Sorry for the slight delay. We had a few little minor technical difficulties, but we are working through them. I know midnight dropped last night, and certainly I respect all the Swifties out there, but as you can tell, we're Erinators, and so we named this talk Thank You, Next. We're going to talk about different types of practice styles that we've all seen as we've evolved through our careers. Hopefully, it'll give you a little bit of insight to some of the pros and cons. You know, I don't think there's any one right career path. There's certainly no one best path in physiatry. In fact, it'd be hard to find a specialty that had more diversity, right, within the field than PM&R. So, it's really about creating what's right for you, and hopefully, you can learn a little bit from us. We're slightly seasoned at this point. We're not going to go old, but we're certainly not, none of us are right out of residency or fellowship, but hopefully, we're not so old that we've lost touch with the things that are important in the current practice, so we'll try and give you some insight from all of our perspectives, and we hope that you can learn from that. So, yeah, so finding a new practice, whether it's your first job or if you're changing jobs, it's always a big, scary thing, right? There's a lot of things that you can't control, you don't know, you're changing your work, your life, your income, and all that has lots of repercussions. But I'll go to the words of our Dr. Osler, one of our forebearers, who said, you really have to live in the moment, right? You can worry about the future, you can reminisce about the past, but living in the moment is really what it's all about. And if you can keep that mindset, I think this becomes a lot more of an exciting process than rather a scary or daunting one, and so I'll give you those words of wisdom. All right, so what we're going to do today, we're going to have a series of presentations from different physiatrists, and they'll talk a little bit about the pros and cons of their practice, but we don't really want to focus on that too much. So we're going to go about as quick as we can through this, and then open up the floor to questions. Everybody has different concerns and interests. I think we did this last year, and we were very impressed at how different people digested this, so we want to hear from all of you about your questions and what we're answering. We tried to push it out on social media as much as we could, we didn't get a whole lot of responses, so just please ask your questions as best as you can. And yeah, I'm going to make everybody come up to the microphone, that's okay. That's part of being assertive and taking control. So the first person up is Dr. Ankur Mehta, a good friend of ours. This is Ankur Mehta, and this is a perspective for practice models for young physiatrists from a physician who has been running an outpatient-based PM&R practice that originated as an inpatient program and has transitioned into a full-service PM&R practice. We'll go over some of the important points and some of the benefits and drawbacks of the different types of practice models, and specifically is clinic-based. So I practice in Houston, Texas. I've been here for about 10 years practicing, and I have a clinic that is focused on interventional techniques utilizing fluoroscopy all the way down to EMG and simple bread-and-butter PM&R such as spasticity and post-stroke shoulders, all the way to kyphoplasty and balloon augmentation. Originally a little bit about my background, I started out in pharmacy school, and I realized that that really wasn't for me. Ended up taking economics classes, and I completely fell in love with the concept of mating business with medicine and to provide a system in which patients have access to care, because at the end of the day, if you can't keep the lights on, you can't practice your art. I did an MBA program while I was in medical school, and that was a combination of osteopathic medicine in Kansas City and an MBA program at Rockhurst. And then I was fortunate enough to join the PM&R program at Loyola University, which is in conjunction with the Heinz VA Hospital. It turned out to be an excellent program where I had opportunity to look at many different models such as a VA model, academic model, and there was one clinic we rotated at that was clinic-based, where there was a physician who had exactly the same practice that I have here in Houston. The beauty of it is when you get exposure to different realms of the same profession, they're all physiatrists, they're all board certified, and they're all practicing physiatry, but they're doing it in different settings. The one that calls out to you, you kind of automatically fall into it, and that's exactly what happened. When a practice-based setting, it was easy, the hours were a little bit less strenuous, especially nights and weekends, no call, no inpatient, no 2 a.m. fall workups. So that really attracted me to it. And also, the other thing was, I got to see a lot of athletes, and I've done triathlons myself, and I try to get to the gym on a weekly to biweekly basis, but being able to treat athletes and sports injuries was also another passion of mine, and I had an excellent opportunity to be flexible, where if I do have a patient who has a stroke, and they have spasticity, or they have post-stroke shoulder syndrome, I can do interventional techniques for that. But at the same time, if I have a tennis athlete that is unable to participate in overhead serves, I can also treat that with PRP. And the dynamic nature and the wide breadth of the practice models really attracted me to practicing in that setting. Practice information, so mainly outpatient practice with EMGs, injections, fluoro, MSK ultrasound, and if anybody out there has access to getting ultrasound training in their residency, I strongly, strongly advise you to take every single second of ultrasound exposure under the hands of an attending, or under the training of the ultrasound technicians. At the VA hospital, I spent hours and hours with the ultrasound technicians after rounding, and they trained me on ultrasound. I think any physiatrist in this country needs to be amazing at ultrasound, whether they're doing brain injury, and they want to look at if there's some heterotopic ossification, they can just peek at it real quick, or if they're looking for perineural edema in carpal tunnel, or if they're a post-stroke patient, and they want to measure the distance between the humeral head and the acromial bone, having ultrasound in your back pocket is the best thing that you can do for your career. Basically we practice our clinic around surgery centers, hospitals, ER, and then some inpatient. The benefits of private practice is you're independent, it's dynamic, you can make your own decisions. An example with ultrasound, going back to that, I worked for a very large pain group before, and I asked them to buy me an ultrasound. It was six months of evaluation to see if it would fit into their business model, and then finally they came back to me and said, oh, the cost-benefit doesn't make sense, we're not buying an ultrasound, versus in private practice, you can pretty much just buy it. You just go out and just buy it, start using it, and provide care to patients. The benefit is America's built on entrepreneurship and providing and creating, so that's what I liked about that. It's a team, and then I built lifelong relationships with my staff. I've had some staff that have been with me for over a decade, and when you find good people, don't let them go, that's the number one advice I can give you guys. It's the most important thing, and you have flexibility. If you have a staff that's really great, you can have the flexibility to bonus them extra, or if you have a staff that is not exactly living up to their responsibilities, you can relieve them very easily, versus if you work for a hospital or a big corporation, you have to go through many programs, there's administrators and stuff like that, that you have to go through all these loopholes to get changes done, or hoops, you have to jump through a lot of hoops to get things changed. Community building, going to high schools and working football games, you can do