Hello, I'm Dr. Craig DeTomasso, and thank you for joining our session today. We're going to talk about different practice management styles for early career physicians. I'm going to go ahead and share my screen. We're going to have a wonderful panel for you today. And so hopefully, regardless of which practice management style you're interested in, you'll learn something about all of them and help to better prepare you for the future, regardless of which path. So one, I just wanted to say that, you know, exiting residency or fellowship or starting a new career is a very big step, and everyone on this panel has been through that before, and so we really do appreciate what you're going through. Everything that we can say or do, of course, will make that easier, but hopefully we'll be able to impart to you some knowledge or at least some perspective to help you make a good decision and make your next step a successful one. And speaking of success, I think the one thing that physicians, especially early career physicians, get very concerned or interested in is how it's all going to work together, how it's going to come to be, so that they get the life-work balance, the income, the stimulation that they need. But really, the thing I would encourage everybody out there who's tuned into this talk to remember is that if the primary focus in your career, if the thing that you do, number one, more than anything else that you worry the most about is taking care of the patient, then everything else will fall into place. And I know that may seem trite, but it really is true. Administration, support systems, payment systems will always be in flux, but what we do best as physiatrists and what makes the field so magical is the fact that we are very patient-centric, and when you can really bring that to the forefront, then really the rest of this will become quite simple. But that being said, we're going to go through a bit of a presentation today to give you some different perspectives. Each presenter will talk a little bit about who they are, their current position, and their background. Each presenter will give you some pros and cons of their field as they see it. After that, the panelists will ask each other some questions to kind of flesh out things that caught our interest, and then we're going to open it up to the floor so that you all can ask us questions. If you're available, we do have a follow-up to this session from 10 to 1030, which will only be a question-and-answer session, so if we don't get to your question or we don't get to address the things that you want to, please try and join us from 10 to 1030. In order to keep the discussion somewhat controlled, I would ask that if you do have a question, at least put the stem of your question in the chat box, which you can find on the controls at the top. By putting at least the stem of your question, I'll be able to identify you for the question and answer and get to you at an appropriate time, as time allows, at least. We will end sharply at 10 o'clock. Not my rules. The technology people will physically end this room, and so you'll have to join us in the second room at 10 o'clock if you want to continue with the questions, okay? So without further delay, I will introduce Dr. Hetchin Cheh to talk a little bit about his career path and his practice setting. All right, thank you, Craig. Hello, everyone. Thank you for joining us this morning, and a little bit about myself, currently, actually, I'm in academic medicine at MedStar Washington Hospital Center through Georgetown University Medical School, and actually, 16 years of my career have been in academic medicine, but I'm here to talk about life in Department of Defense. I had the privilege to be the physician and DOD for past 10 years until April this year, when I joined the MedStar in Washington, D.C., and not many people know about the opportunities in Department of Defense. So hopefully, this time will be informative for all of you, just to see what kind of career you can have in Department of Defense. So obviously, my role there was to start a brand new department of traumatic brain injury at a Department of Defense Hospital Center at Fort Belvoir, Virginia. I started there in June 2011 and ended my time in February 2021, officially, and you see the type of practice that I was fortunate to create from 11 staff department to 51 staff, and it was zero research activity, but by the end, we actually had robust research activities with 4.1 million research grants and also was able to create a part of, I should say, a collaborative effort of building a 10-center, similar outpatient TBI centers throughout the DOD network, almost similar to TBI model system that we have in civilian side, except this is outpatient TBI center model network, and was primarily to address the wounded service members from the recent conflict in Iraq and Afghanistan. I should all know that TBI and PTSD were the signature wounds of war. And just to background on DOD, it's actually, there are three types of employments that you can be hired into DOD. One is my position, which was government service, also called GS, permanent. What that means is that once you're hired, your term is not limited. You can pretty much continue to work until you resign, you retire. Of course, you can be fired from the government job, but until whatever happens, that position is pretty much assigned to you. So there's no job insecurity and things like that. And also there's GS temporary, which is actually a term position. So it will let you know if it's like four-year term, five years term, and things like that. So that's where some of the things are happening. And then contract position, which actually is more flexible, but they also can terminate position in a short notice. So that's a little bit more jobs insecurity. So there's three employment possibilities there. I just want you to know. The next slide, please. And as you can see, the other thing I want to mention is that job is officer rank equivalent. And most of the jobs available in DOD are musculoskeletal and pain. But there are some, for my position was more neuro rehab. So that was also created. And also it's all for joint services. So Army, Navy, Marines, Air Force, and Coast Guard. And also they deal with family members, treat family members. Veterans are dependent on capacity of that center hospital. So again, it varies by location. So the benefits of the practice, it is definitely a unique professional opportunity. It really gives you a lot of freedom, autonomy to practice your set of skills. Nobody's going to look over your shoulder as far as like your patient care is concerned. They actually really respect and appreciate your service. Because most of the positions initially, if they had their own way, they