Hi, everybody. Are we good to go? All right. My name is Zach Bohart. I'm a physiatrist, just like you guys. This is a class entitled Profitable Compassion, which is near and dear to our heart, diverse approaches to creating spasticity clinics. There are three esteemed practitioners of spasticity here and me. There is Christina Kwasnika from Barrow Neurologic Institute, Dr. Tiffany Sheehan, as well, from Barrow Neurologic Institute, and the godfather, Dr. Atul Patel, as well, from Kansas City Bone and Joint Clinic. What unites us all, we love spasticity. We love taking care of the patient population. We love learning how to make it work and following these patients. We all do botulinum toxins. We all do the intrathecal back of the pump and nerve blocks, work with physical therapy, work with occupational therapy, bracing, orthotics. And we've all come from it from different approaches, which is really key. But we've all really found a way to make it work. And, you know, spasticity is difficult. You know, it's not like just opening up an MSK practice or opening a spine practice or getting a job at an inpatient rehab facility. You kind of have to find a way to make it work based on your insurers, based on who can refer patients to you, based on what kind of a setting you want to be in. And so we're all in very different clinical settings. And so we just wanted to share some of our tales of glory and of woe with you, things that we've learned for good or for bad. And really, as I said, kind of discover our innovative approaches to really follow and take care of this patient population with spasticity. We've all had our own degree of success in this field. You know, we all do a lot of teaching around the country, and I love giving lectures on the back of the pump for Botox, botulinum toxin. And every once in a while, a resident comes up to me afterwards, and they say, you know, that was a great lecture, but how do I do it? How do I build a spasticity practice? Well, this is kind of how to do it. And I'm really lucky to have these three esteemed colleagues here with us to share some of their life stories. And our first one is Dr. Christina Kwasnika, who I've known for years, and she's great. And take it away. Okay. So the way I approach this is kind of tell you a little bit about what we've done in our practice, and specifically how I've partnered with my organization, Barrow Neurological Institute, to solve a problem which we were seeing, which was how do we make sure the patients are identified, not lost to follow-up, and are treated for their spasticity earlier so that you don't want to see them when they come back to your office, and it is now, you know, three years since, and they have a clenched fist, and you can't treat them. We want it to be able to identify them sooner. So that's kind of our approach to how things have worked. Oops. I think I went the wrong way. Ah, that's the way. There we go. So this is Barrow Neurological Institute in Phoenix, Arizona. It is a portion of St. Joseph's Hospital and Medical Center. The neurologic portion includes neurosurgery, neurology, neurorehabilitation, neuroradiology, and radiation oncology, and we actually have a pretty large portion, three real buildings of that campus are specifically for the neurologic disorders. So I am kind of immersed in the setting in which I see these patients for many different neurologic disorders, and they're cared for within our institution. At our hospital, it's a large trauma center, 571 licensed beds, top 11 hospital in the nation for neurology and neurosurgery. We finally actually got on the rehab rankings, which has been one of the things that has been very important to us because we were kind of viewed as part of neurology, and it took a while to get people to realize that the PM&R department actually exists and is separate from neurology. We are CAR for Credit. Since 1988, actually, one of the largest number of CAR for Credit programs in the country because we have a lot of continuum programs, including vocational rehabilitation, adolescent vocational rehabilitation, outpatient core program, outpatient spinal cord injury program, and the like. So we also have a certified stroke program, and that's how we start down this journey is that sometimes you need to figure out who are the people in your institution who are doing the things that you do and partner with them, partly because they may have the ear of certain people in administration that you don't have, and partly because we all wanted the same outcomes, and so partnering with our stroke people in the stroke program really has helped grow this program. So this is how the stroke center evolved. It started as they got the designated primary stroke center in 2003. We then had a designated neuroscience tower that was built and opened, seven floors of designated neuroscience beds, including ORs and the like, and with an eighth floor actually shelled out to potentially be used. They continue to really be focused on improving our metrics to be able to meet the goals to get the GWTG stroke goal plus, target stroke on a roll, et cetera, and then the best part was in 2017 they said, we want to be innovators in the area of mobile stroke unit. So I kind of view it as that's when the hospital made a commitment that, yeah, we understand that we need to provide the best stroke care available here in Phoenix, and so they made the commitment to that mobile stroke unit. They're now moving into a, they have a telestroke program because the desert southwest has a lot of cities that really don't have that degree of neurologic care, and that telestroke program continues to expand. This is the neuroscience center. We talked about the mobile stroke unit. We have those neuro ICU beds, acute telemetry beds. It's pretty much a dream job for a PM&R doctor, frankly. You know, when you've got a place where everybody is doing neuro and everybody's speaking the same language, you really can be able to affect change to make sure that those patients come to you to be able to help them on their chronic care journey. So they may not make it to your acute rehab. There might be a contracting issue. There might not be a bed available, whatever, but we are still there when they come back around in the outpatient setting to be able to help them. We have 46 beds on our inpatient neuro rehab unit, and hopefully we can treat as many of them as possible in those 46 beds. We also have a very strong outpatient program. I think one of the solutions to helping treat the chronic patients with stroke or the sub-acute patients with stroke, which is when they develop the spasticity, is having a strong outpatient program. It works better when they're under your roof. You can talk to the therapist. You can identify. You can meet with therapists. I round with them once a month. I can identify their needs. Sometimes it's as simple as saying, you know, we could look at that. We could look at that for splinting. We can look at that for, you know, how the tone affects their actions. And in getting them in the door back to you is how you then institute treatment. And we also have a stroke prevention clinic. And that's how we get to the next part of our story. So we both had things we wanted out of this journey. I wanted to make sure that patients didn't go untreated and that they weren't being identified years later coming into our clinic. The stroke prevention, or the vascular neurologist wanted to make sure that patients had a follow up with regards to stroke etiology, making sure the entire workup was done. And, you know, you dotted all your I's, crossed all your T's, and got them the care they needed. So we both came at it with the same goal, which is to not lose patients. Pretty simple. That is how this stroke prevention clinic came up because, frankly, you need to be very, you need to direct the direction patients are going. You need to be very clear to them why they're going back to those places. And you also, unfortunately, need to kind of pre-schedule and make sure you have some way to track so that when they miss that appointment the first time because they didn't know who that person was, it will allow you to track that patient and get them back into the stroke prevention clinic. We have internal referrals. We also take community referrals. It's another place to come in to the system is you had a stroke out somewhere else, they identify us as the neurologic facility, and so the patient then calls for an external referral or community referral to come into the stroke clinic. And then emergency room encounters that don't require admission. And so, you know, we always think about in rehab that they like, of course, they're not going to have any deficits if they went to the ER as a possible stroke and didn't require admission. But, frankly, oftentimes those might be somebody who had a previous stroke and now had some other transient neurologic deficits. So, these are people that still could potentially benefit definitely from stroke prevention but also benefit from the opportunity to see us if necessary. My story of how I got here is I joined Barre Neurological Institute in 2000. I wanted to come back to Phoenix. Phoenix was where I grew up. And I started a private practice to provide rehabilitation services and really was interested in the rehab of neurologic patients. Really, we made a commitment to providing care for patients throughout the continuum. That was very important to me. And that allowed for a really robust clinic environment. We really, we took control of some of the pieces that other people talk about. The cost of toxin, how you make decisions, what do you do about contracting. We really had put together a model that was very, very successful. Toxin pumps, therapy follow-ups, and the like. And then I realized that as many times as Dr. Sheehan and