We'll give just a little bit of time for folks to jump on for our PEDS Rehab Community. And on behalf of the Pediatric Rehabilitation Community leaders, Dr. David Burbrayer, Mike Green, Mary Dubon, and myself, Jolene Brandenburg, I would like to welcome you to the 2020 AAPMNR Virtual Annual Assembly. This is the Pediatric Rehabilitation Community Session, Session 1. Thank you for joining us for the first part of our two-part Community Day session. The second part of our session will take place at the same time on Thursday. And please also see the Pediatric Community on FYS forum for sign-up details for the other Virtual Peds Rehab Day that will be taking place tomorrow through Rady Children's and Dr. Andrew Skolaski. Also if you are not a member of the Pediatric Community, please go on to the AAPMNR website and join our lovely group. So during this session, please put the questions you have for the speakers in the Q&A box. That's the box down at the bottom of your screen. If you can't see it, move your mouse or hover over an area on the bottom of your Zoom screen and you should see the Q&A come up. There's also a box where you can do chat, where you can talk to others in the community or talk to the presenters. And I know how much our community likes the chat, so I'm looking forward to seeing all those questions in the chat box. To claim CME credit, you will need to complete an evaluation for each session you attend live or watch on demand during the Assembly. All sessions will be recorded and made available on demand until July 31, 2021. Visit the Member Resource Center if you have any questions. Also note, your feedback on the evaluation does help the Program Planning Committee outline content for future annual Assemblies. So please ensure to give suggestive comment. Please also, if you're sharing anything on social media with regard to the annual meeting, use the hashtag AAPMR20. For today's pediatric rehab session, we have two presentations. First, we have an in-depth look at the multidisciplinary model in pediatric pain management. This will be presented by Andy Collins, Chait Konda, Sarah Williams, Emily Deet, and Nicole Samuel. But our second presentation will be Physicians and All Their Complexity, Strengths, Stressors, Wellness, and Suicide. Where Are We Now? This will be presented by Elaine Pico and Renat Sukhov. And with that, I will turn it over to our first speakers. Hi, everyone. Let me figure out how to share my screen and then we'll get started. So for those of you who don't know me, I'm Andy Collins. I have a group of people here with me from Cincinnati Children's or formerly from Cincinnati Children's. And we're going to talk about an in-depth look at the multidisciplinary model for pediatric pain management. I will introduce each of the other speakers as we're going rather than all at once right now. And I'll go kind of through the overall plan for the talk. So overall, here's the objectives we're going to go through. We're going to talk about characteristics of pediatric patients with chronic pain, talk about the role of different PT and OT strategies, and the role of cognitive behavioral therapy in pain treatment. And then we're going to talk a little bit about medication choices for use in chronic pain management. And throughout the talk, we'll talk about different strategies to implement multidisciplinary pain care in medical communities that do not have such programming already in place. As I know, while we are fortunate in Cincinnati to have a big pediatric pain center, a lot of places don't have all of the expertise of the colleagues that I'm sharing this presentation with today. And so how can you kind of, as a pediatric rehab doctor, implement some of these things with the community of PTs, OTs, and psychologists that you already work with, who have all the foundational skills to be pediatric pain experts, but don't have that expertise yet? The way we're going to go through that is first, I'm going to kind of talk about multidisciplinary pain care in general, including pain rehab programs or intensive interdisciplinary pain treatment. We'll talk about optimizing referrals to pain rehab programs. So if you're in a community that doesn't have one of these intensive interdisciplinary pain treatment programs, how can you kind of do some things to prep people for when they come over to one of these programs, so they're ready to go shortly afterward rather than coming to see pain rehab program, then being told, oh, go back home for a few months to work on these other things. We'll talk about pain psychology, PT and OT, some basics of medication, and then question and answer. I want to make sure we get to the question and answer appropriately. So some of the medication part might be skipped. I am happy to share my slides with anyone, and I go through a little bit of kind of my way that I dose a few different medications for chronic pain if people want advice from that. If we don't get to it, I'll skip that because those things are easier to look up than if you guys have questions for us. One main disclosure I have is that we will be discussing off-label use of medications because everything is off-label for PDF for pain pretty much. So getting started. Pain is complicated, and the definitions of chronic pain are not always super consistent from place to place, but generally from the ISP, the definitions center on pain that lasts longer than expected for an inflammatory process or for whatever other process is initially causing the pain. Sometimes the month cutoff will be considered three months, and it likely involves changes in the peripheral and central portions of the nervous system, but it doesn't talk specifically about a cause for that pain. Chronic pain is pretty common in children. There's been an estimate through multiple different research studies. This study is a little bit older now, but it was a review that included lots of other studies and shows the range is somewhere around one in four kids experiences chronic pain at some point in childhood. Of all kids, about one in 20 have been shown to have pain-associated disability. However, that study was done in Spain, so it may not exactly translate to the United States, though I don't have a specific reason to believe that it's drastically different, and one in 20 kids is still a lot to have significant disability related to their children. In general, there are lots of types of chronic pain. I listed on here a variety of areas of the body that we say that people have pain or types of pain we have, and then diagnoses that we use, which you can mix back and forth whether you want to consider a location to be the diagnosis itself or that you need another diagnosis, but one of the things I bring up, these diagnoses, some of which you'll see in that second column, and people may have some varied opinions on what those diagnoses mean or what they are. The goal that I have between use of diagnostic labels is that they can be helpful for patients to help bring together all of their symptoms and help use that as a framework to provide education about what's been going on in their body and provide reassurance about how these symptoms are related and that we're kind of at a good place diagnostically and we don't need to continue to search for more information. However, there's challenges with these diagnostic labels because there's often inaccurate or unhelpful information either online, through peers, through family members, or through other sources that people get information from. When I like those diagnostic labels, because I use that to explain pain for people, so in general, when I'm talking to a patient and I talk about chronic pain for them, I like to talk about how the pain system works in general and then move on to what happens when pain becomes stuck and becomes chronic. I'll give kind of a little bit of a synopsis of this, but I'm happy to talk to anyone about it later because I think talking about pain is one of the most important things when we're working with patients who have chronic pain, reinforcing that it is a real phenomenon, that we believe them and understand a little bit about what's going on. The way I talk about that is I first talk about what happens when someone stubs their toe. The pain signals go up to their spinal cord and their brain. Those signals cause some changes down in the toe with changes in their autonomic nervous system, though I phrase that differently often for patients, so I'll often use the word autonomic. Their pain volume going up and their muscles getting tighter, and then explain that between their brain looking down and thinking about what's going on with their toe, seeing that it's a stubbed toe and knowing how it heals, and then their toe sending up healing signals from the brain down, the toe up, things should go back towards normal. I then explain that when it's chronic pain, sometimes that doesn't happen. Instead, the pain signals go up to the spinal cord and the brain. The brain sometimes doesn't know what's going on, doesn't send down those signals that say it's okay to get better. The toe feels more and more pain. It gets tighter, which is a normal response pain, which causes more pain, which causes tightness, causes pain, and explain to them that that can get stuck. I often tell people we don't always know why it gets stuck. Sometimes I explain to them that it could be related to worry or anxiety, it could be related to worry or anxiety because they don't know what's going on, could be related to other underlying medical conditions or pain that happens over and over, but I think it's helpful to talk about pain overall for these patients. I also like to talk about pain in this way because I talk about pain being related to signals coming up from the body and signals coming down from the brain. I use that to introduce the idea of multidisciplinary treatment, where we focus on psychological strategies to help improve the way the brain sends down signals, physical and occupational therapy to help send signals back up that are more normalized, and then self-care, medications or procedures to help support those portions. I really emphasize the medications and procedures only support the PT, OT, and psychology. They don't replace those things. Sometimes when multidisciplinary treatment's not working on an outpatient basis, we move towards intensive interdisciplinary pain treatments or pain rehab. Those are day programs or inpatient rehab programs with increased intensity and increased interdisciplinarity where the providers can work really together in the same room to move a little more intense than the traditional outpatient treatment. All of this multidisciplinary care is evidence-based, and there's a lot of research to back up that these are the things that happen, showing