Hi everyone, my name is Dr. Deborah Bennessy and I'm president-elect of the American Academy of Physical Medicine and Rehabilitation, AAPMNR. And you are listening to our first PMNR bold discussion or dialogue. And we are very grateful that you are tuning in tonight. You will see that we are on all coast and have all time zones represented. So we appreciate you, whether you're coming in from work or making dinner or driving home or whether you're like Kevin and I on the East Coast and we're kind of winding down but we really appreciate you being here. I have an easy job tonight and I'm very excited because I get to introduce you to all of our wonderful co-hosts for this evening. So I'm gonna do them in order. So we have our two co-chairs for the musculoskeletal care bold practice area, Drs. Carnaro and Cottrell. We have two special guests from an innovative MSK primary care practice model in Seattle, Drs. McMullen and Maestara as well as our academy president, Dr. Stu Weinstein. So let me tell you a little bit about our co-chairs. Kevin Carnaro is a board certified physiatrist well, I guess actually all of us are aside from Dr. Maestara but he's also in sports medicine and he's practicing at the University of North Carolina in Chapel Hill. Kevin completed his PM&R residency and sports spine fellowship at Northwestern University or Rehab Institute of Chicago. As many people on this call, he conducts research and he's written book chapters and articles about musculoskeletal sports, occupational rehab and my favorite low back pain. Jared Cottrell is also a board certified physiatrist with fellowship training in interventional spine and sports medicine and Jared practices in Portland, Oregon. Like Kevin, he completed his PM&R residency at Northwestern and he did an interventional spine and sports fellowship at the Chicago Institute of Neurosurgery and Neuroresearch. Jared serves on a medical pool for the US ski team, ski and snowboard teams and he provides local, national and international medical coverage for teams while training in competition. And as I said, we have two special guests. They're from, as I said, a MSK primary care practice model in Seattle, Drs. McMullen and Maestera and they'll be sharing later after we talk a little bit about a paper about their partnership between primary care and PM&R and what it's like in their office. We are excited to welcome Dr. Nina Maestera. She is a board certified family medicine physician and she's clinic chief at the University of Washington neighborhood, South Lake Union Clinic and Dr. Maestera received her doctor of medicine from the University of California, San Francisco and then completed her residency at UC Davis Medical Center. Dr. Maestera's clinical interests include family medicine, longitudinal care and comprehensive chronic disease care and as I was thinking about that, that's a lot of what we do aside from the family medicine aspect. Christopher McMullen is a physiatrist who specializes in sports medicine and he's an assistant professor of rehabilitation medicine and sports and spine medicine at the University of Washington. Just to change things up a little bit, Chris did his PM&R residency at the University of Colorado and then did a sports medicine fellowship at the University of Washington. And I'm sure Jared, I know you're doing, Jared, I know Kevin, you're doing some research with the soccer players and Jared has the ski interest but it seems like according to Chris's bio, he has an interest in climbers. Maybe I'll talk about that, I don't know. Last but not least is Dr. Stu Weinstein who has been an incredible mentor and friend to me. Stu is originally from New York and he did his internship and residency at the University of Washington. Stu was in private practice for at least 15 years before he joined the University of Washington and he's a clinical professor in the Department of Rehabilitation Medicine, Outpatient Sports and Spine Clinic. And I can share a little bit about his journey at the academy since this is an academy event but he was president of PASR and he was also chair of the academy work group so that when we reintegrated PASR back into our academy, he was the chair of that group. Stu was also the founding editor-in-chief of our PM&R journal of which this article we're gonna talk about. We can do the next slide, Chris. Thanks so much. So this slide is really just a reminder of what the academy and our specialty's vision is but we're talking about PM&R BOLD and this is our first dialogue. So to me, I guess I wanted to share what PM&R BOLD means to me. And PM&R BOLD is our strategic plan and motion to advance our specialty by communicating the unique value we as physiatrists bring to patient care and healthcare broadly. BOLD is how we think about the mission of your academy. BOLD is how we think about advocacy efforts. BOLD is how we think about driving patient outcomes. BOLD is how we think about our involvement in the evolving healthcare landscape. And BOLD is really how we think about you, our members, all of us, and how we are navigating the challenges of medicine, especially during this time of incredible need. I was reminded, because some of us are at home doing this and I saw Nina with her mask on. So we, again, appreciate your time. Enough about my introductions. I am super excited about this conversation. I'm gonna turn the mic over to Drs. Cornero and Cottrell. I think Dr. Cottrell might be still with patients but hopefully he joined. And I'm excited to dig in a little bit. Thanks. Thank you so much, Dr. Vennessy. Like you, I'm excited to be on this distinguished