have other physical therapists who do TMJ, pelvic health, shoulder, hip, you name it, and then an extended network of sub-specialists at Northwestern. And so again, all of the sort of sub-specialties you see, and we have social workers, which is helpful sometimes for cost management for some of my amateurs, and then I have case managers that help with the workers' comp for my professionals. So it's again, just this big network that you're just continuing to feed is really helpful. And in terms of who we treat, and this could look like any, again, for any sort of area of sub-specialty, the individuals that come into your clinic, we have relationships with theaters, we do community outreach, and then because we're a teaching institution, we teach as well. Individuals can be anything from students to professionals, young to old, and do kind of any and all of the types of arts. I have photographers, I have visual artists, multimedia artists with their stylists that are getting wrist and hand pain, and of course the cast and crew that you can't forget about them as well. I find that my patients fall into two main categories, either someone who's had a prior neurologic injury or insult that wants to get back to their activity, or more commonly, the chronic or acute neuromuscular conditions that would be similar to what you would see in a sports medicine clinic. The top being the more common, the latter being the sort of more the zebras. For those of you who don't know what an embouchure is, you probably do, but Dizzy Gillespie is pretty famous for his embouchure, that's the relationship of the oral facial muscles with the instrument. And so that's a pretty unique aspect of performing arts medicine, because not a lot of athletes are using their embouchure in the same way that instrumentalists are. With our theaters, we try to establish a contract, so that helps us establish what you see here. Again, having easy access to physicians, the direct email and phone access, as you can imagine, that's my cell phone, they can contact me any time they need to. Having a workers' comp liaison is really helpful, and then kind of your bargaining stick is oftentimes marketing opportunities, right? We'll put your name on our website if you'll put our name on your website, and that helps again save them costs, because not a lot of theaters are really looking to dish out money to save money. So also trying to see how you can sort of spin it to show them how much money you're actually saving them, and the high quality of care that you're providing. And then on the physician-therapist side, we are previewing shows, we're looking to provide movement sessions, and then we have therapists providing wellness care at the theaters several times a week. Within the community, we do outreach sessions to schools, theaters, and then of course as a teaching institution, residence fellows and medical students have the opportunity to learn, but then also provide them with opportunities to do presentations, manuscripts, and medical education research. So in review, whatever your niche may want to be, think about how to grow it from a grassroots efforts in finding folks of similar interests, and then thinking about all the team members that you'll want to employ, and how to keep those relationships nurtured. Thank you. Alrighty, I am so excited. Password's on, but we have this here. I'm so excited to introduce Dr. Eastman. She is a big reason why I found PM&R. I met her as a medical student and there's a lot of pathways to pain, sports medicine, you could do it, family medicine, you could do EM medicine, you could find your way into anesthesiology, but she helped me see PM&R as the best place to be because it is the field that feels the most at home for me and I have the great privilege to work with her now as a fellow at UCSD and see her once a week inside of our clinic. So Dr. Eastman is a board-certified physical medicine rehabilitation specialist. She's a physician who meets with patients at different types of UC San Diego health clinics to help with physical impairments and rehabilitation. She uses a hands-on approach to diagnose injury and illness and encourage the body's natural tendency for good health. Dr. Eastman does not prescribe pain meds. Her treatments focus on multimodal solutions including physical or occupational therapy, injection options, equipment, bracing, or technology to enhance recovery. Dr. Eastman is trained in both integrative medicine and conventional medicine, allowing her to integrate all aspects of her health and best method for each patient. She also has a preventive medicine background, aerospace, occupational medicine, so a wealth of experience that's unique but very well fitted to physical medicine rehabilitation. So with great pleasure I'm so excited to introduce Dr. Eastman. Hi, did my one slide make it in? It's okay if it didn't because it didn't say much. But I'm here to answer your questions of course. We each have our little space within rehab and I did, how many DOs are in the audience or up here? How many DOs? Okay, so I do osteopathic manual medicine and for those of you who