will give it to the active military officer positions. But because there are not enough of them, especially in physiatry, they have to create some positions for civilian physicians to come in and treat the service members and their families. So it is a unique opportunity. It is different than veteran administration, VA opportunities that most of us are aware of. But this is a sort of unique opportunities that you have to look for actively to actually get in. And it's funded very well. Department of Defense has its own funding for their healthcare system, the NBA Hospital Network. So it is funded very well, obviously, is to treat their own service members and has excellent work-life balance. What I mean by that is the time that you are actually asked to work, believe it or not, is 40 hours per week, which as you all know, that's just crazy for us physicians to think about. But literally nobody's going to really ask you to work more than that. And usually if it's outpatient setting, the template is built out so that you only work 40 hours max, and they don't pay you for overtime. So they don't want you to work more than that. And it is a mission service-oriented type of opportunity. So you do have this sense of working for a higher call, which I certainly had the privilege to do that, treating our wounded service members. And they are primarily young, healthy population. And that's also very different than VA population, which is opposite. And diversity, just so many different type of patients that you'll probably never encounter if you worked in civilian side. It certainly has not for me. It is definitely a privilege to treat such a diverse patient population. And one positive is no prior authorization. So there's no paperwork to fill out. Most of the medications are covered. I never had to request authorization for Botox injection, any type of injections I wanted to do. They're all covered. There's some obviously extreme sort of non-FDA approved treatments that you have to get authorization. But other than that, you don't have to deal with insurance red tapes. The drawback, it is a practice, it is a military culture. I want to say that it is good or not so good if you're not used to that, or if you don't like type of culture, which is very hierarchical. You do have to respect their ranks. Certainly that's less so in the military health care system. But still, at least that's something that you just have to be aware. You do have a lot of rules and things that you have to sort of follow. So you have to be sort of rule based person. You have to respect that. And change of priorities, what I mean by that is, you know, sort of, it's like almost like being a team physician for a sports team. It depends on the priorities of the team, the coaches. Same thing with DOD, like the war is a perfect example. When the war starts, obviously all the priorities in health care shifts to support that. And also, if it's, you know, not a war time like right now, it actually changes on the particular subpopulation in the DOD that tends to be more active and get injured. For example, special forces are still actually engaged in a lot of conflict right now. And that's the priority right now for DOD. So all the practices or shifts are making sure that they get the priorities to be seen, you know, not the dependent, you know, service members dependent, you know, wife or spouse to come and see instead, you know, things like that. And there's lack of job security if you're not GS employed, like contract, I told you, and changes in leadership and chain command. So each hospital, their director, which is usually active duties officer, they change their, they rotate out every two, three years. So what that means is that you have new director every two, three years, which is something that you don't really deal with in civilian side. That's something that we have to deal with in DOD, which is not really terrible, but something that the more higher up in your leaders, leadership rank, you have to deal with their change of priorities there. The next slide, I think I'm done there, right? Okay. Yeah, so take home message, unique opportunity for professionals. I think we physiatrists have just be more aware of it. Not many of us know that an opportunity to become an expert in the military medicine and certainly build up your skill, you have a lot of autonomy and understand the reason for the job creation is actually very important. So like I said, this has to be created for civilian physicians to come in. So you have to understand why they created it, what their expectation is, as long as you understand that, and it seems good to you, I think you have pretty secure job, contrary to what people think it is, and great work-life balance. Like I said, 40 hours per week can't beat that. Everything is negotiable within certain limits, especially the biggest limitation is salary. They give you a range of salaries that you can negotiate, but it's similar to our VA counterpart salary. And all the postings for DOD employment can be found in USAJOBS, which is similar same site as the VA opportunities, but you just have to flag DOD opportunity to catch those. I think that's all for me. I'd like to introduce back to Dr. Ditamaso for his next presentation. Thank you, Dr. Choi, that was enlightening. My name is Craig Ditamaso, and I'm going to talk to you a little bit about my career path and things that I have found helpful and not so helpful. Okay, a little bit about me. I started my career as an assistant professor in the Baylor College of Medicine system. About three years ago, I left Baylor and became an employed physician through U.S. physiatry. I've taken on many roles through that, including being the director of early career physician development, as well as being the medical director of post-acute medical rehab hospital of Humboldt, Texas. So I think that things to know about my current role are that one is the early career physician development. It's my job to help physicians who are transitioning from residency, fellowship, or other walks of life into private practice on making that transition, and I find that very rewarding. As a medical director, I'm doing the things that you're probably familiar with already, seeing patients, establishing protocols, and making sure that we have appropriate physician staffing and resources within a large rehab center. The thing about private practice that I would highlight in particular is that you are free in private practice to wear lots of hats. So even though I'm no longer in an academic mission by name in that clinician scientist or clinician researcher type path, I am an adjunct professor at UTMB, which is the Galveston, Texas Medical School, so I still get to teach med students and residents at times, although