Welcome everyone. Good afternoon. I'm Stephanie Firmer, assistant professor at West Virginia University under the Rockefeller Neuroscience Institute in the Department of Physical Medicine and Rehabilitation. The Academy has a few announcements before we start our presentation this afternoon. Cell phones should be turned to silent during the presentation and we will be doing audio recording during our session. Please also remember to fill out your evaluation forms as they will also help the Academy with future planning. And then also you can find those evaluations on the mobile app or online platform. And then also visit the PM&R pavilion areas or booths as appropriate. I know those are transitioning as of this afternoon. And then reminder that the Phys Talks are on Sunday morning with a complimentary breakfast. Thank you for attending or viewing the presentation today on curricula development for a rural residency setting. I wanted to introduce my co-presenters that are also from the same institution and department. I'm presenting along with Dr. John Alm, chair of the Department of Physical Medicine and Rehabilitation, as well as Dr. Megan Clark, associate professor in the Department of Physical Medicine and Rehabilitation. And we have no relevant financial disclosures. So the outline for our presentation today will include a brief introduction on what is rural medicine. That's a vital concept to our state in which we practice as well as the region and how can we successfully deliver healthcare in those areas. And to try to overcome barriers that are specific to providing care in those regions. And also we'd like to cover healthcare delivery in these areas and what have been some successful models that have been helpful as well as address some potential challenges or barriers to care. And then specific to us as a department in our institution that's developing a physical medicine and rehabilitation residency program, we'd like to review different models of training, looking at longitudinal training experiences, varied training sites such as rural or urban, resident wellness and career development. And then also think about community engagement and partnerships in those areas and regions in which we will be serving, which will be vital to our care. And it's important to highlight the need for community engagement in order to implement care in a rural setting specifically that might be unique to this region. So rural medicine as a whole, the FDA had noted that as of 2021, one in five people in the U.S. live in rural areas. And those residents can be older in age or also subsequently be at higher risk for poorer health outcomes if they are further from their healthcare facilities that they might need assistance and care from. And then researchers at the GoodRx community in September of 2021 highlighted with this map as an example above areas that are in most need by county, which is the darker shaded areas on the map, that they lack the resources related to access to facilities such as pharmacies, primary care providers, hospitals, trauma centers, as well as any other low-cost health centers in their area. And that 80% of the U.S. lacks adequate access to healthcare in general. And then why is that important to us, highlighting specifically rural West Virginia and the region that we serve, specifically West Virginia where our clinic is located and our university academic center is in north central West Virginia, Morgantown. The Health Resources and Services Administration reports on resources and clinics in areas that are in need, especially ones that are lacking the access and attainment that need critical access, hospitals or clinics. And while it might look like on this map there's a lot of different resources for patients in this area, the ability for our patients to connect to facilities like this is still a challenge due to topographical barriers and also especially with rehab medicine our patients have a lot of mobility difficulties or impairments that might limit transportation. Our residency curricula in this presentation hopes to address some ways that we can overcome those challenges, think outside the box, be more innovative in our presentation and delivery to prepare our trainees for this setting and their future career in physiatry. I'd like to transition to our next point to talk about healthcare delivery in rural areas. There's a lot of challenges specifically with the workforce. Areas often struggle to attract and retain doctors and nurses and other specialists. And then also having access to a supportive infrastructure that's also accessible. Patients might have to travel long distances to access their care and that can be also really challenging if they have limited transportation options and also in different seasonal climates that might limit transportation. And then also there's a lot of financial constraints. Rural healthcare facilities might operate on specific budget and financial constraints and needs in order to be sustainable. And then the healthcare disparities too with the higher populations of being older individuals that might have more chronic disease puts more of a barrier and strain on these resources. And then other challenges too, just technological barriers. Some of the access to internet or cell services might be limited in these areas. An aging population could also have limited health literacy as well as technological literacy to be able to support themselves in the healthcare setting. And addressing these challenges is very important and needs a multifaceted approach including policy changes, increasing the funding sources, innovative solutions to approach access to care such as telemedicine or telehealth. So how have they done these kinds of challenges? So they've done a number of programs in the past in the more remote regions. There's some pillars of care related to telemedicine. So creating more tele-ICU models for example so that they can access the patient where they are and have the experts kind of video in or kind of communicate care into those settings. Otherwise they can also create some mobile health units that can bring clinics to those patients. Or digital health innovations kind of looking at the patient where they are and remotely checking into their vital signs without having to see the patient maybe directly. And then portable ultrasound devices have been used in more remote regions such as Kenya for example. And that brings the needs to the patient in a more direct way that is still sustainable economically too. Other delivery that has been noted is drone delivery with medical supply drones. You can see these in regions such as Latin America. For this one example the drones were able to carry up to 3 kilograms of supplies over distances up to 100 kilometers. And then also training the local community healthcare workers is vital. Many of the remote regions the community members are trained to give the basic healthcare services and needs as well as provide education to the region too. And that helps that the local knowledge is disseminated to these patients and their caregivers and community leaders to help with continuity of care. I wanted to include that these models of care they are showing how you can be innovated in your approaches and technologies even if you might have limited resources and help to bridge the gap in healthcare access for remote and underserved populations. But there are also a lot of different approaches you can take to the rural training experiences themselves. And it's an advantage to do this in a unique model that's multifactorial in your delivery. That would include rural training tracks or RTTs. That would be the way to have an integrated program and implement residency programs that have a lot of time for the residents to spend in a rural setting. And as well as rural rotation specifically so that the residents could complete multiple rotations in a rural area. That might