whatever you want. You can work as hard as you want or as little as you want. And then bottom-up management, so the staff can provide feedback to you and you can immediately make changes. The drawbacks of the practice, when you're off, there's no money coming in, the staff still wants to get paid, vacations cost a lot of money, you have to pay for the vacation, and you have to pay for your overhead, and everything is your problem, everything falls down to you. For example, there's a nationwide backorder of contrast in lidocaine right now, you can't get contrast for doing these interventional procedures. Well, if you're in a hospital, they have the buying power, they can get it immediately, and they have administrative staff that will be able to pretty much insulate you from even knowing that that isolation or that supply chain issue has happened, but when you're having your own practice, everything is on point, and you're on point for everything. The cost of goods, as it keeps on going up, there's risk, there's hard work, it's a ton of work, and not just being a good doctor, you have to be a good manager, you have to be a good employer, you have to be a good team member, so that's a hard thing. You have to be very precise and almost have to have the ability to wear a lot of hats instantaneously. But it just depends on your personality and what you want to do with your career. So my advice to people is find out who you are, always put patient number one, always take care of your staff, and then put financial profitability last, because if you do it right the first time, and you do it right the right way from the beginning, and you set up good business ethics and good patient care values, then you'll have really good success in your career, and you'll have longevity. Don't look short term, look long term. One location versus multiple locations, overhead will definitely erode your practice, reputation is everything, be really proud that you're a PM&R doctor, because there's not many doctors out there that know the appropriate angle of your elbow when you're using a cane, or the appropriate height or width of a doorknob, or the width of a door entry for somebody who has a wheelchair. There's a saying that says you're too poor to buy cheap, so buy the good equipment. I only buy Japanese or German surgical equipment and American x-ray equipment, because you pay twice as much at the beginning, but I have some equipment that's lasted me over a decade, so that's pretty exciting, rather than having to replace it constantly. Cut costs without cutting quality, and the patient experience is the future. It's going to be more and more, it's about healthcare turning into a commodity, where patients have choices, and they want to have the Disney World experience where you can give them an amazing roller coaster, but at the same time they'll enjoy standing in line the same way you want to give them amazing injections, and medical care, and intrathecal therapies, but at the same time you want it to be a pleasurable experience getting in and out of the clinic. So not only do you have to be an amazing doctor, you actually have to be a high customer service focused physician. And that is it. Thank you guys for your attention, and if you want to email me questions, you can. My email is mehta, M-E-H-T-A, M-E-H-T-A, M-E-H-T-A, M-E-H-T-A, M-E-H-T-A, M-E-H-T-A, M-E-H-T-A, M-E-H-T-A, M-E-H-T-A, M-E-H-T-A. M-E-H-T-A, M-E-H-T-A. and for service there. So this is what happens in military treatment facility, DOD, compared to VA. The services sort of fluctuates depending on the demand. So if there's a war, there's only limited physicians in the military treatment facility that wears uniform. And as you can see, when there's a surge of casualties or injured service members due to war, there's not enough physicians to treat them. So what they do is they actually increase the force, the medical force, by recruiting civilians. And you can get into this type of opportunity two ways. One is through government service, which is more permanent position, or contractor. And I got into through GS, or government service, which is more stable, permanent position. And I was part of that surge. And they created this brand new position called Department of TBI, no originality there. And basically, my job was to treat people in outpatient setting. And it started with a very small budget, 11 staff in 2011, then grew up to 51 staff, truly multidisciplinary clinic. Did great things, learned all about program development, the business side that I didn't know anything about, and also research. We created this nice database for collecting data. Did amazing research. Even got grants, millions of dollars of grants outside of DOD and DOD. And the encounter, by the time we left, was about 25,000 encounters per year. We created an intensive outpatient program for these service members, which most of them went into that, and we had a very good outcome. And this center became part of 10 DOD network, 10 outpatient TBI centers and DOD military treatment facilities, almost like TBI model system, except in outpatient settings. So we share all these programs, and data, and great things like that. And this is like the picture of a typical building. The 10 buildings look about the same, because it was 100% donation from this nonprofit to create the buildings for us, except DOD had to fund the staffing inside the building. So what is the benefit of this type of opportunity? Like I said, it's very time and opportunity based. So I think for civilians, it really has to be linked with what's going on in the military. So if there's a war going on, there's plenty opportunities for even us physiatrists, because a lot of it is pain, MSK, neurorehab. And I think that's good and bad. There's a lot of opportunity depending on war. If there's no war, like right now, the opportunity diminishes, or it's very little. But once you have it, it's like a true freedom, independence to be creative, and put your own stamp into it, and really do exciting things. It's basically a healthy population, unlike VA population. These are the people that they want to stay in the military. They want to go back and fight with their teammates. So the motivation to recover is really great. And there's less of comorbid conditions, unless, of course, you have other injuries in the war. And there's really diversity. I met all types of people that I would not have met if I did not go into DOD. All people, all walks of life enlisted or joining as officers to fight our country, and really get that sense of unity, because we have the same motivation to serve our country and fight for the same goal. And it's truly inspiring to meet all these diverse people coming together to fight for freedom for our country. And it can be a really unique opportunity. The drawback, of course, is, like I said, if the war ends, that's when you have to ask yourself, what is the priorities of DOD changes? So you have to be sensitive to that. I think, for me, it was time for me to leave because of that factor. And also, I accomplished. I felt like I served. I came in to do what I had to do, in a sense of serving our country. I was one of many Americans who were directly affected by 9-11 event. So this was my payback coming from immigrant family as America was good for our family. This was for me to pay back without actually picking up the gun and joining the army. I was told I was too old for that. I missed the reserve, actually, by one year, I found out. Anyway, that's besides the point. And the military culture can be good or can be bad. It's very hierarchical sort of culture. So if you're not used to having top-down type of atmosphere, this is very foreign. Actually, I was OK with that. And more importantly, the general who was my boss or colonel, my boss, kind of left me be because he didn't really, he actually, hey, I recruited you for this. So why do I tell you what to do? So I got completely autonomy and freedom. But then there are some incidences where they can be a little bit micromanaging boss. But that happens anywhere. But the culture, you have to get used to the hierarchical. But they really respect the physicians. There's a huge support system that really considers you as a part of the officer ranks. And