So good afternoon, good morning, wherever you may be. My name is Dr. Derek Allred. I'm the residency program director for PM&R and UT Health San Antonio. And we're very happy and thrilled to be here today with you to talk about Shifting the Paradigm, Team Physiatry in Acute Care Hospitals. Our discussion today is going to really be focusing on how physiatry can and should be taking a more expanded role within the hospital setting. So to begin, I have no disclosures, and hopefully by the end of our discussion today, you'll have a better understanding of the scope of what the consultation physiatrist can do in an acute hospital, identify some of the barriers to an integrated inpatient service. We'll also briefly review some of the scope of the disease processes that can be addressed by a physiatrist, and also reviewing goals of cares and prognostication. I would like to begin my talk by first talking about the end goal. So to sum up, by the end of your time with us, and if I may just read that, although many times the role of a physiatrist in a hospital setting is viewed mainly to assist in issues related to post-hospitalization disposition, and are often only involved after all acute medical issues are resolved, rehab physicians are uniquely poised to take a more assertive role in the continuum of patient care and play a more prominent role in the medical management of multiple pathologies. We have a lot to offer our colleagues on acute care services, and often in many institutions, we're just viewed at as a disposition service. Now, there are some institutions that have integrated very well into the acute hospital setting, and we can learn from their models, but my idea of rehab has certainly evolved quite a bit over the course of my time as a physician, starting way back when I was a resident. I, to give you a little idea of what my first exposure to inpatient consultation was like, my intern year, we rotated with an attending on the consultation service, who was an ex-Navy SEAL, and loved getting up at five o'clock in the morning to do rounds even before the surgeons. So there we were, team rehab, seeing all of these patients, waking them up, bullwrestling their rooms before the surgeons even got ahold of them, and then we'd be in and out quick, go back to the workroom, and really just leave recommendations on whether or not someone should or should not come to rehab. Now, as my knowledge grew and expanded over the course of residency, I became much more, I became very frustrated with the limitations that we were imposing on ourselves, and the lack of quality care that we were providing the patients with whom we were consulted on. And I've had the opportunity to stay at my institution post-residency, and I've seen a drastic change in some of the programs that we've implemented that we'll discuss here. I do want to show a video where many of you can probably relate to some of the content in this little exaggerated scenario between an all-star physiatry resident and a very well-intended trauma intern. So can I have the video, please? Hello, is this rehab medicine? Yes, how can I help you? I have a couple of patients that I would like to have come to rehab. Will you take them? Well, can you tell me a little bit more about them? Yes. The first is a spinal cord injury patient. He needs rehab. What are some of his medical needs? Is he urinating? He has failed six voiding trials. So, we just kept a Foley in him and consulted urology. He needs rehab. Is he having bowel movements? No, he has been constipated for 10 days and we have consulted GI. He needs rehab. Well, we can help with both of those things. Are his vitals stable? His blood pressure fluctuates from really hypotensive to really hypertensive. He also has severe bouts of bradycardia. We consulted cardiology for that. He needs rehab. I wish you would have called us sooner. We can help with all of these problems. I didn't think rehab doctors went to medical school. Good to know. Maybe we will call you sooner next time. But this patient needs rehab. Will you take him? I will see him and give you our recommendations. Can you tell me about your other patient? Yes. It is a traumatic brain injury patient who has been on our service for more than a month. She also needs rehab. Well, can you tell me how she is doing in therapy? She doesn't do much therapy. She is too tired in the mornings because she is up all night watching TV. Then she gets really agitated when she wakes up in the afternoon. She needs rehab. How are you treating her agitation? We have consulted psychiatry who is helping us manage her with copious amounts of Haldol and Ativan. She needs rehab. Do you know that's not the best way to treat agitation in brain injury patients? It has really decreased the number of times a nurse has had to call me. Maybe you can try it on your rehab floor, too. We really want to be involved in these cases so we can help you improve their outcomes and get them to rehab earlier. Good to know. I only consulted you because my case manager told me to. Out of curiosity, can you tell me the difference between what you do and what a physical therapist does? And will you take my patients to rehab? So again, there's a little bit of exaggeration, but I get the sense that in some circumstances we may have had similar encounters with our colleagues and other services who are asking for a rehabilitation consult. And honestly, that's exactly what it was like here at my home institution just four or five years ago. Hello. Things started changing here in this institution shortly after we, when I was just in attending here, we had a case of a traumatic brain injury patient who had sustained a karate kick to the head and was left in a quote-unquote comatose state. We were consulted roughly about two weeks after his injury and his surgery, and nothing was being done for him. He was just literally sitting on a floor and he had no funding, so the surgeons had no idea what to do with him. So we swept into action and we started directing the therapies. Out of bed, tilt table, we had speech come and do some formal assessments on a disorder of consciousness, medically managed arousal, bladder program, spasticity. And eventually after following him for 46 days, he emerged and was admitted to acute rehab. And that story began a chain reaction within our