panel with such amazing clinicians and staff members here at AVMNR. And this journey for Jared and I started several years ago. And in that process, what had happened prior to us joining was many members in our academy were polled on how do they see physiatry and how do they see musculoskeletal physiatry in the future? And based on all the feedback, we were given essentially and from many members and thought leaders, we came up with this Envision Future as a collective effort from all of our members. And we felt that physiatry's role is sort of evolved in the future and where physiatry would be a primary carious frontline partner for this emergent and new musculoskeletal paradigm. And that was based on where we felt, where everyone felt physiatry was heading and where healthcare was heading. And so based on that, we came up with sort of three different high priority goals. And it'll be really interesting today because one of those goals has sort of been achieved at the University of Washington with Dr. Maestera and Dr. McMullen. So speaking about that'll be really wonderful. But high priority goals in this endeavor to explore and define models of this musculoskeletal care that offer strong future alignment and value to the primary care partnership. So what do we as physiatrists offer to primary care? In the process of doing that and then to create good clinicians, we'd wanna set a standard for training both residency fellowship and those who have graduated already in practice to advance the knowledge and skills of all physiatrists to meet the needs of this model. And then as we'll hear in a few minutes, but how do we generate demand for physiatrists and creating the market for that to happen and work with our primary care partners as valuable partners in this endeavor. And so that was sort of the goal that we set off for three years and COVID has come and sort of seen that physiatry has played a larger role in the care of many patients and specifically in the musculoskeletal spectrum. So if you wanna advance the slide. So again, many years of sort of planning and we've done things at academy meetings and got a lot of feedback from many of you who are out here today. And today is really a cool endeavor. We have, as Dr. Vennessy mentioned, Dr. Maestara and Dr. McMullen in Seattle and they're just getting off work or still at work today. And they're gonna really guide this and talk to us about how this PM&R or physiatry and primary care collaboration has been fruitful there on the West Coast and lessons learned on how we can improve care going forward. So again, very thankful for you guys both beyond today. Thanks for making time for us and sharing your expertise with us. So I was gonna ask you Dr. Maestara first, if you don't mind describing the clinic and your role in the clinic. Sure. Thank you so much for inviting me. This is a really great opportunity. As Dr. Vennessy mentioned, I'm the clinic chief at the Neighborhood Clinic at South Lake Union in Seattle, Washington and family physician as well. And I've been chief here since we opened in 2019. We are a multi-specialty clinic. We have OBGYN, PM&R and primary care family medicine in our clinic. And we also exist within a multi-specialty building with subspecialists above and below us as well. So we're sort of embedded in a multi-specialty kind of academic environment. We have eight primary care docs, three OBGYN providers and then our two sports medicine PM&R docs within our clinic setting. We're in a busy city center. South Lake Union neighborhood is kind of right in the heart of Seattle. We're surrounded by a lot of walking and businesses, residences, apartments and some administrative offices for University of Washington as well as research buildings. We've seen tremendous growth since our opening of the clinic in terms of our primary care volumes, in terms of demand for services and new patients here. And in that regard, we've just seen a lot of growth and addition of patients. Our panel is about 7,500 among all of our providers. We have a pretty wide variety of ages. We tend to skew towards the middle age but we also have obviously pediatrics as well as the geriatric population. And because of our setting here among some specialty practices, we have quite a bit of variation and complexity of patient continued conditions and chronicity. So that's a little bit about us at South Lake Union. That's wonderful. Dr. McMillan, how did this come to be? How did you create a role in this clinic? How did this role come to be? And tell us a little bit more how you got started. Yeah, for sure. So this vision I think started even before I was at the University of Washington. So our leadership and our division lead, Dr. Stan Herring was involved in kind of thinking about how can we see patients in musculoskeletal physiatry sort of earlier in the care continuum and what does that look like? And the framework for that was trialing, putting a MSK physiatrist within a primary care practice. And so several years ago, as this new clinic was being literally constructed and opened in 2019 before we got there, there was kind of this plan in place that we were gonna introduce physiatry into that clinic. And so that thought process had been going on. And again, the idea there is, how can we intervene earlier in that process when patients come into the University of Washington system for musculoskeletal care, can they get to us sooner so we can help triage if they need to see a surgeon or not, if we can start their rehab earlier, whether or not they need imaging and instead of delaying that process, get