I met or other physicians and I met in the institution, I was an outsider. So, meaning that I wasn't a department in the institution. I couldn't use some of the resources of the institution. And kind of went through a decision making about what would be the best thing for myself and for my patients. And so, what I decided to do was to join the institution to be able to work more closely with these guys. Some of the challenges that I faced, and I could do a huge lecture on every one of these, it's really hard to manage a revenue cycle with toxin. I, man, I can tell you about 15 years ago, I don't think I slept half the time because I knew when I owed my bill to the toxin companies and when they were going to put it on the practice credit card and how soon I had to pay it so that I wouldn't have to pay interest. It's hard. And when you are good at what you do or successful at recruiting those patients, it's even harder because there's more patients. So, that is probably, I think, the hardest things to make a decision about is how you manage the revenue cycle. In my world, I managed it with the use of using specialty pharmacy. That might have some higher cost to some patients. But in the end, they wouldn't have me doing toxin if I was, if I couldn't continue to work under those stressful environments. So, I kind of figured it was a tradeoff that had to happen. The other thing that I always wanted to do research, man, every one of the toxin companies would come to me and be like, can you do this? Can you do that? I do peds and adults, so I'd have them coming from both sides. And really, quite frankly, in a private practice, Dr. Patel has been able to figure it out, but I was never able to figure out how to handle that overhead to manage the research in my practice. And so, really, that was a part of my decision making, is it was something that was important to me. But in my private practice situation, it wasn't going to be feasible. The other thing that all of us probably all recognize is there's not a ton of physiatrists out there that are like, yay, I want to do outpatient neuro rehab. We'd love that if they did. But it's a small group. And so how do you take care of those numbers? And so we've really kind of looked at different practice models. I have used physician extenders. My current physician extender has been with me for 24 years. She's as good at it as I am, but she doesn't inject. We've had people who inject. And I feel like, you know, if I've trained them, they're able to do it. I haven't had concerns about it. But, you know, that's a way you can expand how you can provide care. We use our physician extender currently to do follow-ups. And, you know, I think it's one way to be able to just, if you think about it, when you're seeing lots of patients, you've got to almost clone yourself. And that's one way to clone yourself in the interim. I still think a physician offers more flexibility and allows us more options. But in the end, I want to make sure that I'm providing the care to the patients because we are woefully underserving this population anyway, and that's with a crazy busy clinic like we have. So as I already told you, I integrated into Barrow Neurological Institute as a department last August. And the world opened up. And the beauty was I already knew everybody. It was just that they couldn't provide me the resources. And we have a really strong collaborative model with neurology. I would, you know, I would tell everybody, know your neurologist. They feel kind of like competition. And so I think sometimes we kind of back away from that. But frankly, kind of find out who are your collaborators and who really do want to talk to you about those difficult patients. We trade back and forth. Like my little rule is I'd rather not inject above the jawline. So I'll send them to my movement disorder people for that. And they would actually really rather not give more than 300 units of Botox. So that makes them nervous. And so they'll send them over to me. And so we tend to, on a physician-to-physician basis, we tend to collaborate very well. And the other thing that I would say that made this work for us, we took our private practice model and moved it into the department. And so we did not change how we use specialty pharmacy, how we get intrathecal baclofen, any of that sort of stuff. We just basically said we're going to take all this staff, you're going to take that into our clinic, and we're going to continue to control it. That was key. And really because I knew that I had a successful business model, it kind of actually makes me pretty good when you compare my numbers to neurology that doesn't know the detail of how many patients you're treating, what's the turnaround for billing cycle, et cetera. We've been very successful because we've taken that private practice model and moved it over into the department. So I would say, not that I'm telling everybody to come join institutions and that, but know your business. If you know your business and you know it's good, then keep your business. So keep it at least in structure even if somebody else is going to be in charge. So this is where I'm going to go on to where Tiffany, I came with a problem, which is that where are these patients with tone going? And Tiffany helped me come and understand where the patients are going, how we can identify them, and how we can put this clinic together to be successful. It's like a perfect QI project. Hi, good afternoon. My name is Tiffany Sheehan. I am the manager of our stroke program. And so I wear many hats, and mainly it's to implement evidence-based practice, education programs. I help lift off big ideas from our teams. And so my ask is that you just journey into maybe a different space today with what I'm going to talk about because I live in the land of quality, and I'm not to be feared. Okay? Quality is not a scary thing. But there are methods that I think when you realize that you have a good product, that implementing a quality program to make sure you have access barriers removed so you get your patients into the right place. So just journey with me. So I'm going to start with a brief reflection. This is a parable. Maybe you've seen this on the Internet. But basically I'm going to talk about the elephant in the room with health care. So this parable basically says there are six blind men, and they were asked to describe what this object was. And so from their different lens, different position around the elephant, you might have one that says, oh, well, this is a rope as he yanks on the tail, or this is a spear as he touches the husk. And so I would say that in health care we are quite siloed, and we tend to be very committed to our own beliefs and ideas of knowledge that's right in front of us. But often when you can put other departments or individuals in a room with you to talk about that elephant in the room, you get a clearer photo or picture of what you're dealing with, so today our elephant is spasticity and access to care for our patients, so. I'm gonna explore some of the elements, but then I'm also going to give you some hard or objective items that you can take with you and things that you can apply in your practice with quality, quality improvement programs. They increase compliance with clinical practice guidelines, so we know what we need to do for our patients through research and evidence, but how do we get our patients there for that treatment? These programs really help with that. And successful programs, we know that they improve patient outcomes, right, and access to care. But I think the point that I want to make, really, about QI programs for this audience is that when you have a multidisciplinary approach, when we put all the blind men in the room together, there's actually benefits for us as well. So there's role clarity across departments and comprehending a true plan of care for that patient. So over my years, 13 years of lifting comprehensive stroke programs, I've identified just a few tenets that are paramount in delivering evidence-based practice. The first is engagement. You have to have people that really care about what you're working towards. Identifying those individuals, and that can be a small group, and then you can pull in additional stakeholders as needed. But then identifying the evidence. So you have to have the literature and the research to support what you're doing, and so when that is sound, it's kind of hard to argue that these patients need the care that we're trying to get them to. But then identifying clear objectives. If you are clear in what your goal is for your project, then you have a captive audience that has a very clear expectation of what we're doing today in the room, right? And then a data collection plan. I think this is probably the facet that gets kind of brushed past. Data drives practice, and when you have numbers that you can show that really does help continue with that stakeholder engagement. And know that you're working on the right areas when you're making changes or improvements. And then using a quality improvement methodology. So just like research where we have methods for doing certain research trials, it's the same thing in quality improvement. So we got together, Dr. Kwasnika and I, and talked about the stakeholders that we needed for identifying how do we get patients treated for spasticity and really identified. And so the first thing you can do wherever you are working is start to identify those people, the ones that need to be engaged with you in the project. Brainstorming, consider both internal and external partners. Dr. Kwasnika did that. I'm considered an external partner, which I never would have thought that because everybody's in the family of stroke. It's a team effort. But yeah, we're internal and external partners. And then prioritizing