institution of showing and demonstrating the benefit of our services here. So how can you, if you have similar experiences in your own institutions, how can we change the paradigm? How can we move from being an overqualified disposition service who literally just talks about, can my patient go to rehab? I'm playing gatekeeper to earth versus becoming a very robust medical service and actually assist our colleagues in the medical management of these very complex patients. A lot of the barriers that we have and may be applicable to you is a lack of awareness or visibility of physiatry in your institution, which may lead to a lack of respect for specialty. So a lot of, I think these things can be self-inflicted if in, but we can take appropriate measures to become more of a prominent force within the hospital in which you work. Some of the other barriers, and I'm highlighting this paper, it's a good paper. This was published about 2018, two years ago. It's a paper that basically concluded that ICU acquired weakness should basically be co-managed by a physiatrist. Now, while we appreciate the shout out and the recognition and the notoriety, this type of narrative with PMR being established back in 1945, should have evolved much earlier. Right now, you don't hear evidence of orthopedics. You don't hear literature saying evidence shows that a hip replacement is better seen by, has better outcomes when you see an orthopod. We need to ingrain in our culture more of a, an understanding of what rehab medicine does. So, for the sake of time, and allowing my colleagues to jump in, I'm just gonna kinda, so what can physiatry bring to the table? All right, so it's very well known that there are improved length of stay and overall costs. We can help diagnose a, a patient with a hip replacement. We can help diagnose a disease specific, we can help in disease management of specific issues, help with prognostication and family education. There's a lot of evidence out there that is showing that physiatry really does assist in, in helping save costs for hospitals and for patients. In addition, there's a lot of evidence that will probably be discussed earlier about early mobilization protocols, which I will kinda defer to my colleagues a little bit later in the presentation. Sorry, my time is short. So, just to give you an idea of a couple of examples of things you can address on your consultation service. Spinal cord injury. I'm getting involved right at the time they hit the door. Being able to perform an age exam and help neurosurgeons prognosticate with families and patients. Ongoing assessments of spinal shock. There's also additional medical management that we can engage with in the acute setting. The Consortium for Spinal Cord Medicine and the Congress of Neurologic Surgeons have issued guidelines for resuscitation efforts. And within our institution, or at least a couple of years ago, that our intensivists weren't operating by those guidelines. GI issues as it relates to initiating bowel program or PPI prophylaxis. The timing of intermittent catheterization programs, treatment for orthostasis. Respiratory issues for vented patients, co-managing a vented, high tetraplegics. As well as identifying dysphagia and ensuring that our patients receive the proper thromboembolism prevention that will prevent them from getting clots. Just a few ideas with the spinal cord injury patient population. Amputation medicine, assisting with phantom limb pain, residual limb shaping, proper positioning, ensuring that the early contact is made with the prosthetist. And really start the process early for prosthesis fabrication. My colleagues will really delve into the things that we can do for brain injury medicine. So I won't spend too much time on that. But this, I found this article very, very interesting. This was a study done back in 2016 that compared outcomes, functional outcomes between brain injured patients who went through an ICU team that had a physiatrist versus those that did not have a physiatrist. And the evidence yielded, the evidence showed that the patients that had a physiatrist intervene while they were in ICU actually had an accelerated rate of functional outcomes compared to those who did not have a physiatrist embedded in their trauma team. So what have we done here in our own institution? Well, we've, and you may be doing these where you're at, or you may be implementing some of the, or you've already implemented them within your own program. But we've started meeting quite frequently with all of our case managers to make sure that all patients who would benefit from the physiatrist do get the chance to have that consultation. We've started rounding with our intensivists and providing recommendations on all trauma patients and neuro ICU patients who may not be considered for IRF at that time. We've also been implementing what I call untrustable professional activities, which are essentially a means by which the attendings on these other services will actually be grading our residents on how they provide consultations, which has given us a more kind of visibility within the hospital. Hospital administration has asked us to implement a institution-wide CAUTI prevention program. We've taken the initiative of really spearheading family meetings and taking over the acute pain management. So all of these things that we've done in our own institution have really increased our standing in the hospital and have helped provide better business for our IRF and provide better care for our patients. So next I will turn the time over to Dr. Mosley. Good afternoon. My name is Nicole Mosley. I am a physiatrist specializing in brain injury medicine at Spaulding Rehabilitation Hospital and Massachusetts General Hospital. I'm the director of the Brain Injury Medicine Fellowship Program at Spaulding and Mass General. And I've served as a consultant in the Neurointensive Care Unit since 2012 as the first dedicated physiatrist in that unit. And so it's from this perspective that I offer my expertise on early rehab intervention, specifically geared toward the neurologic population. So there's this new paradigm, as Derek referred to, of early rehab, and it's replaced the old paradigm that Howard Rusk, who originally described rehab as this third phase of medicine. You know, it initially, it used to