them to us sooner. So when I was coming on board, that was kind of the plan. And sort of even when I was interviewing, the plan was that I would be introduced into this clinic and was fortunate to be there kind of day one when we opened. So we were able to kind of build this together. And it's been a real partnership between PM&R and primary care. Dr. Maesteras, our clinic chief, has really been the leader of this in helping promote physiatry and promote musculoskeletal services kind of within the clinic. There's been a lot of communication between both the primary care providers in our clinic, but also some of the surrounding neighborhood clinics or other primary care clinics in our area, as far as these are the physiatrists, the providers that are in this clinic, these are the services they offer. And so that's kind of how I got started and how we've grown. And we've been really fortunate to, even through a pandemic, see continued growth over the past couple of years. It's been a real productive system. That's wonderful. And Dr. Maesteras, sort of follow up to that, had you worked with a musculoskeletal physiatrist prior to this? And how has the experience been working with, now you don't have to single out Dr. McMullen, but how has it been working with a musculoskeletal physiatrist in general? Yeah, no, this is definitely a new experience for us. And it's been quite a positive experience. We really hit the ground with a great relationship between Dr. McMullen and Dr. Chen, who joined our practice. So it's been just really very positive. Specifically the layout of the clinic where we are, that's played a role. Actually our physical space, it's kind of an open concept where we have a charting clinic area in the center where the providers are, and then they go off to see patients. And it's really been important in allowing for that interchange of ideas and having discussions while we're in clinic. One of the providers noted that it's important to have them physically positioned where we are. And that sort of physical proximity has been really valuable. Dr. McMullen, Dr. Chen practicing with an earshot, asking quick questions, those sort of in the moment kind of experiences have been really valuable. Some of the specific feedback, this is coming from providers in the clinic. Some of the ways that they've been really helpful helping us navigate the system, find a provider who performs a specific procedure, identifying when that procedure is indicated, allowing for communication with other specialists in MSK care to correctly direct patients to the right treatment at the right time. Some specific clinical scenarios, and this came from, I sent out an email to the group and they spontaneously provided these case studies and just different things that Chris also had, which asking a question about an X-ray for both shoulder alignment and confirming a fracture. What clinic is appropriate for a displaced humeral shaft fracture or the timing for that referral and what's appropriate. I'm wondering if a patient needs an MRI for acute hand weakness and helping to triage the acuity of that situation. Helping with same day evaluation of an acute Achilles tear. Helping with management of a torn ACL that was identified. Assistance with diagnosis and management of a patellar tendon rupture. And also helping with the evaluation of a patient with an evolving hematoma, providing point of care ultrasound and allowing the patient to avoid an ER visit. And yeah, so those are just some of the really real life clinical scenarios that have been really valuable for us. Well, that's great. Thank you. And then Chris, the same similar question, working in a primary care environment is very different than what you've done for through residency and fellowship, et cetera. And so what is that like for you? And if you could just talk a little bit about how you interact with the primary care physicians and sort of share patients with them. Yeah, absolutely. I think as Dr. Meister pointed out, the actual physical space is really important that we're sitting in proximity to each other, kind of operating in the same hallway and desks next to each other. So I think that co-location, being able to bounce questions off of each other is just really important and helpful. There's definitely been a number of advantages to having primary care right on site, our family medicine doctors right there. I think most notably is knowing that your patients are gonna have this very clean and clear follow-up with their primary doctor. So I'll see people with complex medical issues and my focus is on their musculoskeletal condition, but we know that pain is a complex process and system and if someone has uncontrolled diabetes or the blood pressure is not controlled, those things are gonna factor in into how they are experiencing pain. And so, from my perspective, if I can have the knowledge that I have a trusting primary care doctor right there who is managing those things, then I can just really focus on the musculoskeletal issues. So it really, I think, alleviates a lot of that sort of concern or worry that you might have with those complex patients where you're not sure when they leave your clinic, if they're gonna have that follow-up or just kind of be sent into the void. And so knowing that that's right there on site, I think is the most beneficial part of this. And then, of course, there are these issues where I can go straight to someone for a medical question. And so there are these things that my expertise is not there and I may have questions about sort of diabetes management or a blood thinner