those, recognizing who has influence to your cause. That's a really key factor. And then assembling that core team. Clinical practice guidelines. Again, like I said, these are the roots to what you're trying to drive. But when we met together, we understood the care that we were wanting to provide. And she has the clinic and we have the patients. But what we didn't have was a broad understanding of education across the interdisciplinary team in the hospital. So I direct the education plan and I realized, oh, we don't even talk about spasticity. We talk about depression and patients that are likely to have depression after having a stroke, but we really didn't talk about spasticity. So this is one of the steps in looking at your clinical practice guidelines and how you're going to educate those that are caring for these patients. Just an important facet. So we decided that our goal was to align ourselves, actually, with this assembly and improve healthcare professionals' understanding in our institution, identification of this patient population, and management of spasticity. So we developed a post-stroke spasticity care roadmap. We knew that there would be elements that we would need to focus on. And so the first piece is, how many of you go on a trip and don't look at a map? We all do. We're like, Siri, help, I don't know where I am. So the first step is really looking at your workflow. Draw your map. Where are your people? Where are the big parts of the process that are gonna make a difference? So we did that with our referral workflow and we identified gaps, which I'll talk about. The multidisciplinary education plan, we identified what that would look like, and then a continuous quality improvement program where we were gonna identify improvements needed and areas where we were succeeding. So here's our map. It starts for us, patients discharged from our stroke service, and they might not have spasticity at the time. But we felt that this is the key point in having a conversation both with our nursing staff so they understand what spasticity is, our residents, our fellows, our vascular neurology team, and the workflow with that. But also, where are they going after discharge? We wanted to engage our care coordinators and our navigation nurse and clinic. And then from there, they're either DCed to the B&I Acute Rehab or back to home, or they go to an outside center. And then ultimately, we do have an amazing prevention clinic for stroke, so we wanted to make sure the patients were getting there. And then they can be referred there to our PMR outpatient clinic. But where we identified gaps by looking at this is that we really didn't know from our outpatient rehab how many of those are referring into our stroke clinic. And then also, when they discharge from St. Joe's Hospital or hospital, were they having follow-up appointments? And were they actually coming to the follow-up appointment? And then is our clinic identifying spasticity as well? I will not belabor this slide, but it is data. And I just will say, if nothing else, data is really important and drives practice. So there are steps to a data collection, starting with the theoretical concept. So obviously, we can look at health outcomes, patient experience, the cost, and also equity. And then it's important when you're defining what data metrics that you're going to benchmark for your project that you have a clear, concise definition of that metric. And then the data collection piece, you wanna look at process as well as outcome. And I have another slide to talk about that. Then how are you gonna show your data? Is it a graph? Is it a slide? Is it just a dashboard? Those are all important things. And then having that team together to decide what you're doing with that analysis. So the first step to any project is, how will we know a change is an improvement? So these are just where we started with a lot of process metrics, really looking at and using our map to look at the process and referral process. What is the follow-up appointment scheduled? What's our percentage of compliance with that? And we weren't doing a very good job with that as the patients were leaving the hospital for a time. We did implement something that I'll talk about. But also, stroke clinic follow-up appointment completed, referral to our PMR clinic, and then treatment of spasticity. So this is, as I mentioned in research, there are models that you use for specific research projects. This is the PDSA cycle. It might sound familiar. Most comprehensive stroke programs are required to have this model or a model like it. But it does keep you organized in your project. So I just wanted to share it. And then unlike research, quality improvement is an iterative process. So not always building upon itself, but constantly changing and evolving towards your outcome. So I wanted to put this on here because a lot of people tend to think that quality improvement is a one and done, or you have to have some big, great, innovative idea. They actually can be really small things like putting together a committee to map out your referral process. That was one of our PDSA cycles. It's not always that big, inventive thing. It's the practical thing that can make a difference. So what we did when we realized that we weren't having much follow-up from our patients as they discharged to going to our stroke clinic, we implemented two nursing positions. So the first one is a stroke care coordinator. This nurse is Monday through Friday, and she rounds with our stroke team on the inpatient side. So this is in the hospital. And helps with notifying our outpatient clinic nurse navigator. So she lets our nurse navigator know that the patient's being discharged. So that way, clinic appointments can be established. And that's been very helpful. I wanted to just highlight these two nursing roles. And I realized that we have a lot of resource where we are. But we also have 1,500 stroke patients discharged annually. So we're a rather large stroke center. And then as a team, once we started mapping out and writing down our process, we realized that we have quite a few quality improvement projects that perhaps you do as well in your facilities. But identification of spasticity being one. I wanted to just bring to you that the American Heart Association has a spasticity care checklist that is meant to be completed by patients and clinic. And so that's something that we talked about implementing into our clinic, just for identification. But also from education, we're adding this into patient education on the inpatient side. So that they know to expect things post-discharge that might happen. And so they're knowledgeable of it. But then with our external partners, we'll be developing a targeted education approach for our external members. So they're doing a little bit of outreach there for our rehab facilities about the services we have through PMR Clinic and then also our Stroke Clinic. And then finally, data collection. I told you I like data, right? So we need to improve our clinical documentation. It's a little bit of a disconnect from the inpatient side to our clinics, to align the factors with these patients. So that's something we're working towards, standardizing documentation templates and improving our coding. I guess in conclusion, I would just say that it's important to have a well-structured quality improvement program to enhance your mission and vision of your clinics or your practice around spasticity. Assembling a passionate and dedicated core team is essential, aligning clinical practice guidelines with your practice so that everybody has a shared knowledge base. Setting clear project goals and objectives so everybody's moving along with you. And then developing a data collection strategy and using a standardized or a methodology to support your practice there. Thank you. Hi again, everybody. So you know the interesting thing about this talk and I'm going to be followed by Dr. Patel is that we all really have our own approaches for how to develop a specificity practice. Again, some of us are strictly private. Some of us are strictly public or should I say academic and some of us are kind of a hybrid. Some of us have been a hybrid in our lives and have now switched to private or academic and it's interesting. And all of these different... There's many different pathways to roam. All of these are valid. All of these are good. It's whatever you want to do in your heart, whatever you find interesting and where you can best thrive to take care of our patients. My practice has primarily been about not really having a stroke clinic or a TBI clinic or an MS clinic or a CP clinic, but it's really a spasticity clinic and it's a spasticity only clinic. And so what I do all day long is I'll do botulinum toxin injections and nerve blocks and backbone pumps regardless of the diagnosis. I get a lot of referrals from Boston Children's Hospital. When they're no longer kids, they have pumps on their second pump, they have CP, they send a lot of those patients to me. I get a lot of referrals with multiple sclerosis or either very advanced MS or milder MS. So sometimes I'll do Botox, sometimes I'll do the pump. A lot of, you know, a fair amount of HSP, some PLS, but obviously a lot of strokes and TBI's and spinal cord injuries. But the focus of my practice is really spasticity. Do I deal with other things that are part of that? Of course. I'll send them to BT, I'll send them to OT. There are orthotists who I really like who I'll send them to. If there's other things going on, bowel or bladder or neurologic complications or they need an orthopedic surgery for a contracture, then I have kind of preferred people I send to within Boston and Rhode Island and partly New Hampshire as well. But the focus of my clinic is spasticity. And then the nice thing about that is