that you can have long- and short-term improvements in pain intensity, function, school, sleep, and some other things with healthcare utilization. People have to be ready to change, and then it's also really important to talk about that function improves before the pain, and that's what I talk to my patients about on a regular basis and why we use all of our strategies together to help them function, and then that will help the pain get better. The way that we measure function is through a measure called the Functional Disability Inventory. Obviously, we use other functional measures as well sometimes, but the primary one we use in pain clinic is the FDI, and this is a 0-to-60 scale. There's 15 items. Each item is scored by the patient and tells us about people's physical limitations related to their illness, which in this case is related to their pain. This measure is used very frequently for children with chronic pain, and if you're looking to find a way to track patients that you're seeing with chronic pain, the FDI is a good option. The numbers I have up here with a significant improvement in disability is through the first program, which I mentioned in the last slide, but first is the Functional Independence Restoration Program, which is our intensive interdisciplinary pain treatment program at Cincinnati Children's. As you can see, we have pretty significant improvement. Above 30 is considered severe disability on this score, and below 13 is considered mild or minimal. This is the range from that standpoint. For a little more information about how we get patients ready for the first program and how things are going with that, I am going to switch over to Chait Konda, who is a former fellow of ours at Cincinnati Children's and is now down at UT Southwestern. Before I introduce Dr. Konda, I'll start answering questions at the end of the Q&A for most of them, but I do see a question up there about how to measure readiness to change. I don't have a really high-tech scale we use for that, but we ask people in clinic to rate their readiness to change or their readiness to participate in such programs on a really fancy Likert scale of 1 to 10, which is not very helpful if you've only seen them once, but if I see someone over time and I can see how that changes over time related to their readiness, then that helps me decide when we can go towards next steps in treatment. So we'll go back to Dr. Konda for now, and then I will keep track of questions over time, and we will answer those during the Q&A from now on. All right. Thank you, Andy. As Dr. Collins mentioned, my name is Chait Konda. I'm currently an assistant professor at University of Texas Southwestern and a former graduate of the Pediatric Pain Fellowship. Today I wanted to talk to you about the issues surrounding referrals to a pediatric pain program and how we can best serve our patients in optimizing their treatment plan before we send them to a resource-intense, resource-heavy kind of a program. Next slide, please. So why is this important? Well, like money, intense pain rehab programs do not grow on trees, and there are a number of barriers that can prevent care for these patients, especially when we're talking about the functional loss, as Dr. Collins alluded to earlier in the presentation. And again, it leads to delays in critical care of the patient. Next slide. Sorry, this is my fault. Go ahead, Chait. No problem. So this is just a slide to talk a little bit about what our role in pain management as pain management physicians kind of play with evaluation. We have a role in the initial evaluation in the outpatient setting. We are interacting, most of our interactions are with pediatric rehab, pediatric physiatrists in the inpatient setting. And then we, as pain management physicians, are following up these patients at kind of measured periods to kind of engage and see how the treatment plan is continuing on after they've gone through an intense experience. Next slide. Okay. And this is, again, to kind of show how much goes into the work before we try to get them into an inpatient, into an intense pain rehabilitation program. As pediatric physiatrists, I think we're all familiar with this kind of work, considering we do a lot of this in different patient populations. So it's a lot of patient family education, establishing goals for their care, understanding the motivation portion for the family and the patient whenever we're trying to assess whether they'd be a good candidate for a rehabilitation program. And then collaboration with other providers in the care treatment plan of the patient. And then also coordinating with the nurses in terms of when we think they're ready to be admitted. Next slide. So this is just, again, a prettier pie chart of the type of diagnosis we see in our clinic. As you can see, a big portion of it is amplified musculoskeletal pain syndrome. At least in Cincinnati Children's, we see a large population of hypermobility EDS or hypermobility spectrum patients. And then CRPS as well. Next slide. And this is a little bit of an algorithm. Again, it kind of shows, you know, a lot of our work is being done in the outpatient setting before to assess the next step in terms of whether they're appropriate for the, an intense pain rehabilitation program. Or if we can continue their work from their work and their treatment from an outpatient setting. I think it's important because these are really intensive, resource intense programs. And, you know, most of these patients, if we can help get them better before having to consider this, that's ultimately our end game and our goal. But it kind of tells you a little bit about, you know, not necessarily every referral to a pain program is going to end up in an inpatient program. Next slide. So some of the barriers that we see in referrals, when we think about our patient population, well, you know, like I said, we don't have, they're not in every state. And so distance is a significant barrier to referring a patient into a program. You'll see this one come up in multiple slides, insurance, you know, our patient population, for the most part, typically have exhausted resources in our Medicaid. I think we have a lot of experience with that. And so that can be a barrier to referral into a particular program. And of course, the state to state barriers from that standpoint. And then as well as compliance, you know, understanding our patients and whether they will comply and will be able to go follow through with the referral. So those are some of the barriers to think about whenever we're referring patients. Next slide, please. So just looking at the first four years of our program, this went through fiscal year 2018. We, as you can kind of see, about 30% of the patients that we had referrals for actually ended up being admitted into our intense inpatient program. And they're coming from all over the country, about 28 states that were sending referrals. And that's probably only grown in the last two years, even more so. So again, it kind of tells you there's a little bit of a gap in terms of what patient referrals are being admitted into the program versus how many of them are staying in the outpatient setting. And the question that we wanted to answer was trying to, we were just trying to figure out, well, how can we, what's happening with these patients? Next slide, please. So we think about the barriers to admission and the things that we in the pain program kind of consider. Well, diagnosis is a big part of it, whether, you know, establishing the proper diagnosis or whether the diagnosis that we've had is accurate for the patient and whether that might lead to more workup or not, whether there's a strong type of component when we think about the biopsychosocial component of pain and whether those are the stronger factors in that patient that need to be treated before we talk about pain itself. Insurance, again, that's always a big barrier. And then some of the other things in terms of ensuring the level of workup that's been done and then as well, the level of participation that patient has complied with in the outpatient setting, which insurances will look at and could be a determining factor for their willingness to allow for admission. Next slide. So when we looked at our numbers, we saw that, and we looked from 2020 back into about 2017, we saw that about 34% of the patients that were referred for a first program evaluation ended up actually going into our first program after the initial outpatient visit, while 66% still requires some level of further workup or management before they were able to be admitted into the first program for our first incentive children's. Next slide, please. So we also looked at the type of management that was being done for that 66% of that population. And what we found was there's still, you know, a lot of basics that were being reconnected, so to speak. So about 50% of our outpatient evaluations on initial visit just included referrals or reestablishment of services that the patients have been participating in that may have created, there may have been a gap from their last visit. So that's a large portion of the management that we were doing, which kind of hints that, you know, that there's a gap in optimization versus exhausting our resources for the patients. The other things, you'd be surprised, 16%, that's a large percentage of the patients that just haven't had proper referral to the right type of therapies, or, you know, the therapists in their location may not have had a comfort level with pain rehabilitation. And then a lot of medication management, such as whether medications have been optimized or other medications had or had not been tried, you can see the diagnostic workup interventions, referral to other specialists, like new referrals to other specialists. And then also psychology or psychiatry evaluations that were not part of a visit. Those are a smaller part of what we're doing to optimize them in readiness for the first program at the Institution of Sustained Children's. Next slide. So I think the thing that we wanted to emphasize ultimately is, you know, as pediatric physiatrists, we have a unique skill set that other specialties that are involved with pain and function, you know, for better or worse, don't have not developed. And, you know, we have an ability to coordinate our treatment plan for our patients. We work with so many different other specialties. So you know, our role, you know, there are a lot of us that are big systems that have access to a pain program, but there are plenty of us that are in new areas in new communities that are trying to build up our program. So, you know, this is kind of a recommendation for all of us to think about, you know, when we're talking about optimizing versus