or medication interactions. And I can just very quickly kind of pop over and ask someone a question about that. And so I have numerous instances like that where I just can ask one of the providers a quick question and get that immediate feedback. Whereas in other settings I've worked in, that question may come up and maybe think about putting in a phone call to the primary doctor, but then you just kind of decide to look it up yourself or push it off. And so that close proximity again is really key and helpful. And it sounds like that would be like efficiency of care in that setting as well. And Jared's joined. So Jared, you can take over. I wanna have fun too. You know, to both, I guess more to both of you, Dr. Maesteros spoke to some of the feedback from the providers, but I'm interested in some of the feedback from patients. I can't imagine that that wouldn't be such a wonderful experience for a patient to see this collaborative effort. Definitely. We have some really good examples of that. I can sort of speak a little bit to what providers are doing. But it really touches on the patient experience as well of this model. One provider noted that it has been awesome, majorly convenient for our patients as they already know where to go after a referral, can schedule at our front desk and or use the same phone number. And it's very, another provider noted being very grateful that they do bedside ultrasound, can save on advanced imaging orders and establishing diagnostic records. And, and Chris and Eric, or Dr. McMullin and Dr. Chen had come up with some smart phrases that they share with patients. And patients have been quite grateful to have that expertise on site. And there was a patient who gave the feedback for Dr. Chen, who is the other provider who was a patient who was on the call for Dr. Chen, who is the other doc in our group, stating he was exceptionally kind, caring and professional. I came in extreme pain, all the staff did everything possible to get me in and helped. I'm new to the area. This was my first visit with you, Doug. Dr. Chen and his team took the time, spent an hour when I was in really bad shape. And that really speaks to that point of care and really getting to the patient when they need to be seen. Yeah, I can go off of that as well. And I think most of the feedback I hear from patients kind of follows that theme as far as just convenience of the visit. Again, they already know the building, they know the parking situation, those kind of little things that patients are concerned about when they may be going to a new specialty practice. And so having that all kind of familiar and not being an issue is I think really helpful for patients and useful. And often they'll end up scheduling visits on the same day where they might see their primary doctor first and then see me later for a musculoskeletal issue and they can just get it all done in one visit. I definitely think I am seeing patients who may otherwise just have not gone to see a physiatrist or just not gone to a specialist because of the inconvenience of it, where maybe they have this issue and I'll have patients specifically say like, I probably wouldn't have come in, but you're right here, it's easy, why not? Just kind of take care of it, have you check this out. So I think we get a lot of feedback from patients like that, that just the kind of convenience of co-location is great. And then also the timeframe, we're able to get patients in much quicker than I think some larger musculoskeletal centers because patients can schedule right away and we try to keep our availability open so that we can see these more urgent issues. If there is something like, I mentioned earlier, patellar tendon tear, Achilles tear, we wanna be available to see those things right away and patients I think really benefit from that. Do you mind if I ask a question myself? I was thinking, not knowing your setup, are you close to an emergency department or an urgent care? I'm thinking about my patients that come in for follow-up with maybe their primary, I see a lot of back pain patients. So I was wondering kind of what the flow is. I could see that working really well with you guys with sports injuries and all the stuff that, all the kids and adults that are hurting themselves. Right, so we don't have an urgent care on site. We're not attached to an emergency department necessarily, but we do often, if there are same day issues where patients can get in quickly to see their primary doctor and then they might see myself or Dr. Chen, our partner the same day. And so we do try to triage those more critical issues or time-sensitive issues if we can. And then if someone needs to go to the emergency department, one advantage of being on site is, someone walks in with a fracture and it's not something we can necessarily manage in clinic, but I can at least contact the orthopedic surgeon ahead of time or direct them to the right clinic. We can get x-rays. We can kind of start the process of moving them along in the right direction, even if we can't do that emergent care on sites. Yeah, so you guys have mentioned a couple of the certainly positives to help the model successful, including the sharing a call center, open location, open concept location but any other tips for us trying to recreate what you're doing. I can take that initially. So kind of as, as Dr. McMullen mentioned, really making the referrals as low barrier and easy as possible. The way it happens for us is we, we have an epic EMR and we can enter a referral pretty quickly and select the location. And, you know, it's it's really