raised your hands I would very much encourage you to try to keep your skills up because I went to Western University of Health Sciences so I, you know, we all have DO training for our hands-on skills and your hands are where you can take everywhere you go, you know, and I did a MD residency in Baylor and so I only had one attending who did manipulation and he would do it kind of like on the fly for like people would be, oh I have a headache right here, and you know he would find the counter-strain point and he would just say uh-huh okay tell me about your headache, how was your weekend, blah blah blah, two minutes goes by and then you know he readjusts them and he says okay is your do you feel better and they're like oh thank you my headache's gone. So that was the for four years that was the only, you know, one attending just a trickle of doing osteopathic manual medicine. I really didn't use my hands that much but you know you keep the skills that you learn and then years later when you know I got a job opportunity they said so you're a DO can you do manipulation and I said yes I can and you know then you kind of get you bring your skills back up because you can always, you know, do CME courses and that's what I do two days a week now is I just do manipulation and I work in the pain management group and I use my hands. So for those of you who are not DO trained you should know that I'm currently at an MD University, you know, I'm at University of California San Diego and right now we're training MDs to do manipulation. That's a large part of what I do. You can bill for it. You do not need to be a DO. You can do the same CME credits that I did when I was offered the job and said yes I can do this and I needed a refresher. You can do those same courses. There's nothing that prevents you from doing osteopathic manual medicine and it's very simple. So I would encourage all of you to, you know, start to use your hands in a therapeutic because when you're a physiatrist it's all about investigation. It's about objective data but when you're doing manipulation it's all about a therapeutic response that you can deliver with your hands. So, oh good that made it up. That's osteopathic manual medicine. It's a hands-on procedure to reduce pain or improve function and then the other part of what I wanted to talk to you guys about just briefly and then I'll take whoever has questions is occupational medicine and I don't practice this anymore but I have a good background in occupational medicine and you should know that it's not a fellowship. You do not have to go on to get additional training. You can come out PM&R, general PM&R. You don't need any type of fellowship. You don't need any type of additional certification and there's really good jobs in the space of occupational medicine. I had so much fun. This was so such a wonderful part of what I did is treating people with acute disease. That was actually the most fun because most PM&R were like a referral. Like the way I practice right now I'm a referral. I see patients like, you know, the soonest is like three weeks, two weeks and that's like the soonest but in occupational medicine you're like same day. You can intervene so fast and it is so much fun because you're really just quicker in the whole time cascade while they're just like waiting for an appointment. Occupational medicine doesn't usually work like that. Occupational medicine is same day and then it's next day follow-up and then it's, you know, next week follow-up and then it's like back to work. So it's fast-paced and occupational medicine is just super fun and then the other thing you might want to put in the back of your mind is that there's a huge need. So right now if you do PM&R and you're interested in occupational medicine you could probably find a job just about anywhere. There's a huge need. The occupational medicine boarded physicians are kind of like, you know, they're all retiring and they're having a hard time filling, you know, the gaps with just people who are boarded in occupational medicine. So you can practice occupational medicine without being boarded in it and with PM&R it's like a natural fit. It's, there's nothing really that you're not gonna know because I mean, you know, it's like musculoskeletal and then, you know, if they have a traumatic problem it's, you know, post amputee. You're not the one, you know, seeing them in the ER but, you know, you're the one who's seeing them, you know, immediately after their injury. So I think I'll keep it at that but I'm happy to take any questions you guys have. It is my pleasure to introduce Dr. Brian Fricke. He's a board certified physiatrist who specializes in cancer rehab and is an assistant professor at UT Health San Antonio in San Antonio, Texas. He completed his medical education and internship at UT Health San Antonio, where he's originally from. He went on to complete his PM&R residency training at MedStar National Rehabilitation Hospital at Georgetown University in Washington, D.C., where he also served as an administrative chief resident. He then went on to complete a fellowship in cancer rehab at MD