include some of the core specialties such as pediatrics, obstetrics or emergency medicine. And then also have telemedicine training if it's a good idea to have the resources but you need to train the trainees on how to use it once they're in practice. So making sure that they're familiar with technological use as well as using simulation labs to model some of these patterns. And I feel that the rural training tracks might be a unique opportunity to highlight for medical students interested in a career in physical medicine and rehab if you have them more one on one in an apprenticeship model perhaps. That might ease the burden of the congestion that might happen in training settings and more urban settings where there's multiple trainees in multiple levels getting an experience with the patient. This might add to more hands on opportunities. And then physiatry residency training in a rural environment is continuing to be a multifactorial experience. Training in physiatry residents to deliver care in rural areas you need to have a combination of the specialized education as well as hands on experience and a support system to deliver that care which also is vital with having community engagement to be able to implement your training programs and then mentorship and support is also key so that the trainees as well as future physiatrists in rural medicine don't feel isolated or alone. Financial incentives are also very helpful such as loan repayment programs and stipends and grants and then looking at curriculum development with focus courses on specific rural health issues or public health concerns as well as resource management and in the residency curriculum itself and then research opportunities trying to have the residents engage in creating ideas that are relevant to the communities that they're going to serve. These discussion points will be in part of our discussion today and we will address them as the talk continues but wanted to have them as food for thought to think of while we present our material. And one question we wanted to pose to the group as well as our panelists is regarding rural models of care. Which innovation will most likely positively impact care over the next 10 years and how can physiatry residents be trained to prepare for future models of care? And the next I'd like to pass along to my co-presenter Dr. Megan Clark. Thank you. All right. So in continuing on and using this discussion point as kind of a leading line talking about the residency and how do we train our trainees to be able to take on this challenge like Dr. Firmer's talking about of increasing access, the increased need in rural communities for our patients and especially our patient populations who sometimes are very underserved in those rural communities. So curriculum and residency training we hope include multiple of these kind of milestones as we're now even grading our residents in those milestones. But how do these things all contribute together to create that lifelong learner, to create that good foundation, create that broad experience that really allows them to feel confident going out into the world and being ready to take on any of these challenges that might come their way. So obviously our bias is trying to advocate for a little more of that rural exposure even in residency. So for a resident to be able to have that opportunity to care for a patient in a rural setting they get to see the long term relationships that the provider is able to have with that patient which we all develop probably. It's part of what drew us to PMR. But in those rural communities a lot of times they're taking care of their neighbor. It's a little bit more tight knit community. They have a little bit more buy in that, you know, I know your uncle or I know your second cousin and you're my neighbor. But how that helps in developing trust, developing that provider patient relationship, how it helps them in being able to give better care and understanding for that patient and their family. Which leads into the community engagement part. When it is your neighbor, when it is your family, when it is the person that you go to church with or bingo on Wednesday, you do want to provide that extra for them. You want to be able to help them get reintegrated into the community, help them have the other opportunities that are available in a more urban setting or a more metropolitan setting. It's hard to have a wheelchair basketball team if you are one of one in a community. You know, you've got to travel a distance to be able to join in leagues like that or to have different opportunities and engagement with other people, you know, support groups and how do we make that happen in a community. So I think it's nice not only having that experience in our large academic settings where we have these systems in place of a very long standing spinal cord injury support group that we get to be a part of and we get to see how well it functions, but do you get to see how that developed to begin with so that when you go out into the world, what if your program doesn't have that? What if you don't have something like that already established? Are we giving our residents the tools and the confidence to be able to start something like that for themselves and for their patients? So having that increased engagement. With that, again, part of the milestones as listed earlier, having a rural opportunity, does it give that broader range of skills for a resident? So things that are done or the different tools and techniques that we see, sometimes in our rural communities you need a little bit more creativity, some resourcefulness. You know, you don't have the guy down the street or next door who's doing the orthobiologics. Maybe that's something you've got to learn and research and do yourself if you want your patients to be able to have access to that. You don't necessarily have the prosthetist that's in the office with you. The closest one is 40 miles away. So how do you connect and provide that good care for your patient if you don't have those people that are there on site or close by? So again, it's still a skill that is learned from our residents in that resourcefulness. Rural modeling and mentorship. Sometimes it's nice, like Dr. Fermor had mentioned, you really get that one-on-one experience. For a lot of the community providers or community providers that I've had the pleasure of getting to know over the years, they're really hungry for that chance to give back to academics again, right? They're not inundated in it. It's not day in, day out and, oh, which student do I get today and who's the resident that's with me today? They're looking for those opportunities to be able to get a new learner and be able to share some of their love of the field. So you sometimes are able to have the opportunity to have a better relationship and a working relationship and maybe even a resource if that resident goes on and is in a similar situation when they have the chance to work with a community mentor. But ideally and hopefully, when they get to see the opportunity and see it in practice for someone who is actually working in a more remote setting, they like it. It's something different. It is a different feel and it is a different pace than academics. So you might find something that you didn't know you liked, but if nothing else, you have a little bit more confidence, a little bit of that background that you never know where life is going to send you. Life just sent me to West Virginia and I didn't expect that I was ever going to live there either. So we want to be able to have all of the background and the experiences that we can so that wherever life sets us, we've got some of those things to be able to pull from, which lends towards the hope for lifelong learning and adaptability that we do have a good, at the end of the day, neuromuscular foundation that we can add to and continue to build from so that we are