as simple as entering a few fields the clinical scenario, and that helps Dr. McMullen and Dr. Chen know what what are what we're concerned about what we're sending the patient in for what who the referring providers it gives them that basic framework of information but it's really pretty straightforward for the primary to do that and in some situations, we have an appointment with them in the morning we write the referral and the patient is scheduled and seen in the afternoon. So, so making that process easy making it very low barrier for patients. Our front desk is very comfortable with all the scheduling that needs to happen and for working with their schedules so so that's really great preserving good access, you know, making sure that they're getting sort of, if not same day within a week, perhaps a couple weeks, really enhances the benefit of that service and and really gets patients to buy into to the value that they're getting having departmental level support, both on the primary care side as well as the PM and our departments who support the growth process the, the fact that this is a newer model, and sort of having the patients to let this culture develop and for the volumes to increase engagement by both the primary providers in terms of being educated in this process, understanding where referrals are understanding who the providers are who are involved and that's just that takes time that's that's having meetings and in services and email e care messages are different, you know, different ways that we can engage and, you know, as, as what we've seen as providers have made referrals have had good outcomes for patients have had great access, the volumes have increased and it's really the momentum has increased because of Dr. McMullen did a great job of getting to know the community the PT groups that were in the area developing relationships with them, creating point of care tools for the PCPS to use those things have also been really important for the engagement and the benefit to primary care. And so yeah I think those are kind of in the marketing you know so we engage our marketing department, and really use our social media and, you know, whatever our internal marketing tools were and advertising for that so I'd say those are the things that have helped to make this really successful. Yeah, I agree with all of that and I, you know, the one thing I'll point out is, you know, I've been very fortunate to have Dr my stare I mean having a clinic chief who, who really is backing the idea, and really helping to make this work I think has been hugely important and beneficial so, you know, as we were getting going and trying to build clinic volume, Dr my stare was reaching out to other primary care providers, kind of talking to the providers in our clinic, and again also in some of the local neighborhood clinics so some of the other UW clinics and surrounding neighborhoods to reach out to other clinic chiefs and say hey we have this new service available. You can reach out to, to send your patients this way, if needed. And so that was really, I think, important in getting those patient volumes initially. And then from, you know, from my side I've just been very focused, especially initially on making sure that for every patient, I'm following up with that primary doctor. And this is what I did today. This is my plan going forward. These are the services I offer and just trying to build those connections with individual providers because I think that made a difference in kind of building that trust with other providers that that this was a good place to refer your patients. That was, that was important as well. You know, just to touch on maybe some of the areas where where you might struggle in this practice setting. You know, it is not a sports medicine only practice obviously that's the, that's the point so it's not a center where you maybe have all of these specialized resources. The medical assistants that work with me are the same medical assistants that work with the primary care providers so these are not sort of MSK trained medical assistants necessarily. And we have a great team and I've been able to coach our medical assistant, and so on, things that are kind of more physiatry or MSK specific. But they have to be able to kind of bounce between primary care and OB at our site and in sports medicine so there's more flexibility there. But maybe you miss out on kind of some of the just clear specific care that you might get at a sort of sports and spine hub. And so I think flexibility in kind of understanding that and preparing for that is needed when when building a practice like this. And so just recognizing that going into it. I agree. We you know when we were setting up the clinic itself, you know, we had to think through okay so what are the needs of a MS care sports medicine provider, you know what what kind of procedural tools do they need what kind of imaging tools do they need what kind of support, because that's going to differ than it would in a primary care setting and so meeting halfway somewhat. As Dr. McMahon was saying maybe not being the same tools that you have in a traditional sports medicine practice but also primary care stretching to provide some things that we don't often, or usually have for typical practice. Hey Chris can I ask you a question from a real practical point of view. When you see patients do you see patients together with Dr. Mr. or the primary care docs go in the same room have the same visit or they all separate and if they're in the same room. Are there billing issues for you in terms of how that