Welcome to the 2020 AAPMNR Virtual Annual Assembly and the Sports Medicine Community Session. Can PMR doctors be head team physicians? So some housekeeping, to claim CME credit, you need to complete an evaluation for each session you attend. So whether it's live or you're watching on demand during the assembly, all sessions will be recorded and made available on demand until January 31st, 2021. Please visit the Member Resource Center if you have any questions. Also note your feedback on the evaluation helps the Program Planning Committee outline content for future annual assemblies. So we welcome suggestions and content. So welcome all to the Sports Medicine Session. Wow, they're showing everybody's face. It's very confusing. I'm Mark Ellen, and we're going to talk about what it takes to be a team physician today. We have, I think, a really good program with some fantastic speakers. I want to especially thank the Academy for allowing us to do this and for all their help in setting this up, especially Myra Stanley, who's really helped us, and I know she spent a lot of hours doing this. For next year, if anybody has any suggestions, please start thinking about them because we're going to be entertaining them over the next few weeks. So today's discussion is going to be what it takes to be a team physician. We've rounded up some phenomenal people who are already head team physicians, and we're going to start off with Mike Fredrickson, who everybody here probably knows. Mike is the head team physician at Stanford University. He's really responsible for track and field as well as swimming. He's a full professor of both orthopedic surgery and physical medicine and rehabilitation within the Division of Physical Medicine and Rehabilitation in the Department of Orthopedic Surgery. He's very well known. He has over 175 peer-reviewed publications at this point and over 30 book chapters. He has been a liaison for the Academy for several musculoskeletal initiatives, including the CAQ for sports medicine, and unfortunately, I've known Mike for longer than I'd like to admit as a friend and a good colleague, and welcome, Mike, and take us down the path. Thanks, Mark. Let me just share my screen here. Great. Yeah, so thanks again, and thanks, everybody, for joining us today. I guess it's evening for some of you. I want to just go over some of my experience, what it was like to become a team physician, and then also just give us some history, too, behind our specialty. So I'd like to go over some of the shared roots between sports medicine and PM&R, which I found interesting, go over the skills needed for being a team physician, and then just give you four practical steps on what it takes to become a team physician. This is a paper I put together a few years back, and it was really going over the history of PM&R, and what I was really surprised to learn was how many of our initial pioneers in this field of PM&R were involved in sports medicine. It was actually really gratifying to me. We all know that PM&R is a logical stepping stone for physicians whose training involves around biomechanics and optimizing restoration of function, but I'll bet you many of you did not know that Frank Krusen was actually the first sports medicine team physician in the United States. When I was a resident, everybody used Krusen's textbook, and he's considered the father of our field because of his efforts to help establish PM&R as an actual entity in the American Board of Medical Specialties. So he initially was the chair of PM&R at Temple, and at the same time was actually the team physician for their football team. He subsequently went on to Mayo and a number of other great things in his career, but I found that really gratifying that he was the first team physician in the United States as a physician, because it used to be that it was more these things were handled more by the athletic trainers. John Coulter was also a very important pioneer in our field. He focused on the importance of physical therapy since his experience as an Army physician after World War I, and he became the president of the American College of Physical Therapy and later director of the first PM&R program at Northwestern University. There's also Frances Hillebrandt. Her work in exercise physiology had a substantial influence on the development of PM&R in sports medicine, and she went on to help form PM&R programs at what's now known as Virginia Commonwealth University, University of Wisconsin, and University of Illinois. And then there's George Deaver, who is considered the grandfather of PM&R, and this is before PM&R fully became a medical specialty. But way back in 1932, he actually wrote a very influential article titled Physical Medicine Applied to Athletic Injuries, and then authored a textbook on prevention and treatment of athletic injuries. I mean, this is stuff that we're trying to do now, focusing on prevention of athletic injuries, and he was talking about this way back in 1936. The medical specialty of PM&R was formed in large parts from contributions from Bernard Beruch, who was a New York philanthropist and financier, and he established this committee with Dr. Cruzan, Dr. Russ, Dr. Coltier, and in 1947, PM&R became an actual medical specialty. Now at that time, the goal was really to help all these injured soldiers coming back from World War II, and that's where the focus of our field was for a long time. In fact, when I was a resident, most of the training was still in inpatient rehabilitation. The only sports medicine I actually received was really limited to chronic spine and joint pain at the VA hospital. We didn't really have a formal sports medicine clinic at that time or an elective. You really had to learn this on your own. I did go on to do fellowship training, though, at what's called the SOAR Clinic, and Jeff Saul was my program director, and just to let you know, the fellowships were very different back then. It was really more of an apprenticeship. We didn't have formal ACGME guidance. There wasn't all these guidelines that we needed to achieve and such, but still, it was a very good experience, and Jeff Saul was really a pioneer because he realized that sports medicine, musculoskeletal medicine, spine medicine really wasn't being represented fully by our own specialty, so he formed PASOR, the Physiatric Association for Spine, Sports, and Occupational Rehabilitation, and PASOR really helped change our field, really gave a voice to those of us who were interested in sports medicine. Eventually, in 2009, PASOR became reintegrated back into the academy, and it's now known as the Musculoskeletal Medicine Council. Now, along with that, the American Medical Society of Sports Medicine was founded in 1991, and in 1996, they started the Certificate of Added Qualification in Sports Medicine, so you could then actually get this, what we call the CAQ. Now it's called a subspecialty or certification, but you could get this CAQ, and that gave you credentials in sports medicine. Unfortunately, the American Board of PM&R declined the opportunity to join with the other four specialties that formed this, so Family Practice, Internal Medicine, Pediatrics, and Emergency Medicine, they asked us if we wanted to be part of that, but the American Board of PM&R said no. So at the same time, our board decided that they would grant subspecialty certification in pain medicine, and this was good for a lot of PM&R clinicians who were practicing pain medicine, and it allowed them to compete head-on with anesthesiologists, but for those of us who were dedicated to sports medicine, we started to wonder if we were really in the wrong specialty. It was actually a very trying time for us, but fortunately, in 2007, the American Board of PM&R did grant subspecialty certification in sports medicine. It allowed us to then take the CAQ exam, or what has now become known as the subspecialty certification in sports medicine, and allowed us to create our own ACGME fellowship programs in sports medicine. So PM&R physicians who complete an ACGME fellowship are eligible to take the CAQ, or again, as it's known in our field, is a subspecialty exam in sports, and two PM&R representatives now serve on the exam committee, and Dr. William Macheo was the first representative, still serves on that, and I was fortunate to serve with him as one of our two representatives for a number of years on that committee, and that really gave us a full voice at the table in terms of our representation in the field of primary care sports medicine. So what does it take to become a team physician? I think number one is to get good training, and that starts with a good fellowship training. So you really want an immersive experience and exposure in the full field of sports medicine. This is going to be required if you want to work with a collegiate, national, or certainly most professional teams. You need to become comfortable in the training room environment, learning how to interact with coaches, athletic trainers, and athletes, and this experience is really going to allow you to sell yourself to future organizations or team ownership in terms of your experience. Keep in mind, though, that even among the various ACGME sports medicine fellowships, there's a lot of variability in terms of the relative strength in specific areas of training. So some may have more aspects preparing you to be a team physician, some more on being more of an outpatient MSK specialist, some more still even on spine issues. So just keep in mind that not all ACGME sports medicine fellowships are the same, so depending on what your future interests are, you should take that into consideration. The AMSSM has been looking at this in terms of all the things that we want to cover to say that we are sports medicine experts and to do it in one year. As Tracy Ray says, one year does not seem to be an adequate amount of time to maintain a strong medical background while at the same time adding expertise in MSK medicine, emerging technologies, and meaningful research. Adequately teaching our fellows each of the learning goals in our accreditation guidelines is virtually impossible in one year. And a lot of this has come from how do we really distinguish ourselves? If our training is really limited to a year, can we really separate ourselves from the advanced practitioners, from PTs, athletic trainers, in terms of our skills and our knowledge base? This is a recent article that we put together that was published in the American Journal of PM&R, coming up with recommendations for enhancing sports medicine fellowship training, particularly within PM&R sports medicine fellowship programs. It's really imperative, this is Chad Osborne, he's the past president of the AMSSM, and as he states, it's imperative that we are able to create a robust sports medicine physician so that we are recognized as sports medicine experts. And I put in PM&R, but he said just PM&R, just general sports medicine experts with a little extra knowledge in sports medicine. So basically, are we trying to be PM&R physicians with a little extra knowledge in sports medicine, or do we really want to become known as sports medicine experts? And that's important to think about. And that's why there's a lot of discussion right now about expanding the fellowships to two years. If you look at the guidelines for what our international colleagues are doing, and even what is proposed by the American Medical Society for Sports Medicine, in terms of the guidelines for proposed standards of excellence, it's really hard to achieve this within one year. This is what's recommended for any sports medicine fellowship curriculum. And I won't go into all the details of this, but suffice it to say that to become very skilled and to cover all of these within your program in terms of didactics, clinical experience, musculoskeletal topics, primary care topics, all of the different specialty topics within the field, to become skilled in orthobiologics, to get adequate exposure in a training room environment, mass event coverage, PPEs, dealing with a range of sports medicine conditions and different ages of patients, including such things as exercise and lifestyle medicine, sports cardiology, sports ultrasound, and then trying to train people who are going to go out and be clinical educators or researchers. Again, it's almost impossible in one year. I think we do a decent job, but that's why there's all this discussion about increasing the amount of training to two years. You have to keep in mind, the number one thing in training someone to be a sports medicine physician is you really need to become proficient at sideline coverage. That's something as PM&R physicians that we're probably not as strong in compared to the other primary care fields. You really need to be proficient in procedures such as laceration repair, dislocation and fracture reduction, acute spine and head trauma, airway