imply that rehab interventions should really wait until patients were medically and surgically stable. But now we have centers like mine at MGH with embedded physical, occupational, and speech therapists who start seeing patients really on day one in our ICUs. So things have obviously changed quite dramatically. I'll speak on some of the commonest issues now that are encountered in the acute care setting. This is a lengthy, but not a completely encompassing list of issues that I address in the ICU, as well as a step-down in the acute care setting. In the ICU, as well as the step-down neurology units, you'll find that most of these issues are the same that you would encounter in any freestanding IRF, for example. Certainly it stands to reason, in that case, that identifying these issues in week one in the acute care setting, as opposed to only at the start of a patient's post-acute hospitalization, would be ideal and certainly benefit not only the care team, but ultimately the patient, which is the goal. Aside from the inciting spinal cord injury, or TBI, or stroke, or other neurologic event, there are several extremely common medical issues and impairments that a podiatrist will encounter and can help manage in the acute setting. ICU-associated weakness is seen in up to 60% of patients, sometimes more, depending on the literature that you're looking at. Muscle strength, the loss of muscle strength, anyway, as we are familiar with, can be up to 5% per week on patients who are on bed rest, which is almost by default what you are on as an ICU patient in most cases. And delirium is quite common, affecting up to 80% of patients and really across all ICUs. It's extremely common. Pain is, again, stands to reason, anywhere from headache to musculoskeletal pain. We see the gamut after subarachnoid hemorrhage, for example. Patients can have really severe neuropathic pain from irritation of the neuroaxis. Psych symptoms are very common. Patients may not actually meet DSM-5 criteria for clinical depression. However, they do readily show signs of adjustment disorder and mood impairment, even in the acute care setting. Anxiety and PTSD. Again, PTSD, particularly in the subarachnoid hemorrhage population is much more common than I think many clinicians are aware. And not only do these problems are, can you identify them in the ICU, but they obviously persist beyond just the acute care hospitalization. So we're looking at myriad issues aside from just the direct sort of physical symptoms and direct sort of physical and cognitive impairments from the initial neurologic insult. One of the most appealing interventions that physiatrists have been looking at and studying along with neurologists as well is that of early mobilization. It's essentially defined as the application of physical activity within the first two to five days of critical illness or injury. Now, other papers have defined it as within the first 24 hours. They're one of the, some of the larger trials look into it a little bit earlier, but we'll generalize it to the first two to five days as defined by Cameron, Dr. Cameron. And what does it include? There's a range. It's not just walking, right? Because not all patients can walk. So it's range of motion, bed exercises, bed mobility, transfers, ADLs, working on postural stability. And, you know, the ultimate is mobility. But many of the patients actually, particularly the neuro patients, don't actually have the option. They don't have the strength. They don't have the wherewithal to be able to ambulate yet. So there are many other sort of lower hanging sources of fruit that can be addressed. That being said, implementing an early mobilization protocol is very difficult. It's not easy. If you're thinking of moving this kind of concept and practice into the acute care setting, I'll caution you that it needs to be approached with the utmost diplomacy, more diplomacy than you think you might even have and be able to muster up, because it really requires broad buy-in from multiple specialists. And in centers that are sort of world-class centers, top-rated areas where people already feel like they are doing the very best, it can be a challenge to to convince your colleagues that you can actually do even better by protocolizing some of the work that we do. This is actually one of the papers that did just that. So this is the SOMES score, SOMES algorithm. This comes from the SOMES study, which is a study that was done in part at Mass General, but also at other studies. It was an international RCT where a goal-directed early mobilization protocol was actually put in place, and that was tested against standard of care. And this is actually in one of those ICUs where there are embedded PT, OT, and physical therapists already working in the unit. But the use of this protocol actually was really, really impressive. I recall that the ICU length of stay was decreased by three days. And so, you know, even in a center where things are going really well and folks are leaders in the field, it shows us that it can be done even better. That being said, the data on, sorry, this is that trial. That being said, the data on early mobilization is not as consistent as I would like. There have been many trials. There's been a Cochrane database. This was another RCT that was done and looked at also some systematic reviews. And this study found that there was no difference in hospital length of stay, no difference in ventilator-free days, ICU length of stay, but the physical function measures were significantly better at the six-month mark. And so it's a little bit frustrating because the data isn't, again, as rock-solid as we like. I think the jury is still out. What we do know is that it's probably not harmful, but it's not necessarily something you can take to the bank in every instance at every institution. And you also have to be quite careful about how it's done because you don't want to end up costing hospital money when the goal is, in fact, to save money. So moving on from just early mobilization, there is an evidence-based guide that was created to optimize ICU patient recovery. Now, this wasn't specific to neuropatients. This is just ICU patients in general. And it's called the ABCDEF bundle. Many academic centers use this bundle. You'll find it at the end of the ICU notes. And that stands