that my day is really exclusively procedural all day long and their, you know, the title of this course is Profitable Compassion. And that's a part of it, you know. I think we have to learn how to bill and code and in so doing, you know, pay the rent and, you know, and try to build a successful life. I'm in a couple of different places. I'm at Tufts Medical Center in Boston and I teach the residents there spasticity management, again, from the back of a pump to Botox and some nerve blocks as well. One of my old residents is here, which is really nice to see. And I'm also at University Orthopedics, which is the, it's a physician-owned. There's about 60 or 70 surgeons there. It's a physician-owned private practice. It's the orthopedic department for the Warren Alford Medical School of Brown University. So in Rhode Island, just a little bit of South Boston. And there I primarily do EMGs and some spasticity as well. And it's been kind of a twisty road to get there. So I'm going to talk about that. I do see a lot of, you know, younger folks here, including myself, of course, you know. And, you know, my advice is know your career goals and follow your heart. This is really important. You know, you're the valuable person in the room. You are extremely valuable. We may not feel valuable sometimes going through residency and getting tired and MCATs and all these, you know, tests we have to take and failing this and late night doing that. But you are really, really valuable. You've sacrificed a tremendous amount to get into medical school, to become a physician, to becoming a resident, and to graduating. And, you know, your family has sacrificed a lot. You've sacrificed a lot. And you owe it to yourself and you owe it to your families and you owe it to your future children and grandchildren to do something that you really love and something that is really, you know, dear to your heart. And don't give up on that. When I finished PM&R residency, I was exclusively interested in orthopedic EMGs and spasticity management. And that's it. I don't want to do anything else. And that's really all I wanted to do. But, you know, I didn't know how to do that. I didn't know how to get there. I felt personally, just my own career goals, that if I was in a rehab hospital, I wouldn't really be able to achieve this goal because I wasn't particularly interested in rounding on inpatients and all that stuff. Very valuable, but it wasn't really what I wanted to do. And I also always, I realized I always enjoyed working in a very diverse background of multiple specialists. I didn't want to be siloed off with a bunch of other physiatrists. I wanted to work with orthopedic surgeons. I wanted to work with neurosurgeons. I wanted to work with anesthesiologists. I wanted to work with neurologists. Why? Because I honestly feel that we have the best field in all of medicine. And I think that we really help people in ways that, and I say this all the time, I feel that we really help patients in ways that nobody else can. When it comes to spasticity, physiatrists are number one. Neurologists can't shake a stick at us. Anesthesiologists don't know how to do it. Neurosurgeons are too busy doing other stuff. It's us. The PTs, you know, can't, you know, they obviously can't do that. Primary care physicians, obviously not qualified. We are in a perfect place to own spasticity and to take care of this patient population. But I didn't want to do it in a rehab hospital. I wanted to do it with a bunch of other physicians because I, because, you know, it takes a village, you know. If I need an orthopedic surgeon, I want to be able to work with them for tendon lengthening procedures. I want to, you know, know my neurosurgeon is putting in my baclofen pumps, you know. I want to work with the anesthesiologist. I want to work with the neurointensivist when the patient's in the neuro ICU going through baclofen withdrawal, you know. And I, you know, that was important to me. But I didn't know how, you know. I graduated residency and I didn't know how because, you know, I mean can anybody think of a practice that's hiring a physiatric electromyographer who also wants to manage spasticity? No. There's no job hiring for that in, you know, anywhere. You know. So I kind of had to figure out how to do it. A tools hiring. Well, you know, he's been a role model for me. And then did I want to be in a private practice setting or did I want to be in an academic setting? And really each has its advantages and disadvantages. I'm really kind of hybrid at this point. I do both. And so I'm going to share some of my stories of what I've learned along the way of how each may benefit you. So when I first graduated I worked in a private spasticity practice outside of Boston. And there I just got really good at what I did. I got really good at, you know, botulinum toxin injections. I got really good at baclofen pumps and troubleshooting and side access for desperations and nuclear medicine studies and CT dye studies and all that stuff, phenol nerve blocks. But I also got good at communicating with patients, talking to them, making them feel comfortable, letting them know, you know, goal setting, what I can achieve, excuse me, what I can't achieve. And also, you know, keeping your eye on the prize, you know, knowing how to stay profitable, knowing how to, you know, break even, not spending, you know, three hours with, you know, one injection. And I got decent at that. And then what I did is I opened up a spasticity practice at Tufts Medical Center in Boston because, you know, I really, you know, I missed, you know, when I left residency, I was like, I'm done. I'm never going to do another, you know, residency thing ever again. But then I missed it, you know. I really missed it. I missed teaching. I missed learning from residents. I missed working with them. And at the time, there was an opening at Tufts. The Tufts kind of had a storied reputation of pediatric and adult spasticity, but like a couple of people left. I was like, well, let me set up shop here. I was living nearby in Cambridge. So I kind of set up shop there and built up that spasticity practice. And now we get, you know, tons of referrals from, you know, all the hospitals in Boston with a really interesting patient population. A lot of, you know, patient, you know, inner city population with poor insurance. But Tufts really gives me the support to do that. And then I also started performing orthopedic EMGs. You know, so look, if they need single fiber or ALS, I send them to the neuromuscular specialist. But, you know, orthopedic EMGs, so, you know, carpal tunnel, or neuropathy, drop foot, red dicks, plexopathy, things like that. I started doing that at a medium-sized, privately-owned orthopedic practice, which then merged with a larger private practice, which is partly academic. That's the one that's affiliated with Brown University several years later. So it's kind of been a bit of a road. So my practice setting now is that I really work in a hybrid setting of a primarily private practice, which is university orthopedics and my own private setting, and also the academic setting at Tufts Medical Center. And it's been really interesting, and I love it. But each has its pluses and its minuses, especially for the residents out there or junior attendings who are kind of looking, how do I proceed with my life? Each has its benefits, but each has its drawbacks as well. I find the private practice setting exhilarating because, like Dr. Kwasnick was saying, you kind of take this private practice model and you make it work. Regardless of where you are, you make it work. And how do you make it work? You get really good at billing, and you get really good at coding, and that stuff is really boring, but really important. Your practice will sink in a week if you don't do that stuff properly. So I got really good at that, and just really the concept of financial viability. And again, to the residents out there, learn billing and coding. If you don't know it well, someone who may not have your interest in heart does know it well, and you may be a little bit taken advantage of. If you know how to bill, if you know how to code, if you know how to really make a practice financially viable, patients will just keep coming and coming and coming, and then you become a very valuable person to wherever you are. I find that in private practice, there is far greater financial reward, especially if you're billing globally. If anyone wants to talk about global billing versus RVU at a later time, you can check me down afterwards. Global billing is really the way to go. RVU, you really just wind up getting a portion, a small portion, of what you generate. But if you bill globally, which is you bill for owning the EMG machine, for owning the ultrasound, for the injection, and the profitability from the medication, if any, then you can really do quite well with a spasticity practice. There's lots of flexibility in a private practice setting as well, as long as your clinic is financially viable. If it's not financially viable, someone's going to shut it down. I also find that in a private practice setting, there is tremendous camaraderie with like-minded physicians working in a team effort. It really is, at University Orthopedics, it's really a band of brothers and sisters that I work with. I work with the orthotists, I work with the PTs, I work with the hand surgeon, with the foot and ankle surgeon, with the podiatrist, and the spine surgeons, the knee surgeons, et cetera. We really are a group of brothers and sisters who are kind of working together to take care of our patients and make the practice thrive. There's also, I find, in a successful private practice setting, I've also had a tremendous degree of support. Administrative support, clinical support, people who can really help me