there is lack of job security. If not, you have some commit as a contract. Because again, once the war ends, they can't pull back the job. And you have to look for something else. So there is a little finite moment. That's something that you have to watch out for. And the change of leadership, which changes every three years, that's something I have to get used to. The command in a hospital or a post in the military, they rotate every three years. So you get new leaders every three years. So you have to get used to that. I personally did not get affected too much because my work was very specific and specialty driven. So they didn't really bother me too much. But that's something I have to get used to, their style of work. So take-home message for Department of Defense, it is definitely a unique opportunity. But I think all physiatrists should be aware of it, especially if, God forbid, if the war breaks out. It's a great opportunity to serve a unique population. And also use your skill set to serve the country and help the military population who are wounded. And really become an expert to become military medicine. Once you get hired for a GS position like myself, I could stay in the military medicine until I retire. But I chose to leave voluntarily. But that's another thing. I can continue to be there and become an expert in the military medicine. So that's an opportunity there. And also, very important to understand the reason for that job creation. So if you get hired going to DOD, just understand why they created that job for you. I had a very specific mission. And I went, accomplished, and left. And the great work life balance, they actually kicked me out because I worked 40 hours a week. They said you shouldn't be there more than that. I never heard that. Before I came to, when I was a Spalding, like 10, 12 hours a day was normal. Actually, it was a shame if you left earlier. It was that kind of culture. Coming to the military, it's like, hey doc, 40 hours. I don't want to pay you overtime. Get out of there. And also, everything is negotiable. So I negotiated like eight hours of paid time off per week. So it turns out like 40 days per year, you hardly hear that. You actually, I said, OK, I want to work four days and one day off. That was actually granted, things like that. So a lot of things outside of salary can be negotiable. So it's an exciting thing. You actually apply usajobs.gov. But that's like mostly VA positions. DOD can get posted there. But a lot of times, it's through headhunters and the internal network. That's how I got to know this job position. Somebody at Walter Reed reached out to me because I'm in TBI world, say, hey, are you interested in that? So a lot of network-dependent job opportunities and headhunters, not so much the USA job. All right, thank you so much. Thank you. Thank you. All right, I'm Craig DiTomasso. And I'm going to tell you a little bit about my career now, if that's OK. This is me and my family at the Canfield Fair in Northeast Ohio. So I started in academics, transitioned to private practice about four years ago. I do a little bit of everything. I have kind of a frenetic personality, in case you didn't notice. It's not just the nerves from being up here or dealing with the technical issues. I'm like this all the time. So I bounce around from an inpatient rehab facility to an LTAC to a skilled nursing facility. And I do acute care consults. Medical director at the rehab. And I run a pulmonary, quote unquote, rehab program at the skilled nursing facility. I also do a little bit of teaching as an adjunct faculty at UTMB. And I work for US Physiatry as their director of early career physician development, which is kind of what spurred me to think about this and create this talk for you guys. I also do consulting work for Exobionics and for PAMHELP. So yeah, so I'm busy, right? I have a private practice job. I have an employer. I'm a W-2. But I eat what I kill is the way that people speak about it. The more patients I see, the more money I bill, the more I get paid. And so it's good for me to be on skates and to be moving because that brings an income that keeps me connected to my patients and helps create a continuity of care for them as well. So US Physiatry is the management group I use. And they have kind of a unique situation. So you can certainly be a 1099 for them. But that's not really my jam. I get a baseline salary. So I'll never not make $150,000 a year. But in private practice, I would probably jump off a bridge if I only made $150,000 a year for everything I'm doing, right? So the goal is to be as productive as possible to get some of those revenue back once I get above the $150,000. In addition to that, I, of course, am compensated for my administrative duties as well as my consulting duties. And because I'm a W-2 instead of a 1099, I get the benefits of getting the health care and the dental and the benefits package, the malpractice, the administrative support, and the mentorship that comes with that. I also work as an independent contractor for PAM. Again, I do their medical director at their rehab hospital in Humboldt, Texas, as well as consult on difficult cases and work on different committees for them. And, of course, I get paid for that. So if you're kind of breaking down the pros and cons of working the way I do for a group practice, one, I think the reimbursement is pretty good. There's not a lot of jobs where you can get a W-2. And still, I think my worst year was $250,000 and my best year was around $400,000. So the pay is pretty good. I also have a tremendous amount of autonomy, even being a W-2, because as long as I'm making money, US Physiatry really doesn't care what I do day to day. So I have pretty good control of my lifestyle despite being a W-2, as opposed to, say, Dr. Encore Meadow, who did the video talk. I mean, he's out there all by himself. He has a bad day. He's got nobody to get his back. So the negatives of that, of course, are then the reimbursement mirrors my work. So if you have a little bit of a frenetic personality like me, that can be a bad thing, too. You start thinking, I've got to see more patients. I've got to keep moving. I've got to get going. You've got to be able to kind of roll that in and take a breath sometimes, too. At USP, I said, I do have some safety net, not as much as somebody working for the DOD or the VA. But there are some resources, but definitely not the same. It's definitely much, much different. And there's a whole lot less infrastructure and resources than when I was in academic practice. I've got to go out and figure out my own stuff. Nobody's paying for my up-to-date subscription. I don't have a colleague down the hall in orthopedic surgery who I can just call up or send a patient to if things start going sideways. I'm on my own. I got to fix it. I got to get my friends involved. I got to make the plan up. So I don't want to read this, because I'll certainly put everybody to sleep. But again, just like every decision you make in life, whether you get the steak for dinner or the salad, there's advantages and disadvantages to both. And so these are some of the things that come to mind when I think about the advantages and disadvantages. And big thank you to Charlotte Smith who helped me come up with this list. So my take-home message, I think working this kind of job, a W-2 for a large multi-state organization, is that you do have the potential to create the practice you want within some parameters, right? But I think it can be, again, an advantage or disadvantage. The reimbursement reflects the work you put in. Just like Dr. Mehta says, the more you hustle, the more you make is great. You need to slow down and take a breath sometimes, obviously. But when you do that, you make less money, of course. So then in the end, the work-life balance ends up being what you want it to be. You work more, you have less work-life balance, you make more money. You work less, you have a better work-life balance, you make less money, right? But there's more to life than money, right? I don't want it to be all about that. So one thing I want you to think about is we go through the rest of the speakers and from what Dr. Chase said. Think about who has the most free time or who has control