Well, again, thank you very much for coming today, everyone. I really appreciate it. I'm Dr. Kevin Murphy. I work in Northern Minnesota, North Dakota, more rural specialty health care. I have the privilege of working with the academy here on the Dr. Molnar sessions. Dr. Molnar was my mentor for many, many years, wonderful lady. If anybody wants to talk about Dr. Molnar, just get all the way afterwards and we can have a nice chat and such. They only give us 75 wonderful minutes, so I don't want to waste one. I have this little form I'm supposed to read to you all right now. You've probably heard it so many times, but I still have to read a little bit of it anyway. Cell phones and such are off the sessions being recorded. So, be careful what you say. Evaluation forms at the end, please fill those out in the apps. You'll find those on the apps and of course, a reminder to visit the pavilion for all those good resources, and educational opportunities. Finally, we want to announce this will be the first year that we give the Jacob A. Neufeld the best paper of the year award. That'll be announced later and presented by the staff from the journal. We're very proud of that. We want to make sure we encourage donations to the Dr. Gabriella E. Molnar Research Education Fund, which puts on this presentation every year and allows us to give a lifetime achievement award in addition to a $10,000 per year grant every year. Dr. Terry Misogly from Seattle won the award last year, and she has a presentation today to give on a Google video that we have pulled up. She's off-site and could not make it in today, but we're playing her recorded video for us to hear. That's very nice too. We should recognize Dr. Marie Nelson, who has won the Lifetime Achievement Award for 2023 from Texas Children. Dr. Nelson will be presenting in person next year at the academy during this session. So, congratulations to Dr. Nelson. So, next we'll keep on time because I am 24 years military trained and we will keep on time. So, Dr. Azizi is coming up here for an introduction and we'll get started right away. Thanks again for coming. Thank you, Dr. Murphy. It is my great pleasure to introduce the first speaker, Dr. Jessica Jarvis. Dr. Jarvis is an assistant professor in the Department of Physical Medicine and Rehabilitation at the University of Pittsburgh. She has clinical experience as a musical therapist working in pediatric critical care. After obtaining a PhD in Rehab Sciences from the University of Texas Medical Branch, she completed post-doctoral training in pediatric rehabilitation research at the University of Illinois at Chicago and in pediatric neurological care and resuscitation research at the University of Pittsburgh. The overarching goal of her program of research is to improve pediatric rehabilitation equity and efficacy for children with chronic and critical illnesses through three related lines of inquiry. First, characterizing functional outcomes, assessing equity in access to care and care experiences across the care continuum, and developing and testing non-pharmacologic interventions to improve functional outcomes for families of chronically and critically ill children. Dr. Jarvis recently received a K23 career development award from the National Institute of Health to examine the use of music to decrease stress and pain among critically ill children receiving mechanical ventilation. Dr. Jarvis. Thank you. Well, thank you, Dr. Azizi, for that introduction. And thank you all for being here today, giving me your limited time and attention. I am very excited to be here. It is an honor to be a part of this presentation. And for that, I have the Foundation for PM&R to thank for funding this work through their Dr. Molnar Pediatric Research Grants. And I also want to thank my staff and my colleagues who also assisted with some of the data acquisition and management for the work that we're about to talk about. So in my talk today, I'm going to be reporting on the trends in rehabilitation therapies that children receive in the Pediatric Intensive Care Unit, or the PICU, after they have a new traumatic brain injury. And then we're going to be looking at the variation or the inequities and service use that the children received. And then ever so briefly, in the last of the ten minutes, talking about our role as rehabilitation professionals in addressing these health inequities and disparities. All right, but to get us all on the same page for this talk, I want to clarify some of the terminology I'll be using. So health disparities is the term that we use for describing avoidable differences in health or health-related outcomes experienced within certain subgroups of our population due to a social factor. Similarly, health care inequities are unjust differences in access to care and the quality of that care, again, experienced by certain social factors. Race and ethnicity are examples of those types of social factors. These are social constructs. These are not biologically based variables. But traditionally, race is used to refer to some of the physical phenotypes or what someone might look like. And we use ethnicity to describe heritage or your nationality, although in the United States, we typically just use Hispanic and non-Hispanic. And so this work actually stemmed out of my pivot into intervention work. So after I got my PhD in Rehab Sciences, my work was predominantly as an outcomes researcher trying to understand what functional recovery looks like for children and their families. And then I wanted the chance to actually bring in my clinical background and start intervening in the PICU to improve those outcomes. And so when I was preparing my K23 application to get that training and intervention work, I'm at UPMC Children's Hospital of Pittsburgh, and they've had a music therapy program for 20 years. And so for preliminary data, I was able to look at our medical records and say, hey, how is music therapy being used currently in our hospital? And so throughout those years, we saw that about 9,000 children were admitted. And while I expected music therapy service use to be low, what I hadn't expected, but I honestly should have, is that children who are white, and my regression that was controlling for their age, how long they were in the ICU, their illness severity, etc., children who are white had 50% higher odds of receiving music therapy in the PICU than children of color. And I realized that this, two things really, when this data hit me. One is that I was surprised, and I realized there's this assumption we have sometimes where we know things are problems, but we don't think it happens with us, or with our institution, or maybe in our field. And I thought if this is happening here, it is also likely happening across the United States. And I thought we really do need to know, are rehabilitation therapies being provided equitably when children are in the PICU after a new traumatic brain injury? All right, and so to answer that research question, I contacted the Pediatric Health Information System. This is an administrative database that collects data from over 50 children's hospitals in the United States. I asked them to send me data from the years 2016 through 2019. The year was 2021, so they're still