management. This is just to name a few things. That's why in our fellowship, at least for the PM&R candidates, we have them do have an experience in the emergency room as soon as they get here, just to help them get up to speed so we can get them on the sideline. The number two thing, so first is get good training. Make sure you get into a good fellowship. The second is once you're out of fellowship, and you could even do some of this in fellowship, but start volunteering at the youth or high school level. When you first get out, this is a good way to get on your path to being a head team physician. You want to develop a network in these leagues to get the attention of people who are in charge of the professional leagues. Working with the athletic trainers in your community and other professionals is really a way to build up your reputation and your network. Then over time, as you establish yourself, when a position opens up in a collegiate atmosphere or national professional team, people are going to start to think about you. One area that I would say, too, is a good way to get your foot in the door is to think about getting affiliated with a minor league or a semi-pro team. The pro teams, you have to keep in mind these days that oftentimes this is who pays the most money to actually have the privilege of taking care of these teams. With minor league teams or semi-pro teams, this isn't really the case. These teams are really in need of high-quality physicians and typically aren't financially able to support a regular team physician, so if you can volunteer and provide a high level of care, you're going to get your name out there. The players are going to get to know you, and then when they end up in the majors or professional leagues, they're going to know about you, and if there's an opening, they're going to help give you some credence when you apply for these positions. The number one fourth thing, and I think this is really important, is establish yourself as a good physician with one sport, at least initially. Working exclusively with athletes in a single sport allows you to establish yourself as an expert with this group of athletes. This can start during fellowship training where you might be working under team physicians for college or professional athletes, but then continue this as you finish your fellowship training and begin your practice. Just to give you an example of my path, I was a former collegiate track and field athlete, and I understood the sport, I was able to relate to the athletes, so when I came on to the Stanford faculty, and one of the reasons they wanted me to come on was to help take care of the Stanford track team, and eventually, you know, this led to involvement to taking on a number of the other sports teams at Stanford. I was then asked to be the head physician for the Nike farm team that was based in Palo Alto for 12 years, and you know, we had many of those athletes go on to the Olympic trials and many on the Olympic team, and this led to involvement with USA track and field. So again, just focusing on that one sport was at least my inroad to working with at a higher level with national and professional teams, and then to also showing my capability to working with a variety of different teams. This is another article that I put together just trying to look at what's the future for sports medicine, the role of the physiatrist, and these are four things that I outlined that I'm sure all of you are aware of, but I think these are really the areas that we're really growing in the most, so obviously musculoskeletal ultrasonography, regenerative therapies, injury prevention in human performance, and being able to have skills to evaluate athletes in a lab or even to run a lab, and then this idea of promotion of exercises medicine and lifestyle medicine, and the beauty of this is that you can specialize in any of these areas or all of these areas, but all of them are a great way to find your voice within sports medicine and to get your name out there. So I'm going to stop there. We've got some other really great talks, and then we hopefully will have some time for questions at the end. Thank you. Yeah, that was fantastic, Michael. Really well thought out. Thanks. So next up we have Dr. Adam Porcho, who's going to discuss the pre-participation physical examination. Dr. Porcho comes to us via Wayne State and then the Mayo Clinic Fellowship. He's now out at the Swedish Medical in Seattle, where he is the head team physician for the Seattle Storm. Dr. Porcho, it's all yours. All right, can you hear me? Yeah. All right. So Mike and the academy actually asked me to kind of go over what was the differences between a professional sports team when you're doing PPEs versus your average high school kid or collegiate athlete. So I'm just going to briefly go over that and kind of give you my two cents on the difference. Some of these things are obvious and some of them are not as obvious. So disclosures, we got the AMSSM grant with a few other people to research ultrasonic tonotomy. Outside from that, nothing else to disclose. Again you guys got my background. We now have two championships within three years, so it's been a kind of a fun experience. This year was a little bit surreal, kind of watching it on TV from a bubble in micromanaging, which presented its own interesting challenges from a team doctor standpoint. Basically having to be essentially just looking at images and knowing the athletes and guiding them through their injuries kind of through a proxy. So this year kind of provided a unique, unique experience from that, but a special thanks to my mentors, Jacob Sullen, Jay Smith, Doug Hoffman. Anyway so objective is this, we're going to list kind of the primary and secondary objectives of doing a PPE. I'm not going to go into specific details about PPE minus a few things. Obviously your goals are kind of identify red flags in history and physical that would prompt further evaluation for cardiac concerns and then also orthopedic concerns. And so and then the different options available for clearing an athlete and then discuss kind of the difference between a PPE and professional athletes. Again there are an estimated 13,600 professional athletes in the world. That's a small number of athletes. And so remember this is their job. So when you tell an athlete they can't do their job, it has potential financial impact, future career impacts. And again, you have an obligation at first to protect the athlete as a physician. So do what's right for the athlete. Sometimes that may involve having a private conversation with coaches. Luckily with my professional team, the coaches trust my medical opinion and I'm kind of the bottom line from a medical standpoint. And when you set up these relationships, I suggest you kind of approach it in that way and say, look, I'm the medical opinion. I'm not going to make any coaching decisions. I may see an athlete's ready to go from a medical standpoint and then the coaches make a decision whether they're ready to go from a coaching standpoint. And I think it's important to have those kind of rules defined so that you're not running into like, you know, basically the coaches know if I see an athlete's not going from a medical standpoint, they're not going. And so until they clear that hurdle, then it's like, okay, then they make a coaching decision. I may say, hey, medically, they look great, but, you know, they're slow on the court or something. Anyway, and then you got to kind of protect the team as well from a financial standpoint. We get trades in the middle of the season and we failed people based off their physical and that protects the team a little bit from making potentially a bad trade. But it is a business at the bottom line, which kind of changes the role of how you do this. So again, a recommended PPE form. Usually these are developed by a consensus panel of experts. We have one for the WNBA, usually vetted by legal professional. Usually the sports players union association is involved in kind of the questions that are asked on here and it's kind of vetted out. So know your league requirements. It's probably different for different leagues. The NBA slash WNBA has a standard form for this. And anyway, their rules are basically upon signing of a player, this is their verbatim standard player contract. During each training camp, a player submits to a complete physical examination by a team physician designated by the team. So questionnaires filled out by the athlete before you see them. Usually these are yes, no type questions, obviously identifying the yeses, but also I identify the no's because I think athletes are horrible historians. Half of them don't even remember who did their surgery, when they had surgery, what type of injuries they've had. You know, you'll find out, oh my God, you've had four concussions. Oh, well I, you know, oh yeah, I've been knocked out three times and you know, they don't remember any of it yet. It's documented online. So you have to do some digging, I think sometimes, and ultimately like this, they're applying for a job in a way. So what do people do on job applications? They lie. So I think you have to be very careful about what their history is and what, and, and dive into it and ask the questions, you know, Hey, you know, your other coach said he had heat stroke one time. And you remember that? Oh yeah. The heat thing. Yeah. Okay. We marked no on that question. Can we change that to a yes? So I think maybe making sure that these are filled out. It's going to take 15 to 20 minutes to do an excellent exam. I think a lot of it's going to be derived from your history. So again, screen for life threatening conditions, disabling conditions. You're looking for things that may predispose them to injury or illness. A lot of what we do, at least in the professional sports, all of these girls have some sort of injury on the teams. They all have bad ankles, bad knees, patellar tendonitis, Achilles tendonitis, lower back issues, shoulder problems, et cetera, et cetera. And so I think a lot of what we do from a medical standpoint is get their strength and conditioning on par so that they can make it through an entire season. And knowing that sometimes we may have to rest these athletes if they're not fully recovering. Luckily, some of the rings that they wear give me real-time data on how they recovered from the prior day. And maybe that means, oh, coach, they're not fully recovered from a nutritional standpoint. Maybe we hold back a little bit in practice. So make sure you're meeting your administrative requirements. And again, the big difference between these is in youth sports, it's basically about participation, right? Can this athlete do their sport? Let's go out, have fun, learn some rules, have fun, maximize the participation. Collegiate, pretty similar. Most people, you're going to clear them because you don't have a restriction of how many athletes you can have on a team, et cetera, et cetera. In professional sports, we get to keep 12 players. So it's really important to, if there's a medical concern that, hey, this athlete's not going to make it through a season, I have an obligation to tell the coaches and say, hey, look, I think from a medical standpoint, we have these issues. This athlete may miss some games because of X, Y, Z. And then understanding, they may say, hey, we still want this athlete. This is the role we're going to use him as to come off the bench. And maybe that's okay. But at least giving them that opinion, I think is really important. And obviously, if you're not passing the physical, you need to involve their agent. You're going to get a call from their agent or their agent's going to get involved with the team. And so making sure that everyone's kind of on the same page from that and why you're not doing it. So again, the secondary objective is to kind of determine the general health in general and serve as an entry point to the healthcare system. Certainly, as any team position knows, we see a lot of things that are not sport-related or musculoskeletal-related. We have to be able to deal with these. We had C. diff on our team last year. This year was COVID. Luckily, we didn't have anyone test positive. We had one false positive, which kind of delayed one of our playoff games. So I think these other health issues come up, OB issues. We have athletes in the WNBA that want to freeze eggs, things like that, which the league now actually pays for, which is awesome for these girls in their professional careers. And so having to set up that fertilization clinic, things like that. So making sure you're kind of their entryway into these health problems and to discuss other health topics. So again, history, most important, 80% of medical and 67% of MSK conditions are gone through history. I'm not going to belabor the point. 