because it's an orthopedic practice and orthopedists really do quite well in the American healthcare system. They're not strapped for cash, I guess you can say. They can really help me in what I want to do. That's really been the benefit of being in more of a kind of group private practice setting. At Tufts, where I am several times a month, this is in downtown Boston, we're taking care of a very needy population, a very difficult population, a profound situation, a lot of spasticity, a lot of cognitive delay. Again, a lot of referrals from Boston Children's Hospital and patients with teenagers with CP and things like that. It's an academic setting. This enables me to see patients of really all backgrounds regardless of socioeconomic status. That's really a blessing, that I'm able to see anybody regardless of insurance, regardless of their ability to pay. I'm really able to take care of these patients. There, I'm doing a comprehensive spasticity. It's botulinum toxin injections, baclofen pumps, and nerve blocks. I love teaching the PMR residents. I hope I'm an OK1 hero. Working closely with neurosurgery, neurology, anesthesia, and radiology. I do my nuclear medicine studies there for malfunctioning baclofen pumps. The nuclear medicine radiologist will sit me down and say, yes, it's working, or no, it's not working. I really value that. I find that a lot harder to do in just a private practice setting. In a large academic setting, there's multiple different specialties, and that's really what it takes to properly take care of this patient population. There's tremendous institutional backup for my baclofen pump patients. If there's an emergency, there's no way that I can take care of hundreds of baclofen pumps and do it alone. There's just no way. The orthopedic PAs who are on call, they're going to say, no way. The orthopedist, it's not what they do. They deal with trauma surgery and all this stuff. They're not going to want to deal with a beeping baclofen pump at two in the morning. It's just not what they do. At Tufts, we have our excellent residents who I've trained from day one how to do this. They know how to fill a pump. They know how to put a needle in a pump and do some troubleshooting. They know what baclofen withdrawal looks like, and if they're going through withdrawal, they need to be admitted to neurology or the neuroICU or not. Look for a UTI. Look for the other causes of spasticity exacerbation. I wouldn't be able to do this if I were strictly alone in private practice or even strictly in the large practice of the orthopedic practice where I am. It enables me a place to do my baclofen trials. I've got the PMR residents. Neurosurgery is there if there really is a true surgical emergency. The neuroICU is there as well for cases of baclofen withdrawal, and I can do my imaging troubleshooting procedures there as well. This I would not be able to do in more of a private practice setting. The private practice setting where I am is University Orthopedics. This is right in East Providence in Rhode Island. They own the whole building. It's really a beautiful place. Again, it's a multi-specialty orthopedic private practice, about 50 or 60 surgeons, physician-owned. They've been very supportive of my interest in treating patients with spasticity, and the hand surgeons see patients who have contractures and the foot and ankle surgeons do the same thing. But in return, I perform their orthopedic EMGs, so they get a physiatrist to do their orthopedic EMGs, which I hope they find valuable. And then they give me an office to see my patients as well. I scratch their back, and they scratch mine in a way, and it works pretty well. The biggest challenge I face is really not being able to be everywhere at once. I'm in several different locations, and it can kind of make me a little crazy sometimes. So at Tufts, I really depend on the residents. I depend on my colleagues. If there is an emergency at University Orthopedics, a large challenge is really remaining profitable, but the endless supply of focused EMGs enables me to really maintain financial viability. I really, though, had to train the billers and the coders how to bill for spasticity, and I had to train my support staff how to really get prior authorizations as well. So this really took me a while to get up and going, but now it's going pretty well. The benefit is that working in two very different work settings, for me, I just find fascinating. I find it really a lot of fun, and I'm surrounded by a lot of kind of like-minded colleagues who I enjoy working with. And then also the disabled spasticity patients who have tremendous mobility challenges, they can see me anywhere. They can see me in Boston, north of Boston, or south of Boston, depending on where I am. So obviously that means a lot for them because of their difficulties in getting around. So what does my day look like now? At University Orthopedics, they gave me a nice little corner area there. I don't want to use the word suite, but a little corner area. At University Orthopedics, I have one room for spasticity with an accessible bed and two for EMGs. So for example, I'll be filling a pump or performing a Botox injection while my EMG tech does the nerve conduction for carpal tunnel study in one room and drop foot in another, and I just kind of hop back from room to room and do the best that I can. And at Tufts, the residents and I will plow through patients, you know, 20, 25 patients in a day, receiving toxins, back home refills, perform my Baclofen trial, which is done in the PACU, and then I go back to see the patients, then I go back and see the patient in the PACU doing the Baclofen trial, and we just kind of plow through that all day. And you know, I wear my sneakers to work, but it works and, yes, that is Whitney Houston, because the greatest love of all, really, at the end of all this is that I love what I do, you know? I love my patients. I love my colleagues. I kind of have a crazy ADHD psycho mind, and I'm never bored. You know, I always find it interesting. I never go home at the end of the day saying, oh, this is so boring. I don't like what I'm doing. I feel that I'm really helping patients and working with a team of like-minded physicians, some in my specialty and some not. And it's a team effort, and it's a lot of fun. So anyway, I hope you learned something. Thank you very much. And now we have Dr. Patel. All right. Good afternoon. Does anybody need to stand up, stretch? Oh, there's quite a few people here. This is good. You've heard some great things, and like everyone has already mentioned, we're all very passionate about taking care of our patients, particularly with those with spasticity. But really, I could change this title, How to Run a Practice. So think about it in that sense. But how many of you already take care of patients with spasticity? Just a show of hands. Okay. How many of you are thinking of starting or wanting to learn how to start a clinic or incorporate it in your practice? A few. Okay. Good. Very good. All right. Atul Patel. I'm in Kansas City. I work in the orthopedic group. These are my disclosures. I get clinical grants from the toxin companies. I'm a consultant for some of them, and I'm a speaker for a couple of them. This slide is... I was going to take this slide out because I've given a similar presentation to a group of people who are not physiatrists, but I thought I'd keep it in there. Who am I, my training, what do I do, and what do I treat? And you are all, I'm assuming, physiatrists, right? So you would probably agree with this part, that we'd like to treat patients. And as a field, we take care of patients of all ages. We focus on treatment, on function. That's what makes us different than everyone else, right? At least we say that, that we focus on function. We have broad medical practice expertise, right? We've got people who take care of pain management in our field with disabling conditions throughout a person's life. And we diagnose and treat pain. We work in teams. We like to take care of the whole person, not just the problem, whether they come in just with a sport type of injury or a pain kind of problem or spasticity, right? And the main thing that really differentiates us from all different specialties is that we improve function and quality of life. And so I think we all agree that that's what we do as PM&R physicians, right? And I'd like to start with this slide and I'll end with this slide too, but this is just my one learning throughout my whole career. And that is, you know, like sometimes you're trying to figure out what do I want to do? What do I really like? But things happen. Things happen. Your external forces come in and you don't always have control of what you're going to do. And that's happened to me several times in my career. And you have to be prepared to make bold moves. But the way I would do it, instead of looking for a path all the time, sometimes the path is right there. Just walk on that path. Go. And you can figure out your way in life and in your practice and everything. But you need guardrails around this. What you need is some of the things that I'm going to talk about a little bit later. And that's what's going to keep you in the right lane. So my career has been more around what do the patients and what does the community need? And then I go do it, right? But there's one thing that has happened and has come along my way. And that is this one tool that has completely and profoundly changed my career. And that's medications for the treatment of spasticity, primarily botulinum toxin. And I don't only use botulinum toxins for spasticity. It's my entire practice pretty much now. I'm using botulinum toxins for so many different things. My background, 30 years of managing patients with spasticity and dystonia. But is that all I've done for 30 