for Assess, Prevent, and Manage Pain, both spontaneous awakening trials and spontaneous breathing trials, choice of analgesia and sedation, and delirium. And so this is an algorithm of such that is designed to maximize outcome, minimize complications for ICU patients. And this is at work as well in our ICU. So I always think about this as I'm seeing patients, and certainly the neurointensivists and I are discussing these issues and this algorithm of sorts. The spontaneous awakening and breathing trials, I won't go into that too much, but suffice it to say that we are trialing these much earlier and earlier. It is a normal and expected part of care in the neuro-ICU. And essentially, we are trying to test earlier if patients are looking like they are ready to come off the ventilator. And sometimes that can be independent of their neurologic status. And so even patients who seem very low level will undergo these spontaneous trials. The PADIS guidelines, it's another set of clinical practice guidelines for the care of ICU patients. Again, not specific to neuropatients, but certainly utilized by caregivers of neuropatients. And there were guidelines originally released in 2013. They were updated in 2018 to include immobility, the IS, and sleep disturbance, because it was thought that they were quote, inextricably linked. And certainly those are two of the issues that we are quite passionate about in the physiatric world. So just to review the evidence, I won't go into detail here. I think you should probably just look over to the far right column and note that unfortunately, the evidence rating in general is either absent, low or very low for most of these interventions. So pain management, agitation, sedations, looking at things like cryotherapy, relaxation therapy, physical restraints, which we use all the time. There was some studies on cyber therapy as well, which is becoming of increasing interest. Looking at delirium and immobility and how we address and manage those. Again, evidence at best, high, only in the case of delirium, and that's with bright light therapy, but generally sort of in the low to moderate range. So not as encouraging as I would like, but we are paying attention to these things. At least it is at the forefront of clinicians' minds in the ICU setting. Sleep was the other component that has been looked at in the PADIS guidelines. Again, low to very low evidence. This is looking at using AAC mode, which is a specific ventilation mode for patients who are intubated. Acupressure, music therapy has been and continues to be studied. And then noise and light reduction, which are really kind of standard parts of delirium protocols and management. I just wanted to show you what is out there and what has been looked at. Who are these guidelines even guiding? So this was taken from the clinical practice guidelines, as I mentioned. And, you know, I think awareness is the first step and then implementation being the second step. So awareness is quite a hurdle. And this is, I think, in part why we are seeing that in spite of decades really of emphasis on some of these issues, a minority of patients are actually sort of having these things addressed. 60% of ICUs in the U.S. have implemented the PADIS protocols, but the adherence to the protocols can be low. You still find clinicians wanting to sort of move to the beat of their own drum. And so even though we have these guidelines, standardizing and implementing them and making sure that clinicians are following them continues to be a problem, including in our institution as well. So this is my home away from home. This is the Lunder 6 neurointensive care unit. This is a sample room. There's a beautiful bamboo garden in the background. And this is kind of where I live. I want to talk just about a few things that I encounter essentially almost daily in terms of management. Delirium is maybe number one or at least top three. There is, I teach my fellows and residents about how to think about delirium. So when you have a patient that folks are saying, oh, this patient's delirious, well, understand that that's kind of a trashcan term and it may in fact not be true, that not every patient that is called delirious is actually delirious. And secondly, before moving to treat delirium, you want to rule out other things. Before you move to give a patient a medication to treat anything, go down the list. Think about what could be happening. Certainly reversible causes are key. So there are two acronyms, Dr. Dre and THINK. I like to have the residents and fellows take a look at these. It helps, I think, to not miss different potential underlying causes of alteration in mental status, which is sort of the umbrella term that everyone goes under. And then for neuro patients in particular, you want to think if you've got a patient in the neuro ICU and they've got an alteration in mental status, they are suddenly hyperactive or hypoactive. They're suddenly more confused. Their sleep-wake cycle is off and things are changing neurologically. Think about these things. Is there a new stroke? Is there new onset hydrocephalus? Is there midline shift? Does this patient suddenly have worsening edema? Are they seizing or is this an underlying psychiatric issue? Have they become catatonic? Is this some form of hallucination? What else might be causing this change? It's very quick to try to move to treat something, but I really think it's important that we think through. And again, particularly for the neuro population who may be experiencing very unique changes that are detectable on CT or MI or EEG, for example, not to forget those things. I also think it's very important to be systematic in assessment. So I use the CAM-ICU all the time. This is an algorithm. I think it's very straightforward. It's a very quick bedside assessment. And again, helps one or prevents one from forgetting to cross the T and dot the I. So the CAM-ICU is a wonderful tool that I really, really think that every acute care clinician should be using when assessing someone with alteration in mental status for whom delirium is suspected. There is a delirium protocol as well that I find to be very helpful. This is from ICUdelirium.org, published by the Critical Care Medicine Society. Again, protocolize it. If you don't know what to do, go to the protocol, go to the