Hi, I'll thank you all for coming out on Saturday afternoon. We appreciate it. Been a long meeting for people, lots of information. So, we're just going to flood you with a whole bunch more before you start going home or go out Saturday night. I am Chris Standard, we're all from UPMC. We're going to talk about the spine program we developed, they're the program for spine health, and a bit about, talk about several aspects. So, I'm going to be speaking. Charlotte Brown is a clinical psychologist who works with us in our program. She's going to be talking about the role of, psychology and pain, the role of her role within our group and program a bit. Karen Barr is going to talk about the sort of the physiatry role in this, and how you actually practice medicine in this way. And we're going to start with sort of this idea of value, and some of you may have been at a different symposium, and yesterday we were talking about value-based care and PM&R, and if you're at any of the things, there's a lot of talk of this, of what is value, what is our field, how do we do this, how do we achieve this, how do we get there, and this is what we tried to do. And I'm going to go through a bit, personally, I'm going to go through a couple things here. Why do we focus on low back pain? And for those of you who are low back pain people, this is helpful. There's more of a paradigm here, and it really could cover all sorts of things. It doesn't just apply to back pain, it applies to stroke, it applies to spinal cord, it applies to abdominal pain, if you really start to think about it the right way. Right, that's what we're trying to do. What we're trying to do is something that's sort of replicatable and expandable. And we'll talk about low back pain, we'll talk about what is effective care in back pain, and how we look at this. Talk about how you actually start building a value-based program. Like, what does that actually mean? Like, how do you do that? And we'll talk, really, about what we did, and I'll show you some of our numbers, right, and what our numbers, what we did, and where we are and where we gotta go. So, why back pain, right? Back pain's the most expensive health condition in the United States. It's kind of absurd, right? I just don't get it. Why we spend more money on back and neck pain than every other health condition, which, from a societal, like, what makes us better, what keeps us alive, what makes us healthy, what makes us everything else, I don't understand. But we do. It probably tells me something's wrong more with our payment system than with our people. This is followed by other MSK things, then diabetes and heart disease. You know, and really, this is my own view of this after having done this for 25 or more years. Our spine care system is broken in this country. It's just fragmented, right? We don't do the right things. If you track our data over 20 or 30 years, the cost, the amount we spend on spine care has gone up dramatically, and our population health for spine issues has gone down dramatically. So, in the process of spending more money and doing more stuff, we have disabled a higher and higher proportion of our population. We've done the exact opposite of what we'd be trying to do, right? If you made the peril to the cancer, we'd be killing more people, but we're not, right? We're just making them more disabled. We track this, every study on guideline-based care, we grossly overutilize guideline-discordant care, right? We don't follow guidelines. People are paid to do things irrespective of benefit, right? It doesn't really matter. We don't have outcome tied to payment. Huge disparities in care and outcomes across geography, across economic lines, across racial and ethnic lines, huge disparities everywhere. And I think we build a care paradigm really disempowering patients and creating an unhealthy codependency around belief structures and payment that is essentially impenetrable by data, it seems. We don't change it, despite the data. So, I was asked to define this a while ago. What is effective spine care? This is what I came up with. I'm open to suggestions, right? I think spine care, if it's effective, should optimize health, quality of life, physical and social function, work or avocational capacity, mental health, safety, and pain, right? That's what an effective treatment would do, both for individuals and a society, right? Across a population. It would be evidence-based and it would be economically sustainable, right? Then you're into something you can do. Is this what we do, right? This is data on lumbar fusion rates. The top lines are New York. The bottom lines are Ontario, right? The black line is total spine surgeries. The yellow lines are elective surgeries. And the blue lines at the bottom are emergent surgeries, which are identical, right? The other surgeries are not identical, right? We have about four times the rate of elective spine surgery in New York City as we do in Ontario. I don't think people are that different, right? So, I don't know if this is a good example of effective spine care, right? The real reality, if we pay too much for something, too much of it gets done. If we don't pay enough for something, not enough of it gets done, right? The average orthopedic surgeon in the United States, not a spine surgeon, who probably does more, bills $10 million a year. I don't think anybody in this room bills $10 million a year, right? The average physical therapist gets paid $90,000. Right, that's how the money goes, right? So, if you think about this in a broader societal context, power, profit, and equity are sort of intertwined here, right, they all go together, right? If you make policy, and policy is made by those with money and power, it tends to perpetuate those very issues and perpetuate the inequalities, and then they create a sustaining narrative to explain it, why it's important that we do it this way, why it's important that we keep the inequity and the imbalance, right? So, the only way to actually get to better health and equity is to change all of this. We have to change policy, we have to change payment, we have to change the way that we deliver care. It's the only way to get there. So, I showed this slide a second ago, and I said it's a problem, but in every problem lies an opportunity, right? So, for us, maybe this difference is the opportunity, and in that, I mean that if you could capture all the money spent in those quadrupling of surgical rates, maybe you have money to do something else, right? You could repurpose all this. That's, it is a problem, but in that problem lies our opportunity, as PM&R, right? I think if you're in Canada, you sort of go, you know, is the need to quadruple the rate of spine surgery really impairing the health of those in Ontario? I don't think so, right? I don't think they want four times as much surgery. I haven't asked them, but I don't think so. Anybody here from Canada? Yeah, but I don't think they want it. So, we need to approach low back pain as a chronic disease, and to think about this correctly, right? It coexists with other chronic conditions. It's tied to the health of populations and communities, and it's a huge source of disability. It's tied to our communities. We need to focus on health rather than just pain. It isn't a pain problem. It's a health problem. Whatever we do, whatever you look at, whatever data you want, there is no medication, intervention, shot, surgery, anything that reliably absolves people of low back pain. We don't cure it, right? And if we focus on pain and imaging, we medicalize complex issues. We underestimate what we're up against. Spine problems cross disciplines, right? Service lines and integrated care are way better than silos. You can't do this by yourself. It's a system-based thing. Evidence and risk stratification become important, right? You have to track this. Behavioral care is essential, right? One, mental health problems are really high in people with chronic pain and spinal issues. And as we just heard in that talk, getting better involves behavioral change, right? That's what the whole symposium was a second ago that we just heard, if you were down there. So how do you get there? So this is the, like, if you want to know, like, how do I do this? This is the slide. It's a big slide, but it's got all, this is the concept, right? How do you do this? How do you start saying, I have a problem. I want to make it better. I want to capture value. I want to be a physiatrist. I want to lead this. I want to do it. This is how you do it. You find the gap in care. Where is the problem, right? What is the population in need? Where is care failing? Where are problems that just perpetuate the problems, right? Then you need to align the right thing for the patient with the economics. So you have to understand what's right for the patient, and you have to understand the economics of where you are, right? In most systems, ineffective care pays better. So you're up against that. You have to align the stakeholders in the system, right? That means kind of everybody, surgeons, PCPs, pain management, PM&R, PT, payers, patients, everybody else you want to think about in this sort of ecosystem of spine care. You have to align them all for the same thing. The commonality is patient care. That becomes the currency. What is best for the patient? If you can get to that, you can get people to move. You need to build a team around a mission, right? You really have to get people motivated to go there. To do that, you need data, right? You'll need data to prove and improve. You need to prove what you're doing, but then to get better, you need data. It becomes a giant QI sort of approach. And you need somebody, you need a convener, which is sort of like a lightning rod. You need somebody who is powerful, probably has an economic, some economic control, to say this has to be done. You all have to get along, right? And they can take the heat, they can take the complaints, they can take it all. That's hard. If you're the one trying to do the change, it's hard to do all of that. You almost need somebody else on your side to do this. But, to do it, you have to be in the middle, right? As a physiatrist. You need to be, to do this, you and anybody who works with you have to be really good clinicians with no perception of conflict of interest, right? If it becomes, it's about you. You want us to help you build this program inside a patient because you want more, right? That's not going to work, right? If it's because all of our patients need to be better, that might work, right? And you have to know what everyone else does and you have to make them all better. They all have to get something out of it. If they're going to work with you and give you their time, give you their energy, give you their patience, what do they get, right? You got to make their lives better, right? That's the only way to do it. You do have to follow the evidence and know what works. If, if we think of value as change in patient outcomes over cost, it is very hard to get there by doing things that are expensive and ineffective, right? So you can't build a whole system to deliver highly expensive, ineffective care to drive revenue and improve value, right? That doesn't work. And you have to be transformative, right? That's what inspires. You have to be transformative. It's got to be different. You have to inspire. You have to go there, right? So I said, you have to understand your economics, right? I'm not going to talk about the best in spine, the ways to take care of spine. There's a whole different lecture. Economics, you have to capture what is important to your stakeholders. So this means you have to understand your stakeholders and what they want to do, right? Ideally value, we're trying to improve outcomes and lower costs for our payers, right? If our patients get better and our payers have to pay less, we have achieved better value, right? What is the economic model in which you work and what are the goals for that model, right? If you're an integrated payer, which is sort of what we are at UPMC, if you can improve patient outcomes and lower costs, that works collectively, right? If you are not that and your goal is you're not going to do that, but you're going to drive volume to your center by out-competing on value, you're going to be better and cheaper than everybody around you to get people to come to your center and drive volume that way. That can work. You can get into risk-sharing or capitated sort of arrangements where you're going to sort of share savings with people, with the payers in some way. And you can talk about bundling things and going after employers directly. These are examples of how you can do it. They're all