I don't regularly lecture and do those kinds of things. I also work for Exobionics as a consultant, as well as Kindred Healthcare as a consultant, and so I'm able to lend my expertise to help these organizations improve, and I'm compensated well for that time doing these. So what are kind of the benefits that I see of being in private practice in an inpatient-focused manner? Well, number one, I think that the reimbursement mirrors your activity, which is a important point I think to make. In other roles, sometimes you may be asked to work above and beyond what you anticipated, or other times you may be less busy, but the income is typically pretty flat in those particular roles. In private practice, if I work harder, I see the fruits of my labor. I'm reimbursed quite well, and I would say that, you know, I think in physiatry, there's a lot of hush-hush or lack of discussion about salary, and I think that really is to the detriment of the young physicians and people applying for new roles. For example, I can say that everybody within my pod of U.S. physiatry in private practice is between three and four hundred thousand, which is pretty normal, I think, in private practice. The one thing about being in a large group by U.S. physiatry, one, we can kind of see how each other are performing and what we can do to help each other, but we also sacrifice a little bit of the reimbursement and the autonomy to have them run our practice, but there still remains tremendous autonomy in private practice. Whatever it is you think you can do, you're welcome to do. No one is going to tell you no as long as you can make it happen, and then you have total control of your lifestyle, right? If you don't want to go to work Monday, Wednesday, Friday, if you want to stop every day at two o'clock, again, you have the control to do that because you're your own boss. The flip side of that becomes the drawback of the practice in that your activity is your reimbursement, so if you're stopping work every day at 2 p.m., you're probably making a lot less than somebody who's going to work till 4 or 5 or 6 or 7 p.m. regardless, you know, dependent upon their particular goals and work ethic and so on. I will say the big thing about private practice is that you don't have that kind of safety net behind you. If your referral patterns change, if you're sick, if you're on vacation, you're not going to make any money, right? So there's nobody to help buoy you in those situations, and Dr. Mehta is going to cover that in much more detail than I could. And then lastly, in private practice, you really don't have that same infrastructure that you have. You know, Dr. Che was able to talk about the tremendous infrastructure that he helped create there in the Department of Defense. It's different in the private practice world. Hospitals may have some infrastructure. You may create some in an outpatient setting if that's your interest, but that's not going to be provided or supported within your organization because you don't have one, right? So you've got to create that on your own, and you have to think about whether you're someone who can work with less infrastructure or if you need to be in a big programmatic system. So to kind of wrap it up, I think that the best things for me about being in private practice are that you create the practice your way, the way that you want to. For me, I'm most interested in severe traumatic brain injury. those patients tend to touch a lot of different levels of care. So I'm able to consult in the acute care on the brain injured patient, help them transition to LTAC if that's appropriate, guide them through the LTAC process into my inpatient rehab, and then hopefully home, if not, to a skilled nursing facility where I can continue to follow their progress and establish next levels of care. So that's the way that I wanted my practice to be because of my interest in severe traumatic brain injury. So I was able to create that. You may have other interests. And again, being in private practice is great because you can make it the way that you want it. Secondly, both the blessing and the curse of private practice is that the reimbursement directly reflects the work that you do. I think that tends to be a blessing, but not everyone sees it that way, of course. And then the same thing goes for the work-life balance. If you want to make a lot of money, if you're very engaged in your patients, you're going to tend to work harder. You're going to have a little bit worse work-life balance. If you're more interested on that, you can certainly push away the work. No one's going to tell you no, but then obviously you're going to make less money. So everything's a given trade. There's no one best answer. But for me, those are the things that I see. All right. So I will push it now to Dr. Gara. She will talk to us a little bit about military medicine. Hi, this is Dr. Melissa Gara. I currently work for the VA in San Antonio. I had the pleasure and honor of working for Dr. Che prior at the Intrepid Spirit Center at Fort Belvoir. And I'm going to talk to you a little bit about what it's like to work in the VA system. Next slide, please. So I guess the first thing to tell you is that I'm a non-traditional student. Probably like many of you, I came to medicine later. And so by the time I came to medicine, I already had children and I really wanted an excellent work-life balance and I wanted a lot of stability. And what I can say working for the Department of Defense and the VA is I've had both of those in addition to the joy of just having an incredible mission and working with amazing colleagues. Currently, I'm at San Antonio VA and I have a offsite brain injury unit. We take vets as well as severe brain injury patients who are still active duty. And we've recently stood up a four-bed special forces program working with MTBI PTSD, which has been incredibly rewarding. Next slide, please. So I definitely want to highlight, I know Dr. Che talked a lot about kind of the benefits. And so it's very much the same between the DOD and the VA. And I definitely want to highlight a couple other ones. So first of all, the programs in the VA, we have wonderful funding. So I'm at one of the five poly-trauma centers of excellence. My personal interest is obviously brain injury. And they've given us a great deal of money and funds to build these amazing programs to support our active duty and veterans. The next thing is, it's an incredible work-life balance. So I have friends who are also doing just outpatient in the VA where they're not at a poly-trauma center and they have that same benefit of just a great work-life balance with wonderful benefits, great insurance, great sick leave, tons of time off. We have a TSP matching program, which is fantastic. So you