Alright, hello everyone. Thank you so much for joining us all tonight. It's great to see so many faces here. Welcome to our AAP and ASRA collaboration event. It's called Practicing Pain Management Perspectives from Physiatry, Sports and Spine and Anesthesiology. We're really honored tonight to be joined by three panelists and attending members here. We have a couple from the AAP, Association of Academic Physiatrists, and then one member from ASRA, the American Society of Regional Anesthesia and Pain Medicine. Before we introduce our panelists, just kind of a brief rundown of what we'll be talking about tonight. We know that when applicants are interested in pain medicine, there's a lot of different routes to the field, whether that's PM&R, anesthesia, whether that's doing a sports and spine fellowship or an ACGME pain fellowship. So we'll kind of be going into all those details today. Hopefully our panelists can help kind of clarify some things for all of you guys. With that being said, we'll be going through a list of pre-prepared questions for the majority of the session, and then we'll open it up the last 10 to 15 minutes or so for you guys to ask questions. You can ask them in the chat, and then Catherine and I will announce those at the end. And I should also mention I'm joined tonight by one of my co-moderators, Catherine Kingrey. She's a PGY3 PM&R resident, Texas Fort Worth Rehab, and also on the AAP Resident Fellow Council with myself. And I should mention too, I'm Eric Jones, a PGY3 resident at Mount Sinai and PM&R, and I'll be applying to the ACGME Pain Fellowship. But Catherine, do you want to go ahead and introduce our panelists? Yeah, absolutely. Thank you all, everyone who's logged in so far for joining us this evening. We have two of our attendings here so far. Dr. Yu will be joining us as soon as he gets off of his flight, which hopefully will just be in a few moments. Dr. Raghunandan is an assistant professor and the Associate Residency Program Director in the Department of Rehabilitation Medicine, the Long School of Medicine at UT Health San Antonio. He's board certified both in PM&R and sports medicine. He did his PM&R residency at Mount Sinai, just like Eric, and he completed Spine and Sports Medicine Fellowship at the Hospital for Special Surgery, Weill Cornell College of Medicine. Dr. Kohan is a Program Director at the University of Virginia Pain Medicine Fellowship Program. She's also the Medical Director at the University of Virginia Health Pain Management Center as well. She completed her anesthesiology residency at Georgetown and completed Pain Medicine Fellowship at the University of Virginia. I'll just go ahead and mention Dr. Yu as well. He's an attending physiatrist at Mayo Clinic in Arizona. He is the Site Director of the Mayo Clinic Sports Rotation for the Honor Health PM&R Residency Program out there in Phoenix. He specializes in ultrasound and fluoroscopy guided spine and peripheral injections. He completed his PM&R residency at UC Irvine and he did his Pain Medicine Fellowship at Shirley Ryan Northwestern. So Dr. Raghunandan, Dr. Kohan, thank you all so much for being here. We'll go ahead and get started. Easy softball question, how did you decide to pursue your subspecialty? Dr. Kohan, you want to start? Either way is fine. As you mentioned, I did an anesthesia residency at Dorgar Anesthesia Residency. We do rotations in pain medicine. And so, you know, I was not, I really had no idea going into anesthesia residency that I would end up pursuing a pain medicine fellowship. But when I did my rotation, you know, rotations, I just really gravitated towards it. It was just a really nice mix of kind of being able to see patients and really talk to people and spend more time talking to people than you normally get to in anesthesia, because anesthesia is like, you know, you have a short amount of time and then you put them to sleep. But so that was nice to have those relationships with patients again. And then, but there was also, you know, the procedural aspect of pain medicine. So I think that kind of nice mix of continuity, like really being able to establish relationships with your patients, the mix of pharmacology, interventional treatment, all that is what kind of drew me to pain medicine. Nice. So I'm on the, so if you put the spectrum of like sports into pain, I'm kind of on the left side of that spectrum. So, so there's sports, there's like this mix of like interventional sports and spine, and then there's interventional pain. I kind of took a long route to get there. So I started off my medical career in the military, taking care of aviators and pilots, I was a flight surgeon. So I kind of had that interesting background, I wanted to continue that. So PMNR kind of made sense to me as far as kind of taking, taking care of patients with kind of brain injury, spinal cord injury, mix of both sports spine, and then kind of other components. So it was like a nice foundation background for me. So that was something nice that I pursued. I was on the fence when I started residency, as far as if I wanted to do sports, or if I wanted to do kind of that mix of sports and spine, or if I wanted to go, you know, all the way into interventional spine, which I think is a pretty common conundrum for a lot of residents, especially in PMNR, I don't know if it's similar for anesthesia or not. So I kind of explored, I was at Sinai, as Eric probably knows, we have a very heavy sports and spine presence there. So our chair was a former fellowship director and also was a program director. So he was definitely a big influence for me. But some of the things that I thought about when I decided to pursue fellowship in sports is I really like taking care of higher level athletes. So when I was a flight surgeon, I took care of pilots who are, you know, fighter pilots, helicopter pilots, search and rescue swimmers, so very high level of activity and stuff happens, life happens, and they would kind of get knocked down from their competitiveness, their eliteness of what they did, and they wanted to get back to that. So I really enjoyed working with those patients who just have this innate motivation. So sports kind of really drove me kind of from the beginning of residency. The spine piece, I think, came a little bit later. So I was on the fence if I wanted to do interventional stuff or not. And then, you know, I had great exposure during residency. And then I ended up picking kind of a hybrid. So it's actually, it was an ACG and Recurrent Sports Program that I went to, but we have very heavy spine mix or interventional spine component to it. And that's, you know, I loved what I do. And I really think of it as, think of your fellowship year as gathering a toolkit of things that you want to do moving forward. So as we talk throughout this hour, think about what makes the most sense to you in your career, what tools do you want to have in your toolkit as far as you take, as far as taking care of patients that that might help you as also