different economic models for how you think about this. That's how you're ultimately trying to sell your product and that's how you're starting to find value as you try to achieve it. So what did we do? First, we looked at our population, right? I said you had to go find like your gap, right? What was our gap, right? We did a study of a sample hospital, like a whole catchment area of one of the hospitals in our area. And what we found is that for people who didn't have any back pain for a year or so before our sort of start date, a quarter of them just spun over two or three years. They came in for their back and they never left, right? They just kept spinning for like two, three years, going everywhere to ERs, to anesthesia, to surgery, to PT, to whatever. They just kept spinning, right? And that was our problem. They cost a lot of money and they're not getting better, right, and they're filling up clinics and they're filling up ERs and they're filling up doctor schedules and they're not getting better. So that was our target. Our premise was that if we could provide coordinated patient-focused, transdisciplinary, non-interventional, non-surgical, non-opiate-based care, we could improve value. Essentially, we're gonna try to stop the spin and improve lives for less money through collaboration. That was our premise. That's what we tried to do. So we built a care team to do this. Again, this depends on your resources, on your goals, on everything else is what we did because it's what we thought we needed. We have a nurse navigator. We took PTs who are specially trained, sort of advanced training in spine called primary care, primary spine providers. They go through a whole separate training program at the University of Pittsburgh to do this, but we took them because they're really highly experienced spine PTs, basically. We have PM&R specialists. We don't have a surgeon in our clinic. If we were huge, we might, but we don't. Not that huge yet. But we all, in that clinic, we all practice essentially non-interventional spine care is what we're doing, spine and MSK care. We have a pain psychologist, Dr. Brown. We have a dietician, and we have a health coach from the health plan, all sort of in our team. We located all of our clinic sites within sort of the PT sites. So UPMC owns 70 physical therapy sites. So we're in those. That's where we go. So we're co-located with our PTs. And we have a case conference weekly. We talk all the time. We go through this stuff all the time. We stay connected. Ideally, we educate the patient on their condition. We address fear avoidance, unhealthy beliefs. We engage them in physical therapy very early. We want them moving. We enhance self-efficacy. And we get them back. We're not trying to hold them for life. We're trying to get them better. If they get bad in life later on, we want them to come back to us, but we're not trying to keep them forever. This is not a giant enabling structure where they keep coming in for trigger points every month. That's not what's happening here. We actually don't do those, so. It's focused around this idea of five things people need to be well. This is sort of what I discovered by myself. When you see them, if you know lifestyle medicine, a lot of overlap there, but I didn't know that when I came up with them 15 years ago. I just sort of did. But it's this idea that people need to sleep, right? Sleep is when we repair ourselves. We need decent nutrition. We need to exercise and move, right? We are use it or lose it creatures. We need social engagement. It's interesting. Our speaker on behavioral change said the exact same thing while she was talking. We're social creatures. And we need a goal or passion. This is a positive thing to go chase, right? Not a negative thing to avoid. I don't want pain. I want to walk. I want to play with my grandchildren, right? Those are positive goals you can go after. That's what we build our care around. We try to avoid medicalization. We avoid fear. We avoid passivity. We avoid guideline discordant care. And we avoid low value care. We're trying to empower and switch control of the whole problem over to our patients. We're not trying to own it. So we focused on patients who are high risk, right? These are the spinners, right? This kind of resource structure you just saw, there's no point in doing that for everybody with back pain, right? For those of us in the room who see back pain, we don't need to see everybody with two days of back pain, right? They just don't need us, right? They need somebody else if they... Three days, they need somebody else if they're still in trouble, but not us really. But the people who are going to be spinning, they need us, right? I've discovered over doing this that we see two main groups of people really, right? I think this is my own sort of dimester view of who we see. We see people with poor coping, psychosocial distress, and fear, right? Really sort of psychological, psychosocial sort of barriers to being okay, to getting better, to moving, to doing what they got to do. They just don't know what to do. They don't know how to move forward. They don't have the environment, the support, the psychological skillset. They just don't have it. Or they have complex structural issues, right, that really do need expertise. They need somebody who knows what they're doing, right? Somebody who is a really good doctor has to see them, but they don't need surgery, right? These are things like scoles and spondes and discs and failed prior surgeries and neurologic disorders and neuropathies, and they don't have a good diagnosis, and they have lots of other comorbidities and lots of other things. They don't need surgery, right? But they need somebody who knows what they're doing. They don't just have sort of back pain writ large. They have a specific problem, right? So they need some expertise in there, and a lot of people have both of these, right? It's a combo thing. And in this work, we track everything. This is how you do this. You have to track everything. You have to prove what you're doing, right? We are, yeah, Dr. So is right here. We try, we've tried so many ways to prove what we are doing, right, over and over and over, but we track everything. We track patient-reported outcomes or their PROMIS-16, a sort of short version of PROMIS-29, depression, anxiety, sleep, pain, fatigue, social, physical, and cognitive function are all in the PROMIS scores as well. So we track those domains. Those are our main outcomes. But we track healthcare utilization. We are the payer. So UPMC is a payer. We know everything. We know everything everybody gets. Everything that UPMC gets billed for under their insurance, we see. So when they go to PT, when they go to surgeon, when they go get a prescription, we know how many pills they get. We know everything. But then we track everything else. We track volumes, referrals, geography, payers, the whole sort of ecosystem. We track it all. I'll show you some samples of the data we get. These are our volumes, right? So we started on the far left. That was July 2019 when we opened our doors. And if you get to more recently, the last six months, we have 3,000 visits, right, from about, I don't know, 50, 100 a month when we started. So steadily grown. But we track this. And we track it by provider. We track it by location. All those things. This is what our patients look like. We said we were looking for the people who are in trouble. We have the people who are in trouble, right? This is an anxiety score. So this is a PROMIS score. All PROMIS scores, 50 is norm for the population. That's the blue arrow. That's norm. These are our patients, right? So we have a lot of people in the black and red, which is bad, right? They drift over. If you go to pain interference, again, blue is the norm for the population. Those are ours. A lot of black and red, right? That's the bad. Go to physical function, like almost nobody is like normal, right? So in this physical function, to the right is good, to the left is bad. They have poor physical function. So we went looking for people who are in trouble, and we found people who are in trouble. That's who we get. We compared ourselves. We did that hospital study. And when we did that, we didn't just look at sort of the people who spun. We looked at what they did and what happened to them or where they went and what they cost and all these sorts of things. We compared ourselves to them. And when we do that, if you look at that study, this is 2015 before we started. In those patients, we had about 2,500 of them in that study. Very few went back to their PCP ever. By their third visit for their back in the system, about 13% were in PT. So this is like the third time they've seen somebody or something for their back. The system's gotten a bill. Yeah, less than one in six are in PT. Very high rates of imaging, ED, multiple providers, they go all over the place. Like lots scatter everywhere. Of the money that was spent on spine care for patients insured by UPMC, only 66% was spent within UPMC, which is bad, which means UPMC Health Insurance is paying money to another health system to care for their own patients, which is not a good thing. And almost 60% of the money was spent on EDs, surgeries, surgeons, and pain management. That's where the money went. When you look at us, very high rate of return to the PCP. They go back. 65% are in PT by the third visit for their back. Very low rates of ED use, injections, surgery, chiropractic care. Almost all the money spent on spine care is spent within UPMC. They stay with us. Right? They stay with our providers and with our system. And 4% of dollars are spent on ED, surgery, surgeons, and pain management. And the vast majority of money is now spent on PT, PCPs, and PM&R. We flipped the whole thing, right? Everything flipped. We did this cohort study of ourselves. I'll just give you some of the data. We did a three-to-one match within our system of almost 500 patients to 157 patients in spine health in our program and sort of matched them. They matched them for everything. They could sort of find age, race, sex, line of business, meaning sort of where they're insured through UPMC, Medicare versus commercial versus whatever, comorbidities, SPMI, severe persisting mental illness, so those behavioral health conditions, they matched for that. And we had cost data, how much they cost. When you look at this, we don't use opiates in our clinic. I'm not an opiate fan, so we don't prescribe opiates. We don't take them on. We don't try to detox people. We're not a detox clinic. That's not what we're doing, right? We're not a pain management clinic. We're not really taking that on. But in the idea that we don't do this, I didn't know this would happen, but opiate use within our clinic dropped 25% within a year without us really trying to do anything, compared to our comparative population dropped about 4%. And curiously, our cost went down, but in the other patients, the cost went up even though it dropped a bit because they switched to more expensive long-acting opiates. So in the community, other than us, basically, they're just flipping opiates. They're going from short to long. That's what they're doing, giving them more expensive drugs. And we sort of dropped it by giving them another choice, really. Benzos decreased in our population, went up in the other population. These are our surgical rates, right? So at a year, we're the blue line, 2.8%, 12% in the comparative population. If you go back that slide from New York versus Ontario, that's our opportunity, right? We essentially tried to capture that, and we did capture that. That blue line in Pittsburgh looks much more like the Ontario surgical rate of elective spine surgery, or total spine surgery. But we captured that opportunity. That was what we were trying to do. We do patient outcomes. We have promise, right? So on our patients, we have 85% completion rate of a promise score on our first visit. So we have 1,600 of them. I was just looking into the whole APMNR register, talking about they had 6,000 patients. We have 1,600 ourselves, just trying to do this. We get a follow-up promise score on 59% of those people within 90 days. And we're probably 80% of the people we see, or we can, because the number never come back. We see them once, and they go somewhere else, or whatever. We don't see them again. They don't have another visit. Half of those, half of them met the MCID, met our criteria for improvement on a global sort of summary of the promise scale, that global assessment of all those domains. That was our target. And 35% met double that, right? And these are all basically people who failed. We're taking people who are failing, right? They're not