exhausting, and by that, I mean, where patients are bouncing back and forth from physician to physician to specialty to specialty, and things haven't been coordinated towards a treatment plan, ensuring that full workup has been done. I think we do that a lot in our patient populations. We also have an understanding of how insurance plays a role in certain treatment plans that we offer. So we understand the time delay for some of the things that we do for our patients. So those are skill sets that we can help ensure for paying patient pediatric pain patients to ensure that when they are referred to a big program, they are better optimized so that there's less work to be done, especially considering the lack of the programs and availability that there is in the country right now. And again, we have a small community. So at the end of the day, if you don't know how you can best optimize, reach out. All of us are really happy, I think, in our community to talk to each other in optimizing those resources. And as a lot of us are continuing to go into pain, pediatric pain, I think we can continue to help address the patient population. So next to speak is, thank you, Tate, is Dr. Sarah Williams, and she is the director of our program, and she is also a pain psychologist, and she's going to be talking a little bit about the role of pain psychology in multidisciplinary treatment. So thank you, Dr. Williams. Thank you, Dr. Collins. Hi, everybody. Happy to be here. I'm getting jealous hearing about all the good weather in different parts of the country. We all do wish we were in San Diego. So I just wanted to say quickly to the stages of, or to the ready for a program like this question, there is a measure out there called the pain stages of change questionnaire, and there's adult version and a pediatric version. So I can put that information in the chat, kind of when we're doing the Q&A, but I just wanted to mention that because that was a great question about a measure that can be used to look for readiness to change, because that is one of the factors that we work on with kids in pain psychology. So today, if you'll do the next slide, Andy. Thank you. I was just going to tell you a little bit about pain psychology. I know a lot of people are familiar with this treatment of cognitive behavioral therapy, which I'll say a little bit more about, but we use this for pain because it's effective. There's a Cochran review that's quoted here by Chris Eccleston and colleagues. There's a lot of evidence out there about the efficacy of cognitive behavioral therapy for pain. And sometimes we have to break that down a little bit more for our patients, who sometimes can have a little bit of a chip on their shoulder about getting referred to psychology when they come for a medical problem, because they hear that as, oh, no, this problem must be all in your head or made up, and we want to help them understand that that's not the case at all. This problem is real. This pain you're experiencing is real. And it just so happens that there's a lot of coping strategies and a lot of ways that they can help to learn to improve their function in the field of pain psychology. And so what that really means is helping them learn active kind of ways of being able to deal with this and get back into their lives. We do that through behavioral strategies like relaxation. We use a lot of activity pacing to help them understand how to kind of break out their day and use schedules, as well as using distractions and pleasant activities. And then the cognitive strategies address a lot of goal setting, helping them with optimistic thinking and address any distorted thinking patterns that they might have. Pain catastrophizing is a common one that a lot of people have heard about, where it's kind of making a mountain out of a molehill, so they might wake up one day and have a little bit of pain and then think the whole day is going to be terrible. So addressing that kind of thinking can obviously change a lot of their feelings and their actions as a result of that. Next slide, please. So the role of the pain psychologist in outpatient treatment, but as well as our inpatient program that you've been hearing about, is to really focus on those factors of cognitive behavioral therapy to support children's rehabilitation and recovery from pain. So as the psychologist, my role is to really identify and work through those challenges that kids are having in their thoughts and in their action patterns to help them balance out their emotional feelings and their physical feelings that they're having in the context of pain. We do a lot of work, especially with emotional identification and expression, because we know kids with chronic pain and other related somatic symptom diagnoses often have a hard time expressing their distress emotionally and often do so physically. Both sides are real true experiences they're having, but to help them learn a language and learn a way of expressing themselves through their emotions rather than pain is one of the ways that can help them cope more effectively with the kinds of challenges they're having. Social factors become really huge, too, so a big part of what we do in pain psychology is work with parents around interacting with their kids with pain and helping kids improve their interaction in their daily context, which for many kids means school. So I'm going to break those two out a little bit more. Next slide, please. The first one talks a little bit about parenting support. So in the work that I do, both in the outpatient and the inpatient context, my goal is to really help normalize that parent-child relationship for the age that the child is and what's expected in that parent-child relationship typically for that age. So a lot of times, teenagers have become very dependent on their parents at a time where they should be very independent in their developmental trajectories, and we want to normalize that and give kids the ability to do that and help parents feel confident about that, too. And that is done through direct support. So we do a lot to kind of help parents validate the challenges they're having in parenting their kids and helping them achieve independent goals and really teaching parents skills to support kids' function. Because what we don't want to happen is having kids that are working with us and then going back home and not having parents in a family that's supporting them using the same skills they've learned with us. So we do that through involving parents in pain education so they understand the role of function, they understand that it's safe and okay to encourage their kids to work through pain, really helping them with specific parenting skills. I always like to use the words finding the just right approach. So we don't want to overdo it and we don't want to underdo it with the support that we're giving to kids. So they need boundaries, but they also need support and then helping them a lot transition those skills to the home setting. And so in our inpatient program, one way we do that is help the kids build a schedule with their family so that they can do the same types of activities they've done with us in the hospital at home. And in the outpatient world, you can do the same thing, help the parents learn how to do the skills that you're teaching the kids right there at home. Next slide. School accommodations become a big part of this too. Obviously many kids with chronic pain are impaired academically. They're not attending school. Kind of no one's attending school in a regular way right now with COVID, but certainly kids with pain are still experiencing challenges in the academic environment, even with COVID around. And prior to COVID, it was common for kids to be on virtual or online programs when they typically wouldn't have been and when they typically would be in school. Collaborate a lot with schools to help schools understand that maybe kids don't need as many accommodations physically in the building as they have previously had. So we want to kind of get them back to a typical way of getting around the school building. We want to address any other underlying school avoidance. So it might not just be the pain is the problem. It might also be that there's anxiety or that there's learning challenges that are preventing kids from feeling confident in the school setting. And our bottom line is that we want to return kids to the setting that most aligns with their family's choices. So if the family's decided to homeschool a child because that's aligns with their family's values, then that's what we want to pursue. But if they're only homeschooling the child or using an alternate educational tool because of pain, we really want to help get that kid back to their most typical environment because we all know schools are so important for kids' development. And next. So we know among the kids that come to see us in the first program that psychiatric diagnoses are highly comorbid with pain diagnoses. And when I think about this, to see that 68% of our sample had a comorbid psychiatric diagnosis, that's over two thirds of that population. I think about, we see the kids that are most highly impaired from chronic pain. And so by the time that we see them, it's not just pain that they're trying to fight through, it's other factors too. So to kind of piggyback off of what Chait was saying before, for kids that kind of end up in our program versus kids who may be more successful in outpatient care, I would say that kids who do have psychiatric diagnoses might more often need a more intensive approach like a pain rehab approach to really help them overcome probably not just pain, but other challenges too with anxiety being the most common, also depression, but a lot of neurodevelopmental challenges, histories of trauma, somatic symptom-related disorders, and these other diagnoses you can see here. Many of our kids over half were also on a psychiatric medication to manage these challenges they were experiencing too. Next slide. So in our program, one of the things that we decided to do is kind of measure some changes kids might make with their coping while they were engaging in a pain rehab approach. And we used a measure called the pain coping questionnaire that's just a simple three item measure where kids rate their perceived ability to cope with challenges related to pain on a one to five scale. So a higher score on this measure means better coping. And we assess that at admission and discharge similar to what you saw with the functional disability inventory. Next slide. And what we found is that kids really did improve their ability to cope with pain as a part of being in the program. So we did see a significant change pre to post. So this is some good evidence along with the other evidence we