continuing to learn. We're continuing to adapt. We're continuing to find the new technologies and the informatics that we need to be able to implement into our practice to provide better care for our patients. So having the diversity in their training hopefully will contribute to that as well. So I was saying we're really hoping to include rural or encourage that rural medicine can be some of that diversity in a residency program that helps positively add to a learner's experience. Now, there are challenges, of course. Everyone would do it if it was easy. Part of it can be scheduling. A lot of time in an academic institution, it is tight scheduling in trying to incorporate all of the required core competencies. Is there time and is there ability to be able to schedule in some of these other opportunities? Is there elective opportunity within your program to integrate something like this? We have been at some programs that have a lot of leniency with some of those opportunities, whether that is subspecialty experiences that may not be available in your home institution. Some of it can be even practice in a, I had a co-resident who thought they were going to be practicing out in Idaho, and so they got to go spend a month out with that private group that they thought they were going to be practicing with, and thank goodness they did, because they realized when they went out there, it was horrible. It was completely malignant, and so they were able to have that exposure and that experience to go, oh, gosh, I need to find something else to do. That wasn't the right pick. So how is your residency structured that allows for some of those other opportunities? And that can either be with short visits. Is it a week of an elective? Can you fit it into more of a block rotation if you're doing a month or several months or weeks at a time? Can you fit those block rotations into their schedule also to be able to have that flexibility? But of course, with any of those rotations, other challenges that come into play include money, and that always a challenge. It's expensive to go do those rotations. If you just plant yourself in sunny San Diego, this sounds like a lovely place to come and do a rotation. That would be wonderful, but I'm going to have to sell one kidney to be able to come and do it for a couple of weeks. So are there available options, you know, if you partner with a community hospital or if you partner with some of the other, you know, if there are med school in that location or availability for some shared housing or some sort of subsidized opportunity for the students to be able to rotate. Previously in a fairly rural training site I had been before, a lot of times the attendings would put up some of the students or the learners, and we'd be able to have them come and stay with us for a couple of weeks, which again then lends towards the mentorship like I had mentioned before. But you've got to find those mentors too. So it's not like you're having people from the community knocking down your doors at your academic institution going, please, I would like to do some free work for you. Is there some way I can do all of the paperwork to get, you know, some sort of an interim associate affiliate professorship and then take on extra work in training a trainee? I would love to take free work. But maybe it's a keeping better track of graduating residents as those residents go out into the world. Can you lean on some more than others sometimes? But you probably have a good idea in mind of who might be a good educator from your resident classes graduating and can you lean on them in the future and ask about developing that network for your up and coming residents and being able to get them exposure and experiences outside of the academic world? Because there is something outside the academic world. I've heard at least, I haven't seen it, but I've heard it's there. Other positives that can come from this too, telemedicine, of course, we were all thrust into the world of telemedicine. It kind of got rolled right on out. And while I think there is some that is backed away, we're not all sitting behind the computer the same way that we were a few years ago, I think there is still a place for it. And we'll talk some about the technology advancements that are coming forward and the integration of those into our practice and therefore should be integration into our residency as well. It's that comfort, it's that exposure, it's that awareness of, and I think technology is one of those things. In cross training that's on here as well, the things that we have learned from an urban setting, the things that you learn in a large tertiary hospital system, you figure out what you like. And if you go to some of those rural settings, you realize what not everyone has just at their fingertips. Sometimes you don't recognize how good you've got it until you don't know that it's gone. And so there are a lot of things that sometimes happen magically at a large institution that doesn't just happen on its own. It's got to be put together and put in place, maintained, and paid for. So challenges and rewards as we work through this. Of course, having to have flexibility, which hopefully in training programs there is always allowance for some of that flexibility. Finding the way to get schedules to align so that you can reach your residents' needs and be able to provide them with that ability to not only manage their personal commitments, but being able to allow them to see some other varieties. Hopefully that also comes with more of a team environment at your residency. It helps to, if one resident knows that they're going to be covering more of the inpatient this month because resident A is going to do an away rotation, with the understanding that they get the opportunity to do the same thing and resident A better be covering them with a smile, that's just part of the team and the collaborative nature that hopefully you're able to encourage and allow at your institution. Ideally, that is modeled from their attendings down and they get to see it in work and in practice from their attendings who are willing and able to cover for each other as well. You can really create that collaborative, supportive feel. Then of course the money. Can you help offset some of those costs for the resident at all to able to help with travel stipends or being able to help some with the financial burden that can come with away rotation opportunities? Do they have access when they're at those away rotations to the necessary resources that they need, the educational support that they need? Can they video in for their typical didactic schedules? How do we allow to continue their training even if they're offsite? So hopefully by integrating urban opportunities into a rural, a more rural residency program and vice versa, rural opportunities into a more urban training program, you're able to see more diverse opportunities. You're able to see more diversity in a practice, patient population, the way that you're caring for patients, the necessary skills, the necessary extra that can sometimes be needed for both, which can just be different sometimes. Because we're pushing for the rural rotations, I do think there are more positive impacts from that than negative. We had mentioned the increased autonomy, being able to work more one-on-one with a practitioner, hands-on experience. Usually in that more rural setting, the physiatrist is the jack of all trades and they might be doing an IME and then they're doing an EMG, they'll do some injections in the afternoon. And so can that resident be able to get a lot more hands-on opportunity through all of those patient encounters? The community connection, having that sense of connection with their patients, with that community that they're in, hopefully that contributes to well-being. Hopefully that gives them a little bit more of that purpose and that reason why. Can they get the