don't have to worry about any of that stuff. You also get disability and life insurance deductions when you work in these systems. The pay is not based on productivity. So that might be a benefit of practice or a downside depending on your personality type, but it is nice for the quality of life piece. They do review your pay every two years and you can get increases in your pay every two years. A major benefit to working in the VA, which we did not have on the DOD side, is the education debt reduction program. So what I will tell you is this can change on a yearly basis, this system, but right now it's approved for PM&R. So my colleagues are getting $40,000 a year matched towards their school loans, which is a big deal. And that's not taken into account in your pay. That's just an extra benefit that you get. Currently, they're doing $10,000 a year yearly performance bonuses. Again, wonderful job satisfaction. I can't talk enough about the mission working with veterans in active duty. There's also excellent research funding opportunities. And I know a lot of you probably work in a VA, probably like an academic VA setting. So there's also those opportunities. So here at San Antonio, we collaborate with our UT Health San Antonio partners. And we also collaborate with our active duty partners at SAMHSA, which is also local here. The drawbacks to working in a VA, and some of you all might know this, is you're not always working on the same timeline. So you as a doctor might be like, I want things done ASAP. And it just doesn't happen on that timeline. And it can sometimes be very challenging to kind of navigate to get equipment and what you need. So you sort of have to figure out who your points of contact are. Another big thing, if you are interested in going in, it can take a long time to get through HR. So please, please jump on USAJOBS now and start applying for those jobs, knowing that you're going to be pretty serious about it come July. This would be the time to start looking at those jobs if you want to start right away. Sometimes, depending on where you are, you might not have as much clinical support staff that you would have in the private sector. I will comment on this. When I worked in Dr. Che's clinic, we had excellent clinical support staff. And that didn't necessarily, I didn't necessarily see that in the VA. It just depends on the model, I think. And we have the same benefit where you can get medications for your patient. And you don't have to mess with insurance. And you know that your patients are going to get everything they need. Working in spinal cord in the VA, your patients get all their wheelchairs, all their equipment, you never worry about them. But it can be challenging to start new programs. So an example I want to give is, it has been very challenging to start a PRP program in the VA. Now it gets done, and then it's great. But you really have to put in the legwork to get to that point. And those are the drawbacks. But I guess for me, the benefits greatly outweigh these drawbacks. And I think that's it for me. I do want to pass this on to Dr. Ankur Mehta. Hello. Well, first of all, I appreciate all of you guys being here. And it's a super exciting thing. One thing I want you guys all to be proud of is that you're a physiatrist. It's one of the few specialties that's left over in health care where you have such a wide scope of practice. And as a background, being a physiatrist is kind of like being a Swiss Army knife. You know, your kid has a sprained ankle all the way to somebody's having ischemic stroke. You cover that full breadth. And so just always remember that you're PMR first and then your subsequent specialty. So I'm the founder of TX Fun and Joint. I'm the founder of TX Fun So I'm the founder of TX Fun and Joint. I think I don't know how to advance the slide here. Sorry, guys. Can you go to the next slide? OK, there we go. Thank you. And so a little bit of background about myself. I started out in pharmacy school and I realized and I started working at Walgreens for three years. I realized I didn't like it. I decided to and I took economics, which was required. Pharmacy school requires us to take an economics class. And I just fell in love with the economics of health care. And then I went on to do my DO MBA in Kansas City. And then I went to Loyola for PMR and then further training in Houston for interventional spine. I started the practice in Houston. I just literally and that's one of the things I'll tell you guys about being so proud of being a PMR doctor. You can literally hang up a shingle and say, if you have a decrease in function or if you have any pain, you can come and see me and you'll be able to help them somehow. So I just if you hear here's a little picture of myself and my new partner, Dr. Wynn. He's a graduate from Baylor UTMB. I started my practice about nine years ago at the exact same hospital as Dr. DiTomaso's at in Humboldt, Texas. And it was it was an humbling experience, just kind of jumping out into the real world and just getting into inpatient PMR. And then I started taking my inpatients and having them follow up with me as an outpatient. A lot of times you'll get a stroke patient that will see a neurologist for their anticoagulation status or a TBI patient will just kind of they'll follow up with neurology. That's kind of just the general scheme of things, especially in Texas. But if you are having an inpatient practice, there's a huge opportunity to transition it to outpatient where you can continue to follow your patients. And I know a lot of physiatrists are taking on that model that way that your patients have a great continuation of care. And then right now, my practice is 99.9 percent interventional based. I'm actually at the surgery center right now. We just finished a spinal cord stimulator implant. But, you know, in the clinic, we do EMGs, NCVs, we do injections, we do fluoroscopy. We have musculoskeletal ultrasound and basically pretty much everything that's involved in the care of a physiatrist, the care of a patient that a physiatrist can offer from an outpatient setting is what we offer. I mean, I do patients with prosthetics. I do patients who need power chairs. I have a couple of TBI patients on baclofen. I have some multiple sclerosis patients on baclofen. So I really genuinely embraced the whole idea that PM&R is such a wide field and you have so many tools to help your patients. And that's kind of the idea. One interesting thing I will tell you guys is that I do do some ER consults. A couple of my friends own ERs around the city and some of my ER friends, some of my friends are ER doctors in the hospital. And I'll actually go in the hospital and see patients that have had like, you know, cauda equina syndrome or acute foot drop or some sort