finishing up 2020 data collection and cleaning. And I asked them to send me children 18 and under who are admitted into the PICU for a new traumatic brain injury. Picking that diagnosis, because that is often where we see the most functional need. And then we had to exclude children who are missing data on race and ethnicity. We excluded children who died, although a little post-hoc analysis there, I did also see that those proportions varied between children who died, who were non-Hispanic black versus non-Hispanic whites. All right, so the variables, just to clarify, our ability to look at PICU-based rehabilitation. The FIS does not have data on music therapy, but they were able to provide me information on physical occupational therapy and speech and language pathology. And we looked at service use in three different ways. Did they receive this therapy? How long did it take for them to get this therapy? And what was the total number of sessions that they received while they were inside the PICU? In race and ethnicity, these are the categories that are available within the FIS database. Just wanna clarify that they have Asian, black, white, and Pacific Islander, Alaskan Native, and Native American. Those last three were combined together so it could both fit on all one slide. But I just wanted to clarify, you'll see that acronym, but those are separate categories. And then for ethnicity, we had Hispanic and non-Hispanic. These are the relevant covariates that were also collected so we could control for them when we did our regression analyses. Given the audience, I don't think I need to dive into defining these variables too much. But I do wanna spend a little bit of time on the Child Opportunity Index score. I hadn't been familiar with this variable, but it is something that the FIS provides. And so this is a neighborhood-based score using the child's zip code. And it's a composite score that takes into effect 29 different indicators from the child's neighborhood. And then it is weighted and composite and then nationally norms for percentiles from 1 to 100 with the least opportunity to the most opportunity. And the indicators that they look at are things such as, what are the math and reading levels in your school district at 5th and 8th grade? What is the experience of the teachers in that area about access to fresh food or high levels of heat, even the pollutants in the area? They also look at the state of the economy or the income in that neighborhood, the amount of single parent homes, and the amount of time it takes to commute places. So in our analyses, we did some simple descriptive statistics by each individual therapy type. So we could look at yes, no, PT, OT, speech therapy, and then looking at those as percents, medians, and counts. And then doing some simple comparisons using Kruskal Wallace, cuz our data were not normally distributed, and some Chi Square. And then Bonferroni corrected, because it was multiple comparisons. For the regression models, though, we actually ended up combining the rehab therapies so that it was yes, no, any therapy in the PICU, time to the first session, whichever therapy it was. And then the total number of sessions combining across those three different therapy types. The covariates on that right side of the table were entered into each of the models and used a stepwise backward selection process so that the software could help us identify the variables that were important to keep in. Notably, just quickly, cuz I'm a statistics person, and if there's anyone out there who really likes these things, I'll share that we used logistic regression for looking at our binary yes, no. We had used Cox survival regression for the time to event. And then Poisson regression as it was counts of the number of sessions. So 3,749 children met our criteria for my study. Notably, though, this is actually 37% of the original sample that was sent to me. So over 10,000 children were admitted with a new traumatic brain injury. And then 6% of those children died. And then we wanted to look at children with a length of stay of two days or more to find those who had more neurocritical illness. And that really jumped our population down, and then after excluding also the missing race is how we ended up there. And this map here shows the census region of where these children came from. Now this table has a lot of information. I'm imagining I'm still used to my Zoom days where everyone has their computer screen close up to their face. So I do apologize, but I wanted to be able to show the different categories separately. It's best practice, as I am learning more about my equity work, to try to use the actual different race codes that are used in our data as opposed to kind of lumping them together or using ambiguous terms. So we have on the left side of the table there, we have the Hispanic, Black, and White patients. And then I'll go to non-Hispanic, Black, and White, and then Asian. And then I did end up combining, because it was a very small number. You can see even combined, it was an N of 25 for our Pacific Islanders, Alaska Natives, and Native Americans. And so I just wanna point out here, ooh, I'm sorry, that doesn't go quite there. But that the age ranges, I'm gonna make it disappear cuz I covered it, are ages there, the median age varied. So we've noticed that children who are not white came in younger with median ages of six and seven, whereas children who are white with a TBI came in with a median age of nine years old. I'm gonna, ooh, just gonna, ooh, sorry, my red line is crossing. The numbers, which makes that difficult, but I think I can use a laser pointer. Here we go, that'll be better. All right, so Child Opportunity Index, this is that composite score. It goes from 1 to 100. The median opportunity for children who are non-Hispanic white was 51, and the median opportunity for children who were non-Hispanic black was 14. This is a stark comparison. Similarly, when we look at their prior health, it's about 25%, 30% that had been previously healthy. But when we look down at our complex chronic conditions, which is when there are two or more organs involved, or the condition is progressing over time. We saw that 45% of children who are non-Hispanic and black had a complex chronic condition, compared to 34% of the children who are non-Hispanic and white. And then lastly, also some pretty large differences in their, let me see if I can move it, yeah. Their insurance type. So 53% of children who are non-Hispanic white had private insurance, versus 17% of children who are non-Hispanic black. All right, and so now a description of their PICU admission. What did it look like when they were there? When we look at their severity of their illness, you see a big variation in those who came in with an extreme injury. So it's about half teetering around there, but it's over half for children who are non-Hispanic black, 54%, 41% again for the children who are non-Hispanic whites. We also saw differences in mechanical ventilation use. So there was more children who were Hispanic black and non-Hispanic black that were receiving mechanical ventilation. Which does make sense since we saw more of the illness severity with them. And they were also intubated for a longer