deciding what fellowship you want. Dr. Yu, I'm so glad you were able to make it. We're on our very first question, which is how did you decide to pursue your subspecialty? Are you in a place where you can chat? Yes. Can you hear me okay? Yes. So I'm sitting at a train station at an airport. There was a flight change to my plane. Plus there was a little bit of delay, but I landed about 10 minutes before it started. So I'm glad that I'm, you know, I was able to make it. Let me know if there's any background noise, there might be, and I'll try my best to tune that out. But as for me, what truly did we have was the MSK, primarily the MSK side of rehab. And as I was seeing patients as residents, I noticed that a huge proportion of my MSK clinic patients were coming in with some sort of a spinal related issue. And I really wanted to get the extra training from both procedural, from procedural standpoint and knowledge standpoint, which I felt that doing an extra year of pain medicine training was worth it for me. At some point, to be honest, I actually really enjoyed the inpatient rehab side as well. So there was a couple months period where I was debating to myself, started to skip the fellowship and just do inpatient rehab, because I actually liked that quite a bit as well. But at the end, I think the MSK side of me won out. And then, you know, that's why I decided to do a one year pain medicine training. All right. Thank you all for those thoughtful answers on each of your different backgrounds and kind of similar places now in your careers. So our next question is kind of putting yourself in the shoes of maybe an early career resident, PGY1 or PGY2. What are some key factors that you'd keep in mind when choosing a specialty related to pain medicine, whether that's, you know, ACGME pain fellowship, sports and spine, or anything kind of in between, whether, you know, looking at different patient populations or the procedural toolbox, as Dr. Raghunandan mentioned, lifestyle, career opportunities, kind of what are some things you'd keep in mind if you were an early career resident? Go ahead, Dr. Kahn. But I'm not going to- We can keep the thing in order if you're okay with that. So yeah, I mean, I think, you know, you had actually kind of brought this up, just kind of thinking about like what kind of tools you want. I think, I think there's a difference for me personally than what I've learned as I've been doing this for so long now and like being program director for a long time. So for me personally, like coming out of anesthesia, we didn't really know about these other opportunities, right? Like I think a lot of anesthesiologists, you just rotate through pain management, you know, ACGME pain management, you probably don't know as much about sports or sports and spine as some of these other things. So for me, it was easy because it was kind of the only thing I was exposed to. But looking back, you know, and being able to kind of having, you know, we have a lot of, we've always had non-anesthesiologists in our fellowship program, and that's really important to us. And so kind of learned working with a PMR resident, you know, the thought process that might go into you guys who are making this decision. And so one of the things when people are trying to figure out what to do that I kind of talked to them about is that toolbox that others have mentioned, right? And I think for me, an ACGME pain medicine fellowship really provides maybe the broadest spectrum of tools and others might disagree. But, you know, we do, like we see all sorts of patients, like we see athletes, we see sports, we see spine, we really see everything. And so I think by choosing an ACGME pain fellowship, you're learning those skillset to take care of really whatever type of patient that might present to your office. Because a lot of times they don't also present with just one thing. You know, someone with spine pain also has some kind of sports-related pain or someone who comes in maybe primarily with a chief complaint of some kind of sports-related pain might also have headaches. And so you really can offer kind of the full gamut of care and kind of take care of all these types of situations without having to refer them out. Yeah, just to kind of add on, I agree with all those things. As for you guys in like the Googling world, I would encourage you to look up the PM&R Journal. I think it's the 2013 year. There's essentially this conundrum, a resident who's I think a PGY-3, who's interested in MSK, interested in sports and spine, interested in pain. What's the answer? Like what do they want to do? I mean, and I'll tell you the end result, there is no correct answer, right? So everyone has kind of their own thing that they like. So I think really taking a step back and thinking about what do you want out of your career? Why did you pick medicine? What's kind of that on button for you? I think that will help kind of guide some of that stuff. A couple other kind of forks in the road or things to think about are, is ACGME accreditation, is that important for you or not? Because there are plenty of fellowships that are out there that are really good fellowships that aren't necessarily ACGME accredited. There is a new NAS accreditation. I think that started maybe three years ago at this point now. So they're trying to essentially get a standard for kind of baseline standard to kind of across the board. But it's pretty varied as far as like the experience that you can get. So trying to figure out is ACGME accreditation an important thing for you or not? I think that can help. And then what kind of patient population do you want to see? I think that can also help you kind of figure out which direction you want to go with this. Think about what your day-to-day would be. And then Dr. Cohen, I'm sure your day-to-day is a lot different than my day-to-day, even though we're both in academic medicine and same thing with Dr. Yu. So me personally, I really liked being a physiatrist and physiatry is kind of my base. And I wanted to keep that kind of ongoing. So I pursued a PM&R based sports medicine fellowship because that's kind of really what I wanted my toolkit to be. So I wanted to continue my physiatry training and get a deeper understanding of physiatry. And then I liked the interventional stuff, but I didn't want it to be completely what I did on a daily basis. I still do some EMGs. I do some inpatient medicine. I do things that are not purely a sports. So kind of figure out like what you want to do. And I think that'll help guide you as well. So the big picture, there's no hard answer, but I think it really depends on what you like the most. I have one comment, sorry, Dr. Yu, about the ACGME. I think it's an important point. And just like for credentialing, sometimes it does, jobs will actually, it is often an actual question on some of the credentialing form for jobs. Even it could be the most fantastic non-ACGME fellowship in the country, but it is something you might have to think