have for cognitive behavioral therapy being effective at helping kids learn pain coping strategies. Next slide. And we also wanted to kind of give a little, I think each of us is trying to give a little bit of a shout out to, again, like Andy said, understanding that we have a really resource rich environment and we're so fortunate to have each other collaborate with. And we know that not every setting is the same. And so we really wanted to provide some tips in each area for kind of how some of these different things can be implemented even when you're not in a pain rehab setting like we are. So the suggestions I give to everybody who might be advocating for a patient to engage in pain psychology are kind of listed out here, but truly I can't say enough about the importance of starting with a validation. Like I said, many kids come to me saying, oh, a doctor told me to do this pain coping stuff, but psychology meant it was all in my head so I never did it. I'm like, gosh, I wish they had had that opportunity to try some of this as an outpatient because I believe it could have been helpful. So really validating your pain is real. It's not all in your head. I'm gonna keep working with you so they know medically, you know, that this is still gonna be addressed from a pain standpoint. And then provide that education about CBT being very effective and one of the most effective strategies we have at helping kids with chronic pain. And like I said in the beginning, kind of telling them what it is. It kind of sounds mysterious, you know, this cognitive behavioral therapy, especially when you're a younger kid. So tell them what they get to learn. They get to retrain their nervous system to focus off the pain and on function. And you get to learn relaxation and different ways of thinking and setting goals that can help you do that. My very best tip, and I stole this from Dr. Rachel Zoffness who is a fantastic pain psychologist who wrote a wonderful workbook for kids with chronic pain that's available out there if you're working with any kids that would benefit from a workbook. But she describes it like this. So to kind of break down that stigma, she tells kids, you know, hey, if you were learning a new sports skill, wouldn't you go to a coach to learn how to do it? Well, learning a new pain coping skill requires a pain coping coach. Wouldn't you go to a coach to learn how to cope with pain, just like you would go to a coach to learn how to do a new soccer skill to get good at it? And I find that kids really can buy into that kind of mentality. So calling us pain coping coaches instead of psychologists might also be helpful. So finding pain psychologists in your area, you know, certainly your institutions that you're in, anybody that's a health-focused psychologist is great. Many folks who are trained in cognitive behavioral therapy for anxiety and depression can apply these skills to kids with pain. But also you can look more broadly than that. There's lots of certified counselors, social workers who are out there in communities who would be able to partner with you in treatment too. And really partnering together in treatment is critical. You know, being able to have communication, even in an outpatient world, if that's sharing notes together, you know, communicating every now and then about your patient status and sharing with your patients that you're doing that as they would have to give you permission to do, but really vocalizing to your patients that you're working together is really helpful as well. So those are my psychology tips. And now I think we are gonna kick it over to the other part, yeah, of Emily and Nicole. The next two speakers will be Emily Deet and Nicole Samuel, who are the physical therapists and occupational therapists that work very closely with our team. So they will be up next. So I'm Emily and I do have the awesome opportunity to work as one of the main physical therapists within our inpatient chronic pain rehab program. And the goal of this presentation is kind of to let you guys know some ways you can collaborate with your physical therapist at home, as this tends to be kind of one of the first lines of defense for children who get a chronic pain diagnosis. And then also ways to kind of show and measure progress or to kind of figure out what to do when you have like that stalemate. So PT might be the one thing you're giving these kids and they're not seeing any progress. So what can we do to kind of work together to make that happen? I didn't know the next slide. So the big goal of physical therapy is to work to get right in your body, how to participate in the way you want it to by using those big muscle groups. We create an evaluation that creates those very specific patient goals. And it includes a history, measurements of strength, endurance, general range of motion assessments. We do some balance assessments and then very specific objective measures. One thing that's really important in my evals and that I've learned kind of over the history of working with this patient population is collaborating with the medical team to ensure that you have that clearance and that this is the best option is important for me as the PT, but also for those patients to hear. And often I'll speak to like the pain team or a rehab team and just make sure everyone's on the same page. But I think these patients like to know that this is the safe and the best option for them to do. So that medical clearance is really important when we begin our care. You can go to the next slide. So on my side of things, we do a few objective measures to help measure progress, not only for insurance, but for these patients know that things are getting better even though it might seem very difficult. On our rehab unit, we have to take Liefen scores. So I measure those for transfers, mobility and steps. Sometimes that can be tricky with a ceiling effect for some of these kiddos, but we do often see changes from like supervision to modified independent to an independent setting, which is nice when you explain that to the child about what those differences are. I do a six minute walk test. I time steps in whatever way the kids are able to do them if it's safe to try that first day. We do what our unit calls a 30 second step test. It's basically a test of confidence, coordination and balance to go up and down one step 30 times or within a 30 second period. I only do the balance section of the bot too, which was just kind of a quick test to do as I only have so much time on inpatient to do a lot of tests. So I try to run through what I can, but not make my entire first week with these kids very objective measure focused. And then as discussed earlier, the functional disability inventory relates a lot to the goals that we're working on in physical therapy. So whether that's walking to the bathroom, going up and down steps, walking a football field, trying to shop throughout the day or going to the grocery store. With that, I can also have these kids work really hard in therapy and then we go and do them in real life. So it gives them like the measurement of knowing what they can do in the real world that they could do outside of the hospital as well. During pain rehab, our big goals include improving that functional strength, endurance, balance and all of that stuff that allows these children to progress their gross motor skills. That's the ultimate goal of physical therapy in general. We focus a lot on their independence from mobility. So while it might not be someone who was a total assist transfer to start and then go to independent, we wanna get out of that supervision mod I, min assist range and get them back into that independent stage as best as we can based on their general health and wellness prior to their chronic pain diagnosis too. I work a ton with psychology to facilitate appropriate coping mechanisms that Dr. Williams mentioned. This is huge for our kids because we talk a lot about having the brain and the body connect together and we need both of those resources to understand each other. So often Dr. Williams will come into our sessions with us. We collaborate a lot day by day. And I think that helps the kids know that we're all on the same page too. And we all believe this is going to work as well. So it's a very nice collaborative community that I really appreciate and that in any other setting would be beneficial as well outside of our hospital too. And then with our children, we work a lot to plan for their continued progression of activity. So we wanna make sure we have a plan when you leave therapy. The goal is not to go to more outpatient in our program, but really you don't wanna go to outpatient forever. So we need to know if you're gonna get back to playing soccer, if you're going to go do Zumba classes, but we practice all that stuff and we emphasize that this is the safest place to start it. And then you're gonna go home because you have the confidence to do it when you leave as well. Next slide. Typically though, I have a little bit different approaches. My friends who maybe work in a regular outpatient setting or they aren't seeing kids with chronic pain all the time. So I have to, I shift my focus a little bit with these kids. We have this huge emphasis on functional activities and functional exercise. So you're gonna be maintaining this forever. So we focus a lot on your ability to independently ambulate community distances without limitations consistently throughout your day. We focus on these big whole body activities. Like we want to get your core really strong even though you're coming in for a foot like CRPS diagnosis. We need to make sure your whole body knows how to function in every stretcher. We may do more ankle range of motion exercises if that's limiting, but we're still gonna do a general whole body approach to keep you getting stronger, whether it's deconditioned from not moving or if you just need to remind your whole body how to react again appropriately. I don't do a lot of modality manipulation or other passive strategies for the patient. So like we don't want these children to think they need to live with a TENS unit on them forever. So we've got to kind of get away from those ideas and let them know that they can do other more active things to do. We have a lot of focus on independence. So I'm not necessarily doing passive stretching to these patients, but they're learning how to do it for themselves or we're teaching them kind of how to utilize their body to help calm them down or the coping skills from psychology so they can continue throughout their day. And again, we collaborate a ton with psychology throughout our care and the whole medical team. So everyone's on the same page and we're all promoting our different strategies during functional times, including