years? No. I initially came out of training and went to Kansas City. I was a faculty at KU Medical Center. I thought I was going to be doing. I signed up a contract saying I'm going to be the guy who's going to do all the EMGs and stuff like that. Guess what? It didn't happen. I went there. The EMGs went to the other professor who didn't want to give them to me. I got the patients assigned from the ER, which never showed up. And so I figured out a way to go and do EMGs at the VA and teach the neurology residents. And that's how I kept up my skills. I started doing the patients that nobody else wanted to do. And that was pediatric EMGs. And the community needs that. But guess what? I started doing it. And for 30 years, I've been the main guy who does pediatric EMGs in Kansas City and the surrounding states. Currently, I use botulinum toxins in the market for therapeutic purposes. All the different toxins that are in the market. I don't do any aesthetics or cosmetic kind of stuff. Multimodal comprehensive treatment with these patients with spasticity, including therapies, like intrathecal baclofen, all those things. And there's so many little nuances, how you start doing those things. So I want to kind of share those things with you as we go through this presentation. Experience in various settings. I've been in academics. I got tenured. I quit the same year I became tenured. Hospital office. I've worked in the hospital. I've worked in the office setting, community, and private practice now. Involved in clinical research and trials for 20 years. So how did I incorporate the stuff that I enjoy? What gives me satisfaction is I really wanted to stay in academics. And I enjoy teaching. I enjoy doing research. I want to be intellectually stimulated. I want to take really good care of patients. I want to be involved in my field. I've achieved all those things in private practice. Involved in, sorry, proficient with various tools. Constantly working on ways to get better and better. And that doesn't matter whether you're doing spasticity or pain management Do not become stagnant. Keep improving. So I've become, you know, as different tools come out. I did electro-diagnostic medicine as a resident and got very good training there. But ultrasound was not something we had when I was a resident. I picked it up and learned it and I've been doing it for over 15 years. Cryo-neuralysis. I did some of the initial studies and everything like a decade ago. And now it's becoming something that people are talking about. Educating. I educate people locally, nationally, internationally. And I'm involved in national organizations. So that's just my background. But how did I get there and everything? So I'm going to make this into saying spasticity clinic, what are you treating, right? And then the thing is you've got to remember, it doesn't matter what you're treating. As rehab physicians, and that's why I asked that question, who am I? I'm a physiatrist. I take care of people regardless of what they have to improve their function and quality of life. So same thing applies here. Remember, you're treating patients with other conditions that also have spasticity. And if you're in a community, and I'm just throwing this out as a general thing. Let's say you're in a community and you have become board certified in sports medicine and you're doing sports medicine and you want to diversify. You can start slowly seeing some of these patients because you already have these principles and you can start helping. And the bar, by the way, is super low. If you went and said, I want to do brain surgery and you haven't had training, no one's going to let you do it. If you go out there, it doesn't matter what your title is. If you say, I want to take care of spasticity, go ahead. No one's going to stop you, right? So the bar is super low. And all you have to do is do something for the patient that makes their life a little bit better than what it was before you saw them. And if you start from that point, it's very easy to slowly start building this up. You have the skills to make a real difference in these patients. I mean, it's just amazing. And it depends on the location you are. You may be in a big city where there's a whole nice system and everything is in place. Then why do it? Send the patients there. Or if you can help out in a different way, recognize the problem and send them in. But if you are anywhere else, and that is pretty much all of the country, by the way, that most people don't get treated. I'll throw in some facts here. So a study that I've been involved in and looked at stuff. Guess what? Of all the people who would benefit, and stroke patients that would benefit from botulinum toxin treatment with spasticity, how many of them, what percentage of those patients receive botulinum toxin? Any ideas? 30%, 50%, 10%? 20%? Anything else? What? 30%. Yeah, wish. What's that? 1 to 3? Oh, yeah. 30, yeah, yeah, yeah. It's actually less than 5%. It's actually 3%. That means, say, if you are a cardiologist and you said, you know what? Of all the people of atrial fibrillation, I'll treat 3%. Right? It's so bad. The bar is so super low that you don't have to do much to do something for our patients and improve it. And so how did I get here? I kept learning and investing in myself. And that's not just because of the spasticity. I'm just thinking about my entire practice. So I'm sharing that with you guys. No matter what you do, just keep doing it and keep doing it. Like the person today at the plenary says this, just keep swinging. Keep working at it. Do not stop. Do not become stagnant. Do what's best for the patient and the community. I've kind of stuck with that. That was a principle I had. So even though I came to Kansas City thinking I was going to take care of these, 40% of my patients were stroke. I ended up doing inpatient rehab. So my research became, I was interested in doing research. Well, I never thought I was going to do research in stroke, but I started doing research in stroke. And that's what ended up happening. And I started taking care of stroke patients and started enjoying it. And that was around the time when there were really not that many treatments for spasticity. So how did I start treating these people? I started figuring out ways to do things. I've been in the field in medicine for long enough that when I started with botulinum toxins, the only thing that was FDA approved was for strabismus and blepharospasm. And I was using it for different things. And then one by one, all those things started becoming FDA approved. So I was treating people with spasticity with botulinum toxin before it was FDA approved for that. Using botulinum toxin for migraines before it was approved. For hyperhidrosis, for scleria, for dystonia, all those things. And there are still other things I still use it for now, which are off-label, but one day they will become on-label because they made sense and help these people. So you can be a little bit innovative and can do all these things in your practice. And if it's spasticity or something else, you can still do the same thing. Develop a reputation. How do you develop a good reputation? One thing is to stay in one place. Because if you keep moving, nobody knows you, right? So you have to develop a reputation by staying in a place. So find a place that you really enjoy working and stay there. And don't run away. Stay there. Even if you don't like something. Because really, you know what? The grass is not greener elsewhere. There are problems everywhere. You're never going to have a completely entire practice that every single day you go home happy like Dr. Bohart. That's not going to happen. That's not going to happen. There are days you go home pissed off, really sad, wondering why you're doing all this stuff. So don't give up, and you develop a reputation. And the way you develop a reputation is every time you do work, anything you do, do it as best as you can. And always think of your patient as your family member. Would you send that person for A, B, or C if that was your family member? And if the answer is, ah, I'm not sure, then think about it. And if you say, yes, definitely, then that's good. And if you're saying, no, I wouldn't, then you're still doing the procedure on them, that's really bad. So use that internal judgment to try and improve it. The other thing I want to say about the reputation is this. We are a small field. There are only a few of us who can help certain kinds of conditions, like spasticity. No matter where you go, especially if you go outside the big cities, you're it. We cannot be super specialized. The country, the community needs us. So even if you are, whatever, super specialized in one area, you can do so much for a patient that no one else can do. You're not going to say, I'm not going to do something about them. Create a way to help them, help your fellow clinicians and other physicians in the community and take care of these patients. And you just have to recognize and say, hey, you know what? I think you've got a foot drop. I think you might benefit from a brace. Guess what? That's too long ago. I don't even know how to order a brace. I'll send you to my colleague who'll do that. Just doing something simple like that can make a big difference in people's lives. And I say this because this sounds like a very lousy, odd example. I got a letter from Medicare in Kansas City saying that I am prescribing too many AFOs compared to my colleagues who are physiatrists in Kansas City. So I went and quickly looked at all the charts that they listed, all the names. And every single one of them had a classic foot drop. What does that tell me? My colleagues are not ordering AFOs. They'll inject the hip. They'll inject their back. They'll do something else. Come on, guys. We can help these patients without