And then we should be good. OK, everybody, welcome. Thank you so much for coming to our summer series by the AAP. Our wonderful guests tonight will be talking about spasticity and spasticity fellowship. This is the end of our wonderful summer, kind of leading into fall Q&A series. We're very excited for a wonderful night learning all about spasticity fellowship. We have Dr. Hecker, Dr. McGuire, and Dr. Hafner here with us. If at any point you have any questions and you feel brave, feel free to turn your microphone on and your video on. We'd love to have this be an interactive and very educational session. And it's all to benefit you, all the people who are listening on tonight. If you would rather put a question in the chat, go for it. And you can also direct message me if you would like me to ask the question for you to the group. We're just going to be having a great conversation tonight. And then there also will likely be some presentations as well about different spasticity fellowships that you can have. Thanks for coming. Awesome. Well, yeah, thanks, Gina. That was great. As you mentioned, I'm Ryan Hafner. I actually did a PM&R residency at Temple Moss Rehab in Philadelphia and followed by the Jefferson Spasticity Management Fellowship in Philadelphia. Yeah, very honored, pleased to have both Dr. Kim Hecker and Dr. John McGuire with us tonight. Dr. Hecker, she actually did her physiatry residency at Thomas Jefferson University, followed by a fellowship in stroke rehabilitation up at Kessler in Newark. Dr. McGuire finished his physiatry training at Northwestern University, followed by a stroke rehabilitation fellowship as well at RIC, now currently known as Shirley Ryan Ability Lab. So I'm here to help guide and answer questions. Towards the end, I'll also give my personal twist on fellowship and why you should do this fellowship. I've had the pleasure of working with both of these individuals. And I don't think there's really a wrong way to go. So Dr. Hecker, she is my favorite. We have that history. But Dr. McGuire, he certainly will keep you laughing and smiling throughout the entire day working with him. So with that, I don't know who wants to start first. Who wants to talk about their respective fellowship? Kimberly, why don't you tee it up? Well, thank you, John. John, you're my favorite for what it's worth. Yeah, I'm still trying to be John McGuire when I grow up. Kimberly Heckert, so honored to be here. I started our fellowship program. We're currently training our sixth fellow. So it has been the most professionally rewarding piece in my career. And it is such an honor to direct this program. So basically, a little bit of the background about why spasticity fellowships seem to be popping up and popular right now. Spasticity is a huge problem. There are many people in this country with problematic spasticity. And there are too many of them and too few physicians who treat them. And historically, those physicians who have been able to treat spasticity with various interventions have learned those interventions either in other various neurorehab-type fellowships or as apprentices from other people. And so some may learn these skills. So what we're talking about is this is a fellowship that teaches all aspects of spasticity diagnosis and treatment. And that means managing spasticity by all the possible ways that we can manage it. And we do that personally with our own hands or in the case of surgery, we make sure we expose ourselves to the surgeons. But short of doing the surgeries, we're doing all the other pieces. And to learn those skills, in the past, some may have learned those skills from an SCI fellowship or from a TBI fellowship or from a stroke fellowship. John, I didn't realize you did a stroke fellowship too. Isn't that funny? I know. I really just copy everything you do, don't I? But spasticity occurs, some people really just want to treat spasticity like I do, regardless of where it came from. So a lot of my patients are adults with CP or they're patients with MS. And there aren't fellowships in CP or MS. But spasticity can occur by many ways. And I really like treating the patient's spasticity, regardless of how they obtained it. So that's kind of the idea for it. Let's be experts in managing this problem, regardless of how the patient got it, rather than trying to get these skills piecemealed from various other ways. So that was the thought for forming the fellowship. And now we are living the dream. How about you, John? How'd you get into this business? Well, that was an excellent introduction. So I'm glad we have an hour because my history will take a whole hour to go over. So strap, buckle in. And anyway, so I did a fellowship. I was at the Rehab Institute of Chicago, and fortunate enough to train there. And I was very interested in stroke and also very interested in EMG. And that was at a time when there were no sports medicine fellowships. There were no pain fellowships. There really weren't any really ACGME accredited fellowships. But the Rehab Institute of Chicago had, which is now the Shirley Ryan Ability Lab, but will always be known to me as the Rehab Institute of Chicago. So that's a whole other topic. As you know, they had two unnamed fellowships. It was a Women's Board Fellowship and a Franco Fellowship. And often, it would go to whoever. They would put it up for bid, so to speak. And whoever wanted to do a fellowship, you kind of design your own fellowship. It was popular then to sort of do a spinal cord fellowship. Some people did pain. Some people did TBI. But then Joel Press, when he finished his residency, he started up a whole sports fellowship. That sort of has taken over the world now, as you know. And everyone wants to go into