functioning well, high levels of pain, high levels of disability, high levels of anxiety and depression. They're failing, and they get better. We can track the total surgical rate. So at this point, we've seen about 2,000 patients. We have over 12,000 visits in our clinic. We have a surgical rate of 3.5% over the four years since we've opened. Injections of all types, about 10% of our patients get an injection of some sort in the system somewhere. About half of those are ordered by us. We probably order epidurals, and I'm guessing about 5% of our spine injections, about 5% of our patients, right? Not many at all. That's not what we're doing. I don't know a comparison. Do we know this? This is the kind of data we can get, right? About 11% of our patients go to the ED within six months. I don't know the comparison data. It doesn't seem very high for what we're seeing, really. So in the end, this works. We set out to capture value. We did that slide ahead of the too many lines on it, those little four domains of what you have to do. I put it all on one slide, so you can take a picture of it and see it. We tried to do that, and we did that, right? This actually worked, right? This actually functions. We captured value. We dramatically improved outcomes for these patients, and we dramatically dropped costs for these patients. We captured value in our system. Why? It's about health, right? This is not a pain clinic. We're not transmitting a message of pain. You're not in pain. We're not trying to dissolve you in pain. We're not trying to get rid of your pain. That's not it. We talk about it, obviously. Everybody comes in with pain, but that's not really where we're going, right? We're trying to get people healthier. We coordinate care and apply expertise. We really function well together, and we're skilled. We took people with skills in doing this. Our PTs are skilled. Our doctors are skilled. Our psychologist is skilled in this. Our dietician is skilled in this. Our nurses are skilled in this, right? We took skills. We applied expertise, because you have to. In the end, I don't think we're taking people with myelopathies and not having them get operated on, right? We're not taking progressive cauda equina symptoms with spinal stenosis and taking them away from the OR. We're actually trying to get them to the OR faster. We're not trying to take them away. We're taking these elective, like, they're probably not going to do very well, but I have no other choice. I'm going to operate on them. We have another choice, right? So they don't need it. That's what we're doing. We really follow the evidence, and we really believe in our mission. It's a mission-driven enterprise, right? We want to help people be better. And we are a team, not a group, right? A team works together. They all work collaboratively. In a team, everybody on that team makes everybody else on that team better and makes the whole performance better to get the patients better. And if we were in different places and different locations and didn't talk every week, and I just sent them to some PT in some other town who did whatever, and I got a note once a month, and I talked to my nurse, I don't know, once a week on a phone, it wouldn't be a team. That would be a group, right? It's a different thing. And this is our economic structure, right? We're an integrated delivery and finance system. This is our economic structure. So we understood our economic structure when we built this. That's what we built it for. In that structure, you can apply resources early to capture value later, right? So that's where you have to understand your own economics if you want to do it. How do we sustain it? How do we keep going? We have to get and maintain buy-in, right? We have to keep people engaged in, like, this is a good idea, right? We have to make things better for other people in our system. And we really have to provide good care. We have to be better, right? We have to be better than the alternatives. We have to be better than a surgery, do better than more shots, we have to be better than the alternative. That's the only way to do it. We had to demonstrate proof of concept. Depends who you talk to. I think we did. I think most people think we did. Yeah, maybe one or two more we got to get to, but most people think we did, right? And we're now really diving into how do you sort of start to structure this economically is what we're doing, right? So their way to perpetuate this is we need more of us. We need more clinicians who can practice like I do and Dr. Barr does and Dr. Shivers does and Dr. Eubanks do, who are the people who do this sort of thing. So we built a fellowship to do this, to train people to do this and to understand this and to build these systems and function in these systems and work in them and lead them. So the fellow will do sort of does team-based clinical training, broad rehab skills, deep dive into literature and evidence. Again, you can't... Ineffective, expensive care does not get you to value, right? You have to know what works. The fellows rotate all over the place. They got to know who everybody is, what they do, who they are. This is every other specialty has anything to do with spine care. The fellow goes to all of them and meets them personally and works with them and sees what they do and explains themselves and understands them. A lot of radiology, you got to be better, right? You got to find what other people are not seeing. You got to be better. And we partner with the UPMC Health Plan. We have a whole structured educational system on payment and policy and value. So people can understand this and know how to do it. That's what we do. So I'm done. If you need me, this is how you get me. And Dr. Barr is going to talk a bit on sort of our job, right? I think we're good. I'll pull you up, right? Thank you. So hello, I'm Karen Varr. I'm gonna speak about the clinician perspective. I think Chris did a really great job giving you an overview of what the program's like. So my goal is to really talk to you about what it's like to be a clinician, a physician that works in this system. So they wanted me, Chris asked if I would start by telling people, he said, they don't know what you do. Tell them what you do. I thought it was the strangest question, but then I pondered a little bit like, how do you describe what you do when your expertise is knowledge-based? And it's not as easy as you might think. I think the current medical landscape is not always hospitable to knowledge-based physicians. If you think of in the area of access to knowledge and how that's changed over the last decade or two, in the past, if someone wanted to know information about their back as a patient, they'd need to come to a physician. Maybe they could go to the library and get a book or they might have a home remedy book on their shelf, but otherwise, physicians were the keepers of the knowledge. And now, as we know, knowledge, even on very complex and rare conditions are at anybody's fingertips in a few seconds. Lots of quantity, variable quality. Access to things like medication, therapy, referrals were under the control of physicians. But now, there's a lot of marketing direct to consumers to access things. I remember, I used to live in Seattle, and when medical marijuana was legal but regular marijuana wasn't, there was a guy outside the dispensary and he danced with a sign, the doctor is in. That's direct patient access to the things that you want. And then, it used to be that really, physicians built their referrals based on their personal reputation. But now, I would say often, a referral is sent to a group of people that are part of a healthcare system or are insurance providers for that group rather than your personal reputation. Although, some of that still exists. So, I posed to the group, am I a non-interventionalist spine provider? And the reason I'm asking that question, I know some of you have ever gone looking for your colleagues and you're looking on the web or you're looking at their practice site and it'll say, our program, and there's your colleague and they're masked under a group of non-interventionalist spine providers. It's usually some nurse practitioners, maybe a physiatrist, maybe a family medicine support person. And so, I wanted to see if you guys think that's what I am. So, this is what I actually do. I try to gather nuanced information from patients and I try to place it within a context that's influenced by their other health conditions, their lifestyle choices, and their social environment. Then I perform a hypothesis-based physical exam. It's informed by my knowledge of neurological, musculoskeletal, and other medical conditions and how those things can intertwine to give you physical exam findings. I interpret tests within the context of pre-test probability understanding about asymptomatic abnormals and other factors. I try to form a therapeutic alliance with my patient. Then I establish an individualized plan. It'll include patient education and I may order tests, prescribe medications, prescribe therapies, refer for injections, or seek other consultants such as surgeons or other experts. So, to me, that sounds like a physiatrist. That's what I do. And if I had to narrow it down into one sentence, I'd say I'm a PMNR physician that listens to people, sifts through all the available information to sort out what's going on, and tries to come up with a plan to make it better. So I wanted to switch gears after now you know what I do to say why I like working with the Program for Spine Health. So I think Chris did a great job showing you that we're mission-based. So I'm going to focus on those other two factors, that we're a true, not a pseudo team, and that there are features built into the program that support drivers of physician satisfaction. So there is a literature base now on what are our features of highly functioning teams. So this is an example from an article that was, it said, Insights from Complexity Science, Why the Interdisciplinary Team Approach Works. And so I invite you to look at this list and think of a high-functioning team that you've been a part of. So not necessarily like the group of people you like to go out with after work or who your friends were, but a team that was good at getting things done. Look at this list and see if it rings as true to you. I think for our Program for Spine Health, this list is right on. The other feature I wanted to talk to you about teams, we talk so much at this conference. I've heard so much about teams. And I really wanted to dive into some of the science around this and this principle of collective intelligence of a team. And so this is an idea that groups of diverse problem solvers outperform individual problem solvers or even a group of high-ability problem solvers that aren't diverse. And this is based on cognitive diversity. So the way you approach a problem, the way you would process information, organize it, and how you personally would attempt to solve that problem. And it's some association with cognitive diversity and other features like identity diversity, but it's not exactly the same thing. And so groups that have high collective intelligence tend to have high cognitive diversity. And I'm going to talk about a study they looked at 22 studies, 5,000 individuals, and 1,300 groups. And they solved all sorts of problems. So this was from complex engineering and math problems to very voluminous word tasks. And they found these certain features that correlated with higher performance. And so first, I wanted to start with some of the features that actually correlated with lower performance. And one of these I thought was so interesting was high diversity of age is hard on teams. And I remember so clearly as my time as a teacher going to so many lectures, how do we teach this new generation of learners? How do we integrate them into a team? And I think this really reflects that, that it is difficult. It doesn't mean it's bad or we shouldn't try to do it, but it's difficult to work on teams with high diverse ages. The other thing I thought was really interesting on this is that you can see near the bottom under process, there's one that says effort. And it's on the left side. It's on the side of the line of that hurts teams. And so there's not a high correlation in effective teams by how much work they're doing and the outcome. There's other features that are more important than that. And when they specifically looked at team process, there's two skills that are really important for teams to be high functioning. One is skill congruence. So this gauges how good a group is at achieving agreement between the members and who's the best person that has the skills that contributes