changing your practice at all. And when you do that and you help your patient, most patients will remember those kind of things. The people you send those patients back to, their primary care physician will remember. And you will be helping out the community and your reputation will improve. They'll know this is the guy or this is the gal who's going to take care of my patient when it really comes to it. And you can build up your practice that way. Creating a multidisciplinary network. So I'm in private practice now, right? So some of these people have a really good situation. There are institutions where there is a vertical system. There are therapists in the hospital and things like that. I don't have that. So I have had to go and give lectures and educate the therapists in town. I have networks, depending on which part of Kansas City, Kansas, or Missouri, because of the insurance, north, south. What part are they coming from? Find them a therapist who will appropriately treat them. I even have patients coming from 200 miles from the middle of Kansas. What I'll do is I'll negotiate with them and say, do you mind staying two days in Kansas City? I'll find you a good therapist here. Have that therapist assess you, work with you. And then when you go back home, find the therapist there. And then that therapist will talk to my therapist in Kansas City and will train that therapist what to do. And then when you come in, we'll make sure your appointments are such that you see me and the therapist on the same day in Kansas City. So those kind of things. That's just one example. There's so many ways to building a network because this is teamwork. You can't just treat spasticity and call it good. They're not going to have a good outcome. So modifying the practice. Type of patients and clinical focus. So this is what I would say. When you're first starting out and you're not busy and you're trying to do everything, just do the best you can with every patient. Help them out. As you get busier, that's your opportunity to start focusing on things that you enjoy. So let's say if you enjoy the electrodiagnostic medicine, if you're not getting those EMGs first, slowly you'll start getting more and more of those. As you get more of those, you can back off on the thing that you don't like. But still help out the community as best as you can. And I'm willing to bet, I think these guys would all agree with me, that if you were doing something other than managing neural rehab, and there's a huge need for that, right? Because most of our field has gone to taking care of doing things that are non-neural rehab. Maybe that's not true for this room, but as a whole, as a physiatry in America, more than 10,000 physiatrists, 80% of us identify ourselves as taking care of musculoskeletal pain management, sports medicine, and not neural rehab. And then the ones who do identify themselves as neural rehab are mainly inpatient. So they don't see any outpatient. So this is a very unique situation. There's all these patients that fall through the clinics, and very few of them are being seen in clinic. And that's where all the work is, and it's just low-hanging fruit, guys. You can help these people out, make your career really well, very gratifying. Modify your practice, work on the process to become more efficient and effective. So you constantly have to invest in yourself. Do not become complacent. Whatever you're doing, just keep doing the best you can. Because you'll enjoy your life more, you'll have a better practice and a better career. You know, a successful career is not just a financial return. It's how well you feel, that you don't get burnt out. I don't think any one of us is burnt out. We are so happy, because every day, somebody tells us how happy they are that we took care of them and made their lives so much better. And that's one thing. I don't know how I'm doing for time, because I want to leave time for questions. I can talk for too long, so let me just. We have like seven more minutes. What, seven more minutes? Well, but seven more minutes to the end, so. Oh, let me finish up in two minutes, so we can. And if there are questions, maybe I'll just stop. Because I can take it in any direction, or we can take it in any direction. Are there any burning questions anyone has? Right off the bat, or start thinking of questions. Let me see if there's anything really important I want to say. Process. Outcomes data, process, process, process. That's how you make your reputation. That's how you make sure that you're taking really good care of your patient. If you're doing an intervention, and they're not getting better, don't blame the patient. Don't blame the intervention. Blame yourself, right? Always blame yourself first. Figure it out. Why is this not working? Why is the patient not getting better? And why am I still doing the same thing to this patient if it's not working? If you start doing that, you're questioning yourself all the time, you'll get much better. Your patients will be happier for that, too. Keep learning. Do not become stagnant. There is a lot to be said about processes in running a clinic. You have to know the inside out of everything. And you always have, even if your system is running very smoothly, you have to go back. Because the margins, and I can tell you in private practice, I'm in an orthopedic group. Even my ortho guys are not feeling it. They're not making as much money as they used to. They're still making a lot of money, but not as much they used to. So the margins are getting, the fluff is going away. So you have to be super efficient, and you cannot afford to lose money. And you have to run your clinic very efficiently. You need to know your codes. You need to know how much it's costing. You want to make sure you're not missing out on any discounts on whatever products you're buying, whatever supplies you're getting, how you're using it, how much wastage you are having, how efficient your team is. And what I want to say is, end with this slide here with a key concept. Again, focus on what's good for the patient and the community. Run an efficient and effective clinic. And I put spasticity in parentheses. Just run your clinic efficiently. Keep the health care team motivated. That's very important. We're getting burnt out. Gosh, the staff is getting burnt out. You have to make the staff feel like they are part of the solution. I tell them, when a patient is very happy and walks out, I say, no, don't thank me alone. Thank the whole team. Thank my staff, the person who put you in the room, the person who helped me mix up the medication, the person who got you and helped you get dressed in and out of your clothes and taking it on and off your braces and helped me while I was injecting you. All of us help. So I tell them that the more they help me, the more they're helping the patients. Now they feel ownership. And that way, you keep your whole team energized and motivated. When they do good stuff, you tell them what they're doing. When it doesn't work, it's a process issue. Say, why is this not working? Why are we not getting X number of patients seen in an efficient way in clinic and fix that? Adapt and keep improving. And you have to adapt. Because you could be the best you are, but there's so many external forces and factors that will change your life. You just don't, you cannot predict all those things that happen, so you have to be adaptable. You cannot just keep doing, be happy with what you have. And ensure clinic provides return on investment to healthcare provider. What I meant by that is, you gotta have fun. If you're not happy, you're not gonna be a good provider. If you're grumpy, you feel like you didn't get paid enough, you're not happy, you will not be a good clinician. You wanna go see a clinician that's happy yourself, right? Probably when you see somebody, even the person who's serving you coffee, if it's a big smile, boom, you're gonna feel good about it. Somebody's not grumpy, oh, here's your coffee, take it, forget it, I'm not even gonna do latte art for you, you just have it. You're not gonna be as happy about it. So, same thing with patients. And I think, nobody probably understands this better than us, as PM and our doctors, right? It doesn't take much from having a nicely dressed person, able to walk and talk, and then lose all their dignity. Because now, all of a sudden, they've had a stroke, they're aphasic, they're smelly maybe, because they can't clean themselves properly, no one else does it, and their dignity's gone way down. Look at that person that way. Just ask yourself, gosh, what if I was in that situation? And can you help them make just a little bit of a difference in their life, and start improving them? And when they get better, they'll tell you how happy they are, nobody else might see it, but they will tell you, it'll make you feel so good, and that'll keep you happy. So, do the work with a smile, and if you're not able to do it, you're doing something wrong. You need to change, and add something to your practice. So you could be doing something that's making a lot of money, but if you're not happy, is it worth it, is it worth doing that for 30 years? Okay, so start by doing what's necessary, then do what's possible, and suddenly, you're doing the impossible. That was Francis of Assisi, and then again, I told you I'll end with this slide. Let the path lead you, instead of always trying to find your path, so don't waste too much time looking around, it's all right in front of us. Just take the path in front of you, the first step, second step, and start helping the patients that way. I'll stop with that, and please, guys, if you have questions, happy to answer. We've seen a lot of different perspectives. This is also being recorded, so if you don't mind, either pick up the mic, or just come up to the