of MSK pathology that's not orthopedic and not neurosurgical. Instead of just dumping them out back in the community, you can actually reach out to your ER doctors and you'd be really surprised. I think there's a program in Spalding, I may be mistaken, but I think Spalding started a program where the physiatrists are actually consulted in the ER for acute CVAs, which is really cool because talk about full continuity of care. You can catch the patient and their family and you know, they're, they're pre morbid condition, and then you can follow them all the way to to the rehab IRF. Next slide, please. Okay. Benefits of practice. Okay. So you're, so I always tell everybody, especially the young doctors that rotate with me, I have some residents and med students and some newer, newer doctors come and hang out. And I always tell them, this is exactly what it is. Being in an academic center or a university system or a government job is like a freight train. You're, you're just a passenger. So that freight train is going to go along no matter what. You can get a thousand people to jump on the train or a thousand people to jump off. That institution is going to keep going. It's not changing direction. You being on there has no effect versus like private practice. When I first started, it's like being on a Ducati motorcycle. You're just up and down left and right at any moment in time. You can have a massive influx of patients and you'll be busier than you can imagine. And then there could be a drought. Like for example, like when seasons like holiday season, it goes down and your, your pay will go down. And when, when, you know, school starts up and the kids are out of the house and parents can come and see you again, then your, your volume goes up. So it's kind of like a sinusoidal pattern and you just have to be okay with that. It's very dynamic. You're free to make decisions. I'll give you an example. I'm a big on ultrasound, huge ultrasound guy. And when I was with this group of six physical therapists, three pain doctors, we, I wanted to buy an ultrasound and said, no, we only do floral. And I told them like, this is the cost benefit analysis. We'll make the money back in three months. It's going to be great for the patients. And I will be able to add all these service lines. And six months later, they got back to me and they're like, oh, we had our meeting and we're not going to buy it versus in my own practice. I just went out and bought it the first day and I paid it off within three months. And so in that six months where I was just waiting for admin to change their mind, it was terrible. And then like, you know bottom up management, which is really cool. And Bill, you can build a lifelong relationship with your staff because they're, they're your family now because they see you on the ups. They see you on the downs and they're always with you no matter what, trying to get through the patient care, the financial, the business side of it, the insurance side of it. So I've had staff that have been with me for 10 years now. And it's almost like family and you build this lifelong relationship versus if you're in a hospital setting, you have no control over who's your MA. They're saying, okay, here's your MA. This is what you get. Or this is your pre-op nurse or something like that. And your front desk may be amazing or may be rough to the patients. You don't know. And you really have minimal say on it. So being in private practice, it's pretty neat. You can community build because the people that work for you and work with you are all kind of community-based individuals. So it's, you're not, you don't have to report to anybody. So it's a bottom up management. Like for example, my MA is like, hey, listen, these band-aids are not sticking well to the patient. I said, okay, let's, so we logged in, we ordered three different types of band-aids. We tried them out and that was implemented. So within a matter of 30 seconds, I was able to change the type of band-aid I was using after my injections. And that's kind of the, I love that. I love that about being in private practice is how dynamic and how quickly you can cut out an inefficiency. You can make it super efficient instantaneously, which is awesome. The drawbacks of practice, when you're off, you're off. So when I go on vacation, for example, I had this joke with my wife. We went to Disney world. And I don't know if you guys have been at Disney world, but it's like a thousand bucks a day for anything like with tickets and hotel room and food. And so you just assume thousand bucks a day. And so I said, okay, we're going there for five days. Okay. That's $5,000. And then I did the math in my head. I'm like, well, my clinic is closed, but I still have to pay rent. I still have to pay electricity. I'm still paying my malpractice. I'm still paying my front desk. I'm still paying my office manager. I'm still paying my billing company. I'm still paying for Comcast. So there's all these fixed expenses that are just not going to go away. So when you go on vacation, it's like a double hit. So just be ready for that. So my thing was vacations cost a lot of money. And then everything is your problem. If there's a leak in the faucet, it's your problem. You have to go and call, you have to put a work order in with, you have your office measure, put a work order in, and literally this needle's on back order. Okay. Well, then you're sitting there with your office manager trying to figure out which is the next needle to get. You don't have a team like at a hospital system where they would have a materials department and that whole department's job, it's like five people, their entire job is just to order supplies so they can figure it out. So you have to kind of drop what you're doing and work on that. So that's kind of the hard thing about drawback is like, you're in charge of everything. And if you have that personality, it's so much fun. Staffing, it's hard because cost of goods and staffing, I know there's like a huge labor shortage right now. And there's also the cost of everything went up. Like for example, I do a radio frequency ablation procedure and those needles went up from like $8 a needle. Now they're like $18 a needle because there's a bunch of chips stuck off the port of LA with all my needles on them. So the price of goods goes up and down. But if you're willing to roll with the punches, it's not bad. It's a risk. I spent over $400,000 on equipment over the course of my career in the last decade. So you imagine like $40,000 a year in equipment and it's a risk. So there's a chance that patients may not come or we may not be able to have a good system that keeps the patients happy. And then we may lose patients, stuff like that. But you can compensate for that with