5% to 10% of these require further workup and 1% to 2% disqualified. Obviously, given the reasons, the athlete needs to know why. The agent, you're going to hear from the agent. Every time you cut an athlete, you hear from the agent. And I just kind of let the management of the organization take care of that. Basically, just like that's my bottom line from a medical standpoint. I'm not clearing them. And luckily, they have not gotten any second opinions on anyone that's disqualified yet. But anyway, so obviously, consider, does the problem increase the risk of injury for the athlete? If it's something like, hey, they have Achilles tendonitis, like I said, they all have something. Is it something that I can rehab, that I can have strength and conditioning be aware of, the coaches be aware of, and we can actually rehab it and work through a season? Half of what we do is in strength and conditioning is injury prevention as well. So again, and then from a medical standpoint, from a professional standpoint, is this a good acquisition for the team? Every year for the draft, I get a list of players that they're looking at. They say, give me a medical opinion on this athlete. These are the injuries that we know about it. This is what we know about their past. I may dig into it and call their team physician before we even consider drafting that athlete and trying to avoid a potential falling off a cliff down the line. So will this athlete be able to complete an entire season? Is that what the team needs, et cetera, et cetera. Again, cardiac exam, this is a little bit different than WNBA, so I'm going to go over it. Obviously, most of us know that the number one unexplained reason for a death in an athlete is heterotrophic cardiomyopathy. And so making sure that you know about this and you're screening for it. We get, obviously, the red flags on history, exertional chest pain, exertional syncope or near syncope, unexplained seizures, excessive shortness of breath at a level of exertion, history of a murmur, finding of hypertension, family history of a death less than 50 years old. So these are standard questions that are on all of the most questionnaires. Obviously, this is what we want to avoid, right? We don't want anyone that wants to be on the court when an athlete drops. We had one in the WNBA. This is the year before I took over as team doc. They had one in a locker room of opposing team player that had to get cardioverted in the locker room, had heterotrophic cardiomyopathy, survived, but they had an AED, luckily, in the locker room. And so that's our standard now is to have that available for all of our teams. I'm not going to belabor this because it's kind of out of the scope of this talk, but people can go back and look at this. So higher among African-American and in college basketball players, they have those morphine weight syndromes. So this is why this is screened in the NBA and WNBA every single year in every athlete. And so, again, other reasons for cardiac death, the biggest one is obviously heterotrophic cardiomyopathy. So it's very important that we should be screening and at least thinking about this. So this is what they changed. 2016, they rolled in with new guidelines, and in fact, they're about to publish their paper on this. It might already be out of HSS, and what they're doing is yearly EKGs in every single one of our girls, a treadmill, an echo every year in every player. It's been this way for a long time in the NBA. The WNBA, for cost reasons, wasn't doing this, but they were able to get a deal with the hospital to get these for, you know, we get them for a hugely discounted price and all of our athletes through our hospital system. And so every athlete that makes the team has to have an echo before setting foot on the court for their first game. And so in training camp, if they're just bringing somebody in for, you know, a tryout for a couple of days, we don't have to get an echo. That's a cost thing. In the NBA, everyone gets an echo. So there's a little bit of a cost prohibitive thing here. But what's nice is they're trying to create a protocol for female athletes. There's great protocols for male athletes out there, but there's a lack of protocols, standard protocols for female athletes, and they are finding that it's different. And those protocols should be published fairly soon because they keep telling us different parameters to look at every year that we collect more and more and more data on 144 professional WNBA players. The next thing I can do is bronchospasm. Obviously, the biggest thing with this is it's fairly common, usually undiagnosed in a lot of these athletes that come into our league, especially with what's been happening in the West Coast here with these fires and the air quality. We had three previously undiagnosed asthmatics have full-blown asthma attacks with their peak flows going down and, you know, mid-game having to do nebulizers at halftime. So I think, you know, at least on the West Coast with these forest fires and air quality going down, something to be considered. And obviously, make sure you get a TUE on these athletes. You need to, I have all of them see a pulmonologist a second. If I give a nebulizer treatment in the game, it's considered using, you know, I have to justify it. And so I have to put a note in there saying, I gave this athlete a butyrol, which is considered a performance enhancing drug, you know, and why I did it. And this athlete has to have, you know, a peak flow documented, their pulse ox going down, whatever, you know, wheezing, athlete unable to perform. And then make sure you get a TUE on these athletes, especially your patient on long-term meds. Usually that's good for two years and then you have to renew it. But I have our athletes that have documented asthma get new PFTs every year, beginning of the season. That way, at least it's like, hey, we looked, here's why we have the albuterol on hand for them. Sorry, I'm hitting the wrong keyboard. There we go. And obviously concussions. WNBA has a concussion screen similar to the NFL from what I understand is that each concussion has to be cleared by an independent neurologist. They look at all of our Cogstate testing and then the ultimate final decision is the team physician, but we have to have a thumbs up from Jeff Kreutzer at University of Michigan prior to return to game. So whatever your league's criteria is, obviously with the rush on this, or the recent press on this, making sure that you're paying attention to it. The WNBA uses Cogstate. I don't know why over, you know, impact or some of the other programs is just what they use, but every athlete gets this beginning of the year. A concussion has to be, you know, pass it prior to return to play. And then any athlete that's suspected of having a concussion is not allowed to return to play that same day, similar rules. And then obviously knowing your drugs and supplements, this list gets updated every year. I peruse it every year. Athletes come in, if they're taking any supplement, I have them give this. Luckily we have a nutritionist that's on staff and I send these supplements to them and say, it's amazing how much stuff is hidden in these formulas that these athletes get and making sure that they're not going to get burned by a random drug drop. Because they do these random drug tests all the time. You know, before games, they'll show up and have them pee in a cup. And if they test positive for even Sudafed, then you're going to get them in trouble. And so they can lose game money, financially, everything else. And so again, orthopedically, kind of last thing to cover here. There's obviously your checklist. And then there's, I check every single joint. I have them take their shoes off. I look at their knees, their ankles, everything. And if there's reason for me to scan it, I usually will scan it with my ultrasound, which is in the room. And I'll look at ligament tears. I'll check laxity. I'll ask them what they're doing to manage it. This is how you really protect them from an orthopedic standpoint. Because there are poor historians like this athlete who couldn't remember doing this to her ankle. So you need to make sure that you are protecting the team and the athletes. And they're poor historians. Oftentimes they don't even remember the injuries that they have. So again, check every joint. Identify areas for strength and conditioning in athletic trainers that can be dealt with from a bracing and strengthening. Don't hesitate. This is the other difference too, is like in your collegiate athlete and in your youth athlete, you're probably just going to say, hey, tape your ankle with your trainer, right? We're really careful about protecting and looking for things. So I have a low threshold for pulling imaging on this because ultimately this is their job. And if it's something that I think is going to affect their job, you should be documenting the imaging on it. And then I always give the athlete a copy of it anyway. Again, protect the athlete first, but the organization second. So make sure that you're discussing with the team agent if you're disqualifying people. So again, it's not just a game. This is their job. You have to protect the athlete, but also consider the organization. So that adds that part of money on there, and which ultimately you're there to protect the athletes. But again, that organizational point is always there. Know your league rules and regulations, different for every league. And then again, if you disqualify or fail an athlete, the conversation must be had with the athlete, the team, the owner, the vice president or president of player development, whatever, and the agent. So, all right. Thank you. That's all I got. Hopefully I kept that under 10 minutes. Adam, you did a great job. Thanks. It was really informative. I am shocked that the WNBA only went to this formal cardiac testing a few years ago when the NBA was doing that when I was a fellow. Oh yeah. They've been doing it for over three decades. And I think the WNBA was a cost thing, because it costs a thousand bucks a piece. And when you're paying athletes 30 grand a year, luckily this year they had a great, they upped their salary by like almost 50%. So, the girls are making more money. Maybe they don't have to play year round. Honestly, the number of injuries I see in the WNBA, because of their year round having to play overseas to make money for a living. Some of them are only making 40 grand a year was the league minimum until this year. And so, that's not enough to live in Seattle for a year for sure. So, I think those athletes hopefully don't have to play year round. It will start- That's crazy. Lack of injuries. Yeah. Fascinating. Okay. Our next presenter is Dr. Monica Rowe. She is currently the Reva and David Logan Section Chief of Musculoskeletal Medicine at the Shirley Ryan Ability Lab. She is a RIC person through and through with the fellow training and fellowship there. She is also the Director of the Residency Training for Shirley Ryan Ability Lab. And she serves as the Head Team Physician for the U.S. Women's National Team. Dr. Rowe. All right. Welcome. Thank you. Thank you for that introduction. Thanks everyone for joining us here. I'm here to talk about sideline coverage. I don't have any disclosures other than I'm going to give you the answer to this question right off the bat. So, I start with the end first. Can PM&R doctors be Head Team Physicians? Absolutely. Absolutely. So this was me at the 2019 Women's World Cup after we won. I've been the Head Team Physician for the Women's National Soccer Team for the last three years. Late 2017 is when I started. I assume that all of you are here today to either you're interested in becoming a Head Team Physician. Maybe you are a Head Team. I see a couple of Head Team Physician names in the list of people who are here. But you know, the way I took this approach is to prepare people for sideline coverage and to talk about certain things that I think are important when you think about sideline coverage. You know, the one thing I do want to put out there is I know a lot of people, and I see a couple of trainees in the audience here today too. I know a lot of people think that being a Team Physician is all about sideline coverage. And I'll tell you being a Head Team Physician is about 10% sideline coverage, and it's 90% the other stuff that kind of that's going to be brought up in the different aspects of this talk. But when you think about sideline coverage, I think the number one most important thing to think about is to know your sport. And then, so I am going to talk a little bit about that. I'm going to talk about emergency action plans. And then we're going to talk about the sideline preparedness consensus statement. So when we think about knowing your sport, the rules of the game, and I know that a lot of people may say, oh, I've been a spectator for years, or I used to play in high school or whatnot. But