to the task to get the work done. And the other thing is that a team needs a strategy so that every single piece of a task can get completed. So when you look at this, those factors, having those processes in place, are the factors that best predict a collectively intelligent, high-functioning team. Of course, you need skillful people on your team. That's also very important. But it actually is certainly no more important than having the processes in place. And then there's a few other things that they found were important, like having the right size team, having people on the team with some, they call it social perceptiveness. We might call it emotional intelligence. And then having certain composites of your team, such as having both men and women on your team. So I'm going to talk now about three cases very briefly. And the focus of these cases actually won't be the medical management. It's how the collective intelligence of the team improved this patient's care. And these are, I would say, the essence of the truth. I've changed a few little features to protect the patient's anonymity. But they're basically very true. So this first patient is a 76-year-old woman. She was referred from a spine surgeon to come see me. She was about four months post-op. And she said she did really well after surgery. And then she was doing some gardening, and she hurt her back again. Her leg symptoms had remained basically improved, but it was her back was really bothering her. So she'd gone and seen the surgeon. I reviewed his note. He said he got some new imaging. It looked good. He said, from our standpoint, everything looks great. Go and see the doctor in this program. But there's more to this story. So one of the benefits of this program is I actually have enough time to spend with my patients. So if I had a 15-minute visit, I would have then been like, this looks great. I have a plan. Let's move on. I have a little more time. And so I asked her the question I ask almost every one of my patients I see. I said, so what's going on? How are things going beside your back? And I found out for this patient, she was really suffering. Her husband had been diagnosed with idiopathic pulmonary fibrosis. They'd been married for 50 years, and it was her very best friend. He'd had a really long hospital stay, a long LTAC stay. He is just returning home. She was really in the process of getting him home. He's on 15 liters of oxygen, which is very poor prognosis. So this is what she was dealing with beside her back. So I want to talk next about how the team helped her. So one of the things, I don't know if any of you have this within your system, but sometimes it is very challenging to look at imaging from outside institutions. So there is a hospital that's basically a stone throw where my clinic is that's in another hospital system, very hard to get their imaging. And then when you get it, it could be uploaded in like seven different places in the medical record. A nurse was able to get this imaging, and she said, I pulled it up for you. It's in a weird place. I pulled it up for you. And I thought, you know, I should probably look at it. She went to, I don't think it'll change my impression. I have an idea what's going on. I have a plan for her. But I'll take a look at it for completeness. And so I looked at the imaging. There's this little circle of fluid right near the surgical site. I don't look at imaging like two months post-op, hardly ever. So I thought, you know, I looked at the surgeon note. He said it looked good. It's probably fine. But let's try to get the radiology report to make sure, which actually is nearly as hard or sometimes harder than getting the imaging. So she got the report, and it said, you know, cannot exclude infection. I thought, you know, we are getting together as a group. We meet once a week. I'll just pull up the images, and I'll have the other doctors look at it and see what they think. And so we did that during our team's meeting, which, again, is not the easiest technical feat sometimes. But the nurse pulled up the imaging, and Dr. Standard looked at it for about 13 seconds, maybe 15 seconds. He said, oh, yeah, you've got to get it. He said, that's probably an infection. You've got to get another MRI. This one's two months old. You know, you don't know what's going on in there now. And I use this as my first piece of evidence that a value-based care doesn't mean you always do less. Because I actually wasn't going to do any imaging or further test and the guy who counts the dollars was saying do more tests and do more imaging and and but I push back a little bit you know I was like this lady's overwhelmed she's got a lot going on I did a good physical exam there were no other history signs of infection so I gave like a little you know we have a good working relationship I gave him a little push back and this is the best part of the story so our junior faculty he was our fellow he'd probably been faculty for about six months he piped right up he said you know I just wrote a book chapter on that and it doesn't really matter she doesn't have symptoms and I and I I was like you're absolutely right right there are many features that contribute to diagnosing an infection in the spine and you can't especially in someone under such distress and sleeping at the hospital and I probably couldn't rely on that hang my hat that she didn't have an infection and so we ordered more tests and so she got better care because we reached the wisest medical decision as a group the other things that happened with this patient that got better care because of the team is that inevitably she missed some PT appointments she had a lot going on but the team understood that so instead of saying like she's not interested she'll come back to us when she need us they would reach out to her to reschedule and then the physical therapist were aware of her situation so they were able to modify their treatments have a realistic plan for her and realistic goals so like helping her how is she gonna help her husband and still protect her back became part of her PT treatment how can she do a home exercise program in the like 20 minutes when he's sleeping in the afternoon the next case I want to bring up is a 44 year old woman with persistent low back pain she'd had it for many years she began seeking care for her back in her 20s she listed many treatments she'd had and she either she couldn't remember or she said they didn't help her and there was one note on this patient she'd missed her first appointment she came about half an hour late for a second appointment she'd already missed her first appointment used up a slot so I saw her and then I saw her over lunch but she's she after an hour together she said you know I need to come back tomorrow that's more I got to tell you I didn't get to tell my whole story so but even more there's even more to this story than that so this is a lady you know when I sort of delved into her story I got this sense she very she had probably pretty significant anxiety some other mental health problems and it probably a personality disorder she had alienated probably about every friend or family member she ever had and was completely isolated during the pandemic completely she lived alone and never saw anybody else and during this time I think her anxiety really grew she sort of fell into the hands of a for-profit group that did a lot of tests and diagnosed her with ADD and she began to see this as the answer to every problem she'd ever had she thought it was completely true and she was on very high doses of stimulants so I think a lot of the behavior that I was seeing with her is because of iatrogenic high drugs causing her to act in sort of an erratic fashion so these are ways that the team really helped her one again we were able to obtain her medical records that she really couldn't give us a good history about to avoid ordering unnecessary tests or repeating treatments she'd already have the second thing that was super helpful with her was having identified team members to communicate with and I'll give I don't want to use up too much of my time but I'll give you a real quick example so the day after I saw her she calls the nurse she said I cannot go to my PT appointment tomorrow I am in too much pain that doctor after that exam I am much much worse I think I need to see her again today she really wanted to see me the next day I think I need to see her again and get another evaluation for my back or maybe she can call me in some opioids because I'm not I just don't think I can go to PT so the nurse talked to her she said you know the PTs here are really experts in treating this back pain that's why you're seeing them go to the appointment they'll take a look at you they'll see if anything else is going on they'll be able to hopefully help you so you'll feel more comfortable so who here thinks the next day she went to her PT appointment she did not she did not go to her PT appointment she called the nurse the nurse said why didn't you go to your PT appointment she said I talked to someone in your office and they told me not to go they said I my pain was worse than I should stay home and the doctor was gonna pull caught me in some pills so Stacy my nurse said that was me you talked to yesterday I told you to go to PT and it just nipped that sort of team splitting manipulative behavior just got nipped right in the bud and we had much easier communication after that I think dr. Brown was very helpful with us and helping the team and how to work she just couldn't focus she was all over the place and she would take you with her and she really helped us like focus in how can we help her focus on what we're doing and move forward with progress the other thing we did with her was you got her some sound nutritional advice for her a very positive effect of these high doses of stimulants was that she had lost a lot of weight her BMI was probably about 20 but I think a lot of the weight she lost like it was muscle as well as fat so we got her a really good nutritional advice to sort of make sure she was eating enough calories and enough protein and then we were able to refer her to experts to improve her mental health and then my final patient I wanted to discuss was as an 84 year old woman with worsening low back pain she was sent to me by her PCP I actually sit where I sit in clinic is in an internal medicine office and in their workroom they sent me this patient she'd had back pain for about 30 years on and off but in the last couple of months she was having difficulty tolerating her daily activities like doing her dishes or getting her housework done pain if she was walking longer not too many leg symptoms these were mainly back but if she walked a long way she'd get a few like cramping in her calf kind of symptoms who thinks there's more to that story so there's more to the story and when I really delved into her what had happened was she had an exacerbation of her of heart failure she had an acute heart failure exacerbation she was in the hospital she was really sick she almost died and then after that she was skilled sent to a skilled facility along the way she was like diagnosed with a compression fracture they did a lot of like opioids she had side effects I think she was not much exercise during this time used up her days and was sent home and I think during this whole time she became depressed which is very common after heart failure exacerbations she was also she'd lost weight she had become deconditioned she was really mad at her family she had six children she told me they're all useless because they had let her go to the skilled nursing facility instead of one of them taking them home and she had come to the conclusion that she would rather die than ever go through anything like that again and so the way the team was able to help her she had compression fractures of indeterminate age she had completely during the pandemic sort of fallen out of the system of getting her osteoporosis care and also when I really delved into her symptoms of activity intolerance I think some of them actually were cardiac and the heart workup had never been completed after the inpatient stay like the up he wanted to do some things as an outpatient that just never happened and so since I work so closely with the internal medicine doctors I was able to just say you know we need to get these things done they took it in the spirit that it was intended I work closely with them I think they're really good doctors and she was able to get that care I think we got her to see dr. Brown so her suffering was reduced she was really dealing with important life issues we're all gonna have to deal with at some point right what is the end of