extremely extreme amounts of hard work. Hard work is, I mean, you guys made it, you guys did undergrad, med school, residency, and a lot of you guys are in fellowships and then work. So as a doctor, you kind of like to work hard. You're just programmed to be a hard worker and you just got to do it and just embrace it. It's the journey. And then you have to be an accurate doctor and a business manager at the same time. Yeah. I mean, I guess that's not a drawback, but it's just something that you need to keep in mind that not only do you have to be top level, like 99 percentile of efficacy with your treatments, you have to know all of your medicine, like the back of your hand, all the treatments have to be on your tip of your tongue, but you also have to be good at business and figuring out how to deal with patients and deal with people that are having injuries and patients are coming to you in pain. So there's a lot of spectrum. So that's the rock right there doing hard work. OK, next slide. OK. OK, so this is my take home message for you guys. Number one, find out who you are. My wife, for example, hates this type of job. She would hate to be in charge of so many people and in charge of ordering needles and stuff like that. So she took a job that's like a big corporation. So she has like, you know, 20 people managing HR, 20 people ordering supplies, et cetera. So find out who you are. What is your personality? Do you like to be dynamic? You like to say, hey, I want to do PRP. Get on the phone with the rep. Hey, can you bring me a trial kit? I want to do PRP tomorrow. And the kit shows up. You do the PRP. Patient's happy. You're happy. Oh, you know what? I want to try this other kit instead of a big institution where you have to go through all the chain of command to get anything changed. One thing I'll teach you guys. Number one, your doctor, like Dr. DiTomaso said, you are a physiatrist, your number one responsibility is to the patients, period, end of story. If you guys go into private practice, like what I'm doing, money can corrupt you. It's like the Lord of the Rings has that little ring and it turns that golem into like this creature. So it's kind of like that. You want to make sure in your mind every day when you walk into work, no, patient's number one, take care of your staff is number two and money's number three. There's so many different options in private practice, especially if you go out. I would advise if anybody's doing it in Texas, come and talk to me. I know Texas, like the back of my hand. If you're doing other states, a lot of them allow hospitals to hire doctors. Texas does not allow that. And in that case, you would be really, really successful if you just found a good hospital. Call the CEO, seriously, just cold call the CEO and say, hey, look, I'm thinking about joining PM&R. I'm thinking about starting PM&R practice here. What kind of support can you offer me? They'll give you subsidized rent. They'll give you referrals. They'll introduce you to their orthos. It's a good thing. Reputation is everything. It's everything. If you're in private practice, it's everything because you can't afford to even have one unsuccessful outcome because that'll change your reputation in the community. In a big university system, patients come for the name. Like they have the VA, they have no choice but to go to a VA doctor, which is nice because you're always gonna have a flow of patients. But when you're solo private practice, anything can happen. The patients can find, there's probably over like 2,000 PM&R pain, PM&R doctors in Houston alone. And so patients have options. So you have to make sure that your reputation is very, very perfect, provide great medicine, great customer service, and be very proud to be PM&R. I think our field is such a great field where you have so much breadth of scope and you can really, really help people. Your toolbox has so many different facets that you can use to help change and improve people's function. Reputation's everything. Okay, I don't know if you guys have heard this saying, it's called you're too poor to buy cheap. And basically what that means is that if you're gonna buy an ultrasound machine, if you're gonna buy a fluoroscopy machine, spend the extra money to buy the best one with a warranty. That way, two months, two years down the road, you're not looking at replacing it. And one of my patients is a mechanic. He kind of taught me that when I was in residency. And I was telling him I was starting private practice and he told me, he's like, I only buy Snap-on tools because I'll pay twice the cost upfront, but it lasts me my lifetime. So when you're in a solo practice by yourself, make sure you buy top-notch stuff that'll last a long time. Cut costs without cutting quality. And then patient experience is the future. If you've been to Disney World, every single person there is gonna be kind of a very customer service focus-oriented person. And you wanna make sure your patients feel that. So I really appreciate your guys' attention. I hope I touched all the points. I'm gonna pass it off. Where did it go here? Okay, Dr. Zamseger, are you there? Yeah, thank you. I'm gonna jump in. What a great presentation. Thanks to all of you for attending. We are so excited as your colleagues about your early career and your success. And I'm just loving this panel for the great information and consideration. So I'm gonna add a few things about academic practice and then we'll start some questions. So just a few notes so we're on the same page. As you've heard actually, I think from our panel, academic and scholarship happen in all settings and are really essential for the specialties to survive, let alone advance and thrive. So when you each have the opportunity to teach or enroll patients in a study or do committee service or present at a meeting like this or write up a paper or a chapter, I really hope you'll say yes because that's just a good medical practice and being a good physiatrist. So we're gonna touch on a few other specific academic things. There's also really an important role for clinical faculty in our academic settings, which is perhaps different than say 20 years ago. And we're gonna focus a little bit more here on kind of that longer track clinician educator or clinician scientist pathway where it really impacts your job role. I do wanna highlight that there's an important role for everyone in academic medicine. And so as you're thinking about fit, you do belong in academic medicine, there needs to be space for everyone. And it may be more about finding the fit for you, whether that's a practice type, geography, whatever works, but you do belong in academic medicine. Next slide. A bit about my background. So my work as a physiatrist is really informed by my experiences