of their free time. Think about really who has the most control of their practice and what they do day-to-day. What is it that each of us are stressed out about on a daily basis? Because you're not getting away from stress. No matter where you think, private practice has stress, DOD, VA, county hospital systems. Everybody's got stress. They're just sometimes a little different. So how do you want your stress? Where is it going to come from? And what is it that you really strive for? What is it that's important to you? Because it can't be money. At the end of the day, you're going to make enough to survive. But what is it that motivates you that makes you want to get out of bed and get to work every day? Because that's going to be a whole lot more important. These are supposed to come at the end, but we had some technical difficulties. So I'm just going to run through them real quick. If you are interested in US physiatry, come talk to me about it. We have a USP university to educate people on private practice as well. And we just started a podcast for that. And then if you're interested, I have a talk tomorrow morning on navigating transitions of care. So don't go out too hard tonight. Show up tomorrow morning. Get some more education. And then lastly, if you're really interested in disorders of consciousness and severe traumatic brain injury, which is my jam, I'm doing a total of four courses at the ACRM in Chicago on that. So maybe I'll see you there. Sorry for being out of order. Next up should be Dr. Guerra. Thank you. Hi, I'm Melissa Guerra, I'm from UT San Antonio and I work for the VA, the South Texas VA. So first question I want to ask, who out here has had an experience in the VA? Okay, okay, what VAs are we at, folks? Where are we? Dallas, okay, where else? DC, okay, anyone else? Jersey, okay, so y'all, your experience in your VA is not like anyone else's experience in anyone else's VA. So that's either a pro or a con, I don't know what it is. So this is my background, I'm prior Navy and I went to medical school late, it was a change of career and I worked for Dr. Che, my first job out at the Intrepid Spirit Center and he was an amazing boss and we left about the same time because I couldn't imagine not working for him there. So what I do right now is I work at one of the five polytrauma centers in the country and so we're given a lot of funding to build these TBI programs and the majority of my population is still active duty. I currently have two programs, we do moderate and severe brain injury patients in a transitional setting and we also have an active duty special forces program, I have 11 beds total on my unit. I also cover the acute inpatient rehab and I do outpatient work, my interest is TBI and headaches. So this is what's great about the VA, there's a whole bunch of positives to working at the VA. Dr. Che hit on a lot of them, which is the 40-hour workweek, you're protected, all that, but we have a few more in the VA. The big one I wanna hit here is the education debt reduction program, that's about $40,000 a year that they'll give you towards paying back your loans. So you sign up for the program and they write you a check, you pay 40,000 and they write you a check at the end of the year. That's part of the recruitment package, so you have to check on that when you apply. The other thing I really wanna hit hard is that you have a retirement pension if you stick around, you have to spend five years at the VA before you hit that and then it's up to 30 years that you serve. So for someone like me who's prior military, I'm already at 15 years just because I'm able to buy back my military service and count that towards my retirement. The other thing I wanna tell you about is that we get $10,000 yearly performance bonuses that can change every year, but that's kind of what we're looking at right now. We have excellent research opportunities and a protected time to do research outside of an academic setting, but if I don't wanna do research, I don't have to do research. I could go on and on, I'm pretty excited. Okay, so there's challenges. I would be lying if I said there weren't challenges. Sometimes our buildings really suck. They're government buildings and they don't look like the Intrepid Spirit Center that the DOD paid for. And to get your air conditioning fixed, it may take six months and it might leak. Yeah, and I'm just starting there. The flip side is the people are fantastic. The rehab teams are a dream. I work with the most amazing professionals in the country and I feel blessed to come to work every day even if the building's too hot or too cold or the toilets don't work. And they've put trash cans up for us to get water from to make the toilets work. And that really happened two weeks ago. It happens. Other downsides, your leadership structure. It depends who's leading your VA hospital and the culture of the physicians in your hospital. So that's things you really wanna know. And your pay might be a little higher in the civilian sector, but I would argue that what you get paid per hour in the VA and DOD is actually fantastic. And for me, a huge priority is my family. I have four children and I would not give up that time for anything. So the biggest reason I love the VA, I can do everything for my patients. Working with my active duty patients, we have so much things we can get them that we couldn't even get in the DOD in terms of modalities. We're constantly pushing the envelope with new treatments. We do a lot of whole health. We have acupuncture, massage therapy, all kinds of stuff. When our patients leave us, when you are a veteran, you're a veteran for life. A problem in spinal cord is that patients will get too many wheelchairs issued to them and they will give them away. That's an amazing problem to have. We didn't see that in our community hospital. No offense, Jen. Where we were like literally fighting for to get catheters for some of our patients. That would be me. That would be me. Can you come back to Texas? Okay. It's wonderful. It fills my heart every day. And obviously I was commissioned in 2001 and it is a personal mission for me as well. Okay, so if you are as excited as me about working for the DOD or VA, a couple things. So as Heachin said, make contacts and network. It's very, very important. You definitely want to get out there and start meeting people. You can email me. I'll do the best I can for you. We have Facebook sites. There's all kinds of ways to meet other VA providers. I do want to highlight that recruitment visits are often not paid for. And as we just discussed, one VA is one VA. So you want to take a look at that VA before you take that job, unless you are like okay with surprises. And finally, use USAJOBS to look at jobs for the VA. They are listings for all over the world there. I think that's all I have. Okay. Thank you. How y'all doing? Thanks for being here. We're glad you're here. This is me, Jen Zumsteg from Valley Medical Center. And I'm gonna give you another perspective. And then again, we're very interested in your questions and discussion. So you can get your mind turned in about that. So I want to highlight a little bit about physician engagement and thinking about reflections on those elements, as well as kind of my bottom line of thinking about value match with your job, no matter what angle you take or how that evolves. So my current practice is that I do all acute care consultation, all diagnoses at a public health district hospital. So I work for the taxpayers of public health district one in South Seattle, very near the airport for those of you who have been. And I am employed by the hospital, but again, taxpayer county hospital, safety net hospital. Prior to that, I was at the University of Washington for 12 years as faculty and have had many, many academic hats. So if you're interested in that, always happy to talk. And we have some other excellent mentors in the room as well that can speak to that. So again, this is a public health district hospital. It's a acute care license for about 350 beds at this time, level three trauma center, stroke center, thrombectomy certified, very busy. And we serve a very at-risk complex population in South King County, which I find very important and satisfying. And