about because sometimes it is asked. Yeah. If you want to talk more about that, happy to talk about the ACGME sports component as well. Before I answer the question, could you remind me what the initial question for this one was? Yeah, essentially just if you were in the shoes of like an early career, let's say PGY1, PGY2 resident thinking about this question of ACGME pain versus sports and spine versus maybe NASS, as Dr. Raghunandan mentioned, what are some key factors you would keep in mind at this stage? Okay. So, I went through the ACGME pain fellowship and I did not do a single EMG during my fellowship. And my understanding is that a lot of the non-ACGME fellowships do have you do some EMGs. So, if you really like doing that and if you would like to continue to do that during your fellowship, just something to keep in mind. The other thing is, even though we call them separately, we call them spine fellowship, we call them sports spine, pain fellowship, there's a lot of overlap between what you do. A lot of the procedures, you're learning the same procedures and after you're done with the fellowship, you may be doing something very similar. So, don't think of them as completely separate fellowships, whichever one you decide to do, it doesn't necessarily determine where you're going to be after you're done with your training. For example, I did an ACGME fellowship, what I'm doing right now is probably a little bit closer to somebody who's done a spine heavy sports fellowship. I do epidural injections, but a lot of my practices like ultrasound guided procedures, tenotomies or a peripheral joint and tendon procedures and whatnot. So, you can really decide what you want to do after you're done with your training. The other thing is, when I was deciding between different fellowships, one of the reasons that I ranked the program that I ended up matching very high was, they had me work at a PMNR pain clinic versus an anesthesia pain clinic. The anesthesia pain clinic, at least at an institution, was more procedural heavy. So, I felt like I got to see both sides of different types of pain practice and the other big plus for me was that it was a mix of anesthesia and PMNR trained fellows. So, I had a class of five and two of us are PMNR trained and three were anesthesia trained. Yeah, I totally agree with that. I mentioned with our fellowship, like it's really, I would advocate trying to find one that does have a mix because I think you learn from each other. Yeah, absolutely, absolutely. Thank y'all. My next question for y'all is, what do you feel is a common misconception that residents have about pain management? What is a common misconception that residents may have? I can talk about the misconception I had as a resident. I mean, I thought pain management was like opiate management. And I think that's probably the biggest one that maybe drives people away from doing pain. And I thought it was like people with chronic pain, they didn't have an answer. It was primarily medication management, a lot of mental health issues. And that wasn't just me personally. I just knew I would be drained at the end of the day, mentally drained, if that was what I had to do on a day-to-day basis. I'm sure Dr. Cohn can talk to the day-to-day, same thing with Dr. Yu. That's probably a lot different than what it is, but I'm sure there's kind of a component of that too. Yeah, yeah, that's exactly what it is in terms of the misconception. Do we actually do that every day? No. We do not have much opioid management. You know, we might help in terms of giving other people some suggestions, but in general, I mean, I think everyone kind of knows at this point, right, that long-term opioids are not the most effective therapy. We have so many other things that we can do, but I 100% agree that that is like the misconception, I think, of going into pain management. But it's not really what we do on a daily basis. I agree, and I actually don't do any long-term opioid management in my practice. I might just prescribe them every once in a while for acute pain, but I don't do long-term opioid management myself. And on the other kind of end of the spectrum in misconception is, I think when the residents are thinking about, oh, where should I train? Which program should I pick? I think this is my personal opinion. And I don't think this is necessarily a right or wrong answer, but there is kind of a very strong opinion on you have to pick the fellowship that will give you the biggest procedure numbers, and nothing else matters whatsoever. I personally don't agree with that. Of course, procedures are very important. I think you need to get good, competent procedure training. But at the same time, just doing procedures, procedures, procedures without really thinking about what you're doing and why you're doing, I don't think it's as helpful when you're out there and practice on your own. So you should pick a program, at least in my opinion, where the attendings will sit down with you, go over the MRIs or imaging findings with you, and talk about why you're doing a specific procedures. Or let's say that you're trying to do an epidural injection. Why are you picking an L4-5 transgenominal versus an intralavenocortical lobular blow? So I think it's good to get that type of training where you know what you're doing and why you're doing things, rather than just focusing strictly on the number of procedures that you're getting. I don't agree with that more. That's an extremely important point. You know, most people worry the most about procedures because they worry like, are they going to get enough procedures? The procedures are the easy part, really, right? The technical skills come along. It's the rest of it that you really need to learn. You know, we're, we're physicians. We're not hammers hitting nails. Not technicians. I think there's some, some great perspectives we're getting. All right, so moving on to our next question. Do you feel like your residency training, whether that was anesthesia or PM&R, adequately prepared you for fellowship? And you know, were there any gaps in fellowship where you maybe had to catch up to your colleagues in anesthesia or PM&R? We can start with any of our attendings here. I think PM&R actually, in residency, prepares you the most for pain medicine fellowship. You know, I know, you know, traditionally pain management has been, you know, anesthesia kind of, you know, leads it. But when, you know, the PM&R residents who come into it are more prepared, I think, to do physical exam. They have more of that critical thinking skills. And, you know, the anesthesia residents might come in better prepared for some of the procedural aspects, but we just talked about, you know, there's so much more to practicing pain medicine than just that. And so I think, yeah, I think PM&R really prepares you well to go into pain medicine. Just to add on to that, so I would, obviously, I'm very biased towards PM&R, but that being said, the other thing I would consider also