algorithm, and let it guide you. And this way you are able to offer patients consistent care across the board, at the very least a consistent evaluation across the board. And so I really like this delirium protocol here that the ICUdelirium.org has published for anyone to have access to. And essentially it requires that you go through the CAM-ICU and then move from there depending on if they are CAM-ICU positive or negative, or if they happen to have an even lower stuporous or comatose state, for example. So again, protocol, protocol, consistent, consistent, consistent, I think is key when managing these patients. How do we look at hypoarousal? Again, it's why do we even care about it in the acute care setting? Well, for the patients that are lucky enough to have access to these occupational therapists and so forth, we want them to participate. We want them to get up and get out of bed. And so hypoarousal and fatigue can be really significant barriers. The differential's pretty broad. Again, these are neuropatients. So we're thinking about seizure. We're thinking about a new bleed. We're thinking about hypoxia, a new infection. It doesn't take much to tip the balance. What do we use for these patients? Well, I call these the big three, modafinil, amantadine, and ritalin. We've actually studied these prescribing patterns. Actually, my group has published earlier this year on prescribing patterns in the TBI population, and we are submitting a paper next week on prescribing patterns in the stroke population, ischemic and hemorrhagic stroke. What we find is that they're probably under-prescribed, but luckily the adverse event rate is extremely low for patients receiving any of the big three, generally speaking. There was a MIRAS study, modafinil recovery after stroke, looking at treating modafinil early for fatigue and lethargy in patients, and it was actually associated with increased or improved discharge disposition, again, without significant adverse events. And we also know, I think, Joe Giacino's now very famous study looking at amantadine. Now, this was in sort of subacute populations, didn't start until week four, but in TBI patients did increase clinically relevant behaviors. And so, again, there's a growing body of literature, and so far, at the very least, prescribing these seems generally safe for this population. Agitation, big, big, big. Probably, I don't know, 30 to 40% of my consults on any given day may be because of agitation. It's almost universal in patients in the near ICU. The numbers bear out up to about 86%. Again, the differential is broad, and I think it's very important to look for reversible causes before you go to sedate someone. And so, I tell the trainees all the time, what's going on here? Why do you think this patient's agitated? Let's start there. Let's look at the labs. Let's look at the last time they had a bowel movement. Let's look at the pain management regimen. What's going on that may be causing this first? And then, how should we treat that specific issue? So, conservative measures are king. And then, moving on from that, there's been some studies on dexmethomidine, which is Presidex. We now have a Presidex protocol in place in the neuro ICU. We've moved away from using so much propofol and are preferentially using Presidex. You can examine patients on Presidex. It doesn't suppress respiration. And so, this is a medication in the neuro ICU that has really grown in popularity. It's not perfect, but I think it's better than propofol, which is what we had initially depended on for so many decades. Beta blockers have been shown to reduce agitation on the avert agitation scale. AEDs, I love valproic acid. Second to that, I really like carbamazepine. Antipsychotics and neuroleptics, not bad. Haldol effectiveness is questioned now because of two placebo-controlled RCTs, which didn't show any evidence on an impact of delirium in critically ill patients. So, I remain skeptical of Haldol. Atypicals, I think, are certainly preferred. And then, benzos. Benzos, to me, are kind of bad news, generally speaking. I think most physiatrists believe that. There's been some evidence of it leading to cognitive impairment and slowing down recovery. So, I really try to avoid those unless there's absolutely nothing else left. For sleep-wake cycle disruption, again, almost universal. It leads to poor functional recovery, increased risk of depression and cardiac events. OSA, you really have to think about that. It's not something we can evaluate in the acute care setting, but certainly as patients move through the clinical continuum to keep that very high on the differential, especially for stroke patients. And there was a study called, I call it MEDIAS, looking at treatment of insomnia and delirium. Again, sleep hygiene, hygiene, hygiene is key. And then, in terms of pharmacotherapy, we often use melatonin, which is very well tolerated to reinforce circadian rhythm. And then, zolpidem, actually. It's not as dangerous as I think I thought it was as a trainee. It can have some neuroprotective effects. There's that potential. So, to keep those in mind. Spasticity, I manage that. I do some Botox in the acute care setting. It is, again, quite common, more so in the hemorrhagic versus ischemic stroke patients, more so with patients who have severe paresis than minor paresis. I rarely encounter this in acute stroke and acute TBI patients. But we do have these patients coming back from the rehab setting. And they come back, and they've now developed tone. And so, we get a chance to do something and to address those. I try to stay as much as I can away from pharmacologic management because we are also usually dealing with alterations in mental status. But when I have to, I try to be very careful about approaching it with low dosing and very slow titration. Just quickly, I'll tell you about the post-intensive care syndrome. This is a thing. It's the PICS. It's something that, I think, again, clinicians in acute care setting are becoming more aware of. And just very briefly, there are multiple domains, physical, cognitive, and mental. And it's something that we should all be looking for as patients transition out of the ICU to look for these signs and symptoms of PICS. What we lack in the grand scheme of things in terms of physiatrists or physiatric principals in acute