Anderson Cancer Center in Houston, Texas, before coming full circle to return home to San Antonio, where he has been on the faculty since 2020. He has recently taken on the role of vice chair of clinical operations for the Department of Rehabilitation Medicine at UT Health San Antonio, in addition to serving as co-director of cancer rehabilitation for the MACE Cancer Center and the soon to be the new flagship multispecialty and research hospital at UT Health San Antonio. Dr. Fricke is skilled in the treatment of cancer related impairments, as well as supporting cancer patients with any non-cancer related physical impairments as they move through their cancer journey. Major clinical programs introduced at the MACE Cancer Center so far include the Lymphedema Early Evaluation and Detection Program to identify and proactively treat high risk patients for lymphedema before the onset of clinically evident lymph swelling. He is also set to launch a pilot rehabilitation program for newly diagnosed breast cancer patients at the MACE Cancer Center through introduction of a novel risk stratifying functional assessment. His clinical interests include addressing shoulder dysfunction and post mastectomy pain in patients with breast cancer, as well as performing a variety of ultrasound-guided interventional procedures for pain and spasticity sequelae from cancer and its treatment. He's also very passionate about his advocacy work as part of the AAP Public Policy Committee and loving work. He's done in partnership with patients that he's taking care of in his practice. Above all, though, he's a proud husband and father, too, who are the center of his world. So thank you for being here today. Thank you. So I don't have anything as prepared or put together as my esteemed colleagues on the panel today. So I'll just kind of keep my comments brief. Thank you for that introduction. I know it's the one I provided. I think it was maybe a little bit long-winded, so I'll cut it down next time. But, no, I think one of the things that struck me so far, even listening to my colleagues, here today and what I want to impress upon you guys is, through the lens of cancer rehab, at least, what I tell all of our residents at UTL San Antonio is, really, truly, 90% of what we do in the cancer rehab clinic is just foundational PM&R principles applied to a cancer population. And I see a lot of those same themes throughout the presentation so far today. I think one of the things that really is worthwhile to keep in mind, that although we have these wide variety of what we do in PM&R and all of these fellowships and certified fellowships that do tremendous work, it's really our foundation that we get as rehab doctors and how we approach patients that we're just applying to these subpopulations. And that's really something special and something I think we're all proud of. Some of the other themes I kind of see that I wanted to touch on, as you guys hear the rest of the presentations and we move to the Q&A, that I want you to keep in mind, is that so much of what we do is, in all of these different niches that we have, is really demonstrating the value of PM&R, what we bring to the table. Building a referral source. How do you serve your patients? How do you serve the physicians that you're collaborating with? And especially so, I've started waging my little private war against pain in sports medicine. That there's so much of what we do in PM&R that is beyond that. I appreciate and respect our colleagues in pain and sports medicine, but really, truly, there's a lot that we do. And I even looked within our own department of, I have this little theory of that residents and fellows are really most interested in those fellowships because they're very procedure-focused and they're very procedure-heavy. We all love procedures. They're fun, they're instantly gratifying. Patients walk in, they walk out, they feel better. That's what we got into this to do. And I challenge the idea that you need to do pain or sports to do that. We've heard from our pelvic floor specialist up here that does a fair amount of interventional work. Dr. Reese, it sounds like, does as well. I do in my cancer rehab practice. My boss, Dr. Gutierrez, who many of you know of, at least, or know personally, because she seems to know everyone, has a very, very procedure-focused practice and she is the queen of spasticity and is a brain injuries medicine certified doc. So I want to encourage everyone, which I think, if you're in this crowd, you're probably already, I'm preaching to the converted a bit because you're looking outside of those specialties as well. But definitely spread it around to your colleagues. There's a lot that we can do in rehab and there's a lot of area for all of us to meet the needs that are out there. So with that, I'll turn it over to my colleagues. Thanks. Okay, next up, I have the pleasure of introducing Dr. Chris Lewis, who's a senior clinical informatics fellow at the University of Washington through the Department of Biomedical Informatics and Medical Education. In the Department of Rehab Medicine, he practices cancer rehabilitation