period of time. So jumping into the exciting stuff though, is we wanted to see what did rehab look like. So 53% of the children who had a stay of two days or longer ended up receiving some type of rehabilitation therapy while they were in the PICU. It took a median of two days to get to that session, 25th percentile, one day, 75th, four days. And they received a median of four sessions. This figure here shows the use of rehab therapy by our different categories. And it's showing blue is physical therapy, gray is occupational therapy, and the black here is speech and language pathology. So you can see a trend there with the frequency of these different therapies, with PT continuously being used more often. So I popped their percentages up there to try to make it a little easier to see. And the only difference here is actually seeing that the children who were Asian were less likely, in our chi-square analysis, Bonferroni corrected, to receive any type of rehab while they were in the PICU. Now, this is our model here that included all of our co-variants. And we could see that children who are underneath the age of four years old, compared to children who are five years older and above, was a big area of seeing a discrepancy in the rehab therapies that they use. This didn't so much surprise me from my clinical experience, cuz sometimes there's a lot of education that yes, toddlers, infants, young children need rehabilitation also. And so children five years and older, 70% higher odds of receiving rehab than children who are four and under. And when we put in all of our variables by themselves, we actually didn't see any differences in race by receiving rehab. But given all the differences from the population before they answered the PICU, we then entered an interaction term to say, okay, well, does rehab service use change then when we look at the combination of how sick they were, their illness severity, and race combines? And that's where we noticed that children who had a moderate brain injury, and I moved them to the left side here so it'd be easier to see, sorry. So it's moderate, extreme, the major, and then minor. This is actually where we ended up seeing more of a discrepancy, that children who are non-Hispanic whites ended up receiving more therapy than children who are non-Hispanic black. All right, and so the other way of looking at rehab use is then, well, okay, so how long did it take for them to get their first session? We again see that age is significant in our model. The older you are, the more likely you are to get your rehab quickly. And we again didn't see anything with race by itself, but when we looked at the variation between those who have a chronic condition and their race is where we noticed some differences again. And as much as I love stats, I do think it's easier to see this visually. So when you use a Cox regression, this is their survival rates that they show you. Survival in this sense actually meaning getting their rehab session. And so these lines show how their delay to getting it. So higher means it took longer, lower means they actually got it faster. And while we didn't see variation between children who were non-Hispanic, black, and white in our regression, we did see a more pronounced difference between children who had a complex chronic condition and who did not. So children with complex chronic conditions ended up needing to wait much longer to initiate their first session than children who were previously healthy, and those patterns varied a little bit between race, right? We also noticed the number of sessions varied a lot. This was also to be expected. It's a little bit tricky because everyone has such a different length of stay in our unit. But we saw again, young children received about 31%. They had 31% lower odds of having a greater number of sessions, right? And then again, we also noticed that children who were healthy compared to chronic conditions also had a variation. All right, and then this is just a little figure of this to show, again, the variation in the number of sessions they received. So the bars indicate their average number of sessions. We see in the white column is our non-Hispanic white, and with the dots here is non-Hispanic black. And so we see that it ends up swift being over here in moderate versus over in this extreme. Okay, so that was a lot of information. I'm just gonna summarize it really quick and then give you a chance for a question, my apologies. So we saw rehab therapy was lower for children who are younger, who had prior chronic conditions, and by variation, and that these things also then interacted with their race and ethnicity. We saw a lot of differences in their pre-hospital disparities, right, before they came in. So while we might not have seen very strong differences in the inequities of healthcare provided in the PICU, although there were some, they weren't a large effect size, but my goodness, we were controlling for a lot of factors. And in children, these things can't actually be controlled for, like in regression models. And so there are lots of children who are coming in very sick, disproportionately children who are black and Native American, and then coming in with brain injuries. All right, and I have some stuff about racism on here, and I just wanna say data has been along for a long time. This is why I said I shouldn't have been surprised when I saw there is a difference. I think it is up to us as our rehab professionals to stop, not only evaluate ourselves, but to realize a lot of these drivers of inequities are coming from our systems and our policies. So taking a moment to also think about how are we allocating our services? Do we have those types of plans in place? And what we are trying to do, we're on policy and advocating for children to get their needs met. I'm gonna put this up here, you can scan this for my references, some of the resources to the FIZ database, the Child Opportunity Index, things like that. Maybe take my email if you have questions. I'm sorry, cuz I talked too much. And I know we have to get to another person. Very nice, thank you very, very much for that, Jessica. I don't know if I could open it up for questions or not. We're open up for questions. We have time for a couple questions if you'd like. You just come up to the mic if you could. great talk it's not really a question it's more just a comment like you commented on things that we really feel like and what you were seeing in your data that we can't adjust for those socio-demographic factors that were present outside of the hospital and so as rehab providers we have to make sure that once they hit our doors once they hit our units that we're trying to narrow that gap but there's still so much work to be done that remain outside of the hospital doors with your evidence just reinforced thank you thank you Jessica what one question we can't let you get away without one question at least but I always find it hard sometimes to sort out the socio-economic factors from some of the racial factors and they kind of get intermingled a lot and do you have any advice or guidance on that or any results from your study that might help clarify that yeah well and so it's a big issue I want to say that issues with racism