I do a mix of really consultation, but a lot of co-management. And I'll touch on that. That's something I really like and enjoy co-managing with the teams, not just trying to provide recs and praying that someone will actually write the orders. I am the only PNR physician, which is a big change from working at the University of Washington. And someone hired me and retired, and I'm very glad that Jill Williams got to do that, but it's just a very different setup. I do all diagnoses in the hospital. So I might go from a complex transition patient that has kind of mystery weakness after an ICU stay to someone who just had their amputation to about 60% of what I do is stroke. So I really like that diversity. And my schedule is Monday through Friday, 8.30 to six, no weekends, no call. Slightly different than previous. So again, those benefits. I really appreciate the broad impact of that PMNR expertise. I had my predecessor, co-partner, Dr. Williams, who really paved the way for the value of PMNR. So while not everybody on acute care knows what I do in PMNR, because that will forever be the case, I'm very welcome. There's no turf battles, there's no pushback. I'm very, very welcome. And again, that includes co-management. And so that, I really enjoy that impact. I think I'm the only person in-house that knows what a C4 AJA spinal cord injury means, and that is both slightly frightening and an area for great opportunity. But again, talk about getting up in the morning and feeling like you make an impact and feel like that matters. Being able to get that person to acute inpatient rehab and optimize their outcomes and tell them my experience and that it's gonna be okay is pretty awesome. Again, I really enjoy that co-management. So when I was on the inpatient rehab unit, we did most of our own medical management and I really like that. So I send diagnostic tests, I titrate meds, I do lots of that, which I enjoy. Many potential collaborators. And so I have a great alignment with care management for complex transitions. We have a quadruple boarded psychiatrist who came from Mass General, who's a great partner. And then of course, our entire rehabilitation services team. Relatively speaking, low, low personal financial risk. My dear friend, Ileana Howard at the VA always reminds me that there is a model that has lower financial risk perhaps. So relatively low compared to some of the other models you've heard about. Again, for me, the schedule is a great advantage. It's also because I'm only doing consultation, it's very flexible. So I can trade out that time, I can trade out a day. I don't have a clinic appointment with somebody at nine o'clock, et cetera. Tremendous variety, which I love. Compared to what I was doing before, very low paperwork and insurance burden. I help with peer to peer appeals, but again, it's a clinical question. So I feel like I can, I don't love it, but I can tie that in. And I have very low paperwork burden. And again, very, very high impact. Drawbacks, I think, I talked about kind of the acute care understanding of PM&R. I think we'll find that in many ways. And there's that opportunity to educate people, which is great. I certainly miss my clinic patients. When I closed my clinic, I had people I had followed for over a decade. But because of the service area that I'm in, I've been at this current position for a year, and I have had patients that I have met four, six plus times during their admission. So there are ways to do that, and it can be a good balance. I think, again, I have tremendous support. I sort of couldn't imagine a better setup. But of course, this can be harder if there's not an established PM&R role, and you're really starting from ground zero about what you can do or what you can offer. I'm more limited on just being a service of one. You do need to be ready to represent the interests of the organization, which, again, why I think the values matter. I have no clinical coverage. So when I'm here, again, I'm a consultant, so we find a way to make that work, but it's just a different thing that could be a drawback. And I think especially in acute care, the system is less likely to track data, like in Epic or in the medical record that is going to show the impact of your clinical work. So I do a lot more data collection on my own than I might in another setting. And then for my particular practice, I have no directly affiliated IRF. So I am working hard and advocating for patients in a very satisfying way to get them somewhere else, but it's all external, and that's just a very different flow than if you have your own IRF. So tips, I would beware of mentors who can't get enough sleep or exercise or have no hobbies. So I think if you talk to all of us, we have had moments of sleep deprivation and challenge, and we all have that as human beings, but I had a mentor early on who did a lot of all-nighters for grants and things like that, and that was not a helpful thing to model. We learn something from everybody, but just I would encourage you to think about those things that are really important. I would encourage you to welcome unexpected opportunities, even if they seem like big challenges. Use that formal and informal professional network that you've heard everybody mention. Control what you can and prepare, and then try to let the other stuff go and prioritize that engagement and professional value. I put some information in here just so you have it regarding definitions of physician engagement, what kinds of things you might think about or ask questions about while you're interviewing. And then this is kind of what caught me here that I thought was great. This is the Mission, Vision, and Values Medical Center where I work, and all of these things are aspirational, but they are real, and we review and sign, and it helps with accountability. And the overlap here with these values of what's important to me and is important to them fit really, really well. So we can make things work, even when there's problems. This brings me to dialogue. I can say, I think we had a collaboration problem last week, and there's a infrastructure to say, we value that, we need to talk about that instead of not having an opening to talk about that. So I would encourage you to think about your professional values and factors that support your style of success right now so that you can look for that match or mismatch and stay open to those values and needs changing over time. Thank you. All right, just as planned, we'll have plenty of time for questions. We will not take them virtually. Get on your big boy or big girl pants, come up here and ask us yourself. But if you're an introvert, you can take the first one. Yeah. Hello, yeah, great talk, by the way. This question's for Dr. Zumstead. You mentioned you work in an acute care hospital, but there's no attached IRF, there's no attached SNF, there's no rehab department. How did you, why did they take on a physiatrist? You're in my mind, so it's like, thank you. Yeah, it's a, oh, is this on? Can you hear me? Thank you, sir. Great question. So again, I'm lucky in that I didn't have to personally make that argument. I got to hire into the, but my position is new, entirely 1.0 FTE. I think the answer is that our rehab services department was very large, PTOT and speech, and there was value in that and that leadership trained at the University of Washington and over 30 years maintained pretty close ties. And so when the joint bundle happened from CMS, joint replacement bundle, they really, you can see the values are pretty in a line with value-based care, and they went all in. So especially on the acute care side, there's a whole department, not quite where I report to for a variety of reasons, but it's all in the home of value-based care. The hospital plans to lose dollars on my position every year, but we were able to demonstrate the impact for complex transitions, reduce that length of say, increase adherence to stroke guidelines, make our stroke certification stronger, and just highlight gaps in acute care, especially for spinal cord injury, TBI, and amputee, where it's less risk overall and more efficient. You don't have to justify your profitability to make the assuming you're losing money. Yeah, I'm budgeted to lose money. I