as well, focusing on functional recovery, spasticity management, and quality of life. His research interests include developing rehab-specific learning health systems, implementing artificial intelligence, health systems, artificial intelligence, and other evidence-based clinical decision support tools for patients and providers, and assessing the usability and efficacy of remote patient educational and monitoring tools. He graduated from med school at the University of Washington School of Medicine and completed his residency at Northwestern Shirley Ryan Ability Lab, where he served as academic chief resident as well. Thanks for that introduction. I want to start out with a couple questions. So they're easy questions. Just raise your hand, yes or no. How many people in here have used an electronic health record? Okay. And how many people have heard of a clinical informatics fellowship? A couple people. Oh, awesome, okay. But it's not one-to-one. We have maybe more people use electronic health record than know about clinical informatics. But I think when I talk to people about informatics, usually they fall into a couple categories. One of the categories is this is something I don't want to touch with a 10-foot pole. Keep it away from me. I want to practice medicine. I get that. I love medicine too. I love practicing PM&R. But I think there are people that hear this and they're like this is what I want to be able to do because I want to be able to change the system I'm a part of. I'm working in this electronic health record. It doesn't seem like it's designed with rehab in mind, with physiatry in mind, and it doesn't have the tools we need to necessarily do our job the best of our ability. We want to be able to do our job and we want the tools we have to actually allow us to do that job rather than get in the way. And so informatics is the training on learning how to do that. And you apply your medical training through this technology lens to be able to try to make our practice better for everyone. So I have a couple slides. Why do we even need clinical informatics? Like what is this? Why is this something that we need? And I think all of us are realizing that technology is becoming more and more a part of what we do, but like I mentioned, it doesn't always feel like it's designed with us in mind. And so we need people who have one foot in both camps. They know what we need as providers, but they also have a sense of how to translate that information into the technical speak that people need to know to be able to build it. So there's kind of three categories here, and you'll see this as a recurring theme. The EHR. This is something probably that we've all experienced and we work with, and this is kind of just a word cloud of things we all see. I think from the rehab perspective, there are things that are growing and coming out of this that in informatics, we have an opportunity to try to leverage, and I'm trying to leverage with PM&R in mind and rehab. And one of those things is activity trackers. So you may know patients who have phones that track their step counts or Fitbits or other things. It's becoming easier and easier, and there's a lot of work being done to try to integrate that information into the electronic health record. So imagine this where you have a patient, you give them some activity goals. Hey, go take this number of steps. And then when they come back, you can actually see in the chart that they did that. And you can give them encouragement remotely. You can say, hey, great job. I just saw you went on like an X whatever run or walk, or you did that goal. And it's a way to really see how our patients are doing from far away. And then we can check in with them when they come back and see us. Pop health, we can manage whole populations. As people come in with certain needs, often those needs are not met because we don't recognize them. And if the electronic health record can identify those needs and say, hey, this person needs this, and that way we don't miss it, and we can actually make sure that the people, our patients are getting what they need. Registries also allow us to identify patient populations automatically. I'm sure there's a lot of trainees here, and I've been a trainee. I'm still in training. The amount of time we've spent looking through electronic health records and typing information from the electronic health record into a spreadsheet. What if I told you that a lot of that could be probably done automatically if we put a little elbow grease up at the beginning? So that's something that is exciting as well. Okay, this is a figure to try to show the idea of getting data out of the electronic health record. So I kind of alluded to that. How many people have done research that involves information in the electronic health record? A lot of people. Raise your hand if it was really easy to get that information out. Okay, that's a problem. We need to be able to get the information that we need, and informatics is a skill set that we learn how to do that. So we learn how to pull the data we already have. We learn how to make more data that we need so