care medicine is that we have not yet standardized our functional assessments. We are still needing much more data-driven data in terms of driving the pharmacology that we use. We don't have any standardized post-acute surveillance protocols. And we still lack, I think, universally speaking, long-term outcome monitoring. And this is even at, again, leading institutions. So that's an area of focus, I think, that we should really be looking into, especially as we try to gather more and more data about our patients. And lastly, just a note about common data elements. So this is quite a buzzword now in the academic world. It emphasizes a team-centered approach. There is work now in the trauma common data elements. There's work to get those in place. And this goes back to collaborating and making systematic this data collection so that we hopefully will be able to determine what the effect is of our acute care interventions on patients' long-term outcomes. Thank you for your attention. Dr. Frankel will be coming up next. Good afternoon, everybody. Thank you for joining. Oops. Hang on. I seem to have moved ahead. Okay. I was asked sort of late in the game by my colleagues to provide some perspective on what it's like to create an inpatient consultation service de novo, which I did about 12 years ago at Brigham and Women's Hospital in Boston, which had never had a full-time physiatrist present. I have no disclosures to make for financial or academic concerns. And in response to Dr. Allred's very humorous video before, I have to say, get ready if you're setting up a service. People still don't know what you do. It's very, very hard to explain to people. We struggle to define what we do because it's so broad. I'm glad Dr. Allred went through in some detail just what are the main concerns of a physiatrist, and I have them listed below. But it's important to know that although we do understand how these conditions are treated, treating them sui generis is not exactly what we're concerned with. And I think it's helpful to have sort of a canned phrase, a canned paragraph that you can give to people about what you do. I won't read this in the interest of time, but it's important to help people understand that we don't just treat the specific illnesses and treatments. Explain to them how we work with the other people taking care of them and try to come up with an overall treatment plan, as well as a big picture for the patients and their families about where they stand both medically, surgically, and functionally. And this makes us interdisciplinary physicians, not just multidisciplinary. Big buzzword in the field, as you know. So what is probably the most powerful tool that we use? Don't be afraid to recommend lead meetings involving patients, their families, and large groups of professionals caring for them. It's probably the most efficient way to get information across between the people who are caring for a patient and the patients themselves and their families. Here is a place where I may propose a rehabilitation disposition for a patient, but also identify the barriers that stand in the way. And it's great when everybody hears the same thing about this. But there are lots of less tangible things we do as physiatrists that can make us valuable to patients and their families. So I'm going to give you a few different techniques that I learned over the years. First of all, do what you do. Show how you bring the team together with difficult patients, and the primary services will be a path to your door. Again, I'm going to say it again, don't be afraid to suggest a team meeting or a family team meeting where you feel that the communication hasn't been efficient. This is one of the things that primary services don't always recognize and struggle the most to cope with. They don't need you to speak for them as far as how a treatment plan is going to make somebody's underlying issue better. But you can amplify that message. You can also tie it into the functional outcomes that other people caring for these patients are concerned with, the nurses, the physical therapists, the occupational and speech therapists, and the patients and families themselves. But I will say, I think the slide advancement may have frozen, Catherine, if you could move my slide forward. This is a privilege that you have to earn. It's going to take you a while and you have to be patient so that people understand who this person is coming in and telling them all these things about what they need to do to move a patient through the system. As you're starting your service up, it's important to meet upfront before you ever see a patient with the case managers, the nurses, the therapists, and other consultants and the other consulting teams. And I would say that when you work with patients, you should spend some time outside the patient's room talking to all these people along. In addition to help unifying the team, everyone will know your name, they'll start looking at your notes more. And this helps facilitate productive crosstalk around the table, even if the thing isn't taking place around an actual table. It can foster a lot of things, encourage patients and families to ask questions when they do see other people. Please advance to the next slide. I was asked to make a couple of comments about how staff, hang on, I know, here's the next slide. Do show what you know, and I'm not going to say too much about this because I think Dr. Allred already talked about this. As you know, as you enter the environment, make sure people understand the problems you deal with the most often. And also make an effort to attend team rounds as the primary teams are moving around the floor without other people present. It helps you identify patients that you can help the most and also give input on the headache management after TBI, bladder, bowel, the things that we do have a role in and should be managing earlier in the stay. But also show that your resources are not just limited to rehab hospital placement. You're not just the gateway to IRF, as has already been said. You have connections to lots of other people in the outpatient care world in terms of community resources. We all know those organizations for managing patients with cerebral palsy in the community, et cetera, that are invaluable and not something that inpatient teams