is if you go to a program where you don't have an in-house pain fellowship, sports medicine fellowship, I don't think you're necessarily at a disadvantage. It definitely helps if you have something in-house, you get exposure to it, you have attendings that can write you letters, etc. But that being said, but that being said, that's another reason to consider doing a fellowship, because that's a piece that you want to get training in. So even if you feel like your weeks, for example, let's say you want to do spinal cord injury, and you didn't have it at your program, or was it a robust component of your program, that's why you do a fellowship, to get that knowledge. So I don't necessarily think, I think if you have a passion for it, you've kind of been exposed to it, you've talked to people, and this is kind of what you want to do. You kind of make what you have with your residency. So there, every residency has its advantages, disadvantages, but I wouldn't, I wouldn't feel like you should be, don't feel like you're a disadvantage because you don't have a program at your home institution. So I enjoyed the training that I got during my residency, and I think my residency training did prepare me well for the fellowship. Now, I'm not saying that I felt ready to practice pain medicine at the residency, but I think it set me up well for the additional training that came after, which involved more in-depth discussion and knowledge of spine medicine, nerve ablations, and different types of technical aspects of different procedures. This is another consideration, and there might be some disagreement in the group, but I would also consider training at different institutions, just getting different perspectives, like thought processes. I think it's nice, I mean, like, you know, I give you my personal example, Mount Sinai had, we have our sports program, ACGME sports, with a lot of spine, which is what I wanted to do, but I wanted to go outside the institution because I wanted to see people's, other people's perspectives. So I think it's nice, especially if you're interested in academic medicine, or if you're interested in scholarly activity, or, you know, having a national presence, things like that. It's nice to see what other people do, and how other people do it, because even though you're not learning it, or don't feel ready to practice out of residency, you kind of have an idea as to how the attendings practice, either sports or spine. So it's nice to see how other people in the country are doing the same thing. So that's my personal opinion. No, I totally agree. I mean, I, you know, practice, you know, I didn't do all my training in one institution. And then going back to what you said, in terms of one thing we're trying to help with, for those of you who want to go into pain medicine, ACGME pain medicine, is for programs that don't have that in-house pain medicine program in their institution, is how to help guide you through the process. Because, you know, you might feel that you're at a disadvantage to programs that have, like, a really strong pain medicine program. And so, it is one thing we're working on at Azure Pain Medicine, is to write it, try to create, like, alumni networks or mentoring circles for those of you who might be at programs who don't, who might be considering pain medicine, but don't have a program at your institution, to try to help you with resources, to help you through the process. I shared a similar opinion on training at a different institution. I don't think, again, I don't think this is right or wrong thing, but I, as a resident, spent about seven or eight weeks at my own program's pain clinic. And given that the entire pain medicine fellowship training is 12 months, I personally felt that I could use a different perspective and just being able to see how things are being done differently. So, that was actually one of the big factors when I was in my ranking process for the fellowship. I feel like we've already touched on the question of how do you recommend trainees best prepare for fellowship? Do y'all have any additional advice for what else we could be doing? What else should I be doing to prepare? I think one of the number one things is understanding that, you know, the specialty that you chose, right, and, like, why you want to go into it, and being able to relay that from a genuine perspective, right? That is one thing that we really look for, is, like, knowing the field, knowing what you're getting into, and having a, being able to relay that clearly, versus, like, I just don't want to be that, or I just didn't want to do this, right? Like, why did you choose sports, you know, or why are you choosing pain medicine? I think that's important to be able to convey. Yeah, I 100% agree with that. I mean, I think the sports corollary to that is a lot of people who go into sports medicine want to be a team physician for, you know, fill in the blank, and that's not your day-to-day. I mean, like, yes, if you get lucky, you might, you know, do some high-level sports coverage, and you might be the team doc for that person, or that team. That's not what you do on a daily basis. You still have clinic, you still have to generate our views, I mean, you still have the same hurdles that everyone else does. You might get to go travel with your team on the weekends, and take care of those athletes also in the clinic setting, but just really getting an understanding as to what is a day-to-day in the life of, you know, either pain management, sports medicine, or the mix, I think, makes a mature applicant. The other thing to kind of stand out from the crowd, which I think that's kind of another common question, is what sets me apart? I think it really goes back to what makes you you, and, like, what makes you tick, and being able to really bring that out in a personal statement helps significantly. So, I think a lot of people check the correct boxes, if you want to call it that. So, you know, everyone has some kind of research, you know, whether it's poster, or all the way up to publication. I think most people, if you're interested in sports, we like to look at coverage. So, we like to look at breadth of coverage and depth of coverage. So, how many types of sports have you covered? How long have you covered? Is it just one or two events, or have you done this throughout the course of your residency? Those kind of things. A lot of residents, I think, have checked those boxes, and they've done those things. I think the thing that takes you to that next level is what got you into medicine, what got you into PM&R, what got you into anesthesia, and how does this fellowship fit into that pathway? Because from a fellowship director point of view, we're trying to figure out, okay, we're picking one or two people, you know, maybe more for some of these pain fellowships, but how are we going to get this person to where they want in their career, and can we provide that to this person? And if you can really bring that out on your