depending on what level of sport you are a Team Physician for, you should read the rule book because I will tell you with soccer, there's a lot of crazy rules out there and how a Team Physician acts on the field can actually influence the game. And so certainly how, if you are participating in a sport where you are called onto the field, or just in general, understanding those rules becomes really important. So also understand the rules related to injury. So a great example of this is in soccer, you cannot go on to the field unless the referee calls you onto the field, except in the case of a head injury, right? And so that is a FIFA rule out there. Of course, I'm gonna speak a lot towards soccer because that is the world that I live in, but it's important to understand that rule because if a head injury happens, I can jump on that field as quickly as needed. If a head injury is not, it's not a head injury and it's a knee injury, I have to wait for that ref to be called. And if I try to run on that field without being called in, certainly the team can get penalized for my actions. So understanding those rules are really important. Actually, what's really interesting is we actually had a situation in one of the non World Cup matches where we had a head injury on the field. We went on the field and actually FIFA has a rule that they are allowed to stop the game for three minutes to assess the concussion. And for those of you guys who are sitting out there who've assessed concussions, you're thinking, oh my goodness, three minutes is terrible. That is a terrible amount of time to assess a concussion. But I think FIFA is thinking about revisiting that rule in and of itself, but I'll tell you, the ref was trying to push us off the field and we had to remind the ref, there's a three minute rule. We have three minutes to figure out whether or not this is a concussion and whether or not this person needs to come off the field. And so we pushed back on the ref and then the head ref came in and told the sideline ref, they're right, they have three minutes. But it is in those types of critical moments where the game, those of you who are fans of soccer, you realize the game of soccer is based off of momentum and pace like a lot of games, but they don't like stopping very often. And so it is really important that you do your due diligence to be able to assess that patient with the proper amount of time that you're given that fits within the rules of the game. The last bit I'll tell you again, those of you who've seen soccer as a sport, sometimes it falls, you have to understand the strategy of the game, right? So I'm not saying that my team does this, but there have been teams who have known to time waste when someone gets injured, the medical team saunters on the field and then they take their time evaluating the patient and then they get up and move on. If the team is in the lead and they've got possession and the momentum is going their way. So you certainly see time wasting and you see the strategy of the game coming into play, but you are a part of that. And the most important thing that as a team physician, when you're on the sideline, the most important thing that you wanna do is you do not wanna become the story. You should not be the center of attention during a game, right? And so, but what I mean by that is, you've certainly seen kind of, there've certainly been situations where people have become, the medical team has become part of the story because they make an error and it costs the team some issues or it's cost the team some minutes. And so it is really important to understand the rules of the game, understand the rules related to the injury and understand the strategy of the game before you sign on to be a head team physician. I also think it was a really great point to say focusing, Dr. Fredrickson talked about focusing on one sport. I do think when you do focus on one sport, you get to really understand the nuances of what's going on with the coaches and the players and how they're approaching things at different points in the game. And that can be certainly helpful as well. The next thing I wanna talk about is an emergency action plan. So essentially an emergency action plan is a document that details information needed to navigate any medical emergency during a game or a match. So when you think about different levels of sport, when you're talking at the professional level or the collegiate level, all those sporting venues have emergency action plans. And so for soccer, we often will play at soccer stadiums or we'll play in NFL stadiums. And most of the stadiums that we play in actually already have a preexisting emergency action plan. And oftentimes we just have to adopt that emergency action plan to fit the situation of the match that we're about to go into. But it is important ahead of time before you go on the sideline to have the emergency action plan in hand and be assured that someone is actually, either you are responsible for doing the emergency action plan, or if you're going into a stadium that is not your home territory, then certainly making sure you have that emergency action plan in hand. So when you think about non-professional sports matches, I will strongly advocate that they should also have emergency action plans. High school should have them. You know, I even think like if you are covering club sports or whatnot, you should have an emergency action plan because you need to communicate to everyone involved if an emergency should happen, what are the responsibilities that everyone undertakes and where is the best place to go? So I do think that it is the responsibility of the head team physician working with the head athletic trainer to come up with these emergency action plans. So what is involved in one? So these are the elements of one. You have to include the emergency personnel, emergency communication, emergency equipment, the medical emergency transportation, venue directions with a map, and then the roles of the first responders, and then an action plan for non-medical emergencies like weather emergencies or other threatening things that might happen. So I just wanted to share just a sample of an emergency action plan for the Toyota Stadium in Dallas. And so as you can see here, the emergency personnel, can everyone see my mouse here? I think everyone should be able to. The emergency action plan includes the emergency personnel here. You can see the contact information of all the emergency personnel and then where they're gonna be during the match. You wanna see what equipment is available, AED, splint bag, stretchers, EMT personnel. You wanna understand the emergency communication, the database for emergency communication. Usually the closest hospital is listed. So if someone is injured, where do they go and how far away is it and who do you call? And then certainly you wanna know the role of the first responders. So again, they highlighted all the different elements of the emergency action plan really well here. They also included a stadium map. I mean, for those of you who have never been backstage in an NFL stadium or at a large professional sporting venue, it is super complicated often to navigate the back hallways of these stadiums. And so it's really important that all the people on your team that may be dealing with an emergency understands where all the different people are located. This is where the AED is located. This is where the ambulance is located to make sure if you're taking someone off the field, you go towards the ambulance, where the home team physician's located. And then if someone is gonna require an evaluation in the locker room, these are the tunnels you use. So it's really important to highlight that. And then evacuation procedures. Again, if it is a medical emergency, how do you go from the field to a local hospital? How do you go from the field to the locker room? Or how do you go from the locker room to the local hospital? So all different scenarios are laid out and they really dumb it down for us, right? So they tell you, this is the direction that you go in. This is where the backup elevator is just in case there's no service. So you wanna have this on hand because it's very helpful to be able to enact your emergency action plan as quickly and safely as possible. So some of the game day actions, I think also goes hand in hand with this, is that as the sideline team physician, you should meet all the medical personnel involved. So when I show up to the sideline of a game, I go and meet the opposing team physician. If they have a team physician with them, I go meet the venue doctor. The doctor who's, there's usually a doctor that's in charge of a professional venue that is licensed in whatever state we're in to help kind of facilitate medical needs. Actually, when I was in KC, I believe Dr. Kadavy was my venue doctor at one of the games that I went to. You should know the resources of the location you're playing in. A lot of the NFL stadiums that we play in actually have x-ray on site. I have heard some places also have MRs available as well, but knowing those resources and whether or not an x-ray tech is available is also really important. And always know where all the exits are. And I always, before every game starts, I think if someone gets injured on this part of the field, how are we going to get to the ambulance? If something happens here, how are we going to go to the next place? So you want to anticipate worst case scenario, plan for it, have it in your head, hope that you never have to use it, but make sure you've thought through those things ahead of time. So I wanted to go over the sideline preparedness for the team physician. There was a consensus statement published in 2001. That was a consensus of a lot of different sports medicine societies all coming into conjunction. There are a lot of elements to this particular consensus statement, but I'm going to focus on the part that talks really about sideline coverage. So we're going to talk about what game day medical operations look like, what game day administrative medical policies look like, and the role of the team physician in that sense. And then preparation of a medical sideline bag and supplies. And then obviously the most, the other really important thing during a sideline coverage is to stand for the national anthem and make sure you pay your respect and look good next to the coaches here, okay? All right. So for game day medical operations, you want to, the role of the team physician is to determine final clearance and status of an injured or ill athlete before competition. To be honest, this is probably happening before you get to the stadium, before you get to the sideline, but it is an important thing, responsibility of the physician. You obviously want to assess any game day injuries and medical problems. You want to determine an athlete's same game return to participation. So depending on what sport you're in, that might actually be happening on the field or that might be happening on the sideline. You want to follow up, you want to provide follow-up care and instructions to athletes who require treatment. And, you know, as physiatrists, we actually coordinate that care and we follow through with that coordination after the game as well, of course. And then we want to notify appropriate parties of athletes' injury or illness. So someone's injured and they can't go into the second half, coaches need to know, people need to be informed as early as possible. And one of the big things is you've got to watch the game. And I think one of the things that a lot of physicians, when they first start providing sideline coverage is depending on what sport is going on, they always just watch the ball. And what's really important is to be able to scan not just what's happening at the play, but to be able to scan the entire field of what's going on. Because sometimes there may have been, you know, for instance, in soccer, they may have been a hard tackle, the play moves on, but then, you know, one of your defenders is limping a little bit or is struggling. And it's really important for you to be aware of all the athletes that you're taking care of and see if there are signs that someone needs to come out or someone actually might be injured or someone really probably should sit down so that the ref can call you on the field, those types of things. So, yes, it's important to see the play and what's going on, but also make sure you, every once in a while scan the field and make sure all those athletes are doing well. Certainly the more eyes that are on a game, the better off a medical team is. During the World Cup, we were given opportunities to have VAR assistance for concussion management. So we actually had an individual with eyes in the sky up in the press box, being able to watch any sort of head-to-head contact or any sort of elbow-to-head contact to be