skill development, just like the increased autonomy, leading to confidence, leading to that solid foundation for their education? Which then helps with that resilience piece, that life and their career might throw some curve balls at them, but if we can really arm them with all of the different opportunities, can we help them moving forward to be able to face some of those challenges? Positive impacts, of course, in the rural setting, and this comes for the practicing physiatrist as well, isolation and burnout. When you're out there, it sometimes can very much feel like you are on your own. You don't have the colleague that you can turn to in the hallway or next door to get their second opinion, to get another look on things, and so that can be very isolating. Loneliness for residents who have a family, is their family able to come with them on the away rotations? Are they able to see them more frequently? How are they interacting with their co-residents? So being able to have that. The work-life balance piece of it, sometimes, as we all know, sometimes urban settings can have a very similar demand time-wise, maybe for different reasons, but why in rural healthcare, how does that impact them? What is the pull and the need on the rural provider? How is that different than the urban physician? And limited resources. So I'd mentioned before, sometimes you have to become a little creative in what you have to work with and how you're going to use it, not only in practice, but also of the resources for the patient, in the community, what else is available to them, even within a hundred mile radius. What are they able to get access to? And it's access, not only geographically, but also financially. Are they able to have some of those resources? So more food for thought, since you guys already have lots of thoughts after the first discussion point. Another one, just to fuel the flames, related to community engagement, what positives or negatives do you see with engagement in activities, such as adaptive sports or community health fairs, in the rural residency practice setting? So I'm talking about their opportunity to see some of those. So negative impacts of rural rotations. We talked some about these, again, the support network, so trying to mitigate the isolation, some of the burnout. How do you have that mentorship? How do you develop those resources, peer resources, making sure that they feel supported? Telemedicine can help this, so that you're able to stay connected, not only with your peers, but also be able to access some of the specialists that sometimes we learn to rely on that may or may not be available in a more rural setting. And if you've got residents that are working off campus, making sure that you're staying in touch with them and that you're having frequent debriefing to monitor how they're doing, making sure that it is the good experience that you're wanting it to be, so that it really is an enriching part of their training. They have had studies that if you have more exposure to it, it increases the likelihood of practicing in it as well. For me, being from a rural area where I had done my medical school training, we had the rural track for medicine, and our clinical rotations could be rural, and a lot of my medical school friends who I went to school with who were on those rural tracks, granted a lot of them were going back home when they did the rural tracks to begin with, but a lot of them are still there. And so having that exposure, developing the comfort level with it, figuring out is it something that you really like or not, can ease that transition, makes it a little less scary to get out of big academia and into a more rural setting. So yeah, the community, and we had talked some about how you can be really integrated into a smaller community quickly, and that is easy to win you over, but isn't that why we got won over to physiatry to begin with? And our role models and those mentors that really help us and can guide us along the way, help us think out those decisions and find our own pathway with this. Hopefully we're able to limit the professional isolation. I think that holds true even with attending physicians, whether they can be welcomed into state societies. I think that's where some of the state physiatry societies are great opportunities to reach out to and help to connect with your community physiatrists, continuing education, inviting those folks to give lectures or to attend lectures, or if you've got symposiums, helping to connect with your current providers in your state or in your region. Because sometimes it is the resource constraints, not only that education piece, but location piece, the rural healthcare, the challenges that they face. Sometimes it's even problem solving if you're able to help to integrate, if you've got a larger academic center with the resources, to know what your rural counterpart is needing. Is there something else that you'd be able to provide them to care for your patients in your region that might be helpful for both of you? How does a resident, either they like it or they don't, right? It's my co-resident who went out and tried out their future employer, who turned out not to be their future employer. You don't know what you don't know, and being able to really get some exposure to it to see what it looks like. Are you seeing more patients, but you get a bigger diversity. You get to really be a generalist, and you're not just set to a subsection of seeing the same left pinky finger strain all day, every day. You really get to see the full scope of practice, being able to be a proceduralist and a generalist. Maybe you go to the local hospital, maybe you do consults for them in the stroke team. That can be very exciting. It can also be very overwhelming to some people, so you don't really get a good sense of that until you actually see it and get your feet wet, but I had mentioned before, it's individual. I think it is important for the resident to get an opportunity to see that, to see how it fits for them, their family, personally, socially, how they identify with that. These were challenges, the infrastructure piece that we had discussed earlier about our patients and their challenge that they face with just the basic things of getting to the services that they need. That the services aren't available, and even if they are, they're 200 miles away, which my patients are intimately aware of how many miles, what gas that would take, and how much that costs. They can do calculus level math in figuring that out, but they are acutely aware of it, and it's an issue. They know that they can make one trip to the city this month. When they make that one trip, they want to make sure, maybe they can see two out of their three doctors that they're hoping to see, or they can go and visit my prosthetist, and hopefully I can swing by there, and I can see them, or they can refill their medication because this is their one trip for the month. That is a very important tool. The education piece is very important also, because not only are they not able to come and access the care, but they're not going to just run to the ED. The ED is an hour away, and they don't have the money to run there, and so how can you educate the patient on when they do need to seek medical care, when they do need to be concerned, what are things that we can address and try to manage at home, and what are things that we've got to get eyes on. That's the rural challenge. We hope, overall, and in your residencies, or if you're involved in any of the education programs, that hopefully we'd be able to really create additional opportunities for the residents to have that exposure to either community physiatry or that more rural community exposure to learn a little bit better how that works and what challenges can be unique in that patient situation. Sometimes it's the ability to get something put in place, finding the person, finding