application, be a personal statement, or some of the things that you've done, I think that also makes you really stand out. Thank you. Oh, Dr. Yu, go ahead. Go ahead first. No, no, you go ahead. You go ahead. So, I just wanted to add that for pain, the application process, the cycle starts earlier than other PM&R fellowships. So, if you have a lot of interest in pain medicine, then I think it's good to start getting involved sooner than later during your residency. And by that, I mean, you know, doing research, getting case reports, attending more pain-specific conferences to make connections and things like that. So, I think it's good to get started early. I personally decided it was a little late to apply to fellowship because I'm very indecisive. But if you have a pretty strong interest in this field, I do recommend starting early in the process. But at the same time, I don't think it's ever too late, because for me, I think I decided around October of my PGY-3 year, which I think for pain is pretty late. But I was still able to get my letters, and I was still able to apply. And then, you know, that's the fellowship that I liked. I think, you know, being a strong resident, right? Like a strong resident usually makes a strong fellow. And so, taking, like, if your letter, like, we want to see in the letters that someone takes ownership of their patients, right? That they're not, that they're responsible for the patients and they're dedicated to their patients. Because that's what makes a good fellow. So, that's just my other comment, trying to be able to convey, you know, truthfully that you're someone who's committed to your patients. Yeah, at least for me, you know, if I was in the position of recruiting fellows, of course, it's nice. Somebody is very good procedurally, and their letter states that. But for me, I think more important thing is, is this person that I can work with for a whole year? And is this somebody that's willing to learn, accept feedback, and somebody who's reliable? So, if you can demonstrate those aspects as a resident, and you're attending, whoever is writing your letters can reflect that in the letter very strongly, then I think those are very helpful. Yeah, so now that we've got back to the, I'm sorry, Dr. Ragman, did you have time? No, I was just gonna say like a funny anecdote with this. So, I did a rotation in, I think it's like child neurology, and one of the attendings, he put it really well. So, the interview is almost like going back to the, what is that Colorado, the developmental scale, the child developmental scale. So, you pick up your like your gross motor skills, and then you pick up your like fine motor skills, and then you pick up your verbal skills, and then the last thing to come are those social skills. That's really, like when we're talking about soft skills that we're trying to pick up, that's what we're trying to pick up on these like, you know, letters of recommendation, interviews, personal statement, is that soft skill, and we want to see if you've developed that soft skill. The other stuff will come. I mean, that's where you're doing a fellowship. You're going to be doing it for a year. You'll learn the knowledge base. You know, you'll figure out how to do x, y, and z procedure, but that last piece, we don't, we can't teach you that in a year. So, you come with your personality. You come with your social skills. That also helps you kind of stand out. And to add to that, like when I say me for like understanding the field that you're going into that, you know, that doesn't mean like you already know how to practice pain medicine, right? It's just, you know, you're saying like, we know we're here to teach you those skills, but it is those soft skills. How are you going to relate to patients? How are you going to relate to each other? It's a close working environment for a year. We work side by side with the fellows very closely. And so, you know, that's what's important. Those are really great points. I agree. I think it's good to try to know how to differentiate yourself from a personality standpoint because I think the most common answer when you're on the other side of the interview during pain fellowship process is I like procedures. And because everybody says that it doesn't really make you stand out in any way. All right. So now that we've done a pretty good job of covering the transition from residency to fellowship, I'm kind of curious about the transition to fellowship to career. So what are some of the biggest challenges that you guys see the fellows face when transitioning from training to ultimately independent practice? And how can fellows maybe best prepare for this? Well, COVID, that changed a lot of stuff for me. I graduated COVID year, so that changed a lot of things. But I mean, one thing, again, this kind of goes back to, you know, there's no right answer for this either. So most people, the first job that they get will not be your next job, maybe like ultimate job. So I feel like fellows in general, I mean, in medicine, we're very competitive. We're like, it's next step, next step, like what's next, what's next. And that's just kind of that rat race we've gotten into. Once fellowship is done, like take a breather. I mean, try and figure out like, what do you want to do in your life? Yes, get a job, you need some money, you need some job security, you need health insurance, but it's not your final job. So you might be in that first job for a year. And then you figure out like, okay, maybe this isn't what I actually liked. Maybe I want to do more prior practice, maybe more academic medicine, I want to switch up my day to day. So I think exploring that talking to people as much as you can during your fellowship can help. Talk to your attendings, they're also advocates for you, they picked you for a reason, or you got selected for that fellowship for a reason, they're going to go to bat for you. They'll make connections for you. I think that stuff is never too early to do that stuff. But you know, the other thing I would tell you on the back end is don't stress about it too much. I mean, you will have a job once you graduate fellowship, your first job might not be your last job. So yeah, keep an open mind. I think it's the hardest transition, right? Like going from training to independent practice, we make so many transitions, right? Like undergrad to med school, med school to intern year, intern to residency to fellowship by fellowship, you know, or end of training to independent practice is the hardest transition because it's a totally different, like you're so used to seeing patients, you might be used to doing this procedure, surgical procedures, whatever it might be. But it's a very different feeling when you're suddenly, there's no attending over you, right? But just trust in your training, right? Like trust in your training, like you were trained properly to do it. And don't be afraid to ask for help. There's more learning I think that goes on in that year post fellowship