have been baked into our country since the foundation and we have 400 years of showing that there's a lot of systemic racism built into our health care and so I think acknowledging that and then wanting to address that I had I appreciate when we think about racism dr. Ibram X Kendi talked about racism being the policies actions and ideas that creates or maintain racial inequities and so a lot of times people get a little jumpy at the word racist or racism but realizing that what that is our actions or in actions that allow these disparities to exist so I think my advice is realize that they exist make sure that you have allocation plans in your departments that are appropriate for what your populations needs are and do some work on yourself also that is important but it's our policies and our systems that make things very difficult from your pre-hospital health and through the pick you and then post-recovery also thank you very much thank you guys we'll keep moving along here dr. Kayla Williams if you could come up and with our next two speakers Thank you, Dr. Murphy. As we move into the presentation of this year's JPRM Jacob A. Neufeld Best Paper Award, I'd like to just take a moment to introduce this year's awards presenters. Dr. Nahyun Kim and Ciela Nemo are both in their final year of Peds Rehab Fellowship at the Shirley Ryan Ability Lab in University of Michigan, respectively, and they're looking for jobs, so keep that in mind. They've been involved with the journal and the resident fellow program for the past two years. In this last year, they've both stepped up tremendously within this new and growing program as lead fellows and contributed to its sustainability. They are the embodiment of what we hope this program continues to do, which is provide education and resources to advance our field and support and empower the future leaders to continue this work. It is my honor to work with them over the past two years, and it is my honor today to formally introduce them to you. So without further ado, Dr. Kim, Dr. Nemo. All right, so I'm just going to introduce the journal a little bit. So we're with the Journal of Pediatric Rehabilitation Medicine. It's an international journal focusing on children, adolescents, and adults with childhood onset disabilities and complex care needs worldwide. Every year the journal publishes four issues, two of which are themed issues, specifically on cerebral palsy and spina bifida. In this year alone, we've published three issues so far with 713 pages of content and 80 papers that were submitted. And some of the highlighted issues from this year was the themed issue on cerebral palsy. And then there was, in the third issue, a themed section on moral injury and physician wellness. Yeah, so we'll be alternating presentations. So yeah, thank you, Kayla, for the kind introduction. So JPRM is abstracted, indexed, and multiple, like, yeah, search programs and, like, including Google Scholar, PubMed, Gov, and Scopus. And our journal has been distributed to over 2,000 libraries, hospitals, and scientific institutions worldwide. And it is accessible in every country globally. And we're very happy to announce this, that the journal has become open access as of this year in response to funder mandates and other publishing trends. In terms of geographical distribution of the JPRM authors, they're represented on six continents, except for Antarctica. And while primarily most of the submissions are from North America, there has been a growing increase in submissions from Europe and Asia over the last two years. And the total page view for JPRM content by year has been increasing. So the number for 2023 is until October 31st. Compared to the last year's data for the same period, still the view has been gradually increasing. All right. So just this year, these were the most published articles from 2023. This was from the special cerebral palsy issue. A lot of it was focused on asbestos D, baclofen, and Botox injections. And then since 2019, these are the five, like, most viewed articles as well. As you can see, there's a theme of the COVID-19 pandemic being represented among these articles. And then overall, the top cited JPRM articles in other journals had a kind of a wide variety of topics. But just this year alone, articles that were submitted to JPRM were cited 695 times. And this was as of November 3rd. So a lot of exposure in other journals. And so the size score for our JPRM article has been trending up last three years. It's been growing. And last year's, like, 2022 size score was 1.7. And we're very happy to say that now we have an impact factor of 1.9. In our journal, like, there are many papers with high, like, altmetric attention score. And the paper with the highest altmetric attention score is by Dr. Brendan Burke and her colleagues. The title is School Reopening During COVID-19 Pandemic, Considering Students with Disability. And the score was 61. All right. And then in terms of opportunities at the fellow and resident level, there is the JPRM Mentorship and Publishing Training Program. So this involves peer review training and also visual abstract creation for social media accounts. So if anybody is interested, not just from the fellow or resident level, but also medical students, you can always contact the journal to get involved in various ways. And we're also looking for the mentors for the mentoring program. So if anyone interested or, like, have questions, please reach out to Dr. Inanoglu. Yeah. So get involved. Submit your research and become a volunteer copy editor or podcast editor. You can join JPRM Mentorship and Publishing Training Program as a mentee or mentor. And you can write a blog piece also. And this is a link that this is the address that you can sign up for news for JPRM. So it is with distinct pleasure that we present the second annual Jacob A. Neufeld Best Paper Award, which is given in recognition of an outstanding research article published in the Journal of Pediatric Rehabilitation Medicine in the past year. This award was established in honor of the late Dr. Neufeld, who founded the journal in 2008, and whose passion and vision for the field of pediatric rehabilitation has created an enduring legacy. So I hope there's a drumroll. All right, it worked. Okay, so the paper selected was titled, Attitudes and Practices of Specialty Physicians Regarding the Return to School Process After a Pediatric Acquired Brain Injury. The paper sought to assess how specialty physicians, primarily pediatric neurologists and physiatrists, approach the process of school reentry following an acquired structural brain injury. They were specifically looking at traumatic brain injury and stroke, and excluded other diagnoses such as concussion, encephalitis, and brain tumors. The way they gathered the information was through electronic surveys that they sent, prompting respondents to reflect on their own practices in terms of school reentry and look at the barriers that might arise from this process. And based on those responses, the biggest barrier that was identified was that the biggest challenge was cognitive difficulties in terms of return to school. And they also identified three major gaps in terms of services with school reentry, specifically