on our rehab unit, we'll work with nursing for evening hours to figure out what to do. We have a plan for the mobility outside of therapy. And then we also incorporate the parents as well. That's all I have. Hi, and this is Nicole saying I'm the occupational therapist on the first program. And like Emily was saying, it's such an honor and privilege to get to work with this collaborative team that I know we have a really great opportunity to help these patients. And I know it's something to be really thankful for because a lot of places don't have all the resources and the collaboration possibilities that we have. Occupational therapy is not always the first line of defense for these kiddos. And a lot of the kids that come into the program haven't had occupational therapy before. So I'm really gonna try and talk about why that can be something valuable to add to their plan of care and how we can add that in for those kiddos that are struggling with chronic pain. You can do the next thing. So what I tell the kiddos when they first come into the program is that the role of occupational therapy is really to help you get back to doing the things you need to do and that you wanna do in your daily life. A lot of these kids might look or can look fairly functional in terms of being able to participate in their self-care tasks, but they're not doing it consistently. They're not doing it with the quality that maybe would be expected with their age or what they used to be doing before. So really our focus is on just being able to enable these patients to participate in these activities, activities that they're interested in, that hobbies, promote independence with participating in self-care tasks and like the chores at home, household activities. And then being able to improve overall activity tolerance so they are able to participate in these. Functional strength, their fine motor skills. Sometimes these kids have difficulty with like tolerating different sensations. So we'll work a lot on desensitization skills, some joint protection things while they're participating in these activities. And then we're just gonna reduce their maladaptive changes to activities. So really thinking about being able to participate in self-care tasks, chores, activities of interest, regardless of how they're feeling. A lot of these kids can go, go, go, and then they crash and being able to consistently participate in these is really the main goal and in all settings. So addressing environmental barriers, talking with the families on what's going on at home. Why can't we do these things? Because when I look at you in clinic or when I look at you here, it appears that you should be able to be participating in these things. And then again, working with psychology to promote those positive coping skills and using them while we're practicing and doing a lot of tasks, specific practice in the gym. You can do that next slide. And like I said before, I work in an inpatient setting and we have the first program. So most of the other OTs really know kind of the approach that we take with OTs, but it's not something that's the norm and necessarily familiar for everybody working in like an outpatient setting or another inpatient hospital that doesn't have as much focus on treating patients with chronic pain disability. So ways that you can help facilitate kind of working towards those OT goals is when you're giving a referral or recommending outpatient OT or inpatient OT, really putting specific things that they might be able to work on. So those self-care skills, those household tasks that they're doing, any sort of participation in like a leisure skill or occupation that they aren't doing, fine motor skills, any sort of sensory deficits, those are good things to list. And also talking about, are they doing them consistently? Is the quality good? Goals that we have are like doing them without pain limitations, doing them without restrictive fatigue and doing them with appropriate speed. So have a lot of those qualifiers in there. And then we recommend kind of helping, we will help kind of set up expectations with the kiddo and the family that do in the room. So they should be showering every day. They should be helping tidy up their room and setting specific goals that they might have. A tool that I use and that is very common to use in a lot of occupational therapy settings is the Canadian Occupational Performance Measure. And that's a really great goal-setting tool and the patients respond really well. We usually do that at admission and discharge and then we also do it in follow-up clinic, but it's something that can be done in the outpatient setting as well to help the patients really identify some functional goals. You can go to the next slide. So the Canadian Occupational Therapy Measure, it's a standardized tool and it can include both patient and caregiver input. Typically on the inpatient side, we do mostly the patient, but then kind of share the goals with the caregiver, but on outpatient and other settings, you can kind of make sure that the goal is aligned with what the caregivers are thinking too. And it detects a change in the client's self-perception of their occupational performance and satisfaction over time on a scale of one to 10 and a change of two or more is significant. And you can do the next one. So basically it's an interview tool you're going through and you're looking at different areas of the patient's life. So you're talking about self-care, so grooming, dressing, hygiene, you're looking at productivity. So if they're in school, if they participate in chores, if they are of age to like have a part-time job or volunteer and then their leisure activities. So what are they interested in? Some quiet, like more calm things, which a lot of these kids is kind of what they've gone to to participate in, but then some of the more active things. And I always ask them, what's something that maybe you miss participating in because a lot of these kids don't have a lot of those active leisure things happening right now. And then the socialization piece, and it gives them a opportunity to kind of go through and list any sort of things that are going well, but then also areas that are challenging for them. The next slide. So as we go through, we help them identify kind of a top five goals and priorities that they wanna work on. And then they rank those on their performance. So they rank, how would you rate the way that you can do this activity now? One's not able to do it at all, and 10, able to do it extremely well. And then satisfaction with that goal. So how satisfied are you with the way that you can do this activity now on a one to 10 scale? One, not satisfied at all, 10, extremely satisfied. And some of those goals could be showering, standing up. Some of them are participating in a sport. Some of them are attending school daily. So they're kind of a wide range. You can go to the next slide. And then like all our measures over time, we've seen significant changes. The change of two or more is a statistically significant change. And for performance on average, we've seen a change of 4.66 and satisfaction 5.65. And like I said, we do repeat these measures and kind of remind them of their goals at their follow-up outpatient appointments, which has been, I think a really cool tool and help them kind of keep those goals in mind while they're going forward after they participated in the program. Thanks everyone. So as I mentioned before, I might get cut short on the medication part, but I think medications is something that a lot of you are familiar with. So I'm gonna breeze through most of this and you can always ask me. I will make sure that I think there's a way that we can share the slides, but also you guys can email me if you want any of them. And then we'll go through some of the question and answers, which Dr. Williams has also been typing into the chat and Q&A section. So if you wanna see the answers, check out the chat and the answered section of the Q&A for some of those, but I'll address some verbally as well. When talking about chronic pain medications, there's a whole bunch that we talk about. Some of them might be more familiar to you. Things like NSAIDs, acetaminophen, antipleptics, TCAs and SNRIs, as well as muscle relaxers. Then there's some others that people have started using, like an NDA antagonist, that's ketamine. Topical medications, some like people might talk about opioids, which we'll get to in a second. Marijuana or marijuana analogs and opioid antagonists. So that's like low-dose naltrexone. This is a quote from a Cochran review on amitriptyline. And I stole using this for presentations from one of my colleagues, Dr. Ken Goldschneider. And as you can see, it talks about amitriptyline being a great treatment, a first-line treatment for neuropathic pain, and that there's essentially no evidence, and that is disappointing, but we also know that some people have felt better with it. And so this kind of quote can be replaced with any medication we use for first-line treatments for neuropathic pain or for other types of chronic pain. We're really like, there's issues with the data for all of these things. The treatment effect is hard to prove in research, but that doesn't mean that people can't have success with them, and you kind of have to try a few different things at times. My big thing that I like to talk to patients about though is that the medication will not do everything on their own, and that's probably one of the biggest parts about medications. I think all of you are already aware of this, but opioids generally are not the best treatment for chronic non-malignant pain in children's, but they can be helpful for intermittent exacerbation of inflammatory conditions. Marijuana is a complex topic. There could be a whole talk on that. There are differences between CBD, which is a low-THC product, and medical marijuana. Evidence is anecdotal, which is similar to all of our medications. So the lack of evidence, I think, is hard to say, like, we don't have evidence, so we shouldn't use it at all, because that's the case for pretty much every medicine we use and think about that when you're saying that lack of evidence is a reason to say, no, that's absolutely off the table. I talk about it that I can't officially do it, which is an Ohio rule, and talk about kind of the risks or other ways to treat it like medication. Then I have some more slides on gabapentin pregabalin, TCAs, SNRIs, and then instead of going over those, we can talk about any other questions that people have. One question that was on there was, can we address discussing with the patient about not doing further diagnostic testing? So yes, I think that's a really important question. And how to discuss it, I think, depends on