than, you know, any other year. You just learn in a different way because you have a different responsibility. And so just, you know, trust in your training and don't be afraid to ask colleagues, you know, don't be afraid to kind of touch in and, you know, everyone's been through it. And so we've all been there. And so just, you have lots of support. So particularly the first six months during the transition process is rough because like it's already been said, you're on your own for the first time, you don't have a supervisor who's telling you, okay, you're doing that wrong, or that looks good. So not having that confirmation was difficult. And it takes time to get used to that and takes time to build confidence, but it will happen. So don't worry about that part. The other thing is, it's good to make friends during your fellowship, whether it's your co-fellows or attendings, because what helped me a lot was I was close to my co-fellows. So even after we were done training, and we went all over the country, we were still texting each other to discuss different cases about, hey, you know, can we talk about how we did the procedure, for example. And I was texting not only my previous co-fellow, former co-fellows, but also my former attendings that I felt comfortable enough to do that with. And that was also very helpful when I was, at least for the first few months. And I still talk to them a lot about different cases. And so I think somebody already mentioned building connections. And I think that's where, that's one of the examples where that can be helpful. And you become lifelong friends with your former co-workers, and they continue to help you building your practice and building confidence. I kind of agree more. And then one other thing maybe to add is the practice management side. And I think that's sometimes a challenge when people make that transition. They're not maybe as familiar with how to actually, the billing and coding and authorization and all that stuff. And so, you know, different, you know, and that's where, again, those connections help, you know, trying to get as much of that information as you can during your training. And then different societies, you know, and, you know, since this is a joint Azure webinar, you know, Azure is definitely trying to develop some of those resources to help with that transition. I'm sure some of the sports societies would be doing the same. Definitely. And the other thing I would say, like the first couple months, like when you do start your job. Credentialing, I don't know, everywhere I've gone, credentialing always takes forever. So even though your job says you're starting on October 1, you're probably not going to start seeing patients until two, three months down the road. That's your time to like, you know, think about all the dot phrases that you had from residency fellowship, like incorporate that into Epic if you use Epic. Marketing, if you're going to private practice, figuring out like who's your market, where are you going to get your patients, is it going to be if you're joining like a group, a multi-practice group, is it coming from your surgeons? If it's not, you're setting up your own shop, which probably wouldn't show you at a fellowship, but people do do it. But if you're kind of going to a place where you don't really know anyone, go introduce yourself to people, bring them donuts, like bring your business cards, create like all that stuff. I mean, the first couple of weeks when you start, you have some downtime, you don't like hit the ground running with seeing patients and doing procedures. So use that time wisely. And you're going to, you know, it's going to feel that uptake will take a little bit of time, but when it picks up, it picks up real quick. And then you don't have time to do some of that stuff that you could have done when you initially started. That's a really good point. That is not something I thought about at all, but that makes a lot of sense. And I love hearing rely on your community and build up your connections. That's huge. And I appreciate that a lot. Another question, and we've got maybe a couple more questions, and then we'll open it up to the room. If anybody else who's in the webinar has additional questions, y'all can type them in the chat. Eric and I'll kind of help filter through those and ask as well. But some of the other questions we have written here, can y'all describe your practice and why did you choose this setting to practice in? Dr. Yoo, do you want to go first? Sure. So I'm in an academic physiatry spine MSK practice. I did mention earlier that even when I did a pain fellowship, my current practice is probably closer to somebody who's done kind of a spine heavy sports fellowship. So I see patients in the clinic like everybody does. And I do ultrasound guided procedures, including peripheral joint, bursa injections. I do tenotomies. I do nerve blocks. And I have a dedicated time, usually half a day or full day a week, where I do fluoroscopy guided procedures, including epidural injections. I have a decent amount of time that's set aside for admin time. I'm pretty heavily involved. I like education. I like teaching. That was one of my passions that I always made it clear when I was applying to fellowship in my current job. So I'm involved with our medical school as the MSK course director. So I spent a lot of time teaching our medical students. And then I'm also our department's current education chair. So essentially, I'm kind of the clerkship director for any person that votes us to our department. And I also organize journal clubs and clinical conferences and all those things. Our department is relatively small. We have 10 physiatrists. So I handle all of that. And because of that, I have a decent amount of non-clinical time in addition to the time that I spend seeing patients. So I'm also in academic practice as well. So we have a pretty small group of physiatrists as well. Actually, we have two now, two sports-trained ACGME. And then we do have an anesthesiologist, a pain physician as well. I'm primarily at the Spine Center, which is kind of a multidisciplinary group between orthospine surgeon, neurospine surgeon, and then myself and the anesthesia pain doc. So that's kind of my day-to-day clinic. I primarily do clinic. And then I have a half day of fluoroscopy, fluoroscopic spine procedure. So I do cervical all the way down to lumbar, kind of the bread and butter spine procedures, if you want to call it that. And then same thing with a mix of peripheral joints, nerve blocks, tendon interventions. EMG, I also do kind of half day a week. I do some inpatient work too. So I do inpatient EMG consults. So when those come up, I take some time between clinic to go do those things, which is fun, but also can kind of take away from clinic time. So there's a little bit of balancing that. We do inpatient call in our academic center. So I'd like to keep my feet wet with inpatient rehab a little bit. And then from the sports piece, we