do monitor my own and directly. I monitor my own RVUs and that's kind of part of our peripheral conversation, but that's not the center. And that's part of the data that my support team is so helpful with, is thinking about how do we measure value. I actually report up through palliative care, which just has a good perspective too on not necessarily always paying for themselves, but palliative care reduces trips back to the ICU, for example, with advanced care planning, which this place really values. But again, it's some of that value match. And I'll give you an example. During the COVID surge, we had somebody, a 30-year-old who had an idiopathic cord infarction, had a C3AJA spinal cord injury. It's not what we do all day. Everyone was full. And I said, this person stays here until they go to this one IRF in our area that can do this. And they said, okay, no problem. They stayed for six weeks until we got them into that IRF bed and we did the right thing. So, it's a great place to be. Yeah. And I'll say, if you've ever worked with Dr. Zumstead-Gibbs, I've had the pleasure to do. She is really amazing at tying everything up and getting patients transitioned from one level of care. So good, in fact, I wish you would give a talk on it at the AAPMNR. Like maybe tomorrow at eight with you? Oh. I can tell you about when in Seattle, there were no SNFs and no IRFs open. And then what do you do? So then, a little bit of a follow-up on that. A lot of hospital systems will look at physiatrists to be in a bit of an administrative role, help with the therapy teams, look at length of stay, reduce readmissions. Has that been brought up at all, to have you lean into the administrative area a little more? Yeah, and I certainly welcome this perspective from you guys as well. I think you've had some experience there. Very long story short, the person who hired me also initially had 30% time as medical director for a variety of roles and did a lot of that. With everything that's happened in the last few years and her retirement, we need to reorganize some of the outpatient stuff that she was doing, so we currently do not have a clinic, to make that work. So we are in an interesting but important phase where we are letting our teams feel what it's like to not have a medical director, and that's important and a little painful in order to reorganize a better structure from a department perspective. And so it's very collaborative and project-based, and I get to practice my know. So is the system not feeling pressures financially like systems all over the country are feeling? I mean, if things are allowed to kind of run like that, it doesn't seem like it would be financially sustainable. So I think we have a lot of financial pressure, catastrophically. So we lost one of our matched grants for the safety net hospital that immediately put us an extra 40 million in the hole. So absolutely, it's there. That's where the values and the leadership come in to think about priorities, and we're all working hard, but I'm not gonna be medical director for free, so we gotta figure it out, and it's part of the path. I think it'll be informed. Do I want that to be the case forever? Not at all. I also, I'm not, I wanna collaborate and be a good team member, but I'm not a physical therapist, occupational therapist, speech therapist, and I want them to have that ability to practice at their highest level of license and encourage their structure and find ways to collaborate. You're making a lot of sounding like you want it. You could be an administrator. It should be a role that you should consider. I think physiatry is well set up to be administrators because of the multidisciplinary and interdisciplinary roles we started with in our training. I do that now. I actually love it. It's a headache at times, but I really love it. It's something to consider, I think. Yeah, I appreciate that. I have learned about myself that I'm a great number two. I spent 12 years doing admin in my last job, and there's good things and bad things, but I love the enthusiasm. I don't know. I'm done. Thank you, Dr. Atfedjika. Thank you so much. Again, it's phenomenal job. It's more about quality than even the money, but let's say they offered you an IRF position on top of what you're doing. Would you take that? Just curious. So general. Do I want Valley Medical Center to have an IRF? Yes. Do I want us to be trauma rehab certified first? Yes. Do I want to change our clinic structure first? Yes. Am I less sleep deprived, happier, drawing more, tap dancing more, and clinically contributing at a deeper level than I did when I was doing lots of academic work and 25% clinical time? Yes. I love going to work. I love what I'm doing. I could love what I'm doing in another setting. Ask me again in 10 years, I might tell you something different. It's all good. You're phenomenal. She really is. You're such an inspiration. One more question, and again, this is a very, I'm an early career physician who is trying to get a hold of every single subtype of practice. If you would say, and again, we just got the recent report of the MGMA. Would you mind, as a private versus academia, compare and contrast and set the stage, or like this is your bare minimum, don't go below that. I know this is not the topic of the whole, but if you can just touch base on that, that would be awesome. Yeah, I will push the mic down further at the table. I'll say really quick that that's a really important consideration and I would encourage you to use the academy resources. I know, but it gives you a relative perspective. So for example, cost of living considerations in Seattle, for example, might be slightly different than other places in the country. So it's hard to tell. It also depends on what's important to you. I'm salary with no option for incentive. That is fine with me. That's a good trade off for me. And my pay is basically the same from my previous position, but there's lots of different models. But yeah, certainly if you guys have other thoughts about what's, I mean, I guess I would say just briefly, do your budget and make sure you can pay your bills. Just make sure. And there's lots of other ways to think about it, yeah. Yeah, absolutely. So if I can understand the question, you're saying when looking at academic and private jobs, do you set a minimum? So let me ask the question differently and let me know if I'm. So your question sounds to me really like you're asking, how do you negotiate appropriately to make sure you're getting paid what you're worth? Is that what you're trying to say? So one, I think you have to look at the setting. Your income in private practice is never going to be fixed. In the DOD, it's probably take it or leave it at a particular level. Most likely the same at the VA. Dr. Sumpter, you may have had a little bit of negotiation room, but it was probably pretty set. And so what you've got to then know is how do other people in that field get paid? And there's not a great resource for that. You've got to ask around and you've got to have a feel. Now, within private practice, I can speak very well. There are lots of medical directorships. Hospitals, rehabs, LTACs want you to come in and do a particular skill. And that is very, very negotiable. And again, one of the reasons I really like US Physiatry is we can see what every Kindred, every LTAC, everywhere that we have a docking is paying all those medical directors. So we can let you know, they offered you how much? Wait, what? Don't take that. Or, no, it's pretty good. You can probably accept that. And so if you end up with a big group, that is some of the power that you have there. But I can say if you're doing about the same amount of administrative work in academics compared to what I'm doing for about the same size rehab in private practice, my medical stipend is five times what it was there. So it's a big difference for the same amount of work. I think if you are looking for first job, I think the leverage is less. Meaning you pretty much going to take, well, they offer you what they usually offer bare minimum. And regardless of DOD VA, I mean, DOD VA is publicly, you know, you can't argue. That's basically, you go look it up, and you know what the level will pay. So that's very transparent. I