the availability of school liaisons, the school's inability to implement the school reentry plans, and a lack of an evidence-based cognitive rehabilitation curriculum. Which led to a wide range and variation of how school reentry is approached across the nation. So that was just a little brief overview of the paper, but we'll go with the next one. Okay. So this year, we, our journal had a very excellent multiple, like, articles. So this year, we have a one, close one or up. Okay. So, yeah, the title of the article is Specificity-Related Pain in Children, Adolescents with Cerebral Palsy, Part Two, Incubotulinum Toxin A Efficacy Results from a Pooled Analysis by Bonford and colleagues. So actually, this is a follow-up Part Two study from our previous award-winning article from last year. So congrats again. It was a very competitive, yeah. It was hard to choose one, like, among, like, yeah, a lot of great articles. So this study is, like, looking to the efficacy of Incubotulinum Toxin A on the specificity-related pain and, sorry, and they, in children and adolescents with CP. So they use the QPS, which is a questionnaire on pain caused by specificity. And they, like, measure the, I mean, they use a QPS after each of, like, four injection cycles. So the data show the overall proportion of reporting specificity-related pain gradually decreased with further injection cycles. And by the data, like, they said, the author said, like, complete specificity-related pain, relief was reported from 33% to 53%. And, like, this relief was even, yeah, even with the, like, very strenuous activities, that was surprising also. So the authors stated that the further investigation will be needed to clarify whether this relief from the injection is really from the lessening specificity or is it really from the direct anti, like, non-susceptive effect from the toxin itself. Okay. So thank you. So this was our presentation. It was our honor to, yeah, present the award-winning article for the, yeah, this year again. And if you have any further questions about the journal, you can reach out to Dr. Pico, who is the editor-in-chief for the journal, and our amazing managing editor, Sarah. And then this is just a QR code. You get free access to the journal for three months. So you should scan it. Yeah, and those, like, award-winning article and the closed runner-up articles are, like, free access. So if you want to read about the article further, yeah, you can get to get and read about it, yeah. Okay. Thank you. Well, thank you very much. You both did a wonderful job. I appreciate that. Have a seat, if you'd like to. We may have a couple questions, a couple questions for you. We've got a few extra minutes. We're running a couple minutes ahead of schedule, so the best paper of the year was just for the Jacob A. Neufeld Award, talked about liaisons to the school and specialty physicians having difficulty communicating with the school and the school communicating back to the specialty physicians. And you may not know, but I'm married to a school nurse, and she's sitting in the front row here, so I have to really make some good comments here. But I'm wondering, maybe we could discuss for a few minutes how best we communicate with the school, what that liaison might look like, and I've always wondered with the pediatric fellowships and such, maybe there's an opportunity to spend a couple weeks during your two-year fellowship in the school with the school nurse or the special ed teacher to kind of learn their vocabulary, what the IEP is, write up some IEP goals, go to a few meetings, and do we do that already in Cincinnati or elsewhere? Maybe that's something to do. I know when we take a fellow out of the hospital or clinics, we're not rounding, we're not seeing patients in the clinic, and that may be an administrative barrier that's difficult, but I would seem to give specialty physicians in training a little time in the school to learn the language and the forms and the processes might be a good idea. I'd welcome any comments from the crowd on that or from the podium. Thank you. So we're lucky at Penn State because we're affiliated with Penn State, and so we have actually three educational liaisons that are actually employed by the Capital Area IU that work at the hospital, one inpatient, one in our concussion clinic, and then one in our inpatient rehab unit that liaise directly with the schools in our state and get parental permission. It's interesting as you sit and soak in what people are saying and realize, oh God, I was on that paper that the highest impact score. I was today years old before I figured that out. Thank you, Jolene, and all the rest of y'all that I basically emailed and harassed and to come together to write that. Turns out people wanted to read it. So I'm super excited about that and I don't know how I missed that till today. In any event, I'm here to present to you Dr. Terry Misagly. Terry spent her academic career at the University of Washington. She retired from clinical practice in December of 2022, almost a year ago, and is currently Professor Emeritus of Rehabilitation Medicine. Terry's clinical practice was primarily at Seattle Children's Hospital, but because of her work as residency program director for UW, she chose to work at a variety of clinical sites to have more exposure to residents during their three years of residency. She staffed consoles at the Level I Trauma Center at the University Hospital at a rehabilitation center, but her main clinical and research interests were in pediatric traumatic brain injury and spinal cord injury. At the end of her career, she worked solely as an inpatient medical director for the rehab unit at Seattle Children's. It's important to note that that was the first unit I ever did any work on in pediatric rehab as a medical student. I did a visiting rotation there because at that time Harvard Medical School didn't have a department of PM&R, let alone a rotation in any subspecialty of PM&R. So this is really a full circle moment. Shortly after joining the faculty at UW, Terry was offered the opportunity to become the UW PM&R residency program director to improve her knowledge of medical education. She enrolled in a teaching scholar certificate program. This path opened a door to national work, including helping develop the program director's counsel at AAP and writing SCI board examination questions. Ultimately, she was selected as a director and eventually became chair of the American Board of PM&R. As an American Board of PM&R director, she helped to update and standardize the oral exam, establish a TBI subspecialty exam, and create pathways for pediatric subspecialty certification for those completing five-year combined training or those with consecutive pediatric and PM&R residencies. She was also elected to and chaired the ACGME Residency Review Committee and helped establish TBI training requirements, revised PM&R residency, and pediatric rehabilitation medicine program requirements and assisted in development of the milestones. She has received several awards recognizing her contributions to medical education, including the Parker J. Palmer Courage to Teach Award from the ACGME in 2005. She was also the Outstanding Service Award from the