have a pretty big sports presence in San Antonio as far as UT health in general. So I do a decent amount of sports coverage, both from, I have my own high school team that I'm one of the team physicians for. And then we have UTSA sports, which is division one. And then there's some other professional teams that we cover as well. So there's some of that. And then like Dr. Yu, I also have an interest in education. So I teach a medical school course, an MS2 course called form and function. So it's, I'm in it right now, but it's usually, it's like a six week course with dermatology, rheumatology, musculoskeletal medicine, pretty fun. I actually get a little bit of time off from clinic to go do that for five to six weeks. So, I mean, kind of big picture, academic medicine is what I really wanted because of a lot of like, like Dr. Yu, I'm kind of indecisive a lot. I like a lot of different things. And I don't want to do the same thing every day. And I like that variety of, you know, the interest that I have in being able to kind of fulfill some of that interest. Academic medicine really allows me to do that. I did have some experience with prior practice because of COVID, like I mentioned, my, my contract was on hold for a year. So I did one year of prior practice. It was nice. I did a ton of procedures, but it was definitely not for me. It was, it's a very different way of thinking and different type of philosophy in prior practice, which I didn't personally like, but I do appreciate that. I got a lot of reps as far as procedures go, but it's definitely not what I wanted to do. So it was nice to see that aspect of it and know that that's probably not something I would ever do in my career. So I'm also in academics. And so, yeah, I mean, I do a mix of things as well, similar to everyone else here, clinic, you know, days and procedural days, our procedural days are combination of fluoroscopy and ultrasound guided procedures. It's just kind of, you know, mixed into the procedural day. We also, and procedures really can be anything like spine procedures. We do a lot of joint procedures, including radiofrequency ablations of, you know, shoulders, knees, hips, and that sorts of thing. But we also do things like celiac plexus blocks for mouths for, you know, mouths and things like that. As I have some surgical days, so I do, you know, spinal cord stem, DRG stem, intercept, some reactivate. We also do a fair amount of pumps, intrathecal pumps. So mostly for cancer pain and also for spasticity actually. And so we get a lot of referrals directly for spasticity. And then some will, we will get from our pain, our colleagues, if they have a patient and they would like us to put a pump in. So those that they're asking us, they'll go back to them, they'll manage, but we actually manage a fair amount of the spasticity patients ourselves. And sometimes those will be pure baclofen and sometimes those will have a combination of baclofen or other medications. Also have a fair amount of admin time just from responsibilities as a division chief medical director and program director. So within UVA research time, as well as I just do a fair amount of work for kind of societies, pain societies and academic societies. And so it just, all that stuff takes up a lot of time. So luckily I'm at an institution that helps to support that. All right. Thank you for kind of all detailing a little bit of your day-to-day and kind of talking about some of the ways you approach different patient care and some of the therapies that we can do within our individual fields. If there's any questions in the chat, you guys can add them now. And if not, we still have our list that we can keep going through. Looks like we have, so we have one in the chat from Kevin. He says, could you comment on research or clinical trial opportunities for pain fellows and what kind of preparation helps, whether it's biostats knowledge, networking with potential supervisors, journal clubs, et cetera. So kind of commenting on the research aspect of pain or sports-inspired fellowship. So if I understand the question, is it, what kind of opportunities do you have during fellowship or career-wise or during residency? Could you clarify the question a little bit? Yes. All the above. Okay. Okay. Yeah. I mean, so, I mean, during residency, I would say figure out who those people are or do what you want to do and then go talk with them. So they may not be doing research, but they may be able to point you in the direction of doing research or at least getting a study. So there's some programs that have a lot of, so let's say, for example, you're in a pain and art department, but there's an anesthesiologist, you know, pain doc who does that research. It's nice to kind of collaborate network. So research, it depends on your institution. So I don't have a great answer for you. Kind of, it's varied. Same thing with fellowship. It's pretty varied. Where I did fellowship, we had a dedicated biostatistician for our department, which is a luxury. I don't think a lot of departments have that. Where I'm at now, we share biostatistician. So our department shares it with a couple other departments. So it depends kind of how your setup is as an attending and how much time you have dedicated for research or if it's something you kind of have to build in or you do it on nights and weekends. So it kind of varies. Yeah. So I agree with all that. I think a lot of it is institution dependent. I don't think it's necessarily an expectation that everyone's going to come in with a huge amount of research experience. And so if you do and that's something you're interested in, I would highly suggest that you highlight that because those skills are, you know, those are strong skills. Different institutions, I do think, have different educational opportunities to learn more about research. You mentioned biostatistician. We did hire one recently and she gives lectures. She gives like mini workshops to help with that. If you're interested in pain research, no matter if that's sports, pain, whatever it may be, there is an NIH HEAL initiative called the Purpose Network, which is essentially a consortium of that's trying to connect pain researchers. They give a lot of education on this. You can join. And again, it's an NIH grant that was awarded to create essentially a network of all different kinds of pain researchers, like basic science. It could be physical therapists. Again, it can be sports, anyone that's really doing anything to do with pain. And it's also a way to connect people. So like if you have an idea, but you don't have resources, you can essentially reach out on this network and find people who might have resources, but not ideas or vice versa. It's just really trying to advance the field of pain research. Yeah. Just to add onto that, sorry, I'll give you your time back in a little bit. Multiple societies have this type of opportunity. So CIS, which is the Spine Interventionist Society, they have a research mentorship program. AMSSM has