able to assess how much direct contact there was. And certainly those things can be really helpful when you're trying to determine within three minutes whether or not someone has a concussion. And then most importantly, no one escapes the electronic medical record. So it's really important. Whatever happens, whatever issues you take care of, proper documentation is the responsibility of a head team physician. Medical record keeping is a responsibility. Whatever issues that are taken care of, obviously you're not writing the note right away, but at the end of the game, if you're in the training room, that's when you make sure proper documentation occurs. There are some administrative responsibilities during sideline coverage. You know, really the physician is responsible with the assessment of environmental concerns and playing conditions. Is there lightning nearby? Is something going on environmentally that's unsafe for the players on the field? Yeah, obviously making sure that the appropriate medical personnel is at the competition site, planning with the medical staff on the opposing team. I always introduce myself to the game officials, particularly in soccer, because if I'm running on the field, they want to make sure I'm not a coach. They want to make sure that I'm actually one of the medical personnel running on and not an assistant coach running on with the trainer or anything like that. Although I don't know who would mistake me for an assistant coach in soccer. But it's also really important. You want to review the emergency medical response plan, check and confirm communication equipment. So again, we had a lot of different ATCs working with us during the World Cup. We all had headphones and headsets, and we had walkie-talkies to be able to communicate with each other so that different people had different eyes on different parts of the field so that we could ensure the safety of all the athletes. And then you also want to make sure ahead of time you find the appropriate places where you can examine people. Sometimes it's not appropriate to examine someone for a concussion in the midst of 40,000 people staring at you, and you have to pull them off to the side to be able to have that assessment appropriately. The preparation of sideline medical supplies. There are a lot of different articles kind of published on this. There's an extensive list of things. Obviously from my standpoint, you always want to be prepared. Know your sport, know what happens often, right? So for us, cuts and bleeding happens. And I mean, really that happens in a lot of different sports, but you got to stop that bleeding as quickly as possible so that the player can go back on the field because soccer has limited number of substitutions. And so if that player is off, that means that the play is going on with one person down. So for us, it's really important to know where our gauze and our bandages and the little tricks of the trade that we have to stop bleeding. Like a lot of times we'll soak a lidocaine with epinephrine gauze ahead of time because epinephrine is a vasoconstrictor. And so if someone's having a lot of bleeding and it's not stopping right away, we'll just, it's already a pre-wet gauze. I'll just put it on the area to try a vasoconstrict and we can move on and get that player back on the field. Wearing the gloves on the sideline for sport like soccer is really important because the timeliness of the medical response is really important. Having normal saline, obviously a stethoscope, BP cuff, you might not actually use on the sideline, but you never know. EpiPen, very important. And then obviously there's other supplies that you might need in the training room, not necessarily that you're gonna use on the sideline, but some of these things you might, that becomes really important to that bag. Now, typically the ATC will have a bag. As a physician, I carry my own bag as well so that we have different supplies because if there are two things going on at the same time, you wanna make sure that you have your supplies on the ready and you should know that bag inside out. I always suggest the doctor should pack their own bag so they know where everything is so they're not relying on the trainer to always pull the supplies out for them. Obviously on the sideline, AEDs, having cervical collar, spine boards, flint scrutches, skin staplers, suture kits for soccer are really important. And then a concussion assessment protocol or at least knowing one off the top of your head becomes really important. So again, my main thing is always be prepared, bring everything. This is why I always look like this when I'm walking into the sideline situation. I've got my crutch bag, I've got my doctor's bag and I'm also just carrying the water too. So always be prepared because I will tell you, 90% of the time on the sideline, it's pretty boring and it's pretty dull and it's looking like this. There are times where it gets a lot more exciting and then there are times it gets very exciting and very fun. So this was a nice sideline to be on right as we won the World Cup. So my final points here, being on the actual sideline in my opinion is less than 10% of what I do as a head team physician. The doctor should never be the center of attention on the sideline. So you wanna try to keep it that way. Anticipate the needs of the player and be ready to act. And physiatrists can be head team physicians because we know how to coordinate care, work collaboratively and plan in advance. So thank you all for giving me the opportunity to talk and show a couple of pictures. I feel like I just gave you my pictures from all of 2019 all in one slide deck, but thank you guys again for joining us tonight. Thanks, Dr. Rowe, really well done, really well done. All right, our next speaker is Michael Kadavy. He's out of Apex Sports Medicine in Kansas City. He is the head team physician for KC Sporting, the MLS team there. He wants everybody to know that he did train at the world famous Stanford University Sports Medicine PM&R program under Dr. Fredrickson. Dr. Kadavy. Yes, hello, can everybody hear me? Yes, we can hear you. We're good, Mike. All right, thank you to Dr. Ellen for coordinating this top-notch group of speakers and appropriate to this topic, I wanna give a big thank you to the older generation that paved the trail for this. This is the Mark Ellens and Mike Fredrickson, the Luca Podestas and Stan Herrings who paved this trail for us so that there's no doubt, can we be head team physicians? The tidbits that you guys have heard are just phenomenal for those who have been team physicians for a decade or those who are just starting in your career. A major part of the advancements in the last generation has been technology. And with such a rapid growth of technology, it's even more important to judiciously use our technology. So everybody benefits from it. At the top of this list is communication. Arguably more important than knowledge and skills is the ability to be on the same page with the rest of your medical team. This is something you're doing all the time as a team physician, especially your head athletic trainers. Make sure they know what you know. With all the technology that's available, nothing has replaced talking. Nothing will ever replace talking. It's the best way to exchange ideas and decrease ambiguity about situations in person, in phone. And the interesting thing is, as you get to higher level athletes, professional athletes, Olympic level athletes, they tend to have more direct access with their physicians. They'll have your cell number. They can call you when they have questions. They'll text you. And this is nice, direct communication, but it also makes it even more important that when something is discussed or decided with the athlete, go back to your head team physician or sometimes the coaches and make sure everyone's in the same loop. Big events, mass events, races, when you're on the sidelines, sometimes you'll have a radio in your ear and radios while old fashioned are still very effective and helpful. I wanna make a couple of comments about texting. Everyone does it, but caution it's overuse. Texting can be very helpful when you're in the middle of a busy day and you have a yes or no question and you have direct messages confirming someone's appointment time, but it can limit the exchange of ideas that can affect and improve care. For any line of communication you're using, just be aware of confidentiality issues that might come up for that specific line. Technology can throw a wrench in a team doc's personal life. You're always accessible. You're always accessible when you're at dinner. If it's the middle of the night and you're sleeping, being accessible is crucial to being a good team physician. They have urgent questions, they'll have urgent injuries, but at the same time, it's important to set boundaries. When you're at dinner, put the phone in the other room. When you're at an event, leave your phone in your car. It can wait, it can wait half an hour. As technology continues to advance, we must understand the limitations of the information that we get from our diagnostic technologies. How to use it, when to use it, what does it mean? Put it all together in the clinical scenario. Learn to read your own images and put them in the context of your history and physical exam. And in elite athletes, we often get a lot of diagnostic technology. And remember, in sports medicine, especially our elite athlete, to be aggressive with your diagnostics and conservative with your more invasive treatments. But always ask yourself, how will this technology change your treatment plan? Do we need a diagnostic ultrasound for every ankle sprain and every muscle strain? I would argue at the professional level, we might. Coaches need to know return to play to the nearest week, day, minute to make multimillion dollar personnel changes. So perhaps at the college and high school levels, we're just fine relying on our physical examination skills to make the diagnosis as well as other parts of return to play. And similar concepts go towards many other parts in sports medicine, orthobiologics, other uses of technology. Is it gonna change our decision plan? This is a case of an FHL posterior ankle impingement I had on the Kansas City Ballet, one of our dancers, whose physical exam was still ambiguous. So I did a diagnostic ultrasound that allowed me to visualize a swollen and stiff flexor hallucis longus tendon, which ended up guiding my treatment plan. And I ended up doing an injection, which helped both further even diagnostically and also got this dancer back dancing at a hundred percent. Our training is unique in sports medicine. And this is one of the biggest things I learned from my training with Dr. Fredrickson is we're surrounded by primary care sports medicine and primary care, the family medicine and ER guys, they see rashes and asthma day in and day out. And then our orthopedic surgery colleagues can handle open fractures in their sleep. We can do everything, we can, there's no doubt about it. It's been done before us. I have as much of an exclamation point to my answer as Dr. Rowe does, can we be team physicians? But the formal training that we get sometimes leaves a gap. How good are we with upper respiratory infections? What's mono, what's strep? How good are we with dermatitis, cardiac arrhythmias, complex mental health, orthopedic trauma, suturing. I've had games where I'm suturing four or five different players at halftime to try to get them back in the game on the soccer field. We really must go out of our way to use our resources to find resources to be prepared. And then in our non-emergent situations, we can read on our own and phone a colleague to get the answers we need to make the right decision. And then when it comes to accessing medical information, medical records, the cloud is really helpful. We still have challenges, but get these old reports, get old images, it will absolutely allow better care for our athletes. So in conclusion, my biggest points are talk, talk, talk, communicate. Let's let technology improve the communication pathway between you and the other members of your medical team. Just like Dr. Rowe said, be prepared for what you might see on the primary care side of things, as well as on the orthopedic side of sports medicine. Be aggressive with your diagnostic use of technology and conservative with your invasive treatments. And lastly, your brain, meaning your clinical skills will always, always be more important than any new technology. Thank you, I'll hand it back to you, Dr. Ellen. Thanks, Mike, really well done. And as Dr. Torgue used to say, the MRI is the tool of the devil, but that's a whole nother talk. Oh, wait, how do I, let's see if I can get my stuff up and Megan, is my screen up being shared? Not yet. Not yet? No. Still no. All right. How about now? Yes. Yes, we're good. I