AAP in 2007 and Distinguished Member Award from the AAP and PM&R in 2013. During her 35 years at UW, Terri helped to educate more than 250 residents and many medical students from both UW and other institutions, as well as 10 fellows in pediatric rehabilitation. Faculty development and improving clinical teaching were important goals for her throughout her career. In honor of her work mentoring residents and faculty, the UW established the Teresa L. Misagly MD Award for Excellence in Clinical Education Mentorship in May of 2023. Terri sends her regrets that she's not able to be present today and express her gratitude for the 2022 Gabriella Molnar Pediatric PM&R Lifetime Achievement Award. Her presentation, however, will focus on professional identity formation and development of expertise. It is with great pride that I present to you the 2022 winner of our Gabriella Molnar Pediatric PM&R Lifetime Achievement Award, the very, very deserving Terri Misagly. Thank you. Before we start the video, is there anyone in the room that would like to speak a few words about Dr. Misagly, fellows, people that have worked with her more closely or not? She was our past board chair for the American Board of PM&R, did just a beautiful job just before I came on the board, and many of what she'll speak to in the video today, it goes over cognitive learning, learning theories, and I think the board is trying to incorporate much of that into LAPMR and things that we're doing right now in a good way, so metacognitive learning, and I welcome anybody that wants to speak a few words. She has about a 20-minute video, so we have about an extra few minutes of time, so. I don't see anybody running to the podium right now, so maybe in that sense, I'll go ahead and start the video, and we'll, I lit a candle in church last night that it'll work. It's one of these Google videos that doesn't always, the electrons don't always flow well through all the portals, but I'm assured by my young helpers over here that things should flow pretty well here today. Good afternoon, and thank you for the opportunity to speak with you today. I'm very grateful to my friends and colleagues for nominating me for the Gabriella Molnar Pediatric PM&R Lifetime Achievement Award. Dr. Molnar was, of course, a founding clinician and researcher in our field, and she was also a gifted educator and mentor. Dr. Murphy suggested I use this time to share my thoughts about lessons I've learned over the years. Because medical education has been at the center of my career, I'm going to focus my presentation on an aspect of medical education, namely how we develop our expertise. I started my internship in pediatrics in July 1982, and six years later, I finished my PM&R residency. The next day, on July 1, 1988, I started my job as faculty. I was an attending physician, but I was by no means an expert clinician. I wasn't really a peer to my two colleagues who were so much smarter and more experienced than I, but I was expected to supervise residents. I knew I wanted that supervision to be more than the apprenticeship model I was familiar with from my residency, but sadly, learning how to teach had not been in my training, so I was going to have to learn that on the job. But how? In short, I had a classic case of imposter syndrome, both as a clinician and as an educator, and no roadmap to guide me. So after some reflection, I set a goal to enhance my clinical knowledge, and I began to read in earnest. A book, a physical hard-found book a month during my first year of practice. Then a few years later, I enrolled in a teaching scholars program, and I became a student of medical education. And so I would like to share with you some things I've learned about professional identity formation and deliberate practice. Professional identity formation is a long process by which we construct and deconstruct, and ultimately internalize the characteristics and values and norms of our profession, so that we think and feel and act like a pediatric rehab doc. It starts, of course, in medical school, but it evolves with our transitions to residency, fellowship, and particularly with the transition to unsupervised practice. So there you are, or were, new faculty, having had success throughout your endeavors as a student, resident, and fellow. But now you may feel unprepared to handle the administrative work, trainee supervision, and the increased responsibility for patient care that's part of being an attending physician. And maybe you're also in a brand new, unfamiliar work environment. In this kind of a situation, our sense of personal accomplishment is diminished, and we're stressed. When we question our readiness, decision-making, and overall competence, we feel like an imposter. Why is this transition to attending position so much more difficult than previous ones? I think there are several reasons. One is that along the way, we've always had people just one step ahead of us to role model where we're going next. But once we've completed training, we're now supposedly a peer of these expert clinicians with the expectation that we can practice unsupervised. Yet we're not truly peers, and we're definitely not yet experts. Another reason the transition is difficult is that if you're in a clinician educator role, likely haven't had nearly as much preparation to be an educator as to be a clinician, and you have to learn how to be an effective educator on the job. So how do we develop a sense of competence and autonomy? Two important theorists in the field of how we develop expertise were the Dreyfus brothers. They developed a model of skill acquisition in the 1980s. So when acquiring a skill via instruction and experience, students pass through five developmental phases, novice, advanced beginner, competent, proficient, and then expert. The first three stages, novice, advanced beginner, and competent are analytical. The last two, proficient and expert, are intuitive. We can fit these stages to medical education by using a constructivist model. Medical education starts with learning specific basic knowledge, which we continually refine. We build a scaffolding for the knowledge and eventually construct connected schemas. Medical school moves a student from novice to advanced beginner. So novices start with a low knowledge base. They memorize a lot and learn rules, but they're non-situational. They require deliberative guidance and clinical work. In other words, someone to tell them what is right and what is wrong. At the start of clerkships, students have a lot of declarative knowledge, but little clinical integration. At first, they have to activate all the knowledge they have about symptoms and pathophysiology for each patient problem. But as they see more and more patients, they begin to take mental shortcuts, and eventually, after considerable experience with real situations, they start to recognize recurrent aspects. Residency and fellowship are focused on the progression from advanced beginner to competent or beginning proficiency stage. So competent clinicians can actively make decisions and take responsibility for the progress. They can also make decisions based on the positive results of their actions. During residency and fellowship, repeated patient experiences