the infrastructure to be able to help them create a good experience for themselves and their patients. They may or may not have telehealth available. If they do, how is it maintained? We're lucky enough to have our institutions pay for all of the millions of updates that need to be completed and switch out videos and audios and have all of that support. If you're in a private practice, that may or may not be feasible. In certain regions, it also doesn't matter because your patients aren't going to have it on the other side. Cell phones make it a little bit easier because even if they don't have a computer at home, a lot of times they do have a cell phone and they are able to use that, but maybe they aren't able to use that. They don't have the literacy to be able to access the MyChart, which I think is more difficult than it should be, or they can't access whatever platform the institution is using to have a telehealth visit. And now, of course, they're making it more difficult on our side. They don't want to pay for it anymore. I, for some reason, have to be licensed in 50 states in order to provide the exact same care in any one of those states. So even though a patient may be 10 miles away from me because they're in Pennsylvania, I somehow can't practice my West Virginia medicine on anyone who lives in Pennsylvania because that makes sense. So hopefully we can continue to work on these challenges and integrate this more into our continuing care. So my last discussion point, and then I'll hand it off. If you are faculty at an urban academic center and you're advising residents who want to practice physiatry in a rural setting, because they're one of those crazy few, what are some critical pieces of advice or what are the resources that we need to recommend as they start thinking about starting a practice? Of course, I think there have been lectures on it before, that we're moving more and more towards large center and system-owned practices. And so how do we support those physiatrists who are brave enough to go out and be private practice business owners? Because we need them. And I'll hand it off to you, Dr. Ulm. All right, yes. So that kind of gave me a small section so I don't get too unhinged, I get a little excited about it. Going back to that first discussion point, one of the things that I personally feel is going to make the hugest impact for us is the technology. I think for us as physiatrists, there's the potential to redefine what telemedicine is. Some of the work that we're doing within the Rockefeller Neuroscience Institute, as well as for WVU, is really looking at how to build telemedicine that works for a physiatrist. And getting away from the two-dimensional screen that we're looking at. So does anybody use telehealth currently, in the sense of where it's at? It's all right. You can see your patient, but you can't do much. Off-the-shelf technology currently is being underutilized. So some of what we're doing our research at, and I'm not saying research, sometimes you hear that term, it's like, oh, it's 10 years out, it's 20 years out. Off-the-shelf, I'll say name brands, not that there's necessarily, I'll say a couple, but the Oculus, for example, has enough hardware in it that has LiDAR sensors in the front of it that we are developing software that can do motion tracking from the headset. Headset itself is $399 if you buy it off-the-shelf. So instead of taking out your goniometers and measuring it out, you can capture range of motion and motion using that. And so what we're trying to do is looking at how to get that accessible from a telehealth standpoint where I can have somebody as a physiatrist in my department, whether that's Morgantown or one of our spoken hub hospitals, because we have 25 hospitals in our health system, that they can have, potentially, say, an APP at an even more remote location, be involved, do the examination on a patient wearing the headset, and I can also wear that headset doing the examination, having them be my hands on site. Some of the technologies right now, and this is where working with a multibillion-dollar company helping kind of develop these, but some of the visuals on the cameras and some of this even, when they first showed it to me, I thought it was wizardry, to be honest. They're able to take your normal high-def camera on a laptop, looking at the micro-changes in the skin to check blood pressure, heart rate, and respiratory rate. And again, right now we're in validation studies, but it's looking very promising. The heart rate and the respiratory rate is passing FDA, the initial hurdles going through it. Blood pressure is the harder one. Apple is very good about it, though they've been very secretive, but kind of from an industrial standpoint, we believe that the next iteration of titanium will have blood pressure sensors built into it, using the little green light. So again, those technologies are there being developed, and like I said, a lot of this is going to be dependent on the software that we develop in there. The hardware is there, and so I would encourage, if you're going to do rural medicine, telemedicine is kind of reevaluate what you think you can do. One of the hard parts for us, which is why this slide is up, is broadband access. This is our biggest challenge. For us in particular in West Virginia, we definitely have some communities that are trailer homes in the middle of the mountains. There are some that have communal, hard telephone lines. There is no broadband going out there. So some of what we're trying to do is work with government, state legislature, and this is where we're coming into really trying to become advocates. This is even in the realm where we talk about what training does a rural medicine physiatrist need to have. It's a little bit of everything. They need to be involved in communities. They need to be politicians, at least be able to shake hands with these people so that they can make these connections. Talk to city council and these small communities and, hey, what do we do? Some of where I'm trying to bypass that is, fortunately for us, we have a very large health system with a lot of small hospitals, is setting up regional telehealth exam rooms. And so where a patient can show up that has a lot of these motion captures built into it because unlike even 10 years ago when motion capture studios were $50,000, for about $400 you can get motion captures and put them on every corner of a wall. And so trying to put that in there and then have that visualization so you can monitor that patient on doing an evaluation. So they show up to that room, a nurse will escort them in there, get them checked in. I sit at my desk with my VR, my AR headset, and we do the evaluation. If you're looking at it now as well, if you're following the technology market, currently AR and VR technology accounts for about $5 billion of the healthcare industry. It's expected in five years to hit $13 to $15 billion. So if you're wanting to get involved with it, now is the time. There are large level health systems that are starting to make contracts with name brand hospitals. I don't want to call them out, I mean I don't know what they think about, but most of them you'll see is a lot of the sponsors for our academies where they're building these reputations. So it is a, hey, we will provide some telehealth and have our subspecialists from the whatever clinic, they're a part of it, will they have a licensure in our state? And this is happening currently right now and even happening on a global scale. So again, this is where some of these access to the highest level of care can be done even if you don't have access to it at your health system, at your hospital, but trying to figure out how we can gain access for the public to get into medicine that they need. But how do you do that? And so that's where you almost need to have your future rural physiatrist also be a technologist. They're going