it's not just stuff that we don't need. And you actually get to make a lot of friends because people really want that information, and they want to be able to do their research. And so you get to meet a lot of people across the institution. This last figure is really about innovation, and there's a lot of stuff coming down the pipe, and in informatics you get to be able to learn about and meet these upcoming technologies. You get to identify them, evaluate them from a medical perspective, and say, is this actually going to help doctors? Is this actually going to help patients? Because as you know, industry may want to sell it to you and say, this is going to be the best thing since sliced bread. But from the physician perspective, is it? From the patient perspective, is it? And then you get to assess that and make sure that we're actually doing good by everybody. So what is the fellowship? I just want to talk about this briefly because this was something I didn't know, I found out about this later. It's ACGME accredited, it's a two-year fellowship, PM&R is eligible, really every specialty is eligible for this, and you get to keep seeing patients. I'm not going to go into too much of the details. If you're interested in this, I'm happy to talk more about what this fellowship includes. So what kind of jobs can you get? From this, often you work in the hospital administration trying to build these systems for the entire hospital. That's called operations, just the day-to-day stuff. How do we keep the technology working? You can also work with researchers to try to optimize the data they get and interpret that and implement stuff. So you can study how you implement these things. And you can work for startups in industry. But there's a focus on academics. So happy to answer any questions at the end, and really thank you for everybody's time. A little vertically challenged. Okay, good morning. I'm going to introduce Dr. Burnell. She's awesome. She's amazing. She's my mentor and partially also why I found PMR. So essentially, she is currently site director at Willspan. She focuses on musculoskeletal and spine care. And recently, she's been certified in lifestyle medicine, which she will be talking to you guys about today. So without further ado, here's Dr. Burnell. Yes, I want to make sure we have time for questions and answers. That's the most important part of why you're here today. So I do all outpatient neck, mid-back, and low-back pain. And I use integrative lifestyle, which is a combination of all of those things. I use integrative lifestyle and team-based care. Is this working? Okay. No disclosures. So these are the six pillars of lifestyle medicine, nutrition, and weight management, physical activity, stress management, restorative sleep, social connections, and avoidance of risky substances. It's very important the role of the practitioner in their personal health and how they bring that journey to their patients because that's how you get more buy-in. And we have the same challenge in our physician population that we have in our entire population and our students as well. So the nutrition is a plant-predominant diet. We want to stay away from those fast foods, those cheap and ultra-processed foods that cause inflammation. Of course, we're physiatrists. We're promoting physical activity, making sure that we're using motion as lotion to help those joints, those muscles, posture alignment. Making exercise play for our patients to get some kind of buy-in so they're able to sustain some kind of regular activity. Stress management. Everybody needs to be on that inner journey of taking care of their stress response. People that say, oh, I don't have any stress, they're just not in contact with their bodies and they don't realize it. Sleep management being very important. I've had this challenge coming all the way over to California from the East Coast in the last few days, waking up early in the morning. So getting that restorative sleep. And the environment you're in. So we're talking about your personal family environment, the environment of your community, the social, political environment and how that causes problems. And, of course, toxins, alcohol, drugs, energy drinks that are toxic and killing our kids. There's a wonderful documentary I recommend, They're Trying to Kill Us. I would suggest you look it up on YouTube. You can get good information on the impact of communities, especially disadvantaged communities. And social connections. We all need to find our people and be supported and connected. So it also incorporates the role of the practitioner in community service and advocacy because what we're talking about is a radical change in health care. We're not just delivering care for an incident for a quick fix. We're talking about changing the foundation of how people live. So it's whole health treatment model, not just surgery, prescriptions, interventions. That's just the tip of the iceberg. We're talking about the foundation is how we live day to day. And we're looking into, at lifestyle medicine, incorporating aspects of a person's spirituality as well. We're doing some