gets done. So, so there are definitely times when we do that, where one of the primary care providers will be seeing a patient kind of recognize that they have a more acute musculoskeletal issue and then come out look for me if I'm available I'll go in the room and try to do an evaluation at the same time so we'll, we'll be in there together, kind of get the story from the primary provider, and then do an evaluation right there. And so, again, one example of this was someone who had come in with an Achilles tendon rupture. The primary care doctor sort of note noted that that's probably what was going on pulled me in. I did a quick ultrasound confirmed it exam confirmed it. And then we were able to provide that care right away of kind of starting to manage that. As far as billing for that. Typically, in those cases will kind of do a consultation where they'll quickly, they'll put that patient on my schedule and we'll do that as a consultation and I may be billing at a lower level because maybe I see them for for 15 minutes, but it will still put it in that way as a kind of same day console. I don't know what any challenges that you may have met have the pitfalls and stumbling blocks. Any advice for any of us thinking about doing a similar model. I, I think the main things again are just making sure you're that partnership is really there that the primary care doctor is kind of really backing the endeavor because I've really relied on Dr. support in connecting me with a lot of the primary care physicians and so I think that's one of the, the critical pieces. So, you know, do we need these, this equipment and these tools and is that something that we can provide for the clinic. You know, I think about x ray is one example we want to have an x ray, we have x ray on site, and we have an x ray technician, who's there all the time and for an MSK practice, you know that's, that's really necessary to have that person available throughout the entire clinic primary care practice that may not be critical to sort of have that person available every hour of the day. And if you're at a centralized musculoskeletal center, maybe you have three or four x ray techs available at any given time. For us it's kind of we have one tech available and if they call out, you know, there might be trouble, filling that spot or some difficulty there. We also recognize the other side of it where you don't want to have two or three x ray technicians that are just sitting around doing nothing because there's only one MSK provider. So I think that just striking that balance is, is where, where the issue comes in. Excellent. You know one comment did come in about a future opportunity, certainly to do with a co location with OBGYN as well. And, you know, again, we can't, we can't spend a whole lot more time here but I think that's a very good point. But I think I'm getting charged by the crew to turn the mic over to Dr. Weinstein. Thank you. Thank you all so far it's really incredible discussion of course I'm in Seattle and Chris is in my practice and I work with Dr. Mr as well so I, I get to see firsthand how amazing this relationship is and how it's growing and it really is, it's really something to see. So what I'd like to do is spend just a couple of minutes and talk more about. So what bold means and kind of where bold is heading and, you know, for many of you may recognize that bold started as initiative in the academies is sort of reimagining the future of physiatry, and it was forward thinking, and it was innovative and it resonated with the leadership and with the board and it was really so amazing that the academy basically adopted bold as it has its vision. And we started with two practice areas primarily that being MSK and we've heard a little bit about that so far tonight, and neuro rehab which eventually became known as the rehab care continuum. And now we have five practice areas the other ones being cancer rehab and pediatric rehab, and the newest one being Spain, pain and spine rehabilitation. And in these five practice areas there are points of emphasis and you've heard tonight about MSK, the emphasis on partnering with primary care, getting physiatry early in the care continuum. And really what I'd like to think is having physiatry fill that sweet spot between primary care and surgical care, especially when it comes to sports and spine medicine surgery. The emphasis has been on positioning physiatry as leaders of rehab care at all levels, to be the leaders of consultative work in ICUs, to running IRFs, which is the classic, to really designing and directing rehabilitation and SNFs and LTACs. In pediatrics, the focus has been on workforce concerns and transition of care from pediatric to adult rehab. In the cancer rehab practice area, it's been defining the practice scope and what curriculum looks like and positioning physiatrists within the world of cancer care. And for the newest one, for pain and spine rehab, it's filling those voids of comprehensive care for acute and chronic pain, emphasizing the biopsychosocial model of care and not just procedural-based care, which we don't know. Down the road, maybe not too much in the foreseeable future, procedure-based care may not be paid for the way it is now. So as Deb Vennessy said, BOLD guides basically everything that the Academy does in its strategic direction. It guides our education. It guides research. We have a registry, which is currently collecting clinical data on low back pain and ischemic stroke, hopefully to expand to other areas as well. It guides advocacy work, and it really guides our partnering