our life going to look like and then we were able to get her on a realistic and effective exercise plan and a nutritional plan to address her frailty which was really the base of why her back pain had increased so in the last few minutes of my time with you I wanted to talk about the provider or the physician experience within the program and I put up this slide it's a little disparaging you know if I'm the flea but the reason I brought this up was because often when we think of clinical program development we really look at a couple of things right is this a program that's going to help patients and is this a program that is fiscally feasible it either makes money or at least like doesn't lose too much money and that's what drives our clinical program development but I think it's really important to include a third factor which is physician and other provider satisfaction so we know it's incredibly expensive to replace physicians it's over a hundred thousand dollars if you think a physician leaves and there's this gap they're not there's nobody seeing those patients it's hard on the rest of the team to pick up that gap you had to recruit another person on board up ramp that person it's an expensive proposition if a person doesn't leave but they remain dissatisfied they typically are not very engaged in their work and if that delves down into burnout that can even affect their patient care and so the provider experience is an important consideration when we're thinking about program development there are certain features within the program for spine health that are really built into the program that are drivers of high physician satisfaction of a few references at the end of my talk and the handouts on the app I checked that if you want to delve into these so we've covered the positive work relationships but I wanted to talk about some of these other features one is it to thrive as a physician you need to feel supported in your professional growth and development and I think there's certain ways the spine health program does that we have weekly weekly conferences as a group but we have monthly spine grand rounds break in really interesting speakers like from pit you know basic science researchers or spine researchers we bring in different clinicians or surgeons is a very interesting another thing we're doing as as a group we're all going to go get certified next year in lifestyle medicine which I really think is like a nice mid-career boost for me to think I'm gonna take on this new knowledge base and maybe learn some new skills at this time of my career is really invigorating another feature is alignment between your personal professional goals and the institution goals and one of the things I've heard Chris say is he wanted to build a clinic he wanted to work in and I think that's why it's important that this is a strong physician led effort right it there is alignment between the things we want which is to take good care of our patients and what the institution wants was value-based care the next feature is minimization of work chaos so that you're able to do your job so it's having those those team processes in place where every piece of the job gets done there's a plan to the whole job gets completed and then the final is an ability to integrate your professional and personal responsibilities some people call that work-life balance and so an example of that is I start my clinic at 830 I drop my son off his school starts at 8 I drop him off and then I go to clinic and that little piece of flexibility makes my life so much easier so I put up this fancy diagram so you can see there is science behind this statement that similar features that drive physician satisfaction drive staff retention there's the bibliography thank you Which one are you going? Charlotte. OK. Good afternoon. My name is Charlotte Brown. I'm a clinical psychologist. And I have been working with the spine program since its inception. I'm going to, let me just go back. I'm going to talk about my approach, but kind of drill down into some of the specific. People talk about behavioral stuff. I'm going to talk about some of the specific things that I've seen in patients with chronic pain and in the spine program, and how I tend to work with them. Mostly, I use a cognitive behavioral approach. I do use strategies from dialectical behavior therapy, supportive therapies when needed, and problem-solving strategies. I always work collaboratively with the team to address the goals and the patient's progress. I've worked in a lot of integrated, a number of integrated teams. And it's actually, for a psychologist, it's great, particularly if you're working with a medical population, because you get to talk with the other members of the team to see what's going on. You also, patients tell different things to different people. So if they tell Chris something, or one of the physical therapists something, that's additional information for me to know in working with them. My role on the team as a clinical psychologist is, of course, I get referrals. I evaluate patients and provide counseling. Another important role is consultation during our weekly meetings and on email with our team members. And that includes how to engage patients, whether it's in physical therapy or if somebody is not showing up. Also, how to discuss challenging issues that are interfering with treatment. So we try to figure out, and this is on the team in general. I may not actually be involved with the patient, but it comes up during our meeting. And a lot of times, it has to do with me trying to get a better understanding from the team member of what's going on with the patient, thinking about what might help. And I often offer what words to use. And if people are using words that I don't think is good, I will say, no, no, no, don't say that. And so it allows the team to, I think, become more educated and able to address the behavioral issues. And over time, what I've seen is that all members of our team have felt more comfortable bringing things up, and we discuss it as a team. I also incorporate the team recommendations in my work with patients. The goals of pain psychotherapy, it's to decrease. I specifically let people know, I don't work to decrease your pain. That's not my role. My role is to help you to function better and cope with the pain. I make that very clear up front, because a lot of times, people don't know what a psychologist does or don't understand. They may be told, but they don't really understand. So it's to decrease the distress associated with chronic pain and the decreased functioning, improve their functioning with chronic pain. And a key thing that I often do a lot of psychoeducation around with patients is that chronic pain psychologically decreases your sense of personal control. So you've got to take your garbage out. Then you've got to run to the mailbox. And then you want to run to the store. If you have back pain, you may not be able to do any of that on a given day. That sense of personal control that we use in our everyday activity, just to be able to get up and do things without thinking about it, our pain patients don't have that. It is diminished. So our goal is to increase that sense of personal control by helping them to use strategies to function better. I tell patients that my job is to, and it goes along with Chris was saying, we want to focus on the positive. My job is to help them to reclaim their life. We want you to be able to develop the highest quality life that you can, even with pain, so that they have something to work toward. Why is this not moving? OK. The goal of the initial evaluation, I always start this evaluation with letting the patient know that I've read the chart, because I want to get a sense of all of the medical comorbidity. And our patients often have a lot. But I ask them, how did your pain start? And for some of our patients who had a longer history of pain, they're like, oh, you want me to start? I said, I want, and I tell them, I've read the chart, but I need to hear it from you so that I can get a better understanding of how it's affected you. And what I'm listening for is that time frame, how they've coped with it. Along the way, they tell you how it's affected their children, their marriage, deaths along the way that they had to deal with. So in my mind, as I'm listening to this, I'm getting a sense of how it's affected their identity, how it's affected their functioning, how it's affected their mental health, family, work. Just as I'm listening to them go through the pain, their pain chronology, I, of course, ask them how they cope with it, how they usually cope with it, and what their expectations are for improvement. I evaluate psychological symptoms. Anxiety and depression are the most common. The usual psychiatric evaluation of whether they have psychiatric disorders, history of trauma. I also want to know about the effectiveness of their past treatment psychologically. That's important for me to know because people have a mixed experience. I mean, so I went to this therapist. She was worthless. So now I have an idea why I can't be worthless. I have an idea of what they're coming in with, what they need for current treatment, and the appropriate level of care. Meaning, is this person a person for whom that can be treated in an outpatient medical clinic? Or do they need a higher level of care? Do they need a psychiatrist? We've had people who needed to go into our intensive outpatient program or a partial hospital because of the severity of care. These are some of the most common diagnoses. Depression, adjustment disorder, generalized anxiety disorder, panic attacks, substance use, and post-traumatic stress disorder. As I'm listening to people, I want to really figure out what is the appropriate focus of treatment. Karen talked about a patient who had a lot of stuff going on, life stress. When I hear that, that may be where I start. I don't necessarily automatically go into functioning. The person may have caregiver stress. So we figure out what's going on with that, and we use that as the avenue to start treatment. That's what I'm always looking for. Where is there a path for me to engage this person that is meaningful to them and will help them? So even though I use what is a manualized therapy, I'm always trying to figure out, how do I apply these strategies to this person and their life? I often will start with people with CBT focusing on expectations, developing realistic expectations. One thing I talk to people about is frame of reference. Many patients will say, well, I used to be able to get up Saturday morning and clean up the house. Now I can barely do dishes. So I try to shift them. And I say, well, let's shift to what you can do now. And let's figure out what your baseline is now, and then try to move forward. With the point being that if you always use some prior, often idealized function as the goal, with the way your spine is functioning now, you're going to come up short. And we revisit this, but shifting those expectations is critical, particularly when we're trying to do pacing. Because that will help reduce the amount of frustration and them giving up. So if I can only do five dishes in the sink and I have to sit down, that becomes the plan. Very often, after they're doing physical therapy, they get more endurance. We can increase it. And we point out the progress that they're making. But again, shifting the expectations to functioning now and improving functioning for the future is important. That often leads to us addressing the sense of loss, which is that sense of loss, I used to be this person who did this. And in a few minutes, I'll go into that. But it does trigger a discussion about sense of loss. I can't do that anymore. And ultimately, we want that person to address that, accept that, and focus on the present moving forward. Negative thinking and self-critical thoughts, people blame themselves, is common. I often do relaxation training, mindfulness training, and reducing things to reduce depressive and anxiety symptoms. One of the things that happens as a psychologist working with chronic pain, you get to deal with all of the psychological issues, whatever they have going on. Whatever their diagnosis is. But through the lens of pain and functioning, it all comes up. So I may have to divert to say, well, let's work on these recurrent anxiety-provoking thoughts. Let's use thought-stopping techniques, et cetera, to help them to deal with that. And then come back to pacing and setting expectations. I also, I usually will refer people for medication after I've seen them a couple of months, if their symptoms don't improve. Because I find that mild to moderate depressive and anxiety