research. I'll be back in San Diego to do that in March. So I run this Healthy Lifestyle Pain Relief Program, and I'm starting back with shared medical appointments virtually in January. I'm very excited to do that. I was doing some in person before the pandemic. Haven't done any since, so I'm really looking forward to engaging in a group for them to support each other in lifestyle change and giving me that hour and a half working with the group in order to educate them on lifestyle changes. So the American Board of Lifestyle Medicine has been in place since 2016. You can apply to the board to do an exam. You have to be boarded in some specialty to do so. There's core competencies that you have to get through to sit for the exam. There's lifestyle medical school curriculums across the country, and if you're a medical student, you can engage with lifestyle medicine and start an interest group in your school. You can do the same thing in your residency. You can do the same thing in a fellowship, and there are specific fellowship curriculums available across the country. Here's some information on your slide about those academic programs that are available, and the website is on that slide in your slide deck. And if you're interested in food as medicine, there's a free 5.5 hours of CME available on the College of Lifestyle Medicine website. So if you're interested in any of our niche specialties, just learn as you go. Find your people, collaborate. Find out what your deal breakers are, what you have time and money to commit to, and be nice to yourself. Enjoy the journey. All right, thank you to our incredible speakers. We will take questions at this time. We have a microphone up here and we have some that we can pass around. But if anyone from the audience has questions, feel free to come up and shout them out. All right, we have a question for the panel as we're waiting. Describe what a day-to-day life is like in your practice. So for me, day-to-day, kind of similar to a lot of physiatry practices. I see a combination of new patients, which can be about an hour-long session. I will see follow-ups, which are about 30 minutes. And then we have procedures scheduled as well throughout the week. And since they're ultrasound guided, it's not a dedicated procedure day. I also have some time blocked off to, again, communicate with referral sources and PTs and such. But that's typically what my day is like. I start in the morning and evening. So most of my days are patient care. I just want to say, I'm all outpatient. I do four 10-hour days. I have the same schedule as you, hour for new, half an hour for follow-ups. And those special appointments, those 90-minute group visits. Check, check, cool. For the informatics fellowship, the majority of my time during the fellowship is non-clinical. So you're coordinating with leaders in the institution and working on projects that are coming down the pike. So currently, we're focusing on ambient technology. So the one-liner on that is, you're talking to your patient, you set your phone on the table, it listens to the conversation and drafts your note for you, then deletes the recording and everything so you don't have all that stuff. But essentially, we're trying to figure out how to implement that in a safe and helpful way. Yeah, so my practice has been varied over the years. As a lot of the other panelists I think have mentioned, it started out in the early years of being a little bit more of a generalist. I kind of tell everyone, I feel like I've touched just about every service line in our department has. I've done inpatient, I've done consults, I've done wound care, I've done outpatient sports, I've done outpatient brain injury, spinal cord injury, so on. Do back lift and pump refills, you name it. I've probably done it. But very recently now, I've been able to start to shift as our department's grown. I've been able to shift my clinical activities more to be traditionally outpatient focused and it'll be kind of an outpatient consult-based mix as the new hospital opens up for cancer rehab. So we do a little bit of both. Thank you. My name is Mehul. Thank you all so much for being here. It's really informative. My question was for Dr. Eastman. So I know you mentioned you had aerospace medicine put on your slide. I was wondering if you could talk about that a little bit. What that looks like? Is it more research or clinical? So thank you. So aerospace medicine, you can get to through the, through, sorry, preventative medicine. So I'm boarded in general preventative medicine and through that training, you can do aerospace medicine. I don't practice aerospace medicine. If I do anything, it's on the research side. But I do have colleagues who are PM&R and then if they want to do aerospace medicine, you do need to get a preventative medicine residency. So you do PM&R and then you do preventative medicine and then you work with the astronauts, which is pretty cool. Thank you. Good morning. Thank you. I think this has been the most helpful session I've attended so far. A little bit, I've been in the spine space for over 20 years and my private