enable reorganization of knowledge into increasingly extensive understanding of clinical situations. As a new attending, our expertise grows rapidly over the next five to seven years. We continue to hone our clinical reasoning. When there's a new problem to solve, we assess the situation, access information from our long-term memory, and then we use our metacognitive skills to apply some rules and monitor and evaluate how things are going. We recognize when we don't understand something and similarly recognize when an explanation makes sense. As we develop our expertise, we get to the point where we can deal with many situations intuitively, non-analytically. We start to store illness scripts in our long-term memory. The dual process theory of cognition proposes that clinical reasoning involves two types of mental processes. There's rapid, spontaneous pattern recognition that, as trainees, we marvel at our attendings use frequently. These experts are using illness scripts, but they use the cognitive resources freed up by pattern recognition to direct their attention to metacognitive monitoring and reflection. The second type of mental process is the slower method of deliberate analytical reasoning. As we become more experienced, we can rely on the more rapid, time-efficient pattern recognition process and only revert to the more deliberate, time-consuming analytical processes for ill-defined or entirely new problems. Learning and optimizing our clinical reasoning is a process that extends throughout our professional lives. Every student entering medicine wants to become an expert. Nobody wants to be recognized for only having basic competence in performing clinical care. But the factors that cause large individual differences in expertise are only partly understood. Nobody becomes an outstanding professional without experience. But extensive experience alone does not invariably lead to someone becoming an expert. So how can we focus our growth toward expertise? An important body of work in this vein is that of Anders Ericsson, who developed the notion that acquisition of expertise requires years of intensive engagement in deliberate practice. Deliberate practice is a much more powerful predictor of expertise than experience alone or how smart we are. It includes the intention to improve performance working toward a specific goal, the engagement in activity that is sufficiently challenging, not so hard that we give up, or too easy that we complete the goal without much effort, and the provision of feedback combined with opportunities to apply this feedback by correcting errors. That feedback can come from within as we self-monitor our effectiveness or from an external source, such as a colleague, a patient survey, an evaluation, or even your inability to answer a patient's question. There's a qualitative difference between achieving an everyday skill versus the course of working toward expert performance. So our goal for everyday activities is to rapidly reach a satisfactory level that's stable and autonomous. More experience doesn't lead to higher expertise. So for instance, when we learn to drive a car, we go through a phase concentrating on what we're doing to avoid mistakes. But after about 50 hours or so, we can get to an acceptable level of performance without much need for effortful attention. With more hours of driving, however, most of us don't go on to become technical race car drivers. When physicians are first introduced to an activity, our initial goal is to reach a sufficient mastery that is acceptable for practice. We could stop there, having achieved an average level of performance, and maintain this adequate but unexceptional status for the rest of our careers. But really, medical expertise is not an end state that once attained requires no upkeep. We should aspire to become experts and avoid the arrested development associated with automaticity. So we need to deliberately construct and seek out training and education to attain goals that exceed our current level of reliable performance. Clearly, the timescale is significantly longer than that to become proficient in everyday skills and can take years to achieve. These are the key metacognitive skills that are critical to staying on that higher pathway to expertise. They require high motivation and good concentration. We need to assess the demands of the task, evaluate what we know in our skill level, plan an approach, monitor our progress, and adjust strategies as needed. You probably have strong metacognitive skills yourself, even if you're not explicitly aware of using them. One of my colleagues is amazing at role modeling her use of metacognitive skills to residents and fellows. Trainees need opportunities for regular practice, using their knowledge and skills in similar but not identical scenarios coupled with feedback to improve. This is key to help them retain knowledge and then apply it across new contexts. We should not assume that our residents or fellows have metacognitive skills or that they will develop them naturally and inevitably. My colleague models her metacognitive processes with trainees. She talks out loud about how she assesses a problem and assesses her own knowledge. She will freely admit when she doesn't know something and explains how she's going to figure it out. She's always demonstrating her intrinsic motivation to keep learning. Once we as attendings are past formal training, we need to embrace the habit of spending time and effort to keep up to date in our field. For those of us who've been in medicine a while, deliberate practice can help us maintain performance as we age so that we don't become experienced but non-expert physicians. I'll give you two examples of how I've engaged in deliberate practice. As a clinician, I engaged in deliberate practice to hone my knowledge about pediatric traumatic brain injury. In the late 1980s, after my year of reading books, I began reading neuropsychology research to try to understand clinical outcomes. My motivation was that I didn't know how to answer parents' questions about their child's prognosis. This led me to study neuropsych testing. Then I created a chart of studies and major outcomes and developed a lecture for residents about outcomes. Over time, I focused on new developments such as ICU management, pharmacology, how to read imaging, how to identify the most useful imaging. I looked at how outcomes from TBI differed from hypoxic ischemic encephalopathy. As neuropsych research expanded into younger ages of children, I added developmental aspects of TBI to my knowledge of outcomes and so on. I kept at this study of TBI for my entire career. The other example is how I worked to hone my skills as an educator, specifically in the role of residency program director. In my teaching scholars program, I had gained basic knowledge of learning theory, teaching and assessment, teaching skills, and feedback. As challenges came up with particular residents, I started to explore remediation strategies, generational differences, fast and slow thinking, and self-determination theory. In responding to ACGME expectations for faculty development, I engaged in developing my leadership skills. I ran workshops on clinical teaching, the art of using