mic, it's right up here, and I think we can, do we have another extra mic, we can give one up? No, these are not, that's a, yeah, just come to the mic up here, and if anyone else wants to ask a question, just go and line up, so we can be more efficient. Again, process, you gotta be efficient. Good afternoon, excellent talk. I have two, one question really quick, and another one that might not be so quick. First of all, do any of you guys use guidance, ultrasound, or EMG for your Botox injections? And the second question is, do you ever, or at all, bill E&M codes, and have you gotten any pushback from anybody when you're injecting? So, I think I probably can answer universally. We all use guidance, various, I use eStim and EMG. Ultrasound, if necessary, but I find that at the speed at which I'm seeing patients, frankly, eStim and EMG are faster. And I have not ventured into the E&M code billing, and am interested in it, and my coding and billing person has given me the go-ahead to do so. But I've just, I kind of, I'm a little gun-shy as far as that. Now, it should be less gun-shy, right? Because I'm not buying the talks, and I'm doing, really, almost universally specialty pharmacy, so it's not like I can't make my payment to one of the companies because the code, because it gets denied or held up. But I'm still just not sure I understand how they're gonna follow up if it gets denied. But it's on our radar, let's put it that way. Yeah, I only use guidance. I always use guidance, I never don't use guidance. And yeah, I know when I'm in a gash rock, and yeah, I know when I'm in the semi-tendinosis. But that's not the issue. The issue is guidance will also tell us if the muscle is spastic or not, like the EMG guidance. It can tell us if we're in the largest part of the muscle belly or not, if we're doing an ultrasound. So I do all EMG and some ultrasound. And plus, it's, I mean, why not do guidance? I mean, if we're injecting $3,000 worth of toxin, shouldn't we spend an extra 70 bucks to make sure we know where the hell we are? Absolutely, I'll make that argument all day long. So in a lot of patients, I'll do EMG and ultrasound guidance and I'll bill for both and I get reimbursed for both with Medicare. And then doing the E and M codes, I've thought about that with EMGs, because I have to read the MRIs and read the notes of why they're being referred to me. And same thing with spasticity, I have to read all these notes and all that. But I don't. I don't do, I'll first evaluate the patient and I have them come back. So the first time I see them, I evaluate them and then I bill, you know, 99203, 99204, whatever it is. And then they come back for their procedure once I get approval for their toxin. But I don't do an E and M at the same time I'm doing a toxin injection, unless I'm doing something truly distinct, something different, like, oh, doctor, my shoulder also hurts, you know, something like that. And why not? Because, you know, I don't wanna get rejected with the cost of getting reimbursed for the toxin that I've purchased. Because I do do buy and bill for all my Medicare patients. And so I don't want, you know, an insurance company saying, we're gonna reject the whole thing or we're gonna audit you because you shouldn't have done an E and M code when I did. You know what I mean? And to me, it's just not really worth it. Go ahead. We've not had that problem with the E and M codes. We've had pretty good success. When you have them come in and then you have them come back and you're not doing toxin on the first visit, are you billing a G2211 on the first visit? You can't bill that with a procedure, of course, on subsequent visits. So the first time I see somebody, I just bill a new patient consult and then they come back at a later time for the injection. And then the first time I treat somebody, I have them come back for follow-up a month later. And then that's a separate E and M, of course. But I'm not, then when I come back and treat them again, you know, three months later with botulinum toxin, I'm not billing an E and M and the code and the CPT. You know what I mean? Are you doing an E and M every single time you treat somebody? If it's warranted, if I discuss things outside of the procedure and I can document those appropriately, then I do a low-level E and M typically. And you're having good luck there? I've had zero problems with it. We've had one doc in our practice, I think, got called on it and produced the records and they said, here's your money. But yeah, you make a very good point. We're all learning as we're going. But I mean, if I take the time to prescribe an AFO or send them to the appropriate physical therapist or OT or hand surgeon or whatever it is, then yeah, that is distinct from the medical procedure and we should be. I guess, as you would say, Tina, I was a little afraid of doing that for financial reasons, but if you make it work, thank you. Don't be scared. If you do the work, bill for it. Thank you, guys. I agree. While you're walking, I'll just add to that. The only thing is, yeah, from a process standpoint, for me, it's all about efficiency. So once in a while, there might be something that comes up during the procedure today that we have to add an E and M code, but otherwise, no, all that is done on a separate visit. So yeah, there are days when they're coming in for that and there are days they're coming in for procedures only. Do you do the 25 modifier very quickly? So you'll bill for the Botox injection and do a 25? Or 99213, whatever, and then do the 25 modifier? And then I do a G2211 for the extra little bit of RU when I'm not doing the procedure. So that's the new Medicare thing. Okay, thank you. Right, and our institution is not very happy about the G2211, so they have not cleared us to be able to use it yet. Why? I can't get a very good answer on that, but I've been hounding them about it and I'm the squeaky wheel, so. Right, and the same with me. I'm in private practice, Kansas City. The G codes really never pay for us, so we don't do them. And there is already some included E and M component to any procedure, so unless it's above and beyond that, I don't bill for the E and M. Yeah, go ahead. Actually, on the subject of billing E and M with a botulinum toxin injection, we had the opportunity to discover that a patient who worked for a national employer, who I won't name, but it rhymes with Schmalmart. Yeah. We discovered that if he came in for his botulinum toxin injections, he was on the hook for the cost of the toxin. However, his insurance indicated that if there was an E and M code legitimately done on that day, as well as that he just so happened to be receiving his botulinum toxin injections, suddenly he had a grand total copay of, I think it was $45. Wow. So just as an awareness, sometimes you have a huge impact, not only in the patient's care, but in their pocketbook, as well. Also, the toxin companies have their copay assistance program for patients with private insurance, which would be that, which is huge, which is like $1,000 four times a year, something like that, it's a lot of money. Right, but for this fellow in particular, because his insurance, that's how it covered it, he actually, we were able to get him into it, but the benefit was not covering the full amount of the toxin cost for him four times a year. That's fascinating, yeah, fascinating. So just as a heads up, that was an experience that we had there. And just in brief, we have in our practice, and she came with us to the hospital side, was it, she's a Botox czar, is what we call her. She is an authorization specialist that manages this stuff on a daily basis, and really, actually, first of all, if you want to ask, talk about people having a feeling as if they are doing something good for patients, that woman is happy all the time, because she gets all the phone calls telling them how, telling her how happy they were with the injection, thank you for scheduling me, thank you for taking care of that insurance thing, et cetera, and she really has made a difference in those, because there are some very weird little things where that individual insurance isn't gonna put it under the medical, or isn't gonna put it under the pharma benefit, or whatever, and she really is kind of the key to tell us, and then she'll come to us with, this is the way I think we can work around it. So we have exceptions like that, exceptions where that one's buy and bill, because for this insurance, like actually, people who are employed by my hospital have to receive it buy and bill, because it has to come from the hospital pharmacy, and that's the only way they can get it, they will not allow them to get it from anywhere else, like it's crazy stuff, but she's the kind of, you gotta get one of those, I have to say, to be good at it, you have to have somebody who understands the ins and outs, otherwise you will turn around three months later and be like, oh my God, what am I doing? It happens very fast, because people will find out you're doing injections, and you'll have all these patients, because you're really good, and you're in the hole very quickly. I think we need to turn the room around, so if people have questions, we're all around during the rest of the conference, happy to answer, I'll just add one more thing to that is, start out slow, make mistakes, learn from your mistakes, when you lose money, you learn very quickly, and you don't have to wait until you're making a whole bunch of money, and then make a big mistake. So make mistakes early on, so there'll be a way to learn. All right, thank you guys.

spasticity clinics

interdisciplinary approaches

innovative methods

patient care

multidisciplinary team

quality improvement

hybrid settings

EMG and ultrasound

billing complexities

PM&R relevance

continuous learning

patient-centered care