think even besides the government, I think I learned that it's very variable. There are different ways to sweeten the deal. But after the first job, I'm amazed that it's sort of, the reference is like your previous salary goes a long way. So what I tried to do is not so much chase the money, but what am I trying to, is this a really good fit for me? Right? Then after that, it's really about talking to the people who are in the job or similar to that job. I did learn over the years that geographically it's very different. So even DOD VA, you can argue for cost of living to get more pay. So there's definitely power to negotiate. I think we physicians don't negotiate much. We actually think that, oh, you know, I just love my job. I didn't really, you know, there's a tendency not to argue. And I realized that I lost a lot of money on the table over the years. I'm learning from my younger brother who is totally business minded. He always thinks that I always lost out. But I don't go that extreme. But I will definitely, I will say, ask for the moon. The worst case scenario is like they're going to cut back. And I think that's also when you find out whether they really like you or not. That's why I say it. From a stress perspective, especially as a first job, I would just add that it would seem very odd to me if someone knew that you were coming right out of training and expected you to make them the first offer and was like rigid about that. That seems very odd to me. So it's very reasonable to expect or to ask them to at least make you the first offer. So you're not just pulling something out of nowhere. And then there's great data from the Harvard Business School that both parties are more satisfied if there's some negotiation. So if you actually just take the first offer and sign on the line, both parties will be less satisfied. At least do a little something back and forth. I really liked my most recent contract. And so I negotiated my start date just a little bit. We did a little bit of back and forth and signed it. But from a stress perspective, it's fine for them to make the first offer. Don't focus on just salary. There's negotiation of other things that we forget about. Hi, I'm Edison Wong. And I am a longtime colleague of Dr. Che's and former mentor. And I want to make a comment. You folks have given an excellent, I think, presentation to the audience. And I wanted to add a few more things since I can probably claim to have more jobs than any physiatrist in the room. I'm on my eighth or ninth job right now. And so I've had a variety of different jobs, ranging from academics, like Dr. Che, to private practice. And oh, yeah, that was one thing. When I started up at Spalding, first time job, I actually did negotiate. And one thing I negotiated on at the end of giving me a little bit more was I said, I want more CME time. They said, OK. And because that wasn't anything that was written down. I had to say, hey, why don't you just ask that? It's just something I thought would be kind of good for me. But yeah, if you think of something, especially if it's something related to your own skills that you think makes you stand a little bit apart from the other candidates, you have something in your background you're giving to this job, and therefore it might make sense to give you a little more than asked for it. And point that out, too. But in any case, yeah, I would love to be on your panel. But I think one thing to add, Aldis, is don't be afraid of taking a chance and making a mistake. Because I can say I've probably made a few. And the thing is, if you look at the way technology and the world is progressing, and just economy and jobs in general, a lot of people will be changing their jobs. There is nothing that says you as a physician will be keeping the same job. In fact, every one of these folks has changed their jobs. And traditionally, academic programs focus a lot on academics. So that's what we start out with. That's what we're familiar with. And so a lot of these folks came from that. But they changed to a different type of job. And so similarly, I would say that sometimes if you think of it as there are certain stages in your life, in your career, certain things may be more appropriate. So you'll choose A. And that should be what you should do. But it doesn't mean that you can't do something else five or 10 years later. Because your circumstances change, and you need to do something else. But if you feel like this is what you want, you want something really stable, that's fine. So it's whatever your circumstance is, what really fits you and your life and your plan that you see ahead of you. And again, you don't necessarily have to see 30 years ahead. I didn't when I started out. I didn't know I was going to be in my eighth or ninth job. But that is something to leverage. Make sure you understand what all your skills are and networking and accumulate all these things behind you and understand where you are. And don't be afraid to negotiate. Definitely don't be afraid to negotiate. So anyone who's looking for a mentor, I think we have a volunteer. Which I'm so grateful for. Great points. Yes, thank you. Sure. And I would say that I was one of the people who got a job with Dr. Che with the DoD. Only I went through the contracting sector. And for that, I got the job through LinkedIn. So yeah. And I'm not a big fan of social media and social networking and all that. But LinkedIn is a little different. And it's number one professional social media. So I encourage every one of you, if you don't have a LinkedIn profile, to get on there and do that. Because you can actually get a real job from there. And one that is meaningful. And I can say when I changed and I worked for the DoD, I couldn't have had a more meaningful experience. I certainly can understand those of you who served. Yeah, it is something. Great. Thank you for that. Thank you. Do we have any vetting clinician scientists in the audience? Maybe. We're not sure. If you're interested in that path, please look into the Rehabilitation Medicine Scientist Training Program. And everybody who's done that program, including myself, would be happy to talk to you. And we've got other good mentors in the room, too. Good afternoon. My name is Mona. I'm currently at UT Southwestern one of Dr. Vejicka's mentees. And I am a fourth-year resident looking for a job. And something that comes to my mind is we always talk about skill sets and what you gather at your current job. I know we've talked about having switched from job to job. What do you think have been skill sets at your job one or job two that have actually been your, as we call it, receipts for your future jobs? No. Take it. I think you got something to say. I'm still formulating my response. Yeah, I'm thinking, too. I'm an introvert. I can start, if you want to. Sure. Take it. So maybe just as one example, to give my introverted colleagues, which I'm also, some time to process. There is no way that I would be OK doing my current job by myself if I didn't do inpatient consult and clinic at Harborview for 15 years, where I saw and did everything and had every brain that I needed, and still had them as a community resource to send back to. So that's why I can do amputee, all spectrum of TBI, stroke, spinal cord injury, complex ICU weakness. And my role to the hospital in a value-based care perspective, every single day, I'm so grateful that I was on the Academy's Health Policy and Legislation Committee, because you and I know that CMS rags down to the line, right? And so peer-to-peer appeals, challenges for patients to advocate for them. So the skill set and what's in your toolbox is your clinical training, the expertise that you have, the committees you've served on. However, at the base of it is also just you as a physiatrist and our core training, no matter where you're at. So does my current job have an interest that I know how to do burn rehab? No, because they're never going to come there. Those folks are going to go five miles away to Harborview. But when we had somebody with intractable pain after fasciotomy, it looked a lot like what we were doing on the burn unit. And we were able to use some of those strategies and use ketamine and use that expertise. So just being confident