practice, group private practice was recently bought out by a hospital system and that's changed the entire flavor. And so I've been looking for a change and I would like to get away from just procedures like you've alluded to because that's what the hospital system thrives on. And so this has been very helpful. A couple questions. One is straightforward for Dr. Eastman. I'm an MD. Where would you recommend that I get resources on how to be comfortable in doing manual manipulations? Well, I think that the American Academy, you know, the DO Academy, the American Osteopathic Association, there's a good place to start. And then it also depends on like what region you're in because you really don't have to travel very far. I mean, you can travel to the national convention and do like five days where you get, you know, maybe 100 hours or 90 hours or something. But I'm sure that, where are you located? What region? In Virginia. Oh, yeah. You won't have to travel very far because there'll be something like regional and then just, you know, spend time building it up because it's not magic. It's super easy. You just kind of have to spend time building it up. And we can talk after a few. Sure. And I have a question for all of you really because it seems that you're affiliated mostly with academic centers. Anyone that you know or any of you thought of just going into solo practice? I was in solo practice for 22 years, but I am now with a large organization. So maybe we should talk about how to maneuver, if you know what I mean. Sure. But, you know, you have been practicing all these years. You need to understand your value to that organization and you need to lay out what you want to do. And there are options if you don't want to do other things. So value your experience, value your knowledge and demand what you deserve. Okay. Thank you. Hi, good morning. My name is Christine Chalaka. I'm a PGY3 resident from University of Washington, planning to apply to Payne this December. My question is for Dr. Bernal. I really enjoy lifestyle medicine and when it comes to Payne, I feel like sometimes it's difficult to have patients have buy-in to lifestyle medicine. Sometimes there's idea of like a quick fix. And so I was wondering what type of, how do you get patients basically to buy into lifestyle medicine and to see that in the long run it helps with Payne? Can you hear me? Yeah. That's good. So you have to look at each patient where they are in their journey. Some people seek me out very early because they've heard from other people. Oh, she does a, she looks at you, she does a holistic appreciation. Or they've been sent to you from the neurosurgeon and they've had three spine surgeries. They have a spinal cord stimulator. They have opioids, whatever. And then they're like desperate and they come to you at that end of the spectrum. You have to be a bridge anywhere that a patient comes in. You're looking for any little opportunity with each patient because you're listening to their story. I do narrative medicine too. So you're listening to their story for an opportunity where there's an opening. And we're physiatrists and then with lifestyle medicine you have additional things in your tool belt that you can pull out and use for those patients to just open up that opportunity. You know, they might be smoking. They might not even want to stop smoking but maybe they can start some breathing exercises. They could be completely sedentary but their legs are swollen and you can get them rocking in a rocking chair 15 minutes, three times a day and coming back to you saying, I couldn't believe just rocking in a rocking chair. How much better I'm walking. I haven't fallen. So what you're looking for is that opportunity. And the more tools you have in your tool belt, the more opportunity to open those spaces. And once you get a little benefit, you just keep on building on that. You know, I've seen people for years, people disappear, they come back because now they're ready because they've gotten their spinal cord stimulator and all their other stuff and it still hasn't worked. So they're now ready to try something new. So just get all the tools you can and listen. Thank you. Great, thank you. We have a lot of questions coming in from the QR code. Let's see here. At what stage of training did you all decide on your niches? How did you find mentors and did you face pushback from admin to curate your practice? There are a few questions in there, so I'll try to tackle them one at a time. So for, I can speak for myself on this. I knew going into residency that I wanted to stick around academics. I had played around with the idea of several different subspecialties before committing to cancer. I was fortunate enough to be at an institution that had a cancer physiatrist on staff. So I was able to learn a lot more in that way and be exposed to the idea. I think what really spoke to me about cancer rehab is specifically was kind of what I mentioned earlier, that I really liked different aspects of rotations for PM&R, but had a hard time finding myself and saying, yes, this is the one or two things that I wanna do for the