just have to find the right thing here. Okay, that's good. Everybody can see that. So, unfortunately I have no disclosures. My talk is basically on logistics and what it does is it piggybacks on everybody else's talk as being the head team physician. So, one of the things that you find out when you're the head team physician is you are only covering about 10 to 15% of everything, and the rest of your job are all these other little jobs that you become the point where focus of for everybody else. And what you think is important for your people doesn't mean the rest of the world thinks it's important. So, as when you become head team physician and your players and athletes need you to do something for them the rest of the world doesn't hop to it like you do. And one of the things I found when I first started was that I was very surprised that at my major university that I was at that a lot of the other staff didn't have the same interest that I did that these athletes had very short seasons, and even shorter careers. And it was my job to push them through as fast as possible and I was kind of shocked that after having that intercollegiate athletics for over 100 years, they didn't have any processes for how things were done. And back then, the hard part was, was not getting playing films because we had our own radiology, we were located in the stadium. And we were just set up perfectly during the day, but in the evenings or any other time we weren't so perfect. And forgetting higher level radiology or other tests that became a thing that I had to do with the hospital, we were at a campus that was directly across the street from the university teaching hospital, which was catty corner to our stadium, as well as our main training room. So I started with a casual discussion of a radiologist of our MSK radiologist and ask them for suggestions about how I could fast track our players. They said, you should need to meet with the chairman. So meeting with the chairman at a major university is not as easy as you think. So I begged his secretary for five minutes of his time, which he was begrudgingly gave to me and then he suggested I speak to the chief techs because it was really their realm of how I would get any other tests done. The chief tests were very open. And what we made was a decision that we had beepers laying around that all the techs had numbers to and already rigged into the system. And we wouldn't have to go find individual numbers of the kids that are athletes to go dial up. One of the things about college campus is 10 p.m. is the middle of the day. 12 p.m. is dinner time and 2 a.m. is drink time. And our scanner would run till 2 to 3 a.m. in the morning. And our kids would get paged about 11 p.m. And that just worked out really well for us. And we could get all of our higher level tests done by Tuesday evening in the training room. The other part was getting buy-in from the other specialists. I'm not good at fixing an ear and I'm not good at a broken jaw. So I made inroads and what I did is I sat at our physician dining table whenever I could make lunch for as long as I could to talk with all the other specialists in the hospital and find out who was willing to help our teams. So it helps when you're on the road and you're four hours away and your quarterback breaks his jaw and it's a Friday night at 10 o'clock and you need somebody to see him when you hit the emergency room at 2 or 3 in the morning. And we were able to do that. I made friends with a couple ENTs who really wanted basketball tickets and they fixed our wrestlers ears. I had to get a buy-in then from our own neuro guys for our brain injuries or concussions and stuff that I wasn't good at managing. And you'd be surprised at how some of your colleagues really don't want anything to do with it or we'll tell you they can see them in a month because they're crowded up till then. And so finding somebody like for me, I found the late Bill Schull who was really into helping our athletes and Bill was a great help. And then it was the same with spine injuries. I'm a sports guy. I'm good at seeing a spine for a short amount of time. But if they're not getting better, I don't want to waste time in the middle of the season and not have the skill set to take care of a back because I'm a sports guy and I'm classically trained in sports. And I was able to get a buy-in from my spine partner at the time, Dr. Slipman, who was able to get either his fellow or himself to see the patient same day. And so that's how it starts out is finding buy-in from other people to help you with your players. That's the good part. The other part of logistics is really understanding what it means to be the head team physician. It's not just taking care of things on the sidelines, just not seeing people in the training room or if they make it to your office. It's understanding the bigger issues. And they were really outlined and come to the forefront when you talk about Gathers versus LMU. And Hank Gathers was basketball player for Loyola Marymount back in the 90s. And at the time, Loyola Marymount would lead the country in scoring every year, averaging between 140 and 150 points a game. And as alluded to in one of the earlier talks, hypertrophic cardiomyopathy is a leading cause of athletic sudden death. Well, Mr. Gathers had an irregular heartbeat. He was treated by the team cardiologist. He was put on, I think, Inderol at 240 milligrams and he felt sluggish. He started when working with the cardiologist during the season to bring down the dose, they made it to about 80 milligrams and he still felt sluggish. Here's where everything gets a little confusing. We think that he had taken himself off the medicine for about three weeks. And in the middle of the game against Pepperdine one night, the second half, he dunks the ball, comes back to play on a press on defense and fall straight to the ground with a syncopal episode. The fellow covering the game that night may or may not have been in his seat. He may have been getting a drink of Coca-Cola, but we're not sure. He immediately was out on the court, said he had a pulse. AED was not used at the time. And sometime between the arena and the hospital, which was a five minute drive, Mr. Gathers passed away. So what happened from that is college president gets sued, the head coach gets sued and quits. Team cardiologist gets sued, team physician gets sued, clinic gets sued, and the fellow gets sued separately. So head coach quits, head of the college quits, cardiologist, $960,000 settlement. And then it came down to what we were talking about with testing. Back then, the NBA did a very exact testing for cardiac clearance, and he would never have made it into the NBA based on his cardiac status. So the rest of the suits were dropped. Now, if you're the fellow at the time, the fellow was made to stand alone during this, and he wasn't backed by the clinic. So that's something to think about. The next one that is more well known, that probably is not as well known, but has more of a meaning to everybody is client connect versus Gettysburg. Drew client connect was a lacrosse player who was out doing fall lacrosse practice, which is really a preseason practice. There were two coaches. He was at Gettysburg College, which is a very small school. They only had two athletic trainers and had a student athletic trainer. Because it was fall ball, he had no athletic trainer coverage. They did some running for a few minutes, and then they broke down into six on six drills. He was a defenseman. Nothing hit him, no ball, no strike by another player or anything, and he collapsed on the field. He was first seen by a couple of his teammates, including the team captain. The coach came running over. They saw his neck was in a weird position. Two of the players, including the team captain, then had to scale an eight-foot chain link fence and run 250 yards towards the training room, where one of the athletic trainers was supposedly at. As they were running, one of the players decided that two of them running to the same place was not a great idea, and he split off and went to the student union, which was the closest building, and an ambulance was called. In the meantime, the first person he saw was a student trainer who came back with him. She was able to slip through the fence and start CPR. Drew passed away on the way to the hospital sometime before 6 o'clock, so less than two hours after practice started. The parents were upset that their healthy 20-year-old son had passed away after passing all of his physicals his whole life and never having any real problems. They took this to court. Initially, the school and the team physician and the trainer were all cleared. It then was appealed, and in the appellate, the decision that happened in 1993 was that athletes are different. They're not the same as everybody else on the field. It's reasonable to assess that if it's a lacrosse game or another sport where somebody can get hurt, there should be a medical coverage person, and they were responsible for this person, because this person, who is your player, was brought to campus specifically. He was recruited to play lacrosse there, and he's a special person. He's not a typical student on campus. Now, when you have that, you have to take this into a bigger view. As team physician, you are now responsible for everything that happens on campus to every single player. Our Ivy League experience around the same time was a very similar thing. It happened where we had a male lacrosse player at one of our sister institutions. He was actually hit by a ball, causing commodial cortis. There was an ATC on site during this practice. However, it was the furthest site possible on their practice fields. At the time, there was no cell phone coverage in the area. There was a hardwired phone that was available on a fence nearby. When the trainer ran to the phone to pick it up, the cord was cut. Unfortunately, the trainer had walked out with the team, and while somebody else started CPR, she ran back through all the fields that were fenced off, back to the training room, grabbed the AED, got the gator to come. The gator wasn't gassed up, had a run back with the AED, never checked to see if it was charged. You can imagine what happened from that. Lightning does strike twice. As Dr. Rowe spoke about, there are now position statements from virtually every medical society, including the NADA position, and that's the Trainers Association, about making sure that there's a written plan with buy-in from everybody that has anything to do with athletes, the trainers, the team physicians, any other safety personnel, the school administrators. And if you're at a major university, this is usually handled through the AED's office, but also the coaching staff. Don't forget, again, to include your local EMS with any decisions that are made and try to get them in on the plan as well. Make sure that your equipment is viable and everything works and you have everything you need. Don't wait till it's too late. Location is just as important. Not all stadiums are the same. All NFL stadiums are required to have working x-ray, and that's about it. But not every college and certainly not every high school stadium is the same. And it's not just for your games, it's also practice sites. When I was in college, the swim team used to travel two to three hours down the road to swim the Genesee River. That would probably not be allowed these days because of the problems that can be associated with that. If a swimmer has an event and they're two hours away from campus, it's pretty hard to come back and cover that. So again, communication is key. Make sure that your in-house staff is on the same page. Make sure that you know who your EMS and transport people are. Make sure the parents and the guardians understand that and remember that as the head team physician, you will act as a local parent. Each venue is different. Make sure you understand the venue layout before you get there or as soon as you get there, walk the field, check the stadium tunnels, check for exits. I always check the field as well. Meet with the EMS, let them know who you are and find out where they're going to be positioned. I always try to work out a signal if I need them. Check with anybody else that might be needed. When we were far away from campus and I did have a couple players go down, I had a degloved jaw. I had another fracture and I needed help. Know who your local offsite partners are as well as the offsite partners who are still on call back at home. Remember, it's your responsibility to document everything clearly. Review everything with staff as well. Rehearse as best as you can. Most of us don't have any time for that, but it's at least good to have a plan in your head and discuss things. When we would drive to games or take the bus to games, we'd all talk about what our expectations were, where we