sports. Neurorehab has never been sexy. And it still isn't sexy. But it's down, it's dirty, it's gritty. But it's important. And it's not going away. And it's a big problem. And I mean, I wish. And so that's why I was really happy that we have, at least now, two dedicated fellowships to this. They're sort of morphed into other areas and so. But for me, anyway, so I was sort of trying to figure out what I wanted to do. I knew I was interested in stroke. And I knew I was interested in EMG. And so I worked with Elliot Roth back then. And so I was a woman's board fellow by name. But you could name it and do whatever you wanted. So I wanted to do stroke. And so I did stroke. But every Wednesday, I got to work with an anesthesiologist, Dr. Erickson, who did phenol injections. So every Wednesday, I was doing phenol for spasticity. Because believe it or not, there was a time when we didn't have neurotoxins. And we didn't have baclofen pumps. And we didn't even have cell phones. I know that's really hard to believe. And we had a really ancient computer system. So we actually had written charts. I mean, there was a time like that. There was a time like that. There was a time when we actually wrote our notes. But anyway, so that really kind of got me going. And then the fellowship was one that was you could design it how you wanted to do it. And so I started working in Zev Reimer's lab with Jules DeWald doing measures for spasticity. Because they're engineers. And they take a different view of the world. And because the fellowship was there, it could design it how I wanted, I could spend as much time up in that research lab as I wanted to. So I got to spend a fair amount of time in that lab, which I would have never been able to do as a resident and never been able to do as an attending. Because once you get out there in the real world, I'm not going to sugarcoat it. It's all about getting RVUs. And so that's why fellowships, I think, are very important. Because that's in some ways you are protected. Because now you're in your own little bubble where, and hopefully you're in a fellowship that really emphasizes learning and not just uses you as sort of a clinical person to generate revenue. And then they pay you like a resident that you're doing all the work for. And so there are some fellowships like that. But not our spasticity fellowships. Either of ours are like that. I've been very committed to keeping my fellowship in that same vein as far as being able to design it how you want to do it to suit your needs. And so that's why I never pursued getting ACGM accreditation. Because I didn't want to have any restrictions on how to design it. And so for some people now, not to take anything away, but some people freak out at that. They freak out when they say you can design it how you want to do it. But don't freak out. Because we can design it in a way that really works well. Because we have the volume, both inpatient and outpatient. We have probably one of the largest spasticity programs in the country as far as pumps and injections. And so there's volume for, actually, we've had one fellow. Some years we've had no fellows. Some years we've had two fellows. Some years one fellow. I only want people that really want to do it. I don't want people that just don't know what they want to do and want to waste a year and hang out and do whatever. But I want people that really want to champion the cause. Because I think to really get good at this, you need to dedicate some time to it. And you need to see a lot of patients. Because it's really hard to do. We do these cases. And we try to do these workshops. And you can teach, basically, you teach a monkey how to do an injection. The problem is figuring out what to inject and where to inject and why you're injecting. And so the issue is, so a lot of the emphasis, and it's really hard to do a workshop when you just try to do a session because it's hard for you to do a good patient assessment. In our residency, each resident spends two months with me, for better or for worse. And so they, and at the end of that, they can do injections. They can do refills. They can do pump programming. But the thing that takes the longest is really doing a good assessment. And can you come up with it? Because I know they always say, well, we just do whatever you say anyway. And I go, yeah, but I've been doing this a lot longer than you. But at least you go through the exercise of thinking about it. And you have to do, because getting a good assessment, it's like a good scout in sports or a good coach in sports where you say, well, that person's going to be good. Or that quarterback's going to be good. How do you assess talent? And how do you know who's really going to thrive or that sort of thing? Same thing with these treatments. Because now we have, like I said, we had oral medications and phenol when I first started. Now we have botulinum toxins. And we have baclofen pumps. And now the latest, the new kid on the block is this cryoneuralysis, which is really cold. I mean, it's really cool. But it's sort of the new thing on the block. And cryoneuralysis has been around a long time in the pain world. But it's new in the spasticity world. And so there's clearly a role for there's enough room in the sandbox for all these treatments. So now with all these arrows in your bag, it really makes it very exciting. So for me, like I said, so the fellowship, the one that I did was not accredited. But I designed it how I want. So I spend time at Northwestern with a neurologist doing stroke rehab. And then you have UIC with a neurologist, Dr. Helgeson. And for a whole month doing neurology, I got to spend time doing stroke. And so it was great. And then one day a week, I was doing phenol