symptoms are very, very common. And with our program, as they work with the program, get support from the team. A lot of times, those are people that from the team, a lot of times, those symptoms will come down. But if they persist at, say, a moderate level, that is when I may talk with them about medication. The other reason to wait, unless they're severe, is that people may think, patients may think that you're pushing them off on a psychiatrist. Or saying that it's all in their head. I really find that I need to get to know the person. And I can, we can talk about the trajectory or the course in a meaningful way. And they can be prescribed by the PCP, or we can refer them, I can refer them to a psychiatrist. Some of the common issues that I address as they come up, as I discussed, was expectations. Their frame of reference. Revising that to current functioning. And focusing on, how do I get this done now? So for example, I had a patient who travels a lot for work. She had had back surgery. Still had some intermittent leg pain. And was thinking, I've got this big conference in Italy. I don't know if I can go, but it's very important. So we walk through, how would you manage that if you were going to do that and that? Became a goal for her to be ready to go on this trip to get to this point And we came up with a plan. I mean she had to get say a wheelchair She had to get there a day early so she could rest not do the whole day, but came up with a reasonable plan that she could do and not have to just Tell her boss. I can't do it at all and that's a lot of what I do Is how do I help the person to look at how do I do this now? Even if I'm having these limitations With pacing I actually walk through Tasks with people. How do you do this? And very often what I'm finding is they're using a frame of reference that worked before but doesn't work now And they keep running into roadblocks It's particularly the case with Multitaskers, you know with the key to I used to be a multitasker But the key to multitasking is you've got to finish stuff So you you do a little bit this and you move around but you finish stuff within some expected time frame Otherwise you just have a lot of unfinished stuff So that actually takes it seems simple, but it takes a real cognitive shift from the way you've been used to functioning and to trying on a new style of thinking and Changing that into behavior and I often frame it as let's just think of this as a new skill We're gonna try it on you can do your multitasking You can always fall back on that and that's how I kind of get people to try these new things It also changing those expectations and pacing we manage their frustration That's where the emotions the anxiety the self-critical thoughts come up and we work through them Stress management as I mentioned is key Sometimes we start with that, but we always end up addressing it because when there's a change in functioning There are things that are more difficult to do and get left undone. So people have to learn how to delegate What help do they need they have to learn how to prioritize? Things everything can't get done I often use a problem-solving approach and we walk through it. We'll pick a small thing and walk through Identifying what the problem is, how might you handle it? Very often I tell people let's start with one goal a day These are for people who might be depressed not getting anything done. Just do one to two goals a day. That's it Forget about the list That's some people this long list that you never get through Through that as they're working through those goals, I'm addressing their anxiety Frustration their sense of hopelessness and hopefully teaching them skills to manage that more effectively Very often it's difficult for people to ask for assistance They're used to doing it themselves. I see this a lot with moms who have worked they do everything But they've got 16 17 18 year old kids and a husband and Somebody else living there, but they're doing everything because that's what they've always done so we have to kind of sift through is there somebody else really who could take out the garbage and Maybe if they can't put the garbage but a new garbage bag and maybe somebody else could do that So a lot of times what the way I work with people gets to be very nitpicky But they learn to do it differently. That's my goal with them Pain catastrophizing It is a form of anxiety It's anxiety triggered by pain people fear that they focus on the pain excessively They focus on each new iteration or perceived iteration of it And can't get beyond it so that it does interfere with functioning They may have catastrophic thoughts They may have catastrophic thoughts They're 40 something 50 something years old. Am I going to be in a wheelchair when I'm 90? And I have to work with them again. Let's stay in the present We don't know how you're going to be when you're 90, but if we focus on work working with how you are now We can try to get some improvement and wherever you are. You'll be coping better The the other thing is I tell people if you spend all your time now Worrying about what's going to happen in the future. You don't get to enjoy anything now You don't get to enjoy the things that you like because you're using up all of that psychological energy to worry about the future Some common presentations are I have to know what my diagnosis is we get into what would that tell you? Because sometimes it takes a while for people to get a diagnosis. What would that tell you? What would you do different? a lot of times what that means to the person is if I know my diagnosis someone will be able to fix it and That's not necessarily the case and that's what we talk about in therapy Can you live with this if they can't fix it? Can you have a quality life? I Have a diagnosis, but nothing's working. Maybe they miss something again. It's the fix it can can can someone fix it? and as focusing on different types of pain Every new thing so we use different cognitive strategies whether it's thought stopping Distraction to help them to shift their thinking when they recognize that Will Again will this ever go away? What if this keeps getting worse? I Help them to focus on if we don't know we don't know. I mean, we mostly don't know what's gonna happen tomorrow Can we focus? Can you live with where you are now if this never goes away? Do you have the skills if let's say it is something degenerative? I mean, I'm not a medical doctor So I'm not the one to say but if something gets worse, do you have the skills and resources to cope with it? What would you do and we walk through what they would do? I'll call. Dr. Standard. I'll call. Dr. Barr. I'll do this I'll find out that and I said, okay now, you know that if something were to get worse There you have the skills and resources to figure it out So now we let's see if we can stop worrying about that because you won't know until the time comes if it comes But you know, you can handle it Some of the strategies that I use as I mentioned thought stopping and distraction focusing on Present functioning. I often refer people back to the medical team to the Physical therapist talk to your doctor about it. Ask them about it because Sometimes people say things to me that I I just know nobody told them that You gotta go back to Dr. Standard, Dr. Barr, Dr. Shivers go talk to them about it So that they get into that Habit of checking it out Getting their questions answered from experts on our team. Ask your physical therapist about this So that they're not checking the internet Not checking tick-tock or their friends who have something completely even I know have something completely different than what they have That's that's the that's very challenging We also focus on worry Can you control it if you can't if you can you work on what you can control if you if you can't? Control it. Let's see if we can shift Your thinking to other things Grief as I mentioned before I often deal with grief. It could be loss of a loved one. That's some what we know commonly, but Often with pain it's loss of an ideal or former self the way you used to see yourself or be able to function And some of these changes are changes that are occurring earlier for our patients but some of them many of us will Experience as we experience normal aging you may notice that I didn't try to get up on this big thing right here Right because I just got a new hip The other one needs to be done. So I didn't want to try this and go fall backwards So I walked around so that is a change that happens A normal change that happens to us. It didn't happen by accident It happened through aging but some of our patients that some of the changes are a part of normal aging sometimes the Spinal issues accelerate those things and I often go through a lot of education With them about that The ultimate thing I think is for them To Get to a point where they have acceptance acceptance doesn't mean Giving up a lot of people think that Acceptance means I have to deal with something that's challenging But I have some strategies to do that and I'm going to focus on living my life the best way that I can Again I've talked about this mind over matter That's the way a lot of us function particularly. I'm going to push through this You can't push through chronic pain that worked before when you were 20 and 30 and 40 and maybe 50 Now we have to use some different strategies Multitasking maybe that's not the way to go anymore We address sense of identity a change in sense of accomplishment A change in sense of accomplishment that relates to expectations What is an accomplishment now given some of the changes I experience in functioning? One very important thing is listening to your body First and then setting functional goals and the the example I often use but always gets a laugh other people's a little bit gross This is my next to the last slide I say I want you to think of when you feel that pain I often say I want you to take a break when that pain starts to rise not When you can't do it anymore Think of the pain as your bladder telling you it needs some relief You can ignore that and push through it if you want But you will pay and I tell them you know, my family's in New York. I go to New York a lot I drive and there are a couple of spots. It was his rest stop one mile and I said invariably I said usually this is in the warmer months After that sign after the rest stop There's some poor guy on the side of the road whizzing into the wind because he thought he could make it You don't want to be that guy You want to listen to that pain signal? I said we don't know if there's a woman over there because she'd be squatting but we see the guy But you you don't want to be that guy So that's thinking of the pain as a signal to stop and let your body rest Finally Indications for referral to Psychiatric outpatient services. It's important to know what Level of care your patients need you don't with with mental health issues. You want to get to the the patient to the appropriate level of care Initially because there's a very high probability that they will drop out because they feel like they're telling this story It's very sensitive. It's very intimate often over and over again. So severe psychiatric Symptoms should be treated first PTSD severe anxiety or depression Some personality disorders need long-term therapy. We need to engage them with that therapist initially Borderline personality substance use disorders need to be addressed and grief counseling if the person Feels that they're really into the grief. We need to address that first and then they can come back and work with me. Thank you Thanks Charlotte, I learned something every time I listen to dr. Brown, so we're at time so we're happy to take I got nothing else to do We're happy to take questions. You can come up and talk to us We can talk on the mic whatever y'all want to do y'all got places to go Yeah, I go but if any questions, whatever a lot of information in there, so happy to do whatever works for people One of the questions I have is like the initial buy-in with CBT, how do you propose this to patients and like how accepting are they of it? I find like I'm getting a lot of, I struggle with that a lot with my patients and what is also the compliance once they do start CBT, like how have you been track, like with the data that you've been tracking, like how many patients get past their first or second appointment with CBT and then continue on? I can take that. Like the first half was sort of how I think how I as a clinician approach getting someone to Dr. Brown, right, which is a pretty common question actually. So I sort of, I do a couple of things, I use sort of a version of motivational, I get people to