know much about. Next, I was asked to say a little bit about how staff and how to interact with them. Not everybody's working in a large academic medical center, but as much as possible, I try to take some kind of a teaching role with the house staff and encourage them to enter orders. In the process, you can help them understand what you treat, the scope of your practice, but also help introduce them to medications they may not be familiar with that could be useful to them in the future. What are the side effects they should look for, et cetera. At the same time, you're sort of getting across a secret agenda, I'll say. It's not entirely within your control exactly what's going to happen with a patient, but focus on how what you do helps move the patient through the system quickly and more efficiently. That's language that the team is really going to understand and will, again, help them beat a path to your door. Next slide is technique number three, be proactive and outgoing. Don't be afraid to reach out to teams before you're even asked to help them see things they may be missing. It may be written all over the chart, this patient's going to rehab, this patient's going to rehab. You have to get very good, and as Dr. Maz, we said, very diplomatic about telling people there is something you're missing here that's going to hold up this discharge. They may not like hearing it, but they will appreciate it when they see how smoothly things move afterwards. The other thing that I do is spend a lot of time talking to the patients and the families to make sure that they understand what is happening with them, that they understand the plan. It's not always explained to them as well as the primary teams may think, and this is something that you thankfully have the time as a consultant to do to help fill some knowledge gaps, help people understand the levels of care that are being looked at for them and why, why they may not be ready to leave yet, etc. I have two more slides. I like this one. This is a lot of what we do. Instill hope, because acute care hospitals can be a pretty hopeless place sometimes. There are three situations where I think we really can pull our weight here. First of all, if patients and families and the primary teams are afraid that there's just no way they're going to be able to discharge a patient, they're too complicated, instill hope with them that this can happen by working together, by grabbing opportunities, understand that the choices may be limited, but it's still possible. If patients, family, and team members mistake a severe injury for a bad long-term prognosis, again, diplomatically, feel comfortable stepping in and saying, you know, that might not be true. This patient six months from now could look very different. Modern hospital teams really struggle with functional outcomes. They just don't see these patients as they leave the hospital as we do. Finally, if it looks like it's time to talk about a transition in the goals of care, know your friends and colleagues in pain management and palliative care. I'm so happy to see so many people from physiatry going into palliative care. I can't think of many other fields that are as well-suited to this. And never be afraid to introduce that conversation. Finally, care for yourself. It can be really, really demanding being an inpatient consultant. And sometimes you're the only person doing it, as I was. I didn't always have a resident with me. You must arrange coverage. You must arrange to have time off and be able to have normal human events. And as we all hear about burnout is such a disturbing thing and common thing in our field, avoid it. And for me, it wasn't just learning how to get away from time to time. It was eventually walking away from the consultation service. Not completely, but especially after our hospital moved and it got much harder to move between Brigham and Women's Hospital and Spalding Rehabilitation, I decided it was time to pass the service off to somebody else. I still cover pretty extensively, but I'm not the only person there anymore. Learn how to communicate honestly about what you can and can't do. People don't always like hearing it, but be prepared to explain why not only can you not make a rehabilitation bed appear for a patient, it's important to that intern who's very focused on will you take this patient to rehab to sometimes explain to them that's not a good idea. We could hurt this person more than we help them. Finally, be honest with yourself about what you can and can't do. I love to quote Osler to pretty much anyone who will listen. Practice equanimity. Know that you've gone through the process the right way and understand that the outcomes are not always up to you. And it's not just something you communicate to the other people you work with. It's something that you practice and remind yourself of constantly in an inpatient service where the outcomes are not always what you expect. Okay, thank you very much. I'm going to pass this on to Dr. Gutierrez. Hi, thanks for having me. I'll kind of end up talking about the last part of my talk, which I've given a little bit of versions of this before, and that is just the perspective of what, you know, what decisions we make and a couple hours today I was talking about health disparities in PMR. So I'm going to kind of tie this in. So I want you to be thinking about this in the back of your mind if you're someone who's doing consults in the acute care setting. So academic podiatrist also in UT Health, San Antonio. We have a large, very busy level one trauma hospital. I previously was in Houston, also did acute care consults there, getting neuro rehab specialty and interventional spasticity management. And I do definitely like to talk about healthcare disparities because here in the United States, we spend a disproportionate large amount of GDP on healthcare more than any other country in the world, yet we don't have the best outcomes. And it is not only related to cost, but then it looks into healthcare disparities. May the odds be ever in your favor for even a patient who gets in the hospital who may have a minoritized background. And so part of the reason I care so much about this, my own grandfather had a stroke when I was in college. No one had any medical background then in my family, first generation to be