injections. And then I had two and a half days a week doing EMGs. And I could jump in and out of inpatient whenever I wanted. And that's really what got it jump started. And then right during the fellowship, that's exactly when the toxin, Bobotox, got approved. And so right away, because I was doing EMGs, it was a natural fit. So I went and worked with Cindy Camela down at Rush for a bit and worked with Dennis Dykstra up in Minnesota. They were the first ones to really start doing, Dennis was doing some of the bladder stuff and neck stuff. And Cindy was doing the neck stuff. And people were just starting to do the spasticity thing. And Debbie Gaylor was doing the kids. And so it was just sort of all of a sudden, this thing just started to explode. And this was at a time, believe it or not, there was a time when we actually got samples. And so as Botox was there and then Myoblock came out and then Dyspor came out. And so we actually had a cabinet full of all these toxins. And so we could try different things. And at the front end of this whole thing, we would try different things because we had samples. And so we could do it. And then we'd sit in a room and, I mean, the Allergan people were actually pretty good stewards at first, as far as designing studies. And really driving, it was a good collaboration between industry and what we're seeing in the streets or down there at ground level and what's working and what isn't working. But we would have these, we call the meeting of the minds and we would sit in a room and we'd present cases and what we were doing and how we could design studies. And it was actually very exciting. It was a cool time. So that's how we kind of launched all that. But the fellowship really helped spring, jumpstart all of that. And that's, so when I came here, I wanted, or came to Milwaukee, they wanted me to develop a program. And so that's what I did. But then I really wanted to have a fellowship. And as Kimberly mentioned, it's been the greatest, the thing I'm really probably the most proud of in my academic career. And so, because we've trained 15 fellows so far and each one, I said, as long as they're interested in it and we can design it, but I said, take this time because you're not gonna get time like this ever again to really get good at something. And so whether it's ultrasound or EMG or gait or something related to medicine, not your golf game, but get really good at something related to this. And the nice thing, what makes spasticity really, I mean, it's sort of an umbrella term, but it really lumps in together a lot of different diagnosis. And for me, really where it all started was, is spasticity a constraint on recovery? Because it was Twitchell that first described, he said, severe proximal spasticity is a predictor or prognosis for motor recovery. And so that sort of jumpstarted everything I wanted to do as far as how do you measure it? And if you intervene, when do you intervene and can you make an influence on their recovery So then we went down this whole rabbit hole of measuring it and then doing functional MRI and brain connectivity stuff, which is really kind of cool, but we got it all good and all that. But the whole thing, the fellowship allowed me to kind of get a basis for doing research. And now I collaborate with the engineers that know way more than me, all the PhD people that do this and because we have, we collaborate with Marquette, the biomedical engineering department there, and UWM, University of Wisconsin-Milwaukee. They have a whole research facility here. And so that's part of the fellowship here is to do some research because we've got various projects going on, which if people have questions about it, I can answer it, but which makes it, to me, makes it a lot more fun. And so we have the clinical part, both inpatient, outpatient, and the inpatient side is what I really like to do. I do a lot of diagnostic blocks because you can do lidocaine injections and see if whatever treatment you're gonna do is gonna work and so, or potentially work, but you can get the results right away. And that sort of jumpstarts you as far as if a toxin injection might be worthwhile. And then, and so we have both inpatient, outpatient, and again, you can spend as much time as you want doing either. There's opportunity to do lots of EMGs if you want. I do EMG-guided injections, ultrasound-guided injections. We do some CT-guided injections, not as much anymore, but for the most part, there's that. We have a large pump program, so you learn all that, and you learn how to do phenol and crown neuralysis soon, like this week, but anyway. So that's how, but I think that's why fellowships are a great thing to do. I believe all the fellows that did it said they enjoyed it and got something out of it. And, but yeah, so for our program, I like them to get involved in some research project, and you can do as much or as little as you want of any of that, but I just said, basically it's a way to jumpstart your career in any, even if you go, I mean, some have stayed in academics, some have not stayed in academics, which is all fine, but at least it gives you an opportunity to get good at something and get really good, and you will get good. You will do a lot of injections. And the interesting thing about the toxin injections, of course, and I'm sure you've noticed this too, Dr. Heckert, is that it's like, it's, now I've been doing more and more pain-related things, and I never really wanted to get into pain, but it's, the toxins work really well for a chronic back, butt, neck pain, and a lot of them have this subclinical sort of dystonia, which if you look around, you find that there's some, they have dystonic muscles that it's kind of interesting. So, so the