in kind of what your core PMNR skill set can be helpful. My academic career evolved in kind of an odd way, where I ended up not doing procedures and injections. That's just sort of what happened. So I haven't done Botox or injections or EMGs for a long time. I could get up on that again at some point if I needed to. But that's actually a gap in my skill set. So it's just balancing kind of what people are looking for. But trying to make sure in the job description or with the group that you know what they're looking for. And I'll just say that there is some evidence that men are more likely to apply for a job when they're about 80% matched. And women will often wait until they're 100% matched. So depending on where you're at, maybe nudge yourself down to, it doesn't have to be perfect. Make the most of it. Leave yourself room to grow. That's a great point. So I think that you're talking about skill set that's important to get a job, is what you're asking? Yes. So in the sense that, was there certain kind of concrete things that you've done in the past that have been able to kind of carry forward? Or just things that we can build on? Because, for example, I've learned about acupuncture being a modality. So that's more concrete. But is that other things like that, or even just other? Yeah, that's a good question. I can only speak for myself. I will say the most important skill set, and I continue to see this happening when I apply for a new job, is I think the core physiatry skill, which is being a team player. Absolutely. I don't think any employer wants to hire a, well, they all want to hire a superstar, for sure, right? But not a superstar that has his own agenda, or his agenda. I think really wants a team player that comes and be part of the culture, and develop that culture that exists, unless you're going to a brand new environment, like I did. I had to create a culture. But most of us are going to go into a culture already that's established. And they want you to come, and be part of that, and grow that culture. So understanding their vision, what they're trying to create, and be a team player will go a long way. And I've seen a lot of physiatry shoot themselves in the foot by trying to say, hey, I'm your savior. I'm the best thing there is. Believe me, you don't have to say that. They kind of come across. And just be that team player. Because a lot of them kind of know what your other concrete skill sets are, right? I mean, by your training, by your fellowship, what kind of place you worked on, what is your skill set. But they want to really know, OK, is this going to be a good fit? You want to go, Moussa, or should I jump in? OK. So thank you for the minute to think about this, because I think I have the perfect answer for you. I actually tweeted about this not that long ago. Nobody in my private practice cares that I was the chief of the disorder consciousness program at TIER when I'm going to see their grandma who fell down the stairs, right? Nobody cares. And nobody cares that I had this. And Dr. Smith spent a lot of time trying to beat that out of me. It took me a while to really get it, but I get it now. Because in private practice, things are moving fast. They just want you to show up and do a good job. And so the thing I think that really has had the biggest impact on me, the skill sets that I bring forward all come from waiting tables through high school, college, med school, and as an intern. I waited tables my whole life to make ends meet. If you've ever seen the movie Waiting, it is scary how accurate that movie is sometimes. But it's very similar in private practice. The kitchen's on fire. The chef's in a bad mood. The table is being unreasonable. And you've got to just get those orders through, get everybody happy, get the food there, and figure it out. It's really not that different than what's going on in the rehab. The PT's having a bad day. There's something wrong with the lab. You can't get your results back. But you've got to just kind of get everything moving, get it through it, and get going. So I really think out of everything I've done in my life, the most important thing was waiting tables for 12 years or something, better than anything I learned in med school or residency or whatever. That's probably the skill set for me that I think is most important. And these days, I think when you go on job interviews, you're likely to get asked questions about those kinds of skills. Tell me about a conflict that you had with someone that you resolved effectively. Tell me about a conflict that you didn't resolve effectively, right? I mean, being able to think about your strengths and weaknesses and growth areas is important, too. Please. Hi, thank you for this talk. Can you guys kind of compare, contrast the work-life bounds, especially the home life aspect of it? How much assistance with charting, getting through the day do you guys have in your different work settings? How does that translate to how much work you guys bring home and how that impacts the home side of your life as well? All right, everybody's looking at me. So that was actually a big reason why I left academics. While I really enjoyed teaching and doing research, the expectations in the meetings and the extraneous things really took a toll on my work-life balance and my being there for my family. We have young children, and so trying to balance that definitely influenced my decision. And being in private practice, it's easy. I can work as much or as little as I want. I'm going to make more or less money. But as Dr. Gary was saying, then you just have the question of how much for your family can you tolerate that day? So it's totally your decision. So for me, that's how I figured it out. I'm pretty sure I did not say that, though. That's what I heard. I heard I have four kids, and sometimes, no? So I think it is helpful to think about your strengths and weaknesses and just observe yourself over time. So I have always had a really hard time getting my clinic notes done. And I think I'm a good clinician, but my brain works about 10 times slower than Dr. DiTomaso's. We are a good pair, but man, when he was a fellow, I was like, I better be on it today. It's all good. And so consults are great for me. I need to do things in real time. Somebody's looking for that info. It matters. I need it now. And so it's fantastic. I very rarely take work home, and so my charting at home is almost always because I'm intentionally trading something off, leaving early, seeing patients and finishing notes at home, texting the hospitalist what my recs are, putting a short, remember who had paper charts and could write a brief note, like recommend baclofen 5TID, full note to follow? You can still write that in the computer. It works. Or if I needed, almost always, I just need more time. Some of these cases are so psychosocially complex that I need time to write my 15-page rehab note, and I'm intentionally taking it home. But for me, it's much, much better. That's because of the consult flow. It's a really good fit for me. Well, Dr. Che is really good at writing notes, so he's always really fast. I'm a slow note writer, but it doesn't matter at the VA. The way you manage your time and what you're assigned to, like I'm 25% this, 10% this, 10% that, so it doesn't matter. And we're not based on RVUs, but you do have to get them in in 24 hours, so there's that. I think EMR is a huge work-life balance factor. I definitely agree. I think even if I'm fast, fairly efficient with the note writing, I do envy practices that have scribes, note takers. I know that's not really much of an option in some places, but I do think that if I were to look for a new job or a different job, I think that's definitely one thing that I'd be asking. It's become that important in our quality of life factor. No way to get around it. All right, sorry, guys. We went way over. If you have other questions, please let us know. We'll be out in the hallway, but we gotta get the next talk going. I apologize, I didn't realize someone else was in the room. Thank you.

practice styles

physiatry

private practice

Department of Defense

work-life balance

multi-state organization

autonomy

education debt reduction

acute care

diagnoses

professional values