where along their trajectory of workup they are. So for people who are coming to see me in clinic for the first time, if I feel like really the diagnostic testing they've had to this point has been entirely appropriate, I frame that diagnostic testing discussion around the discussion of their diagnosis and talking about their pain diagnosis and giving them a name for the pain. I will sometimes tell them like, this name is controversial, or like, I often will use amplified pain for people with widespread amplified pain issues. And I'll tell them like, that's the word we have for it now. I might use a different word for you in the future, and I'll talk to you about that if we do. I try not to use the term diagnosis of exclusion or emphasizing that you need to have had all these tests to rule it out before and talk about the positive findings in their kind of explanation that point towards that. For patients coming to an inpatient pain rehab or an intensive interdisciplinary pain treatment program, I talk about the not doing further diagnostic testing in outpatient to make sure that people know they're not gonna get more testing while they're in the program. When I talk about that, if people are like, I still need to have this one last MRI before I can really be sure that it's time to move forward, I talk to them about that meaning like, they're probably not in a place where intensive interdisciplinary pain treatment is the right stage for them. And that I don't order an MRI if I don't think it's indicated, but I kind of try to talk through why they're looking for that and what other information they're really searching for. Sometimes the tests they want are tests that I don't know the answer to or know how to know if it's really the right thing. Like if someone who is like, I need X, Y, or Z other tests, I don't think they wanna pop my head, but I'll refer people back to their primary or to their other specialists for that. I guess a lot of what I do with that is like people that ask for a very unique GI or allergy tests, often for people with gastrointestinal pain, I'll send them back and say like, look, you have to have these questions answered. They may not do the test, but you have to ask the specialist about why this test isn't indicated. And then I just really reiterate from the beginning that there's gonna be no more testing during the program. And I think one thing to emphasize with that question is it can be something as simple that happens on the initial visit. It might take multiple visits. It's almost an activity of attrition. And then the other aspect is, sometimes the patients are getting mixed messages or mixed signals from other providers involved in their workup. And as physicians, we sometimes just wanna figure out the answer and we'll sometimes consider other type of diagnostic workup because we don't wanna miss something. But, and sometimes that can, so those other kinds of recommendations, they might hear from their other physician, oh, I was told I was gonna get this other like workup or an ERCP or something like that. And so it's really important where we collaborate with those physicians and understand their reasoning for what the patient might be hearing so that we can have that discussion and help support a united front for the patient. Because usually that will do a lot in terms of getting the patient on your side to participate. Yeah, so I have a few more questions. How do you address the wait times? For example, you have people with a very, very long wait. So I don't have a great answer to that. One of them is I think by doing some of the things that you can start with during that wait time and trying to partner with people in your local community to do those things. Another way to do that is we get more people trained as pediatric pain doctors or start doing pediatric pain. I fundamentally believe that many pediatric physiatrists could serve in this role if they are interested and want to kind of grow that part of their program. But I think it's really tricky, the whole wait time issue. We've had less wait times since COVID started, which is for lots of reasons or more mixed wait times. But I think trying to start with some of the treatment options is a good place to start from for that. And then the providing ongoing psychology support, yes, is an ongoing need. And we would recommend that's a really big reason to partner with community or with psychologists or mental health providers in your community. Because even if people go out of your area for an intensive program, they're probably going to recommend that people come back to a pain psychologist afterward or a counselor of some sort who can provide those strategies. And then which pediatric age group responds well to CBT and pain management? Dr. Williams will probably type that answer. But my general thought of it is if people have the cognitive skills that they can do it. So Dr. Williams will have more details on that. I do want to, before we move on, so I'm sorry, we're already probably over time. I want to highlight one of the answers that Dr. Williams typed in, which is the one about what do you do when you're in a community without pain psychologists? There's a great app. It is from Seattle Children's called Web Map. There's also a website that's mycarepath.ca from a group in Canada. Those have excellent support resources to help integrate pain psychology strategies into life. She also incorporated, she also referenced that book earlier and that is in the chat under the answer or in the question and answer under the answered section. So please reach out to any of us with any questions. I might not be able to answer them, but I can point you in the direction of the other team members if it's not for me. And if you have other people in your residency programs that want to become pediatric pain doctors so we can reduce those wait times, point them in my direction and I can help them get great training because we need more. Yes. Thank you everyone. Thank you. I do not know who's taking over to introduce the next portion, but okay, I think it was just waiting. Sorry. Thank you guys for that lovely presentation on. I can't wait to ask you more about being met. So you'll be getting an email from me. Next we will have. Yes, thank you for your introduction. My name is Renat Sukhov. I'm a Clinical Research Associate Professor for Rehabilitation Medicine at NYU Langone Health. Do you hear me well? Yes. Okay. Last, yes, please give me a second please. I have to organize a little bit. Okay. Okay. So last year, I attended Dr. Piker's powerful presentation on this topic at the APMNR Pediatric Community Day. It really inspired me to join Dr. Piker's effort educating our physician community about physician burnout, moral injury, and suicide. Dr. Piker and I will have the privilege to provide you with a 30-minute update on this subject, this important issue for us that cannot and should not be ignored or easily dismissed. There's a lot of information in this presentation to cover. In the next 25 to 30 minutes, we'll provide you with the most recent information. In addition, this time around, we will come up with a plan for our community. An extensive updated reference list is provided in your handout. At the end of the presentation, we hope to have an interactive and productive five to 10-minute discussion. We have nothing to disclose for our presentation. Dr. Piker and I don't have any conflicts of interest. Perhaps the best point to start this talk is to the definition of burnout. Burnout is defined as a psychological syndrome involving emotional exhaustion, depersonalization, and diminished sense of personal accomplishment. The human condition of burnout is the same across many healthcare professions, but the specific stresses differ by profession. The mass latch burnout inventory is used for the assessment of burnout. Let's review briefly these three subclasses. Burnout is characterized by emotional exhaustion. This symptom leads to delay of needed interactions with patients. The physician becomes less tolerant and more impatient, and that in turn leads to decreased quality of patient satisfaction and iteration and quality of patient-physician interaction. The second characteristic of burnout is depersonalization. These symptoms lead to withdrawal from the patient, lack of compassion, increased cynicism, and sarcasm. The most disturbing fact is that this symptom can lead to increased risk of workplace violence. The third characteristic is decreased advocacy, leading to poor occupational confidence, poor decision-making, decreased attention, and lack of focus and situational awareness. The burned-out physician with underrecognized and underreported manifestation of their symptoms or combination of their symptoms almost inevitably are being blamed, scolded, or bullied. This is simply wrong implication. Reporting these symptoms assumes that the failure of the physician, and it is flatly wrong. This slide describes the facts related to physician burnout. Evidence of burnout was found in 44% of 15,000 U.S. physicians. Alarming rate of suicidal thoughts have been reported. 14% of physicians reporting suicidal thoughts, but only one-third sought mental health care treatment. The greatest incidence of burnout was reported among 45 to 54-year-old physicians at the prime of their career. The burnout physician is prone to have increased medical errors, work few hours, and live clinical medicine altogether, which in turn exacerbate predicted estimated shortfall of a physician by 2025. Finally, burnout has recognized an occupational phenomenon. In ICD-11 classification on the problem relating to employment-unemployment, there's a code, QD-85. Burnout is directly linked to physician stress and myriad factors. Six categories of work stress have been postulated as main physician stresses. These are excessive workload, lack of control in being able to influence environment, poor balance between effort and reward, lack of community, lack of fairness in resource distribution, value conflict, stress associated with the need to participate in unethical circumstances. Sometimes a little humor helps see the big picture. Dr. Zubin Demania, who goes as ZDoggMD, gave written permission to show this video. You know, administration is always telling me, Vader, we don't want to micromanage you. You're the doctor. You know what's best for the patients. And I'm like, okay, then what is it you do want to do? Well, we just want to know what you're doing every single second of the day, how many clicks you're making, how many patients throughput you're having, what is the throughput through the ER? How many medications are you using? What percentage of them are generic? Have you met PQRS standards? What are your RVUs? And I said, wait, wait, wait, wait, wait, wait, wait. This