growing up with my younger sister who has physical and cognitive impairments with no clear unifying diagnosis and growing up in the mountains in Lake Tahoe. And so that just frames my worldview, of course, but also my core values and what I find rewarding as a physiatrist. I did my medical school at Pritzker School of Medicine in Chicago, which I was pass fail and really grounded me early in lifelong learning and developing expertise and asking for help outside of that. So that also informs my practice. I trained at the University of Washington in Pumanar from 2005 to 2009, and then stayed on as faculty until very recently and completed the AAP's RMSTP grant program starting in 2009. So we'll touch on that at the end. If you're a clinician scientist, please look into that. And I've had many, many titles and roles during my faculty time, but I've also gone through that important promotion process from assistant to associate professor. And I'm happy to talk offline more with anybody who has questions about that or working through that. It's kind of its own extra thing. My academic niche was developed into TBI, and that was both based on my interests and department need. So that can be some of what drives your career and served as brain injury fellowship director, residency program director from 2017 to 2021 and participated in clinical research mostly through the TBI model system. Here's my email. Feel free to reach out. In October of this year, I transitioned to a new role. I'm now at a public health district hospital south of Seattle called Volley Medical Center and doing all inpatient acute care consults, but still have an affiliate associate professor appointment at the UW for the model system. Next slide. So we'll touch on a few things here. So really, we heard a lot about reputation from other folks. It's always important, but reputation is how you get promoted in an academic position. And what that means is that really in your promotion packet, you have to have people who know you and people who've never worked with you write a letter of support. So it's a huge opportunity for you to network, for you to get involved in national activities, but you do really have to define and develop over time that national reputation so that someone can look at your CV, remember seeing you at a meeting, have read one of your papers and say, yes, this person has experience in this area and should be promoted. Productivity is a little bit different than maybe other models that you've heard. And so there will be clinical expectations for your productivity. For example, how many patients you need to see per half day of clinic. But there's additional things for productivity and academic practice, both year to year, but also in your overall promotion that you have some control over, but have long timelines and have steps that you don't really have direct control over. So for example, your promotion might be based on things like number of grants received, and you can certainly spend time on that, but you don't have direct control over whether or not you get a grant, right? The same thing with writing and receiving grants, teaching, creating course content, getting certain emails, getting things to publication. It can take a long time to get a paper published or to get a textbook published. And so since some of those may be counted, like at the University of Washington, you have to provide your five best most recent publications. You gotta have at least five and you can't fix that last minute if you can't get there. There's also very high system complexity, which healthcare is very complicated already, but you add to that in your academic roles, rules or guidelines or processes for these additional activities that you're really taking leadership in. So for example, when I was a program director working clinically in both the clinic and an inpatient rehab setting and doing clinical research, that meant I really needed to know and understand and be involved with the ACGME, the American Board of PM&R, national organizations like AAPMNR, all of the stuff that goes into my clinical care, CMS regulations for inpatient rehab, IRB, thinking about the grants, understanding our model system grant. So it's a huge opportunity for learning. It's very engaging. You can also do amazing leadership and volunteer work with all of those kinds of organizations, which I really enjoyed, but it also can be a little overwhelming and takes time to understand those processes. And I think for some people, it also creates more contacts and more systems that may generate some value mismatch depending on what's important to you. And we know that value mismatch for people and the systems they work in can be a source of burnout. So I think you have to manage that pretty proactively. Financially, I just wanna note that as you heard from others, there's a spectrum of risk and generally academic practice is very low personal financial risk. You're not taking on that practice risk. And then there's also a variety of ways to fund your academic time. So it could be grants, endowments, time from your department for these activities that are essential to the university, to your field. You can get protected time from that. So there's maybe more variety there. And then just to note on professional development, we all need to be reflective and have professional development, but academic practice is typically a place where that's really expected and there are huge opportunities and really rich programs often without additional costs to you. And I think the other point I would make, we can go to summary slide. You'll likely need management skills for any of these roles that you didn't get in training. And so as you advance your career or take on a new role, I encourage you to specifically reflect on what training you need to be successful because there's probably new skills. So take home points for academic practice, promotion, look at the offer that you're getting or what your options are and how that goes and be ready to cultivate a national reputation. As some of you know, I'm very introverted but still really enjoy that part. So again, there's a place for everyone in academic practice but you have to think ahead. Similar for productivity, there's long timelines and you really need to think about discipline, self-management in a way that works for you. Lots of things to do in the systems to learn and manage but many opportunities and you can get creative with your funding sources. So one last pitch that if you're at all interested in a clinician scientist route, please look at and apply for the AAP Rehab Medicine Scientist Training Program. It's really a unique opportunity and a great place to get networking, sponsorship and support. And I wish you all the best of luck. I'm