something called CRN, things like collaborative research network. So definitely, if you don't have something at your institution, look like Dr. Cohen said, look at the national level bodies, they will have opportunities for you to get involved as well. All great points. And thank you for that. You know, we know that clinical research in general takes a really long time. So, you know, I don't think it's like it's already been said, we don't expect every single applicant to come in very research heavy. I think all three of us mentioned earlier that we like, you know, we recommend getting a different experience, for example, different institutions. However, I think this is one example where staying at your institution might be helpful. For example, one of my co-fellows, he did his anesthesia residency at the same institution. And he had already had research process from his residency that he was able to carry over to his fellowship. So he had an extra year to work when he was knowledgeable. And then he was able to get some publications out of that. So I think, and that's why I said, I don't think it's, you know, I like it that way. But there are pros of staying at the same institution. All right, in the last five minutes, I think a good question to end on is, what are some of the emerging trends or innovations in the fields that could potentially change how pain management is approached? Is there anything that y'all see from your perspectives on the horizon that maybe we may or may not see in fellowship or in our careers coming forward? That may be too broad of a question. Yeah, I mean, I could talk a little bit from the sports perspective. So in the sports world, like wearables, wearable devices are pretty popular, pretty ubiquitous. There's all these data points that are coming out from it. A lot of times we don't, I mean, you know, let's say you have like a running watch, like I don't know what to do with some of this data. I think some of this can be user kind of mind for trying to figure out like, are there correlations? I think that can help with patient care, both in the sports and the pain world. So maybe that's something on the horizon potentially. And now with AI being also relatively ubiquitous, you know, there's generative and non-generative AI. I mean, there's different ways to kind of take this data, put it together and make it something, some kind of clinical correlation with it. I don't have any great answers for that, but I'm sure Dr. Cohen and you probably have some better answers for that. It seems like the two hot fields right now, at least for pain or sports spine are neuromodulation and regenerative medicine. So PRP and stem cells. So those are, they're not new new fields, but they're under, they're really being researched heavily. And it seems like there is something new every few months that I, you know, read journals and whatnot. And the other thing is, it seems like there's more and more incorporation of like VR for treating chronic pain. I haven't been able to familiarize myself a lot with using VR for my chronic pain patients, but I think that's something that's non-invasive, interesting. And of course we, you know, do plenty of poking injections, but at the same time with a lot of our patient population, it's important to maximize multidisciplinary treatment modalities. So that's where, you know, things like VR with wearables can come in. I agree with everything that's already said. Maybe the other thing to add would be like biomarkers. I think there's a lot going into, like, are there certain biomarkers that can be predictive of different pain states, things like that. Predictive modeling. So using machine learning to do predictive modeling to see, you know, which proceeds, like who's going to have the best outcomes from certain procedures. Those are also kind of big areas. And I think like medicine in general, the other frontier horizon, I think there's also medicine and even non-medicine worlds, like people have really dug in and done a lot of, you know, research, innovation, things like that. I think the next level is everyone cross-talking. So some of these solutions might already be out there in the engineering world, in the whatever world, and we just need to talk. I think COVID has kind of helped some of that in a way with things like this, like a webinar. I mean, we're talking to people from different coasts and getting them on at the same timeline, sharing information, ideas. So there's a lot of stuff that's probably already out there that just, you know, different fields just need to talk together. Some of this stuff is already happening in medicine. So lifestyle medicine is an example of that, where you have multiple disciplines that are coming together with a similar kind of goal. So there's, it might not be a new innovation, but I think it's just like, you know, putting our minds together and like, how we have, we solve problems in this area and how can we apply it to a different area. All right. Well, thank you to all our panelists. This was an excellent hour and we covered a whole host of topics and I know that everyone on tonight really appreciates it. So thank you to our panelists for your time tonight. Certainly appreciate you all. And also just wanted to highlight, you know, the collaboration between our fields. It's great to see a webinar between AAP and ASRA kind of underscores the value of both organizations. So I just want to extend a thank you to members of AAP and ASRA as well that are here. And then also just wanted to have one last shameless plug for ASRA. We're going to, this is actually the first of our Pathways to Pain Medicine series. So this is of course kind of the PM&R background for going into pain medicine. We'll also be doing some webinars in the emergency medicine background neurology, psychiatry, et cetera. So hope to see everyone at future sessions and spread the word. But again, thank you all so much for being here tonight. Thank you, Catherine, as well. And we appreciate all your time. Thank you. I want to give one more shout out. We have some people in the room, Amy Abbott, Eliza Perez and H.J. They helped with both coming up with some of our questions and helping promote on social media respectively. So I wanted to give them a shout out. Thank you all so much. And again, thank you to our panelists. We really appreciate y'all taking your Monday evening out and talking to us. Really, really appreciate it. And if anyone has any questions, they're welcome to personally reach out and email. I guess our email can be. Yeah, same for me. Same for me. Yeah. Feel free to reach out. Likewise, Catherine has my email. So you can ask for my contact information if you have any questions. And I'm happy to be here. And thank you for having us. Yeah. Thanks for having me. Thank you. Good night. Thank you so much, everyone.

pain management

physiatry

sports medicine

anesthesiology

fellowship pathways

mentorship

neuromodulation

regenerative medicine

interdisciplinary collaboration