sounds to me like you're micromanaging me. And they said, no, we're actually macromanaging you because these are a lot of things and we're just lumping them together and we're measuring you on every single one. And I said, you know what? Is it too late to become a plumber? What is the impact of burnout, physician burnout? First and foremost, it impacts the patient due to increased medical errors, physician aberrant behavior, pervasive reduction of empathy for patients leading to poor patient satisfaction. This impact on financials of institution. Burnout leads to turnover of staff, increased medical claims for employers, data shows points to contribution to short and long-term disability claims. Last but certainly not least, the effects of burnout on physicians are enormous. Here, I would like to quote Dr. Privetera, who was on the leading committee for physician wellness and medical society of New York and published in journal of hospital administration in 2015. High level stress is imposed by multiple regulatory insurance, federal and state forces that do not coordinate well with one another, resulting in desperate conflictual confusing mandates. Each have authoritative capital. Together, they have potential to affect healthcare workers in a personal, physical, emotional, and cognitive level, which in turn adversely affects care relationship and quality of patient care. In the next two slides, I will talk about work-life balance, which is essential for prevention of burnout. Permission is used to slides have been obtained by Dr. Witzig and his work on work-life balance published at the Mayo Clinic Proceedings in April, 2019. The key of successful coping with burnout physician is to maintain a healthy work-life balance. This concept is directly related to physician resilience. Here, I would like to defer to definition of resilience. Is resilience a collection of personal qualities that enables the person to adapt well, even thrive in the face of adversity and stress? Interestingly, the most recent national survey suggests that the physician exhibited higher level of resilience than the general population in the United States. 2020 JAMA article on this topic found that burnout rate were even substantial among the most resilient physician. There are 168 hours in a week that is fixed, but the distribution of time spent in various areas is changeable, and each component affects other components. In this context, it is important to mention the concept of effort-reward imbalance, defined as the effort requiring to meet job demands and the reward for job performance. Elevated effort-reward imbalance was found to be linked to a significant decrease in peak average and total cortisol level among Buffalo police officers. Effort-reward imbalance was linked to depression associated with coronary artery disease and has been linked roughly to a twofold increase in new employment disability. What are the strategies for burnout reduction? Simple to say, but hard to do. Individual intervention should be paired with organizational interventions, specifically alignment of values and strengthening of organizational structure, and even more specifically on a personal level, normalized self-care, exercise mindfulness, use peer support group, use community and family support, meditate, practice healthy diet, exercise. At the level of organization, overcome culture of endurance, refine leadership style, provide access to clinical wellness, use neurocognitive ergonomics. Burnout reduction should put emphasis on aim. Primary aim is to experience of providing care along with other aims, such as cost of care, quality of care, patient experience. One of the best strategies to establish and encourage stronger administrator physician partnership. It is most obvious, but not necessarily easily achievable. Now it's time to talk about moral injury. What's up everybody? It's Dr. Z. Okay, listen, I'm really, really, really tired of people calling it burnout. What over 50% of healthcare professionals are experiencing, they call it burnout. It's exhaustion, low productivity, and a feeling of deep cynicism. And it's so prevalent that everyone, even in administration, is starting to panic. Like, what's going on? Why are physicians and nurses and PAs, why are they burning out? Well, burnout is a kind of victim shaming. It's saying you're not resourceful enough, you're not resilient enough, you're not strong enough to adapt to a system. So maybe you should meditate. Maybe you should use some lavender essential oil. Maybe we could have a wellness retreat or hire a chief wellness officer. Listen, it's all bull. Here's what's really going on. We're not suffering from burnout. We're suffering from something that Wendy Dean and Simon Talbot call moral injury. Moral injury, it leads to mental health, immobility, depression, anxiety, and substance abuse disorders. Gap between what happened and what should have happened, challenging code of individual physician values and norms, giving way for the painful emotion. In healthcare, we have the double bind as a result of the financial and business framework of healthcare. We know what the patient need, but what we need to be maybe forced to choose something else as a priority. In other words, we may be asked to transgress the oath we took to put our patients first always. Physicians are smart, tough, durable, resourceful people. Physicians aren't burning out. They're suffering from moral injury. There are no accepted clinical tools to identify moral injury. No accepted clinical standards for treatment. Moral injury should be included in any discussion. There is a significant overlap between moral injury and symptoms of burnout. Amnesty International, a non-governmental organization committed to responding to human right abuses, and they released a report on July 13, 2020, regarding a serious shortage of personal protective equipment in nearly all of the 63 countries and territories they served. There have been reports of health and essential workers being fired or facing disciplinary action for speaking out about their concerns for lack of PPE. They reported approximately 3,000 COVID-related deaths of health care workers at the time. In September 2020, Amnesty International again reported regarding the abuse inflicting on health care workers and other essential workers during the COVID-19 pandemic. The report indicates that health workers who are identified as Black, Asian, and other minority ethnic groups are at increased risk of infection and death. Reports of community members harassing health care workers, being forced to work under inhumane conditions with threats of violence, retaliation, stigma, discrimination, eviction, and brutal attacks. The authors of the report advocate for increases in access to personal protective equipment for health care workers. Better recording of health care workers' deaths due to COVID-19. Policy changes to limit reprisals against health care workers who speak out. Better compensation for health workers who become sick on the job and improvements in investigation of violence against health care workers. According to Amnesty International monitoring, the countries with the highest number of health workers' deaths, more than 7,000 health care workers are known to have died from COVID-19 worldwide in 79 countries. Mexico has the highest number, followed by the United States, followed by Brazil. Suicide is an occupational hazard for physicians. We lose approximately one physician per day to suicide, approximately 300 to 400 a year. Suicide rates are higher in physicians than non-physicians, males greater than females. However, women physicians' suicide rates are 2.5 to 4 times the general population. Researchers demonstrated that physicians and other health care workers were considered as a high-risk group. The most recent meta-analysis and systematic review by French researchers, published at the end of 2019, studied suicide among physicians and health care workers. The study concluded physicians are an at-risk profession, so suicide is country-dependent. Data on suicide evolution by country, there's a decrease in Europe, but not in the USA. Some specialists are more at risk. Are we one of these specialties? Preferred language, according to an online cross-sectional survey funded by the NIH in 2019, the preferred language is guide by suicide, and took their own lives. And that has the highest median acceptability, scores preferable to the term committed suicide. In one study, more than 6% of surgeons reported suicidal ideations of at least double the rate of the general adult population, and of those, only 26% sought help largely due to concerns about seeking treatment and the effect on their medical license. Prevalence of suicidal ideations begin in medical school. Prevalence of suicidal ideations is 11.1% among medical students. Therefore, we should be openly discussing suicide as an illness, as this helps bring it out of the darkness. This is of utmost importance to any institution, professional group, and association. Regulatory complaints are associated with increased suicidal ideations. In one UK study, an average of 2.5% of physicians had suicidal ideation. And with regulatory complaints, this percentage almost quadrupled to 9.3%. And if it's a new complaint, up to 13.4%. The most common means of death by suicide among physicians are hanging, firearms, poisoning, and blunt force. Overdose is another cause. Benzodiazepines lead barbiturates, and barbiturates lead antipsychotics. Suicidal physicians face unique barriers of care. A recently published article in the Canadian Medical Association Journal outlines these barriers, in addition to stigma, lack of care access, with additional concerns such as confidentiality, discrimination, licensing, and application for hospital privileges. So where do we belong as a pediatric physiatrist? Medscape data compiles data for physicians in the United States, physiatrists, and pediatricians. We're engaged in truly transdisciplinary work. Do we belong to pediatrics of specialty, rehabilitation subspecialty, or just general statistics for physician workforce? 