with industry as well. So our BOLD strategy is designed for interaction. You've seen that tonight, an amazing interaction between primary care and PM&R, but it's also interaction between the practice areas. We want to be able to capitalize on the contribution of all physiatrists to various clinical scenarios. If you think about sports injuries like concussion, you think of acute and chronic back pain, and, of course, think about the newest medical problems in our world being long COVID. These cross multiple practice areas, and for the sake of unifying physiatry, it's really best to avoid siloed care, and these practice areas really intersect and talk to each other. So BOLD was originally a concept. It was based on some assumptions. It was driven by innovation, but really now it's become very empirical and very practical. You've heard that tonight, the incredible practicality of it, and what I'd like to say is it's really a legitimate representation of the future of physiatry, and so BOLD was never meant to be gimmicky and was really never meant to be a PR campaign. It was really informed through data collection, both qualitative and quantitative, and it is really the future of what physiatry is. So the direction is pretty clear for PM&R. We want physiatrists to have value early on in the care continuum. We see physiatrists as being leaders in value-based care, whether that be MSK care or really any type of care that we're involved with. We fill that gap between primary care and surgical care. We make life better for both. We make life better for primary care doctors. We make life better for surgeons, and we certainly make life better for patients, and that's really the key, and as you've seen in one of the first slides tonight, physiatrists really need to be seen as essential, indispensable, and vital in the health care community, and that's really our vision statement. So that's what BOLD's all about. We've heard tonight's incredible practical value, and I'm sure that will continue, and if we can continue to partner with our stakeholders, whether it be primary care or surgical care or others, I think it's a win-win, a win-win-win because patients win as well. So I'm going to pass this back to Dr. Vennessy, I think, for a Q&A session. So, Deb? Thank you, Stu. Thank you guys so much. This is so interesting. I'm reminded that I mentioned the article that we really didn't talk about, but it is referenced here, and it's also PM&R Volume 13, Issue 7. It's called A Closer Look at the American Academy of Physical Medicine and Rehabilitation's Strategic Initiative to Envision and Effectuate the Future of Musculoskeletal Care. So really, I think our time is really just to open it up for questions. I might take a stab at that one about – thank you, Jared, for saying that. It's too engrossed in the conversation there – about PM&R and OBGYN. You guys can answer it, but I can – as I mentioned, I do more spine care. I'm in the North Coast in Cleveland, and we have kind of a similar multi-specialty clinic that I practice in, and we have – and it's great because you're there, you're with people. I've got our sports people that see our kids as well as my patients. But with OBGYN, we do have a good relationship because there's really – with our pregnant folks, we have a – kind of went on the wayside with COVID, but we had a really cool clinic where one of my partners was doing some manual therapy, and I think we have a couple of DOs on the call that – in regards to helping back pain. It was fantastic, and we had a ton of referrals, and that's just one little area. But there's – back pain is – well, that's a different topic, but we'll open it up for questions. If we don't have any, we can certainly – And I'm happy to comment on that as well. Again, in our practice, we do have OB providers in the clinic as well, kind of working in the same space. So I definitely have referrals from our OB doctors too, and like you're saying, back pain during pregnancy is such a big one, and that's what I'm seeing a lot of, that last trimester, SI joint pain, and kind of going through strategies to treat that. And it's been great. I've had a few patients where the last few weeks of pregnancy, I just see them once a week to kind of manage that back pain, get them through their pregnancy, and then it's really easy for the patients because they see their OB and then see me the same day, and we've had a few patients like that where it's worked really well. So I agree. I think there's tons of opportunity there. I was just going to add – I'm sorry, sorry, Stu. Go ahead, Kevin. I was just going to add to that. I think Dr. Fitzgerald is a very well-regarded musculoskeletal physiatrist and women's health specialist. And one of the things that physiatry does offer is sort of women's health care and dealing with the pelvic floor and urinary incontinence, et cetera. And so that is an area that physiatrists are doing more and more of and doing a wonderful job in the process. Yeah, thanks, Kevin. That's why I brought it up. I have a primary appointment in OB-GYN, and that has been a great, great opportunity, I think, not only for me but for a lot of the trainees that have come through. I switched over from a primary appointment in PM&R. I got hired by OB-GYN at Loyola in Chicago. I'm in the division of urogynecology. I see patients with them. I see all my referrals come from urogyne, OB-GYN, and urology, primarily, and GI. We have a multidisciplinary clinic where we all see patients together, similar to your setting. So I was really excited to hear that you're doing it as well. And I joined tonight