were going, and we'd review some things. And on the way back, we always reviewed everything that happened during the game and how we handled it and if we could have done it any differently or any better. And again, anything that you need when it comes down to all these logistical matters, especially emergency things, make sure they're reviewed by legal. And I think that's my talk for tonight. So now we'll open up the floor to questions to any of our committee. So are there any questions at all about tonight's presentation? So far, none. Any comments? I'll put a question out there. This is Mike Kadavy. Obviously, soccer, best sport for PM&R to cover. I think ballet is an excellent sport and running. What would you guys say would be a more challenging sport for PM&R to cover or is there a more challenging sport? I think the most challenging sport for us might be ice hockey. There's a lot of cutting, you know, you're going to get broken bones, you're going to get a lot of lacerations. I know the rumor, you know, when I started my fellowship in Los Angeles is when they started hockey out there, the orthopedic surgeons who were covering weren't sure how much suture to bring to the first game that they covered. And sometime in the middle of the second period, they ran out of sutures. I think for us, that's a bigger challenge. I think basketball is a great sport for us to cover. I think track and field is a great sport for us to cover. I think with some of them, you know, luckily, I take care of 12 girls. They give me a lot when they're playing games back to back to get back. But I think sports with more athletes, obviously, you need to incorporate other people to help you out. I know I got invited to help out with the NHL team out here and they require five physicians at every game. You know, they have an ENT, they have a facial maxillofacial surgeon, they have a dentist, you know, like an oral maxillofacial dentist, an ER doctor and myself. And so it's a lot to coordinate. But I think like, it's nice to know you have that kind of back. Oh, an orthopedic, so six. Anyway, so the, you know, it's a lot to coordinate. So I think like, for those of us, being a former athletic trainer, while still current athletic trainer, and I used to work in the NFL with the Lions for a couple years, it's a lot to coordinate care for those athletes and somebody's injured on every single play in football. Which is not the case in women's basketball, a lot of what I deal with is more chronic injuries and occasional acute injury. I would say other sports, you know, like hockey, like, as was mentioned, is probably more acute stuff that you're dealing with and chronic stuff. So it may add that element. Granted, it's only how many guys are on the hockey team? Is it 20? Either way, whatever the 18-20 players, you know, still not a ton of guys, but it's a lot of injuries in a small number of people. So I think I would guess just from football would be probably the most injury prone one, you know, but you have a plethora of people to help you. So I think either way, that's my two cents on that. Yeah, I spent a couple weeks at Lake Placid taking care of the under-20 hockey team, and I was the only physician there. Yeah, I have to say, I mean, most of the injuries fell within my comfort zone. The only thing I got nervous about was getting a puck hit to the throat, you know, because those can be pretty acute if the airway gets closed. But having said that, I did spend some time in our emergency room before going out there just to kind of, you know, do a little refresher course for myself. So I think it's doable, but you got to be prepared. So we have a bunch of questions coming in now. Oh, there's one thing I wanted to add, Mark. Carly Day wanted me to mention that we now have at least six PM&R physicians who are head physicians within the NCAA, four males and two females. That's fantastic. Yeah, so our numbers are growing. That's really, really nice to hear. So somebody asked if a team MD needs a different insurance policy. So sometimes you're covered under the master policy of your institution, and each state is a little bit different. I could tell you as a fellow, I needed a $5 million, $5 million coverage back in the day, and we all had that, and that was covered for us by the clinic. I will tell you that Pennsylvania, because it's a completely different system, does not do that, and they have a limited thing there. It's a whole to-do, but it's really, if it's within the scope of your practice, if you're at an institution, the institution will cover it. If you're a private person, you're going to need to get extra med mal for it, yes. I was just going to add to it, because I actually think this is a topic that we don't talk enough about, and I think a lot of younger people that are just entering training and whatnot, they want to cover everything. And the truth of the matter is, if your institution doesn't know you're going, they won't cover it. And so it becomes really important to make sure that what you're doing is sanctioned, and that you are really covered, because good Samaritan laws won't actually kick in if you are called the team physician, or you're officially the medical coverage. You will not be covered by a good Samaritan law. So I do think insurance is a big topic to discuss, particularly if you're working for an organization that's not directly affiliated with the organization that employs you. That's correct, and that's what came out in the lawsuit with Gettysburg College, is that initially, in the initial finding, when they found for the school, they were covered by a good Samaritan law. And then when it went back and got re-adjudicated, it was not covered by the good Samaritan law. And even that student trainer was no longer covered, and she was liable as well. So there's another good question. When you cover your team internationally, does what you would treat yourself or take a player to the ER differ? So, Monica or Mike, would you treat things differently internationally than you would do, would you take more things on yourself that far away from home? I guess in certain things, you might, but it completely would depend on the situation. If someone looks like they have a fracture, I mean, or that needs to be set appropriately with x-ray, I mean, I'm not treating that myself. So I think it just really depends on what the situation is. Someone looks like they're having an appendicitis, I'm not treating that myself. But there are certain things, certainly, that we would treat ourselves because we're in an international situation. Yeah, I would agree. Just one example, I remember being in Moscow treating the USA track team at Indoor World Championships. And, you know, one of our pole vaulters went down and hit his head off the mat and, you know, was having direct spine pain. And, you know, so I felt like I needed to get x-rays at that point. But I really was reluctant to, number one, wasn't great with the language. We, you know, to get that, get him transferred to a hospital, to get him to the right hospital where he wasn't going to wait for 12, 14, 24 hours was a task at hand. But anyway, with a little persuasion and some gifts and things, we got things worked out. But it wasn't that easy, particularly since, you know, I had to question, and these are things that will come up. He was in the lead back then, beating one of the Russian pole vaulters, right? So going into the finals, so were they really going to help us? Anyway, it all worked out, but it took a lot of international diplomacy to do that. And it wasn't an easy task. So I would say as much as you can handle and be prepared to handle is much better approach. And I'll tell you, it's not even going international or going out of the country or anything. If you cover a team that happens to go to one of the military academies and is facing the military academy, they will offer you the absolute minimum of help. And that's saying it nicely. You will be on your own. I've had a tib-fib fracture, an army that I had to bring back to Philly, I had a jaw fracture in Annapolis that I had to bring back to Philly. It's not exactly easy, and you're left on your own devices if you're there. So most schools that you go to will feel that you are a brother or sister to them, and they will take care of you as best as they can, because they want the same when you come visit. We have more questions. For residents trying to prepare a sports medicine fellowship. Wow, this is good for you two guys. It was noted that there are some gaps in our training compared to our primary care colleagues. What kind of things can be done during residency to address those gaps? Seek out more primary care type rotations, ED, urgent care? That's a good question. I think, you know, as someone who takes a, we take one PM&R physician and one family med physician, and invariably the PM&R doc is better trained at musculoskeletal and nerves, and then the family med doc knows everything else. And so this is, as we all know, probably half of what comes through our training room is not sports med related. You know, we see UTIs, we see pregnancies through our Seattle University coverage. You know, we see all sorts of colds, mono breakout on the wrestling team, things like that, that honestly, as a PM&R doc, we are not really well trained for. I think what helped me out, honestly, is I moonlighted the last two years of my residency, and I did a lot of urgent care. And I think that that taught me a lot about the things I didn't know from a family med standpoint, because I had a family med physician that was, you know, working with me at the urgent care. And so I think that's a good way to get some of that experience in. And also tons of suturing, fracture care, things like that, I think, come through there, and you learn a lot about splinting and fractures. And I thought that was very helpful going into my sports medicine, because I had already kind of been writing for those medications and things. And even now that I'm farther removed from it, I still turn to my family med fellow and say, hey, what's the right drug for this? And, you know, they have these guidelines changed, and hey, look at this EKG, you know. So I think from those aspects, I think that would be just my advice, is try to expose yourself to it from that standpoint. Yeah, I would agree with you, Adam. And just to give an example that Mike could out of you, when Mike came in as a fellow, Mike had spent time moonlighting as a resident with one of the local EMS crews. And so immediately, we were able to put him on the sideline with soccer. And by the end of the season, the team trusted him so much, they invited him to the NCAA tournament, and then he parlayed that into taking care of professional teams. But the typical PM&R fellow who comes in, it's not until the end of the season that we can even let them handle the sideline on their own, if at all. So I would say, yeah, more urgent care, more ER, whatever you can do to beef up your acute care skills will be helpful. So I will tell you, there's a committee meeting now that we kind of got interrupted, we did get interrupted with COVID, that we're working on changing the MSK curriculum for PM&R. For you guys who are current residents, it may not make a difference by the time it gets out there. But we're going to follow the fellowship guidelines that were put out there by the committee for the AMSSM, the joint thing that came out two years ago that was published. And we're going to follow right through that MSK wise. And I wouldn't be all that concerned. You know, I did a total of two injections when I was a resident. So, you know, there's life after residency, do everything that you can do. And be as familiar as you can. There are a few more questions. Here's one of concern. Do we have to worry about covering games as residents? The story about the fellow being sued separately was a bit chilling. I think what you're going to find in life, no matter what you choose to do, that if something bad happens, there's going to be a lawsuit. And everybody's going to wind up getting individualized and you're going to get separated out. And that's just a thing that's going to be done. It's a protective firewall, if you will. Yeah, it's not the greatest feeling. The fellow wound up staying local to the area in Los Angeles for a couple of years. He then went out, got a phenomenal job, became a team physician at a Division One school, a well-known school. And then took care of a bunch of different professional teams until he passed away. And really well thought of physician. So it didn't hurt him in any way. But yeah, you got to expect that you're going to get separated out a little bit. That's fairly normal. And please don't think it's chilling. And don't change what you want to do because of one story. I just want to say, I just want to answer that a little bit just as a residency program