63% of PM&R physicians reported at least one symptoms of burnout based on a 2019 article published in Purple PM&R Journal. Nearly 50% of pediatricians experiencing symptoms of burnout based on the very informative article by Daniel Taube at Stanford. This article describes organizational challenges affecting physician well-being, and most importantly outlining opportunities. So the question is for us as a group, how can we help? There is an ethical and moral imperative to address physician burnout, moral injury, and suicide with tremendous negative effects on physician, patients, and organizations. How do we want to go from the top of the list to the bottom of the list in physician burnout by specialty? And how, or how can we as physicians, regardless of specialty, race, gender, disability, age, or religious beliefs, combat moral injury? Perhaps the reasons doctors have higher suicide rates than combat soldiers is we do not have the fight in us, or we are as a group controlled with what we are afraid of most, our inability to take care of our patients by the bottom dollar. Proactive slogans can help in looking at our history as physicians and advancements in the field. These have not taken place without those willing to stand by conviction. If we look at Dr. Lynette, who invented the stethoscope in 1816, he was ridiculed, and there were several medical reports detailing that his invention was unnecessary and removed the closeness of the physician from the care they were providing their patient. A hundred years later, the stethoscope became an essential diagnostic tool. Dr. Jacob Newfield wrote an editorial in a 2016 issue of the Journal of Pediatric Rehabilitation Medicine regarding Dr. Semmelweis. Dr. Semmelweis, known for the Semmelweis effect, that new knowledge is rejected because it conflicts with established norms and beliefs. Dr. Semmelweis, who died in 1865 in an insane asylum after reported nervous breakdown, endured ridicule because he advocated hand-washing in the delivery room to minimize infection during childbirth. Today there is a medical school in Budapest named after Dr. Semmelweis. Malcolm Gladwell, in his wonderful book, David and Goliath, Underdogs, Misfits, and the Art of Battling Giants, wrote of Dr. Emil Friedrich, who almost lost his medical license a half a dozen times in the 1950s and 1960s for introducing that platelet transfusion and polypharmacy was necessary to cure childhood leukemia. Using his ground, he was able to take an almost uniformly fatal disease to the most curable childhood cancer. Powerful statements. Our lives begin to end the day we become silent about the things that matter. Martin Luther King was also known to say, we must accept finite disappointment, but never lose infinite hope. What are our dreams and how do we put these into a call for action? The late Congressman John Lewis was known for advocating making good trouble. We are not going back, we are going forward. If you see something that is not right, not fair, not just, you have a moral obligation to do something about it. This goes along with positive deviance. An example of this was combating malnutrition in Vietnamese villages by learning from the well-nourished families. The well-nourished families were called the bright spot. In medicine, this involves looking at those bright spots with lower rates of moral injury, burnout, and suicide. Recent developments. On July 2020, the FCC adopted rules to establish 988 as the new nationwide three-digit phone number for Americans in crisis to connect with suicide prevention and mental health care crisis counselors. The rules require all phone services providers to direct all 988 calls to the existing national suicide prevention lifeline by July 16, 2022. This is the next slide, you see the suicide prevention lifeline, 1-800-273-TALK. On September 29, 2017, we lost one of our visionaries in the field of pediatric rehabilitation medicine, Dr. Jacob Newfield, died by suicide. This video is a tribute to his legacy of care. My husband Jacob Newfield was a really warm and caring man. He loved children, they loved him, and he felt that he had a calling in being a doctor. He lived to take care of others. When he was in college, he went to India, and there he was so touched by the hunger and poverty that when he came back, he said he wanted to be an international public health doctor. Losing Jay was incredibly devastating. I was working very closely with him at the time to get out a special issue that was focused on research for spina bifida. It was heartbreaking and shocking and sad because the field lost someone who was a visionary. He also started a program that still runs today called Strike Out Hunger. When he wanted to start a journal to promote pediatric rehabilitation, he started one. Jay was a wonderful advocate for the field of pediatric rehabilitation medicine. As a professional, he understood the value that our field has for really improving outcomes for children with disabilities. So we're incredibly lucky to have a journal that's dedicated to the field. And without him, we wouldn't have it. He was the individual that everyone flocked to to listen to his humorous stories, to just hang out with him because he was so energetic. He just became a mecca that people would migrate towards. Kids would talk to him and tell him about their lives, and he could relate to them on such a basic level, like he never forgot what it was like to be a child. Bringing a colleague to suicide is horrendous. I didn't see it coming. I had no idea. I was shocked. He always portrayed this enthusiastic, fun, energetic persona who gave hope to everyone else, all these children in need. He was the never-ending source of positive with the different colored socks. If all we can do, like Jay did, is to make a difference in one person's life a day by even smiling at him or her, it would be a tremendous thing. And we would be making a difference in the world, just like Jay did. He really made a difference, and he, I think, certainly for me, and I'm sure for other of my colleagues, inspired us to do our work to make a difference as well. The Talmud tells a short story of Rabbi Chia falls sick, and another rabbi, Rabbi Yochanan, goes to visit. Rabbi Chia tells, he speaks of his pain and his suffering. Rabbi Yochanan extends his arm and says, give me your hand. And the text says that Rabbi Chia gave him his hand, and Rabbi Yochanan raised him up. That is Jay's legacy. He was that kind of healer. Give me your hand. Give me your heart. Let's give each other our hands and our hearts, and so raise each other up. Value clinicians. Value care. Build community and work together. Raise each other up. Be the healers we went into medicine to be. Have a dream where physician suicide is at vision zero. Zero physician, zero physician suicide. Where hospital administrators, be it physician or non-physicians, have as much training to do the administrative job as we physician clinicians have to do ours. Where care of our patients is our first consideration at work, and care of ourselves is our first priority so we can provide care of the highest standards. I have a dream that in the future, we will move from moral injury to moral repair, moral success, moral healing, and moral health care. So we propose for Pediatric Rehabilitation Council, goal number one is to select anonymous and confidential screening tool, questionary, allowing for burnout, moral injury, suicide prevention for pediatric rehab at AAPM and our members by May 2021. How to make this truly confidential and anonymous and reassure respondents. Goal number two. Distribute and collect data responses and analyze responses by August 2021. Goal number three. Provide community data to the AAPMNR on or about September 17, 2021, National Physician Suicide Day. Goal number four. Gain traction with AAPMNR board approval funding on using one of the suggested tools by National Academy of Medicine, valid and reliable survey instruments to measure burnout, well-being, and other work-related dimensions. Goal number five. Collect information from state medical boards. Support abandoning requirements for reporting psychological services so that physicians can obtain the help they need without fear of retribution. Raise awareness on the problems with physiatrist burnout and moral injury. Join the mission of zero vision statement. This statement has been adopted from Illinois emergency medicine physician. Vision zero calls on individuals, residency programs, healthcare organization, and national groups to make a commitment to break down stigma, increase awareness, open the conversation, decrease the fear of consequences, reach out to colleagues, recognize warning signs, and learn to approach our colleagues who may be at risk. Goal number six. We must challenge each other as individuals, communities, institutions, and organizations to make changes to reach zero physician suicides. This is an extensive list of references that one can study or learn from the work on burnout, moral injury, and suicide. And last but not least, we have wonderful opportunity to really preserve Dr. Jacob Neufeld's legacy. The support from American academy of physical medicine foundation for the PMNR, now we can support journal of pediatric rehabilitation medicine with a restricted donation and preserve Dr. Jacob Neufeld's legacy. In order to do so, you can go to foundation for PMNR.org, push the donate now button, put the amount of dollars under special instructions to the seller, please put JPRM. Thank you, Elaine. Thank you, Raynaud. And I think, like everybody else touched by your presentation, when I think about the topics that we've covered today for the PEDS community, they're both very challenging topics, pain in our kids and also pain in ourselves. And I think using Jay's story to help us remember that any one of us can be impacted by moral injury, by burnout, by these feelings of significant hopelessness. And hopefully, with this, be more empowered to reach out to others if we're starting to feel this way and for others to reach out to those that they worried are feeling this way. We can't afford to lose one more physician to suicide. And I think, particularly right now, when there's more demands on us for clinical practice and productivity, COVID-19, increased stresses at home with families having differences in work schedules and our kids' school schedules and trying to do teaching at home, being afraid to go to the grocery store right now, not having the outlets for our stress relief, that this is an incredibly timely topic for all of us. So please, if you see something in one of your colleagues, say something. And if you're feeling something, I hope there's somebody out there that you can reach out to. With that, we will end our Pediatric Community Session for today. Please don't forget about the Rady Children's PEDS Session tomorrow and about Session No. 2 for our PEDS Community Day on Thursday. It will start at 4.30 Central Time, and we will have a lovely discussion about tele-rehabilitation and also have our Pediatric Community General Session. So thank you all for joining us, and I look forward to seeing you all very soon.

pediatric rehabilitation

pain management

multidisciplinary approach

chronic pain

therapy strategies

medication choices

intensive pain treatment programs

barriers to referrals

pain psychology

physical therapy

physician burnout

moral injury

physician suicide