to have to teach not only the patients, but they're going to have to be able to teach some of the staff, their nursing staff, and they may need to know enough where they need to be really make the case for that community hospital, legislature saying, hey, we need to purchase these devices to help provide care for our patients, otherwise we're going to have to ship them every single time. So again, this goes back into what do we teach our residents moving forward if we want to have that track is they need to get back to the basics and again, it's all of medicine, and we're just as guilty where we're becoming very subspecialized, but almost pull it back and reverse and be the general physiatrist. Be the Jack and Jane of all trades, but now including other things of technology, legislature, politics, being able to get these programs out into these communities. Again, policy advocacy, knowing the regulations that they're going to be working with, this is going to be paramount, especially in these rural communities, because you may have, we've got some hospitals that are there, and they may live on a farm, or the patient may live on the farm 25 miles away. Some of the challenges, and again, depending on your community, one of the challenges I never thought I'd have to deal with, which trying to brainstorm ideas, is getting patients into therapy, where in a coal mining state, once they go down the elevator, they don't come back up for 12 to 14 hours. There is no midday, hey, can you leave work to go to therapy to do this? Are there ways that we can do work with these industries saying, hey, from a work comp perspective, we know the challenges, you want your employee to work, you don't want to pay work comp, how can we do this? Some of it is we're also trying to develop virtual and AR technologies on how to deliver therapy services, whether that's doing it down in the tunnel, is where we're trying to get even potentially creative about it, because otherwise, we've got patients that I see for work comp that, again, I had never had that happen before. What was the cause of your back pain? The tunnel collapsed on me, I was stuck for six hours. What did you do? I played on my phone. I have a card game on my phone, but I had a crush injury, they had a couple broken bones. It's nothing catastrophic, fortunately, but legitimate work comp injury, but I can't get him to therapy. What do we do for that? Again, trying to work with these environments. That could be a rancher out in the middle of Montana, if that's where you're from. That could be, what do you do for somebody who's in the fishing industry in Alaska? There's challenges to communities in all aspects of rural medicine is, but how do we deliver that care? The very challenging part for us as physiatrists is, we aren't just looking at lab results. We aren't just going through that and talking over their medication doses. Our treatment plans, our evaluations are range of motion, strength, and our treatment plans are therapy. What do we do to maximize your functional capability, but again, it's hard to do that. Well, it's near impossible to do that in the current status of telemedicine, so again, trying to get creative with what's out there. I guess I'm a little nerdy. I like technology. I'm definitely one of those individual boys and his toys, so I like to follow trends that are going on, but that is the exciting part, is the technology is now at a price point that it can be applied. Really my challenge right now is we're developing softwares, because there aren't a lot of ARVR programs for rehabilitation and to evaluate patients. That's where my partner is, the technology company, is helping us, but even I want to make sure that it doesn't go back to the days of COVID where our patients don't know our face because we're wearing a mask. I don't want that now in the sense of they just know goggled eyes or some cartoonish looking avatar. Even some of it is we're looking at, luckily, the movie industry has made that to a point. The Apple Vision Pro has internal cameras that can motion capture you, so we're looking at ways to do a 3D scan of a physician, have that become your avatar, so now your patient sees your face in real time during the evaluation and not that cartoony character if you've ever played any type of video game that looks like a Nintendo Switch that maybe your child or grandchild is playing. Again, trying to bring that technology because it is at a price point that it works right now. Again, these are some of the things, the satellite internet, when we're really getting out into wilderness areas, mobile hotspots. I have read some articles recently of having satellite links when we see the Great Northwest, the forest there. A lot of times these fire towers, and a lot of them have it, but not only being that location in case of emergency if a hiker is lost, but to have satellite connectivity, so where there's no cell phone connectivity, but then having these mobile satellite internet hotspots. These are things to look at as we push forward. Again, though, this is where it's going to be very important for that future physiatrist that's working in these communities. They need to know well more than just the medicine that's involved in it. Again, the implementation, that's going to be the hard part. For the longest time, it's been one of these things where we've kind of have just not had to think about it because the cost of technology has been the limiting factor. We're not at that point anymore. The limiting factor is how to implement these programs, and so again, if you're in a training environment, that's what you need to think about is, if I'm going to cultivate future general physiatrists to go out there, is what skill sets do they need to know in order to do that, so whether that's now considering elective rotations at your state capitol. Sometimes it's looking at physicians who are also our politicians and saying, hey, these are the things we're trying to promote. We're hoping that these physiatrists stay in our state, but we recognize that they need to know these things, so talk to your politicians. Sometimes it can be a shadowing opportunity to see how that legislative process goes or partnering with your lobbyist or getting a lobbyist as part of your health system and have them work with your, if you have a large academic center, you probably have some form of a lobbyist that's helping get things going, and so think about having your resident do some time with your lobbyist so they can learn these skills and make these connections moving forward. Again, informing patients, this is also going to be very challenging. We're hitting the silver tsunami. I think most people have heard that term, that aging population, we're living longer, but they are not in that generation where they know technology, so again, we need to be able to make sure that our residents and our future physiatrists in these communities are able to teach technology to their patients and those that they're going to prescribe a lot of these tools to, because otherwise, it's going to fall on deaf ears. I think there's a lot of places around that say, you can access your online medical record and just update your chart. I've had plenty of patients that say, do you have a paper? I couldn't do it. We couldn't figure out how to do it. Normally, my wife can do it, or my daughter, she normally helps me, but she's on vacation, so I couldn't figure it out, so we need to have people that will teach how to do that and whether that needs to start from the physiatrist that teaches the staff and so forth, but we've got to have physiatrists that know how to do this, and at times, I'm just as guilty because I'm like, oh, gosh, I don't really know, I'm going to have to, hey, Mary, Mary, can you come in here? I need you to help our patient, but again, that's where if they don't have that staff because they're in a rural community, they need to know