director. Because I would say, you know, within our program, we do have, Northwestern has very strict rules about it. And residents do have to be under the supervision of an attending. So as long as you're under the supervision of an attending who is part of your program, that is of the usual attending supervisors. Meaning not someone who is not a part of your residency program or your department. At least in our institution, that works well. But I think every residency program, every institution is different. So if you have that question, that's a question you should probably be asking your institution and your residency program director. Good point, Monica. The next is, thank you for the wonderful lectures. Are there any barriers anyone has faced in becoming a team physician as a PMR physician? Are there any specific recommendations that we can do as a field? We're a small field. We're getting bigger each day. Things are different now than they were in 1991 and 1992. People actually know what PMR is and what we can do. It's markedly different than it was even 15 years ago. There's a lot more opportunity for you. There are a lot, you know, it's a very bright future for PMR now. And it's completely different. So yeah, feel good about it. I'll make a comment on that also. Feel good about it for sure. Also expect to go in having to educate. And sometimes you feel like you're talking to a kindergartner about what it is that we do. It took me nine months to convince the chief medical officer for sporting that I could handle basic orthopedics in primary care. It took me several years to convince the family medicine sports guy that I could handle the basics in primary care. That I could handle rashes and I wasn't going to just throw cortisone on everything. That I could handle a URI and like I said earlier, differentiate mono from the other URIs. So I think just proving your worth, explaining your training and explaining that you have experience beforehand. Like everyone on this panel has said, get your experience. Absolutely cover, get your emergency, your urgent care experience. Start in residency and then in fellowship, make sure you're caring as well. And then once the time comes, you have the experience and you can just show what you've done. Yeah, I think, yeah, it's the second that is, as Kadavy had said in his lecture there, you know, communication goes a long way. And I think people really respond at physicians that kind of close the loop, you know, especially with the organization. Keeping that communication up and making sure people know their roles. You have a well-defined role, you know, be seen, not heard sort of thing. Athletes tend to trust people that are around. So if you're only coming around occasionally, they will not trust you. It has to be, you have to go to practices. I mean, I take a half day of clinic off. Well, not this year because they were down in the wubble, but you know, and I go to their practice and they see me at practice. And then I have physician hours afterwards and I'm there once a week. So I think it's from that standpoint, athletes tend to trust who's around and you have to build that reputation and trust with them. Because they see a lot of people and especially ones that play overseas. And there's a lot of stuff out there and you have to build that relationship just like any other relationship through good communication and being around. So I think, you know, making those inroads, if there's a sport that you're interested in, you know, find out who the team physician is and be like, hey, can I just come and shadow you? And then eventually it becomes, oh, hey, this guy's here. Hey, do you want to cover a game for me? I got to be out sick, you know? So I think those type of things, creating those opportunities for yourself are really good. And, you know, experience goes a long way and be like, hey, he's covered, you know, 20 games with me. He's being seen, not heard. He's not trying to take over. He's not making coaching decisions. Oh, yeah, I can trust this person covering a game. So I think, you know, from that role, I think that's my advice for it. So I think all of us have probably similar backgrounds where, you know, Stan Herring used to say, wait your turn, you know, do your job, wait your turn. And I don't think any of us were handed anything ever. When I started at, you know, my first job, the group took care of two professional teams. And I got dragged to a couple of games, talked to a couple of players, and that was about it. And my next position at Penn, I went in, I wasn't really doing much of anything. A fellow couldn't make a game, and I covered a game for one of the fellows. And the coaches liked me, the kids liked me. And things progressed. But if I went to the training room by myself, the trainers just looked at me with horror because they thought the only thing I could do was back pain. So it took another year and a half to get the buy-in that you could actually do stuff. And then, you know, we had a bunch of people leave and kind of there was a vacuum that I got to fill. But I had been there and I'd served my time for a couple of years. And people started trusting me because I made the right decisions. But you got to put in your time and do your due diligence like everything else. It's rare that you walk into anything that somebody is just going to give you. If I can make one comment on that, I would just say don't think of yourself and don't market yourself as a PM and our sports physician. You are a sports medicine physician, period. I think that's a much better one. Because if you think I'm a PM and our sports physician, then that tends to sort of pigeonhole you as you're the spine guy or the nerve guy. But you can't be a full team physician. So that's why I tell our fellows to try and shy away from that term. And just if they ask, I'm a sports medicine physician. I've been trained to do it all. I mean, so I think clearly some of the things that have been highlighted is there's still a stigma out there. So if the question is, are there still barriers, clearly there's barriers. We're much further along than in the 90s. So certainly we have a lot of people to thank for that. What I tell my trainees is you have to be spectacular. You have to exceed expectations. You have to be better than the next guy. And you have to be twice as good, I think, in order to get the same amount of credibility. So what can we all do as a field? We all just need to be spectacular. That's what we need to do. And the thing is, we have a lot of people out there, head team physicians now. We have growing numbers in professionals ranks, in the Olympic ranks. And so, I mean, but the train needs to continue, right? We need to have a continuous stream of people who are exceptional. And we'll go above and beyond. And I'll say, Mike, I sort of agree with your point. I also sort of respectfully disagree. Because I actually think that being physiatrists makes us uniquely different as sports medicine physicians. And we do things differently than our primary care colleagues when it comes to the care coordination of athletes and the leading of the interdisciplinary team. I do believe we do it better. It is deeply ingrained in what we do as physiatrists. And so I actually think when you allow those traits to come out that make us uniquely physiatrists, we just end up looking different. I'll tell you, that's how I got where I am today in U.S. soccer. I ended up looking different because I started taking more interest in the whole athlete, not just the body part. I started coordinating care amongst disciplines. I started doing all the stuff that makes us uniquely a physiatrist. And all of a sudden, it made me look very different as a sports medicine physician. And that's why I got the call-up to kind of go to the women's national team. And so I do think we should embrace the aspect of our field that really just, you know, that fits perfectly with PM&R. And I hear you sometimes have to read the room. So this is why I partially agree with you, Mike. Because depending on what room you're in, you know, sometimes I don't say I'm a sports physiatrist. I say I'm a sports medicine physician. So you got to read the room sometimes. But I do think embrace the aspects that we uniquely own as a field and be exceptional. I made my way into the team with sporting by pushing the ultrasound and injection route. We had some muscle injuries and hematomas to aspirate. And so I was the injection guy. And so using your logic, Dr. Rowe, that's how I got on the team as sporting. And then at that point, I just had to prove to them that, hey, when the family medicine guy was out, I could do it. I could handle the neck injuries, the concussions, the rashes, all that other stuff. So being holistic and comprehensive in sports medicine is important. But just like you said, boy, reading the room can really create opportunities. Yeah, I agree. You know, one of the benefits of our field is I honestly think physiatry is leading the way as far as diagnostic ultrasound and interventions. You know, much more so than our family med colleagues, which is our strong suit. And one of the things that was unique about, you know, coming on as the WNBA physician is we have a portable ultrasound. I had it at every game. And before long, I would get the opposing teams who were on the road for two or three games. They say, hey, can you scan this ankle for me? And the word kind of got out that we had that available. And, you know, so I think, you know, those unique aspects, too, will help you out. And so, yeah, I kind of second that. And I agree with reading the room, too. I think there's something to be said for, you know, knowing your audience. Really well taken care of. One last question. How can a med student access opportunities for research in PM&R or sports medicine? My med school and hospital doesn't have any research whatsoever. Look for opportunities. I think I get emails from people looking to help out with research. You know, it's hard to do really good research in a year anyway with, you know, your fellows. I think most of us probably have several IRBs, and we just hand one off to whichever one is whichever bun in the oven is cooked. My fellow gets to write that paper, and then their job is to work on another paper that they're never going to, you know, be on. And I think that's probably all kind of right around that kind of revolving, keeping a couple buns in the oven, so to speak. But I would say just reach out to people that are doing the research and say, hey, look, I would like to help out. I would like to get involved. And, you know, I think that always looks good from the standpoint of applications for anyone for a fellowship program. Gets you exposed to you. You know, you remember the people that are around. It's hard for me to remember people that are, you know, come in every once in a while, or I see for, you know, one week rotation. And, you know, it certainly helps. But I think, like, getting involved would be helpful, too. But there's a lot of people doing great research. Find those people. Hey, can I help out? You know, I'm happy to do a lit review search for you, whatever. And I think there's opportunities out there that way. And it doesn't have to be PM&R. Anyone doing research. Yeah, absolutely. Research is always painful at some point. So there's some aspects of it that you can help out with and learn that process. And I think I would agree with that, too. So I can tell you that I called up my old team trainer at my undergraduate school. And I asked him if Dr. D. Haven had anything going on. And I left my medical school for two months. And I went out and I helped out with their research project. And around the same time, Dr. Sienka was up there doing the same thing. Same place, helping out. And I think that's the way you have to do it. You know, we tell you not to be super aggressive about doing things. But sometimes you have to speak up. And you're going to have to look to go outside of where you are. If you really want something bad enough, you'll figure out a way to get it. So I want to thank you all for being here tonight. I really appreciate all you guys who came to speak. Monica, Mike, Mike, Adam. It was really good. I don't know what we're going to do next year. But we'll have to figure out something to top this. Anybody who has any suggestions, please email us or email me. And we'll try to get something going for next year. Hopefully, we'll be in Nashville. And we'll be all together and not have to do it this way. But thanks again. All right, guys. Thanks, everybody. All right. Good luck.

PMR doctors

head team physicians

sports medicine

fellowship training

training room environment

specific requirements

pre-participation physical examination

cardiac health

bronchospasm

concussions

sideline coverage

emergency action plans

medical supplies

communication

proper documentation