tell me a bit about their life, right, and if they can tell me that they are somewhere they don't want to be, I can use that and say, look, you know, you don't really want to be here, right, you want to be somewhere better than this and I said, you need a different skill set to do that, right, you need to learn new skills so you can get yourself somewhere better. I think the people who run into trouble, like your people who are really sort of high achievers who push through everything in life, which is probably every single person in this room, when they get in chronic pain, they really do a terrible job. They think they can outwork it, outpush it, they can put their head through the wall and get to the other side and they can't because they got hurt, right, and I say, you need a different skill set, you need to think about this differently, you need to understand this differently, you need to accept the pacing piece of this and think about it, you need to set appropriate goals for yourself. I sort of do that, I paint the picture of like, it's not an in your head thing, I don't think that for a second, I think grief and anger and frustration are all normal but they can get in the way, but I paint it as you need a different skill set because you need to get out of this box, some version of that. I'll just real quickly, I think the other thing that really works for us is it's a warm handoff so I don't say like, you need to get counseling, I say, oh, I hope you can see another, these are the members on our team, I hope you can see Dr. Brown on our team, this is what she does, my nurse can help get you scheduled for an appointment. I think what's key, is this on? Yeah. I think what's key is when the physicians emphasize the need for learning how to cope with it, so they frame that in a way that is acceptable to the patient. This is somebody who's going to help you to learn how to cope with this, hopefully improve, help you to work toward improving your functioning. When I work with people, that's why I'm asking them initially, how did this pain begin? Because that's where I'm looking for buy-in. I'm trying to figure out what is the key issue that they're dealing with. For some people, it might be how it's affecting their work or in the future, it may be their sense of identity, it may be whatever it is, and that's what I often say, it sounds like these are the things that are happening that pain has affected. Do you think we could work on this? I usually don't have too much of a problem with buy-in, but I think the key is this listening to, so I let them talk as long as they need to, to get this story out. One of the things that may happen with other practitioners, you jump into this diagnostic stuff, that's not what is most important with chronic pain. It's figuring out what's going on with this person and how do I work with them, and letting them know, I think I have an idea of what's going on with you. Do you think we could work on this? That's been my approach. Thank you guys very much. You actually are one of the reasons I came to AAPMNR this year, so I've been waiting for your talk, actually. The reason I say that is because... I'm either glad or sorry to hear that. It's been great. The reason I say that is because we're trying to create something similar at the institution that I'm at. Okay. I actually really have three questions. I hope that they fall in sequential order here, but can you explain to me what the patient experience is like? Are they referred from their primary care provider, and then do they see all of you or see one of you, and then are referred off to people within the team? Got that one. Two, from a financial perspective, how are you billing for these visits? Are you just doing regular E&M visits? And then these group meetings that you're having, are you billing for those as well? Because I know that there are unique chronic pain codes that recently came out, the G codes, those kinds of things. And then I think three, how can someone like myself, who is very passionate about this type of care model, advocate for it at a local institutional level, a state level, and then I think even higher at a national level as we move into this value-based type perspective or model? I think that's more than three questions. It's four. Can you come back next year? Wait. What was the first one? Patient experience. Oh, so what we do is we built a whole referral system through Epic, which turned out to be remarkably Byzantine, because we have three different sites. We have PTs, we have doctors, and Epic decided to build a different acronym for all of them. So it's really hard to refer to us. So we have a phone number. And we thought we would build off of primary care, and ED would be our start. Over half our patients come from surgeons. So what really happened is that these people who spin, we tried educating our primary care doctors on what we do. It went in their office. Our staff went in. We put the referral stuff into their computers. We put it in their favorites. We gave them start back tools and a prompt, and here's the best practice alert, and they ignored all of it. What really happens is the surgeons innately understand what we're doing. And these people walk in the surgeon's office, and the surgeon goes, you know, maybe I could do something for you, but I don't think this is a good idea right now. Go see Chris and Karen. Like, see ya, right? And so the surgeons see them once, and they're gone. And from a surgeon perspective, that's remarkably helpful, right? So the surgeons innately saw the value very quickly of being able to offload these people who have difficult problems from their schedule, saying, I don't want to see you four times after your failed PT and shots and talk about some surgery. I don't really want to do to you anyway. Go to them, right? And they'll take care of you. So that was the first. That is what we did. It isn't what we thought we would do, but that's what turned out to be the case. When patients call us, the nurses triage them, essentially. So we have skilled nurses who actually answer the phone, right? Which is sort of a novel concept, I understand. But they answer the phone, and they go through this, and they understand it. They can spend half an hour with a lot of people who call them, and they don't all come to us, right? So people are very simple, and they've had five days of back pain or two weeks of back pain. They've never seen PT. They don't have any red flags in their history. They go straight to standard PT. They seem a little more troublesome, and they'll schedule RPTs really quickly. Most people see the PTs first in our group. 30% of people only see a PT. If they failed PT, it's a little more complicated. The diagnosis is unclear. Surgery went badly. It sounds like they need one of, like, Karen or I or Joe or whatever. The nurses just schedule them with us, and then we figure out from there which pieces they need. About, you know, 85% of our patients see a PT. About 70% see one of the providers, the medical providers. About 30% will see a dietician. About 25% see Dr. Brown and our health coach. Somewhere in those numbers, roughly, is how it breaks down. And the last question was a buy-in question. My missing one. Like billing, or are you guys just doing regular DNSs? Oh, billing. Yeah, no. So we don't have a bundle or anything like that at the moment. We have a fee bill sort of insurance. The dietician and health coach are free. We just said we didn't know how to bill for them. I thought about those codes for team visits. We haven't quite gotten those yet, but we probably should. Yeah, that one. And then the last one, how can you sell it or how can you engage it? I used that word convener before, right? So if you look at studies on system-based change in healthcare, how do you do it? The studies talk about this idea of a convener. A convener is somebody who has a vested interest in this going well who has power. I don't really have power. I can't write a check. I don't have power in that way. I have a vision, but I don't have a power. And so you need somebody with that power who aligns with you to say, you know, I think that's a good idea. We're going to pull people together and see if they can talk. And why do people come together? Because you called them? No. They come together because that person called them, right? And then that person sits in the room and they go, but, but, but, he goes, hey, I, you know, I hear what you're saying, but you guys got to work this out, right? Somebody has to help you do that. Somebody has to be invested. You need a partner who's invested in the good outcome you are trying to get to, who has some power to do it. And then you need to go after, like, you need to, like, get along with your, like, you need to align with your surgeons. Like, the surgeons, like, I am not anti-surgeon. The surgeons like me, right, because I solve problems for them. I take these people they don't want to deal with, right? And they don't have to deal with them. I actually went to one of our surgeons who sends us a lot of people, and it was about a year or so ago, and I said, Vince, am I helping you? Like, I don't even know if you like this. Am I helping you? He goes, Chris, you know what? What I know is I've sent you about 50 people and only one of them has ever come back to see me. It works. Right? That was his metric. Right? They don't come back, right? So you need that, like, and if you don't have a convener, then you need to start with your local group and get your surgeons to buy in and get your PTs to buy in. Then you go to your convener or your payer and say, hey, I got these people lined up. We get an idea. Will you talk to us? You got to do it that way. Okay. A lot of questions. I'm curious about the team meeting that you guys mentioned. I'm curious about the logistics. Like, if you're at multiple sites, are only the people at one site getting together, or are you doing, like, a virtual meeting of everybody? And then, like, is it at lunch? Is it? And then do you bring cases? Like, everyone has a case or two that they want to discuss, or you're discussing a panel of all the new patients? I'm just kind of curious about how that's set up, because I... The nurses run it, right? It goes from 1230 to 130 on a Thursday, right? So it starts at lunch, but it runs a bit over. So our afternoon starts at 130 or two. So we make sure we get there. We are splitting north and south. We have two clinics up north of Pittsburgh, one in south. We're all in the same thing now. We thought about splitting. So what we do is the south starts at 1230, right? So there... And it's a Zoom thing. And so all of us are on Zoom. And so in their clinic, they may be in the same place. And the clinic in the north, in the room in the clinic in the north, I am there. The PT who works in... Like, our PTs are co-located, right? So the PT comes up into the room. So he's in the room with us. Our nurse practitioner is there. Two of our nurses are there. If we have a fellow, the fellow's there. We're all in that room. And then the health coach and Dr. Brown and the people in the south and the PTs who work in the other clinic in the north all get on the phone. And the nurses create a list of things they want to talk about. People who are causing... Have coming to them with questions. The nurses run a list. They say, we need to talk about this person. If I say I want somebody in the team, I want to talk to Charlotte about somebody. They'll say... They just put them... I say, put them on a list, right? And then the PTs do the same thing. The PTs contact the nurses. They put this on the list for Dr. Barr. And so the PTs, it all runs back through the nurses who coordinate the whole thing. And most weeks, we get through everything in an hour. And what happens is you have in there, you have the health coach on there, you have the dietician on there, you have us on there. So I'll be on there listening to Karen's patients. And what you'll hear is, like, the PTs will start talking, and somebody will go, wait a second. Like, I'll stop them and say, no, no, no, no, no, no, right? And somebody will say, pull up that film. And Dr. Brown will chirp and say, what did you say to them exactly that made them react that way? Right? So she doesn't know the patient. I don't know the patient. But we're all free to sort of, right, speak. And one of us as a doctor will say, I don't know what that, like, I've tried this and this and this. I don't know what the hell is to do, right? And so Karen may have experience dealing with it, I may, Dr. Brown may. So it becomes an open forum. But so it's not everybody, because that would be too confusing, and that's too much work. It's the people where we need to