rest of my career. And so I really liked how cancer rehab was this broad application of PM&R foundational principles to a unique population that was very challenging and can be medically complex and have its own dynamic nature because cancer is itself a dynamic process. It's not a static injury or illness as it were. And so being able to challenge myself in that way and meeting the needs of cancer patients and their massive population as well, I think it's projected by 2040, we're gonna have over 30 million cancer survivors in the US. And so knowing that there's a huge gap there really spoke to me as well. And then certainly there are challenges that come with building any practice. I can't speak to the challenges of building a private practice, but I know for an academic practice, certainly there are competing interests at play to say the least in terms of what they want you to do. But I would go back to what was said earlier. I think understanding your value and standing up for what you wanna do and say what you wanna do. One of the things that I think is, especially I see is we have a lot of newer faculty join our department and fresh out of residency and fellowship that I wanna speak to those individuals, particularly in this group. Be aware of the fact that all this time up through your training, you've been conditioned to say yes. As undergrad students trying to get into med school, just take me please. Medical students trying to get into residency, please just take me, I'll do anything. Residents trying to get into fellowship. The most common question that you will be asked when you're looking for that first job is what do you want to do? Really, really give some thought to that now because you will be asked that question at some point in your career, especially once you get out of training. Systems to a degree are getting the impression that physicians are unhappy. And as a point of fact, healthcare systems don't make money unless we bill. None of the administrators in these organizations make a cent because they don't bill. They don't make referrals. They don't order diagnostics. They don't do labs, imaging, none of that stuff. They rely on us and they need us more than we need them. And so keep that in mind as you go around and move through your training. I can speak a little bit about how I got interested. So I grew up doing arts and I think that's probably a lot of us who have these subspecialty interests. We either have a family member who was involved or affected by something. There was a lot of other sub-questions. But mentorship, mentorship's a very interesting thing. If you're assigned a mentor, then you're forced into a relationship. But I find that some of the best mentorships are just those that happen naturally from friends, colleagues, physical therapists, as well as other subspecialties that can help give you a different edge, if you will, something that makes you a little bit different than every other sports doc, in my case. And I think the other question was about, did you get any pushback from admin? I mean, honestly, for a lot of the time, a lot of what I do is after hours. And then as the institution sees that you're adding value to their mission and as the theater see that you're adding value to their cause, then that's what actually sort of helped. I wouldn't say minimize, I never got pushback necessarily, but more like reimbursement, per se, for your time. Then you can better advocate that actually your time is reflected because here we are in these advertisements, we're getting all these new patients. So there is a little bit, for me, I didn't get necessarily pushback, but as long as you continue, like it's been said before, showing your value and that you actually do make a difference in various ways. I would just say I'm pushy. Instead of pushback, I am making the case and keeping records so that I can show my value and then asking nicely for whatever I want. So you really have to be your own advocate. You've got to keep records and show what value you're adding and make sure people know. Find your supporters that are in rooms that you're not in to advocate in your behalf and you talk to them. Look for role models. Say, you know, I like the way this person does such and such, I'll be like that. I need this person as my mentor. Ask, people will help you. Thank you all. We are unfortunately out of time, but there are tons of questions in here and someone asked if the panelists would be willing to have their email contacts out there. And I believe most of the panelists put their emails or some way to connect onto the slide deck. So feel free to download that or look at that from the app and reach out to these panelists. I'm sure some of them will stay for a few minutes to connect with y'all if you want to come up. But thank you all for our incredible panelists and for a great session and your questions. Good luck, everyone. Good luck. Thank you.

physical medicine

rehabilitation

niche specialties

mentorship

networking

multi-disciplinary

subspecialize

non-invasive treatments

dynamic ultrasound

interventional injections

emerging technologies