because I think this vision you've put forth is awesome, and I'm hoping that maybe we can, you know, incorporate some of the women's health as it relates to this. So thank you. Yeah, thank you. Thank you so much for your comments. And Nina, I was wondering if I can ask you a question. You know, we know there's primary care docs who do sports medicine or are trained in sports medicine and have specialty in sports medicine. I'm not sure about the clinic that you're the chief of, but have you had any pushback from your colleagues, primary care colleagues, about having a sports medicine doc in the clinic and taking away business or infringing on the care they deliver? Is that a concern? Not as much, because I just feel like there's enough patients, there's so many patients to be seen. And as I mentioned, in our central region, the demand has been so high for services that, you know, I haven't heard that argument per se. But however, when I was advertising to the network at large, there were clinics that had family med docs who had a sports medicine training, and they just kind of let us know that they were probably not going to be doing a lot of referrals to us, which I felt was fine. You know, it was just sort of a different approach. But it wasn't like, hey, this is going to take away from our practice. I think everyone feels busy enough that it doesn't seem to be an issue. Chris, it looks like they wonder if you do EMGs in your setting. I do EMGs, not in the clinic specifically. We don't have a machine available in that clinic. But if there are patients who need an EMG, I do them at our other practice setting, kind of at our main institution. And so I will say for those patients who do need an EMG, I'm able to get them over easily to get that done. Can I ask another question? Yeah, we're open. So I guess either for Chris or for Nina, have you, Chris, in the time you've been there, have you seen patients who have more classic rehab problems, not rehab MSK problems? Have you picked up spasticity? Have you picked up other things that maybe weren't identified that you can direct people in a way that maybe not you, but one of our other rehab colleagues? Yeah, that has definitely come up where spasticity is a good example. I've seen maybe a couple people with kind of with a history of brain injury or spinal cord injury, who may have a component of pain, but spasticity kind of being the driving issue, where then I have had them referred to one of our providers doing Botox or something like that, but I was able to kind of see him as a first line within clinic. I've done definitely some brain injury concussion evaluations as well in that setting. Just saw someone this past week, sort of mild TBI in a 45-year-old in a car accident. So not necessarily your sports concussion, but happy to see that person. So definitely comes up. Yeah, I would agree. I think that that has added a lot to the benefit of the service because it feels broader than what a traditional kind of orthopedic provider could offer. I have patients who've had pretty complex neurosurgical procedures and conditions, and I felt very comfortable referring to Dr. McMullen because I knew that his practice included that kind of training. And so I know that we all understand that and therefore feel that we can refer a more broad range of conditions to them. I think it's important to have a more holistic approach, kind of to your point in your presentation, the overlap of those different realms. There's another comment about collaboration with OBGYN, as Dr. Fitzgerald suggested, would be a great opportunity for osteoporosis care as well. It's just as thought as a women's health issue for sure. And then somebody else, Colleen actually, agreed about the osteoporosis and might get referrals from radiation oncology for sure. There's a question. How has telehealth played a role in your clinic? Certainly something that since pandemic we have embraced wholeheartedly. Our primary care physicians were already doing this prior to COVID and very familiar with telehealth. Actually, pre-COVID, early on in my practice, I had met with Dr. Maestera and just asked kind of how she does her telehealth visits and she had trained me up a little bit on it. And then I had been kind of planning to maybe incorporate it and then March 2020 came and then overnight we were all doing telehealth. So now it's, you know, I see a lot of follow ups for imaging, especially if I'm reviewing someone's MRI or something like that, or following up response to an injection, using it fairly frequently. Thank you, Chris. I think all of us are, well, we are running out of time. Maybe Tracy or Grace can let us know if there's a, if anybody has any other questions or ideas, you know, you guys can email us. I'm not even sure, I guess the aapmnr.org, it'll direct somewhere to us. I just really want to thank everyone, our special guest here and all of the other volunteers this evening for taking time and sharing their experience. We really, Jared and Kevin have worked so hard on this, the MSK collaborative. Well, that was one of their things but we really appreciate Nina and Chris's involvement as well as your, oh thank you so much, there we are, info at aapmnr.org. But it's been great. Wonderful. Keep up the awesome work. Great things to think about in regards to OBGYN and women's health issues as well. So thanks. Thank you all. Thank you.

American Academy of Physical Medicine and Rehabilitation

PMNR Bold discussion

collaboration

physiatrists

primary care physicians

musculoskeletal care

integration

multi-specialty clinic

co-location