gonna hand it back over to Dr. DiTomaso for some questions. And then I'm also gonna put in the chat the next session that you wanna link into as we have another Q&A session for half an hour if you're interested. Thanks and cheers. Thank you, Dr. Zumsteg and all of our presenters for what was really, I think a very interesting and hopefully informative talk. I think most of the questions were answered within the chat during the discussion itself. I'm gonna scan those really quickly. If you have further questions, please let us know. In the meantime, it seemed to be a lot of discussion about different opportunities and role of fellowships and applying for jobs within the DOD and VA. Dr. Chay or Dr. Guerra, do you wanna address them while I scan the chat real quick? Yes, thank you. I think we got the majority of them, but we'll follow up. Maybe I could just speak to that question that I think Emily Steele had about being successful without being a big researcher. The answer is absolutely yes, with the caveat that of course it depends on what you signed up for. So if you're in a clinician scientist pathway, your success, meaning your promotion and ongoing engagement in that role is going to be defined usually by research productivity parameters, including types of grants where you've published productivity within your lab. And so the key is just to make sure that your pathway or your job description, like in any role, matches your skills and productivity of what you're gonna wanna do. So I did start off in a potential research track. There are acting appointments before you usually have to choose that. And when the time came to choose, I had discovered that really my role was as best as a clinician expert and thinking about the clinical side of research and not as the person running the lab. So I was gonna sleep much better at night doing a clinician educator path and having the research productivity be kind of icing on the cake as opposed to really being the powerhouse researcher. And again, you still though do have expectations for scholarship. So you still need to write papers, you still need to disseminate information, but absolutely it's just about the role or type that you take. You do not have to be a basic science researcher or clinician running a lab in order to be successful in academics. Just got a comment on that too, Dr. Semsteig. I think the academics medicine has changed over the years. I think there was a lot of emphasis on research and scholarly activities. And unfortunately the healthcare system really forces academic physicians to be productive somewhere else. So I think I see a lot of departments coming up with the formula that Dr. Semsteig share in our talk. And usually that percentage of activities is critical. So I think just look at what you're signing up for. I think that's the best advice we can give you. And I came from like academics Spalding, which was very heavily researched scholarly activity base like Washington, University of Washington but now in Georgetown, most of the physiatrists are clinician educator. There actually, there aren't that many people who are involved in research. So I go to a very too extreme academic condition or situation. So I think that's the trend nowadays. Go ahead. And so there's some other great questions too, just about, I think that clinician educator role, which again is what I promoted through. So in my promotion packet, I needed to have those internal and external letters for having an area of expertise. For me, that was both in traumatic brain injury and in educational innovation as my work as a program director. So there's ways to define that for promotion and productivity. You still have to have publications and scholarship that can be, for example, several of us, including Dr. DiTomaso just completed a textbook where there are textbook chapters or you could be a textbook editor that synthesis of clinical information is in there. There's also an important role for academics as medical educators to do the medical education research and curriculum innovation and disseminate that. So your publications might be related to medical education or clinical expertise, which is great. And then you have to track other medical education activities like course involvement, teaching evaluations. I use my metrics and feedback from the American Board of PM&R as an oral examiner. You have to put together usually a portfolio. So there's still productivity expectations in a medical educator track as you're hearing from people, very different location to location. So you really wanna look at that. And I know for example, University of Washington versus University of Colorado is quite different, but you do, the clinician, sort of the clinical role of still being in an academic environment, but really focused only on seeing patients is different than these longer tracks of being a medical educator or a clinician scientist where you do need to have that scholarship and productivity. So keep asking questions, look at your offer letters, negotiate, and it can just be a wonderful, wonderful time and involvement. They are gonna cut us off quickly. I think the last question for either Dr. Guerra, Dr. Shea, someone's asking about creating new DOD or VA jobs versus jobs already filled. I'll let you guys answer that. And then any more questions, please join us in the chat. Dr. Zumsik has posted the link in the chat. We'll see you all in the next session after this question. Yeah, so I think you have to go with a job that is posted at USA Jobs. Having said that, there's always opportunities to create job. And sometimes I can speak personally, I met with a potential candidate and created a job for that person after meeting that. So there's all kinds of flexible ways to join. I think DOD is more flexible than VA. What do you think, Dr. Guerra? Yeah, I wanted to add into that. So we have been really blessed with a lot of funding and particularly in our polytrauma program. So if there is something that we can fill, we can actually write the position and then get the funding for it. I think it's more challenging for physicians, but it can happen. So definitely it's worth it to network and ask questions of folks who are in VA leadership to see what you can get done. All right, thank you all for coming out. We had a fantastic presentation as high as 75 people, which I think is great. Appreciate everyone's attention. If you have more questions, again, please join us in the chat afterwards. Otherwise, we hope you have a great annual assembly and we'll see you in person in Baltimore next year.

practice management styles

early career physicians

private practice

academic medicine

government service position

direct reimbursement

excellent funding

work-life balance

research opportunities