communicate, which really runs, it runs through the nurses. The nurses know who a lot of them are, because they call them all the time. But any of us who have somebody who has an issue or I want to speak to the PT, I'll just tell Don, please put this person on the list for next Thursday so I can talk to the PT. You know, I do want to make, just from my perspective, what patients have told me and what I've seen, a comment on the role of our nurses. Our nurses are not just answering phones. They are dealing with a lot of issues. So very often, they have very valuable psychological information because the patients call up and they provide counseling of sorts. They're the first line that the patient will go to to say, this happened. I fell. What should I do? It's a different role than somebody who's just scheduling people in the clinic and making sure the clinic runs. They are having a lot of contact with our patients. And it's that availability, I think, and that initial availability, and then their ability to talk with everybody on the team that you kind of have this holding environment in children's stuff. They call it wraparound services. But you kind of wrap around them, and patients often tell me how important that is. They've been through so much. This is the first time that they've met so many people on a team who really cared. And I think that's a strength of our team when you talk about some of the things we mesh on. There's an authenticity that comes through that we all share and are able to share with patients. And Karen spoke about this briefly, that people like their jobs. In this environment, our nurses get to nurse. They're not handing out pills. We started very bare bones. It was me, one PT, Dawn, one nurse, two rooms on a Thursday for half a day. That's what we started with. And those numbers in July of 2019, they're like 10 people. That's what we started with. And we don't have an MA in one clinic. We have an MA in another clinic. We have a receptionist from one clinic, but not another one. A little bare bones. So the nurses do a lot of non-nursing things, like rooming people and stuff they wouldn't do. But the nurses like it because the nurses get to nurse. They really know their patients. They talk to them. They care about them. They deal with medical issues. They deal with psychological issues. They coordinate all of us. Our nurses love their work because they get to nurse. And they get to see people get better. And they can become involved in their lives. And we took our PTs who usually see, I don't know, three people every 45 minutes. Within 45 minutes, they'll see three different people. And we stopped it. And so our PTs see 45-minute appointments for every patient every time. They just see one person. And so the PT gets time. And the PT gets to talk to me about my patient. And I pull up the MRI. So Mike, our PT, will come up at that lunch thing and say, hey, Mike, look at this. And I'll pull up the MRI and say, look at this. This is what we got. She totally tore her glute meat. She doesn't have one. No clam shells. We'll actually sit there and do it. And so there's a huge amount of emotional and job satisfaction for people. Our PTs love it. The other PTs are jealous that our PTs get to talk to us. So the PTs who are in the program want to be because they want the time. And they want to talk to the providers. And the nurses, everybody likes it because we all get to talk to each other. And that team conference is like, people fight against it. It's time. No, I don't want to take a half hour out. No, I don't want to do it. But you can't take it away because that is the hub of the whole thing. One of the changes I've seen, I've talked with you about this, Chris, from the behavioral health perspective, is as we've worked together as a team, more and more members of the team bring up the behavioral health psychological issues that they see because now they see them. And we can discuss that, whether it's one of our nurses or the PT or one of the physicians or the health coach. We can talk about what's going on, what might be going on. And it doesn't have to be a person that I'm seeing. What might be an approach to deal with this? And on the team, what you'll see is a PT will say something. And one of our doctors will say, oh, yeah, I saw that. So then we can put our heads together and figure out what would be the approach so that we are coming at the person or engaging them in a consistent way. And I often have people tell me, oh, yeah, that's just what Dr. Barr said. That's just what Dr. Shriver said. That's what Dr. Standard said. I said, well, we're a team. And nobody is alone. Yes. We're never alone. And every patient loves the fact that I talk to their PT. Oh, my god, I saw Gina. And she said, you, right, Gina said you talked to her. And that's why it's different. Yeah. That piece really matters. Other questions? Yeah. Thank you so much for this talk. I think this is great. I wonder how, I mean, we were talking about this value-based care, but we're not there yet, right? And so that's what they said last year and the year before and the year before, so no, maybe, maybe. But when I started practicing in 2005, I was with a group, a multidisciplinary group, not a team. But I had a very early awareness of a large subset of patients that I wasn't helping with injections and medications. I was interventional, pain management. And it was just so frustrating. And then I developed a chronic low back pain, and my MRI was normal. And I was like, what does somebody, and I was athletic, and what does somebody like me do? And it just became more and more obvious to me that we were a dead end. I tried to speak with my group and be like, listen, we're doing this wrong. This is how we should do spine care. And I just met with resistance. Then we got bought by the local hospital system in 2011. And all they cared about was the bottom line, money. And then a management company came in, and it was about quotas and metrics and RVUs, which talking to patients doesn't really give you a lot of, right? And then I got burnt out. I was probably disengaged from my patients, and I knew it was time to go. So I opened up my own practice in March of 2018, Integrative Austin Spine Health. And I wanted to bring a lot of the concepts that you guys are doing into my practice. But it's kind of hard to do that as a private practice. I take insurance. I can't hire a CBT. I can't hire a PT. So I've been establishing a base of community people that I really trust. But a lot of psychologists, at least in Austin, are $200 to $300 an hour. They're really expensive. A lot of them don't want to see pain patients. I'm saying, you guys have this great setup. But in the real world, like IRL, it's really hard. And so I became a health coach certified. I became yoga certified in mindfulness and breath. And I decided that I was going to move into a hybrid practice. So I still do probably 10% to 15% injections, right, as maybe a way to get people to feel better to do the rest. But then I do pain coaching for cash. And so I try to buy in patients from more of the chronic pain subset into this coaching program. And I'm just starting it. But until value-based bundled care is going to pay for my bills to keep the lights on, that's the kind of situation. And so I guess, long story, long question is like, how do you guys see physiatrists that want to embrace this type of setup in a non-institution? By the way, UT Austin Dell is starter one. But patients said that their first visit was three hours, and they don't have time. So I tried to squeeze it in. But yeah. Anyhow. Yeah. I just want to say something about referral to psychologists. Most psychologists, even health psychologists, they will focus on the psychological disorder. You have to ask them if they treat pain, period. Don't refer to anybody that doesn't treat pain. In training, for the most part, and I don't know, maybe changing in some programs, we're trained to do the mental health piece. And then if somebody has medical issues, you see your PCP, you see this specialist, and that's over there. So unless the psychologist specializes in that, even if they're using some of the same strategies, like CBT can be applied to a whole lot of things, they're not necessarily hearing. They hear it and it goes out the door that I can't function the way I used to. And making that front and center in addressing how they function, the anxiety or depression surrounding that. So as a private practitioner, if you are going to refer to a behavioral health specialist, you do have to ask them, do you treat patients with chronic pain? Otherwise, it's not necessarily going to get done. It's not that it's that hard. It's just that that's not the paradigm, typically. I'm certainly not tone deaf to your problem or situation. I spent a decade in private practice, a bit of time at University of Washington where they didn't do this. I had an RV-based contract. I get it. The system has to change, in a way. And I think, unfortunately, if I were in private practice, what would I do? You can, there are patients who will seek out and pay for this model. They want your time. Concierge medicine sort of approaches. You could do this. If I had to survive, that probably is what I might have to do for me. I couldn't go into a churn through patients anymore thing. Every 15 minutes, I just couldn't do it. I know I wasn't doing what I could do for people. And so, yeah, I went looking for sort of institutional cover. And I went looking for the institutional imperative to have someone like me. UPMC needed someone like me. They just did, because they didn't really have someone like me who could do this. Gwen, who left here, our chair, is pretty close. Yeah, she does what I do. But she's got to run a department. She can't do this. And so I think there are opportunities in the private sector. But you need linkages, right? Because the way you're going to capture value is by systematically reducing cost in some way or out-competing people. But you really can't do it by yourself very easily. So you need partnerships in PT. You need partnerships in other spaces. And you need people like me to try to fix the system so it becomes a viable argument for you to do it. I mean, that's part of why I do this, right? This isn't, am I going to have it answered by the time I'm done? No, am I going to make, there's nothing here for me to patent or make a million dollars. That's not happening. If it works well, and we can set up a standard of care and say, look, you can do this, and someone wants to hire you because you can do this, right? And nobody else can do it, right? There aren't many people. This is why we create a fellowship. There aren't many people who can do this, right? There just aren't. We're not, like, there aren't. And so you're caught in that space of it. In the fee-for-service world, it is what it is. And I'm actually doing a master's at Dell in healthcare and transformation right now. So with that whole space, and I know Carl Koenig and the people there who built their program. And yeah, they have a model where you come in and you spend three hours, you see everybody the first time you come in. And I was like, that's not really the way this works. And so interestingly, we are not, in Pittsburgh, we are not in downtown Pittsburgh. We are not at the academic hospital. Because that's a tertiary referral center people go for, like, I am there other days. They come see me from God knows where on other days because it's like we're all the, you know, the giant white castle of academia, right? Our clinics are in the community. They're where the community PT sites are. Because someone will see me, but they're not traveling. They'll travel to ours to see me. They won't travel to ours for PT. I gotta be where they are. So we go to where they are, where they'll come to our PTs because the PTs are the hub of the whole thing. And that's the way the thing sort of works. It's tricky in private practice. You need the world to change, or you gotta find a niche thing. And this is why a lot of doctors go into concierge sort of care. And the real problem is then we're building a care system for, what, the top 5% of the economic ladder. And we're just, I mean, you gotta do what you gotta do. If everybody did that, our society sort of fails, right? So you need someone in an institution doing it. So tricky, though. I get it. Yeah. Yeah. Four of you left. Die hard. It's dirty. Thank you. All right, thank you.

physician

UPMC

spine program

value-based care

back and neck pain

fragmented care system

health optimization

team-based approach

coordinated care

patient empowerment

improved outcomes

cost reduction

cognitive behavioral approach

collaboration