a physician. And he ended up having a stroke and then going to a nursing home where he spent the rest of his life, which he didn't get to live long enough to see me become a physician. But in retrospect, I realized that he never had inpatient rehabilitation and he had insurance. He had Medicare. He was a veteran of World War II, so he had VA benefits. And yet still, he went to skilled nursing facility. And he also, when I remember seeing him in his facility, he was able to move his four limbs. He could sit up in a chair. He could move his legs to move the chair around. So really he was a good candidate. But now we come to find out with different studies that have been done that Mexican Americans are four and a half times less likely to go to inpatient rehab versus white persons, even when you control for insurance. And this is when we have to start thinking of issues like implicit bias and systemic racism. There is data also showing other disparities in TBI rehabilitation, even on the acute setting that when patients didn't have health insurance, they're less likely to even get a head CT scan. This is something that's guideline indicated. And so if you don't have insurance, you're also less likely to get the right kind of care that you need, which again, ends up distorting outcomes. In this study, from the American Journal of Study, it was a retrospective analysis where they looked at Medicare beneficiaries, which means they should all have the same amount of coverage who were hospitalized for more moderate or severe TBI. And they compared over the time, you know, one thing that the hospital cares about, the other thing you have to align yourself with what the acute care hospital cares about, and what they care about is length of stay and mortality. So in this study, where they looked over these years, the 30 day mortality was the same. It didn't change over these years. But during that time, they ended up putting more patients into hospice because when they put patients into hospice, it doesn't account against their mortality. And then also they were doing less neurosurgery for these patients at that time. So again, you kind of have to think about what hospitals are doing and what kind of games they're going to be playing with brain injured patients. And this is a study that looked at National Trauma Data Bank, 187,000 patients, different backgrounds, different insurances, which found that insurance status and race affected their treatment and outcome. And if they're uninsured, they're less likely to get surgeries at longer hospital stays, more likely to die in the hospital, and of course, less likely to be discharged to rehabilitation. We did a paper that came out this year where we did a narrative review for disparities in healthcare for black patients in the United States regarding PM&R. And there's pretty interesting stuff also in the spinal cord injury literature where black persons are 13% of the US population, but have 24% of spinal cord injuries. And when you look at the number of spinal cord injuries that are due to violence, then about 48% happen to be African American persons that have violence related spinal cord injury. So again, things that we know, again, related to issues that are going on right now in the news. And also black individuals who had acute spinal cord injury, they're less likely to have surgical decompression, had longer ICU stays, more complications, and were less likely to get inpatient rehab. So some of it is just kind of educating you about what's out there so that you realize that when you're seeing patients, that you can kind of try to decrease these outcomes and make sure everyone who needs rehab gets it. This is also happening in COVID-19. There's more morbidity in populations of color. And so again, wrote a paper making a call to action for physiatrists to make sure that we're taking care of this population as well. What is something that is important, again, in the acute care setting? You've heard it speaker after speaker is interdisciplinary teamwork at the IHI. Now everything's going towards quality, and there's a triple aim, and now it's a quadruple aim, where this is what we should be doing. Healthcare teams from different fields start working together to provide the same goals, you know, better experience, population health improvement, reducing per capita costs, and then again, improving the experience of providing care, meaning also less burnout in the physician. So again, like everyone else said, we're working together with the acute care team to make patient-centered outcomes the most important thing. Like what? So part of the interdisciplinary team, you've heard a little about this, you know, the acute care team, the therapists, the social workers, case managers, the liaisons, the medical directors should all be working together. And then what you really know, what you need to know, let's say what all I really need to know I learned in kindergarten, that's number one is know the rules. So for the patients, know the insurers, know the guidelines, know the coverage, know what the literature says, so that you're, that's also, if you have trainees, that system-based practice, you're teaching them, you know, this is what I know about Medicare, these are the levels, these are the rules. So know that kind of stuff. That's going to be very important to make you a stronger physiatrist. Again, going back to trying to take care of the patients, be equitable in your care, kind of just making you a little bit more aware of what happens to persons of color when they get into our hospital system. So ensure that there are the best outcomes in the end. I am finished. I know we don't have very much time. And a lot of the questions were answered in the chat. So I think all of the questions actually were answered in the chat, at least from what I can see. If there are any others, please submit them now. Otherwise, thank you to Drs. Allred, Gutierrez, Frankel, and to all of the participants here listening today. We've enjoyed your questions and your attentiveness, and have a great afternoon. Enjoy the rest of the conference.

physiatry

acute care hospitals

interdisciplinary teamwork

medical conditions

integrated inpatient service

continuum of patient care

early mobilization protocols

healthcare disparities

rehabilitation services