questions, feedback, development of expertise, and assessment of competency. That continuous deliberate learning process really kept me inspired enough to be a program director for 22 years. So let's circle back to those feelings of imposter syndrome. I think it's important to embrace the idea that you may be recycling through feelings of uncertainty with each new role you take on and at every stage of your career when you seek new competencies. When you identify a way in which you want to stretch, engage in deliberate practice to develop proficiency and expertise at it. Whether it's honing your bedside teaching, learning a new technical skill, identifying new clinical topics to teach, starting a journal club, leading a QI project, tackling an equity issue, or accepting a role as a committee chair, it's useful to stop and consider your skill set. Identify how you want to improve and how you'll measure the impact of that effort. You need to be patient about your growth because it takes a lot of time using deliberate practice to achieve excellence. We can only study so much at a time, right? At best, a college student can maintain their concentration to improve on something for about an hour at a time. Why do we need to actively engage in deliberate practice? Our attention is so easily fragmented by preoccupation with daily tasks like documentation, texts or pages, and ancillary tasks. Without deliberate practice, we may never make the time to focus on work that inspires us and helps us develop expertise and grow. In addition to all those daily work tasks, there are also the demands on our time and attention from life outside work. So remember that one of the principles of deliberate practice is to not set unattainable goals. In my career, I found it helpful to write a mission statement and update it periodically. I chose spring of each year to take out my mission statement and refine it with the intent to focus on setting goals for the next academic year. With each new year, my situation, my opportunities, and my challenges evolved. So my mission statement became a compass to keep me on track and help avoid distractions. In closing, don't forget about the uncertainties you faced and your lessons learned. Please pay it forward as your career progresses and nurture the next generation. Early career faculty want to both fit in as well as stand out. If you foster teamwork and collaboration, it will help early faculty feel like they fit in and belong to your community. As a mentor, you can also foster the goal to stand out, to develop expertise in a specific area of practice so your colleague can distinguish themselves from others, help them set attainable goals, and engage in deliberate practice. If you foster feelings of competence, relatedness, and autonomy in your peers, you help to stimulate and sustain their motivation to advance their professional identity. Finally, have patience with yourself and make sure you take time to reflect so you can focus on work that inspires you and promotes your growth. Thank you very much. Thank you. Well, thank you guys. We have a few minutes. I think it was a wonderful presentation by Dr. Masagli, and I'm just wondering how many of us in the room have a mission statement for our practice, our career, or our lives, or whatever. I think it's a very nice message, and I see a couple of hands go up, and I have a mission statement too that I've modified over time. I started about 45 years ago at the Mayo Clinic. I think one of the best places in the world still is, and when I went through training, sometimes when we saw the patient, we were the last person to get there. Maybe 10 other doctors had already intervened before they finally put in their rehab consult. I'm sure it's quite different now, but that inspired me to go out into North Dakota and the prairies to be the first person to see the patient rather than the last, because I like to see them first and decide where they go after that much of the time. That's why I went out to North Dakota. I have about eight or 10 different Native American reservations. I practice on in Northern Minnesota, and it's a wonderful practice. It's been my mission over time. But to maintain that, I have to keep more of a generalist in me too. If I get too specialized in just tone management or one thing, I can't survive out there. I love musculoskeletal and how the bones develop over time and the joints, and they grow at different rates, and how that plays into sports medicine and other things. Those are part of my mission statement I've had to modify over time, and many people feel, what's Murphy doing looking at hip x-rays or spine x-rays, that's orthopedics, but 95 percent of that is non-surgical, very manageable. You do things differently, because not every bone and tendon needs to be cut on and moved and transferred, and everything else, it still doesn't play into the function a lot. But it's a mission statement that gets modified over time, and I've been out in the prairies 33 years now, and still love it with the kids and take care of them as they become adults. So, you see them three decades later, and it's very nice practice in that sense. But you have to modify it over time, so you don't get burnt out, because there's a lot of kids everywhere. So, as you age, you have to back off and pace yourself a little bit more, and to keep moving and keep grooving in the right direction. But I think it's a nice way to have a mission statement, that you focus on what your purpose is over time, and I think Dr. Misogny brings that out nicely. Dr. Molnar had no idea why I'm going to North Dakota, after I was her fellow for two years or more, and we were together maybe a decade before she passed away. But then she came out to visit twice, and she couldn't believe all the kids just wandering through the prairie of North Dakota, coming in, and so she was very, very supportive. She says, Kevin, what you're going to do out there? She couldn't say the V's, she always said B's, Kevin, Kevin, what are you going to do out there? Why don't you come and see Dr. Molnar? Don't call me Dr. Molnar, my name's Gabriella. I could never call her Gabriella, because she's Dr. Molnar. I don't want to get too much into my Dr. Molnar story, so I'll be here till midnight. But anyways, the mission statement's nice. I also think to make sure you don't get burnt out. That's Dr. Neufeld's mission too in many ways. To nurture yourself is a good one. You got to back off and smell the roses at times as part of your mission statement too in a big way. To be thankful for what you have and for the people that have gone before you, that have helped you to be a better person and a better provider over time. Be thankful for those people just to remember that gratitude is the fuel. Gratitude is the fuel that drives the engine of love, and you keep that in mind with your practice. So, thank you all for coming, really appreciate it. Anybody's welcome to come up and share their mission a little bit or talk if they like, but I think we're right about at the 4.30 time. Thanks a lot for coming, really appreciate it.

Dr. Terry Misagly

professional identity formation

expertise development

medicine

clinician

educator

deliberate practice

goal setting

feedback

reflection