these things. Again, assisting with the setup, and not that they need to be the guy soldering wires together, but understanding how electronic systems work, how digital connections are made so they can work on doing these and talk to telecommunications industry because again, this is not where we're just dealing with corporations on what's the new ultrasound machine, what's the new fluoroscopy? It's going to be like, hey, what do you guys offer for rural access to internet and telephone because this is our problem, and so again, knowing what technology is and how to talk to industry and industry that we really haven't talked to before as physicians as a whole. Again, providing ongoing support, not that they need to be the patient's IT person, but again, being able to communicate and understand what that setup is, what the problem is, maybe talk them through it a little bit or at least teach their staff because again, a lot of times what we see are nurses or MAs and the staff that are in these clinics, they're from those communities and they haven't left, and so if we're planning on sending that support team out to them, the most recently trained person may be that new graduate resident, and so that's where they need to have some of this knowledge going forward without getting too redundant. Let's see. I want to make sure we have time for questions as well. Yeah, so discussion point, state and national support for rural health programs seems vital to their success. In what ways can a rural residency curricula help develop advocacy and leadership tools that trainees can implement in their future practice setting? So again, kind of some of the topics I was talking about in the sense of what else do they need besides just medical training, and then I will turn this back over to Dr. Faramer. Thank you, Dr. Alm. A next topic that would be relevant to rural residency education is interdisciplinary training, and if you're already established as a physiatrist, this isn't a foreign model or a novel model to us, but you have to teach your trainees how to interconnect in this model and be active in this model, and it doesn't just come automatically. Physiatry we're a unique specialty that we're often working in teams and can be leaders in healthcare today, and then residence education is important to know that the trainees have tools to communicate effectively with other healthcare workers and in other fields so that we can collaborate and care for our patients. What does interdisciplinary training look like? It can also include comprehensive skill development. I rely heavily on other specialists in physical therapy or occupational therapy, especially being a pediatric physiatrist. They have a different clinical skill set than I carry specifically. Getting trainees' exposure early in a broad clinical setting will help them through interdisciplinary training so that they can see what their role is and what the role of others is as well. Workshops with trainees from different disciplines can help with this, such as having a student or a trainee in occupational therapy work with your resident trainees for a day. Promoting simulation experiences so that trainees can work together on a particular healthcare question or healthcare patient concern and look at approaches from all different philosophies. And then it also will help to think about team-based care and communication skills would be vital to be able to work as a team member. Real-world examples that I have from my practice, having different interdisciplinary rounding experiences in a pediatric hospital, physiatry is well-equipped to be part of the rounding team in a pediatric critical care ICU, for example, helping to give that exposure and training specifically to trainees in the other disciplines while they're on rotation along with you as well as a trainee that might be, you know, on your physiatry rotation that day as your resident. And you can work with different fields to give your trainees experience hands-on with other clinicians or technicians such as an orthotist or a prosthetist so that they can see a perspective from their eyes as a technologist and an expert in that field as well as what the patient might experience going to that clinic if they haven't had that exposure before. It offers them a broader experience and exposure and then they can think about clinical questions from a different perspective. Cultural competency is also important, so understanding the community needs and being able to disseminate patient education materials is also important. This has also been another real-world example in my practice that a pillar of care for our area to be able to reach pediatric physical therapists or occupational therapists in my region specifically with a brachial plexus and peripheral nerve clinic. We had to develop our own tools and educational resources and pamphlets to help train the families that are going to be the caregivers implementing a lot of the patient or infant therapy as well as, for example, early intervention therapists that are going to be carrying out our treatment plans and be the first eyes and ears when there might be something different than what we're experiencing. Communication was a vital tool in this case where I had a clinic visit in Morgantown with my pediatric occupational therapist and we videoed into the patient's home where they were working with their early intervention therapist and being able to adapt and plan our treatment plan right on the spot and say, no, we need to pivot and transition and think about other different care models. It was a vital way to do care coordination in the region without having to have the patient and the family bring the young child back. They could do it right in their own home with the equipment that they had. Resource management is also key. So efficient use of your resources, interdisciplinary training can help with that because if you're all learning about different diseases or diagnoses and you can approach it from one model, you can maximize your exposure to that scenario and not duplicate the work if you can all work together. And then that might more mimic a real-life model than a typical classroom setting. And then think of innovative solutions. If you're in that area or that region of that clinical campus, for example, if you have that model in your area, you can think, well, this prosthetist is good in this area that they have this experience or exposure with this population. How can we utilize them in this clinical scenario? I just had a recent discussion with a complex care pediatrician and I could see the need that we could serve as a physiatrist to help with brainstorming complex situations in regional and rural settings on how do we get optimal care for these patients where they don't have access. For example, children that are trach or vent-dependent, can we offer ways that we can work together in teams, let's say with the respiratory therapist in the area, connect them to a primary clinic and have physiatry be a champion to help in these models and help with coordinating care with their complex care pediatrician. And if you're not exposed to that in your urban training model, can we get simulations or exposure in workshops to help you with the skills to do that? And then professional support and networking, like we've talked about, common things with mentorship opportunities and peer learning. As physiatrists, we also are vitally aware of appreciating members of different healthcare areas and partnerships are very key to supporting patient care. And they're ultimately hoping to provide good quality care, you know, hoping that we have positive outcomes. I mean, that's the ideal or the goal that we have in every situation. I know it might be hard when the resources are limited, but if we can troubleshoot and brainstorm and then plan for the future, we can maybe anticipate potential problems or concerns. And then resources, the patients, the families, the local clinicians, having, if they have a clinical question, they want to know who can we turn to, who's going to be our resource and when we need something and not just always thinking about the notes that you get from that physical therapist in the area. Sometimes it's making that call, making that connection, that first step approach so that you know them one on one, even over the phone or transitioning care. When I have a patient admitted to pediatric rehab unit, I like to call their primary care doctor, their pediatrician, this is what happened because rehab in our area might be a more novel concept to them that they might not want to know, well, what happened, you know, what did you change and what is your plan going forward? So if you can make that connection, I think it helps with long-term care and quality care initiatives. Also kind of summarizing, if you integrate your interdisciplinary training into your residency program, hopefully it can better prepare the residents as they face these clinical questions and complex patient care models. Hopefully it also leads to better outcomes for our patients and also the community at large. But how can you do this? You need to also think, well, what are the tools that these trainees need and that's often in the setting of interprofessional education or IPE. Interdisciplinary training is supported by the IPE programs. For example, at West Virginia, we have a network of training opportunities that I've participated in, whether they be simulation, that's a very key resource to connect all these trainees together in a safe environment. But how have others done it? There's other programs that you can see on the slides. An example in University of North Carolina at Chapel Hill, they used a Rural Interprofessional Healthcare Initiative, or RIPHI, and ultimately it was founded to try to focus on getting the healthcare professions together, working on population-based initiatives so that they can improve care. Another model was the Trust, or Targeted Rural Underserved Student Track in Montana, and that was one way that they were able to increase the number of graduates that are practicing in their rural areas by giving them the tools to approach different clinical scenarios, especially doing rural rotations and a mentorship, which is a common theme we talked about today. But it definitely depends on your resources in the area. Even if you're not in a rural setting, if there's key initiatives that are vital to your urban practice, it's important to think about that and how can you prepare your trainees for success. Professional education, or IPE, small groups are very important to implement this and focusing on the pillars of care, which are communication, values and ethics, roles and responsibilities and relationship building, all trying to promote good quality care for our patients. And then again, you'll have these slides that there's a couple different initiatives that have ultimately gone across the same principles with relationship building, giving tools for success and partnerships and support networks. And then how can we just see the value of interprofessional education? You know, there's many different models or examples. It definitely depends on the resources in your area, but it's one way to look at the unique challenges that that region might have and ultimately try to improve healthcare by communicating with those in your region, find out who your experts are and know that you aren't in the silo, you aren't alone and you can reach out to those that will help answer those questions and ultimately help your patients. So rural residency training, just to see a couple different issues to addressing local needs is important and feedback mechanisms. So how, once you implement a practice and deliver the care, how are you going to prepare the trainees to continue to grow their practice and evolve? One way is patient advocacy groups or patient caregiver groups in the pediatric setting so that they can be the pulse of your issues and let you know, well, this is what's really important to us, especially if you're not from that region or area, you wouldn't know where to really start. So that might be a way to develop dynamic connections in your community and grow as your needs evolve. And then trust and relationships was also a common theme. If you're not familiar with the area, you need to know who are the key leaders in that field and in that region and that they can help guide you of what their, like almost a grassroots effort I could see to make sure that you're meeting the needs of the community. Hopefully then over time they'd feel comfortable with the care you're providing, especially when you're introducing new technologies or care practices, you know, trying to update the care in the region. One example I ran into was power assist wheelchairs was more of a foreign concept. So trying to let the vendors know that are prescribing, you know, helping you prescribe the wheelchairs, like what this means and why you're prescribing it over a manual wheelchair or a power chair, for example. And again, it takes a whole village. It's community empowerment, making sure that you can be sustainable and meet the needs of a growing environment. And interprofessional education is just one way to do that. There's ways that those programs can create more effective and sustainable and impact programs because you're looking at it from multiple perspectives, not in a silo and hopefully providing holistic care. And again, for our final discussion point, our food for thought and what ways can interprofessional health care training support telehealth care initiatives in rural settings. So I think we've gone over some examples. For example, I had the therapist that worked with the patient in their home and I could video in and then it saves a trip for the family and the patient, especially in a pediatric setting is one example. So it would be unique to your area but might be a way to troubleshoot issues. And then on the same point, make the actual clinician not feel as isolated if they're a therapist practicing in a rural area and they feel like all alone, you're there to help them. Well, in summary, I really wanted to highlight some of the unique points that we had talked about with our training program, specifically how rural health care can be unique but also offer a lot of different challenges as well as opportunities. And I think if you're going into practice in that area, looking at key resources such as community partnerships with your local and regional organizations will be helpful. And then prepare your future physiatrists with the tools to confront these situations. That's vital and critical if they don't feel like they have what they need and they might be less likely to pursue this area. And then career development, know that it's not just you train and you finish and then that's it. You've closed your ties. You need to have a way to kind of keep them connected with different professional engagement and CME that will help them grow their practice and their professional career development. And lifelong learning and mentorship, having this and the success, the efforts and success of your trainees will then reflect on your program. So it's vital to have that connection and I hope that you can see that physiatrists are equipped to care for patients in these rural populations and trainees will be feeling like they're equipped to deal with the different diagnoses or conditions they'll face. Well, I want to thank you for your time and attention and thank my co-presenters too for presenting with me this afternoon. Are there any other questions from the audience? Thank you.

rural healthcare

physiatry residency

telemedicine

community engagement

VR and AR technologies

interdisciplinary training

rural rotations

healthcare access

mentorship

curriculum development

healthcare innovation