pain world is kind of taking over. But anyway, go ahead. Yeah, no, you're absolutely right. We see, I treat a lot of focal dystonias, and even if it seems like the initial etiology was something else, I think having surgery in the past seems to be a risk factor, but these focal dystonias can appear, and they're very responsive to neurotoxin, which is great. But just to sort of dovetail on what you're saying, in our program, we do have a lot of flexibility as well. You know, we don't sit down per se and say you design the experience. For our program, we wanna make sure that each graduate meets the full battery of procedural objectives, which we'll give you a link to. And so I try to position each fellow so that they can be successful in getting those procedures to where they're competent. And what we found is we're getting better and better at that because each fellow is sort of hitting that bar sooner and sooner. And the one thing that is great is that I have the ability, because we're not ACGME accredited, to make an adjustment in real time to make sure that each fellow is successful. So just to give you an example, I remember sitting down with Dr. Hafner here around the first quarter, and he was lucky enough to be a fellow in a pandemic, which is, you know, it was a shame for all of us that had any sort of training hiccups during the pandemic. But I think it was right around the first quarter, and he said, you know, he hadn't had a lot of CAP studies, catheter access port aspirations. So we were very to very quickly identify, okay, where can we get a number of those within the next couple of weeks and turn those numbers around so that you could gain that experience. And so, you know, I'm able to do that. Also, Ryan decided he wanted to spend a week with Dr. McGuire. And so he went out and to his program for a week and got to see how they do things there. And I think it's really a great thing to spend time with a lot of people, because I say it a lot, you know, there's more than one way to skin a cat, so to speak. And doing a fellowship is like making a necklace. You're taking a pearl from this individual, a pearl from that individual, and you're stringing your own necklace. And when you leave, it's yours, and you will practice the way that you feel comfortable. But, you know, hopefully you've been exposed to a lot of good techniques, and then you can choose what feels most comfortable for you. And I think it's also a great idea to know a number of different techniques, because as we all know, the real world isn't perfect, and you don't always have everything you want at hand. Sometimes you're in the emergency room and you have to do a procedure, and you don't have that very special, you know, type of needle that you love, but you know how to do things more than one way, and you can do it more than one way. And so that's always a good skill to be able to pivot. And so we do try to create that experience. But yes, certainly if there is more of an interest in a particular area, we try to allow the fellow to do that. We're lucky that we have some flexibility and some wiggle room where a fellow can have more of a concentration. We have not a research requirement per se, we have a scholarly activity requirement. And so our fellows have all been involved in some research, but if there were a fellow who really said, I just want to get these clinical skills and I'm not really research minded, that's okay. We just would ask that you, you know, present a case at a meeting or something like that. So it's a scholarly activity requirement. And so far, as I said, our fellows have gravitated toward research, but that would not mean that if there was somebody who said, I'm just not a researcher, I don't want to do research, but I really want to do your fellowship, and I really want to treat patients with problematic specificity, I would not see that candidate as any less applying to my program. Awesome. Well, thank you guys for kind of introducing a little bit about each of your programs. Obviously, you mentioned, you know, a lot that's in common, you know, some unique differences and stuff. And I think it's kind of gives a nice flavor for each program. Real quick, before we kind of break up, if there's any sort of questions, I wanted to touch base and kind of echo, you know, I think, yeah, exactly, you know, both of these programs and just any programs that you're working on, and just any program that's focused towards this effort is vital. I think there's a, just as Dr. Hecker mentioned, a huge shortage in terms of the providers who are able to treat this. And so many people out there that just either, you know, have been untreated or not treated well. So certainly- And if you look at the data there, if I could just say, the numbers of people with the conditions that cause problematic specificity are growing. Yeah. Even if all physiatrists graduating from all residency programs had a basic competence in most of the areas, we still wouldn't put out enough doctors to be able to care for those people. Go ahead, Ryan, I cut you off. I was just saying, you know, just a few things that I've kind of gathered since the fellowship that I've really appreciated is, you know, like Dr. Hecker and Dr. McGuire mentioned, you know, knowledge of how to do a bunch of different procedures, right? And not just the neurotoxin. I think neurotoxin is probably the most prevalent, you know, during residency training. But I always say, you know, even down in Florida where I'm at now, you know, there are providers in the community. And I always said, you know, and I love my neurologists, but you know, for them to say that they provide comprehensive specificity management, but all they do is Botox injections, that's kind of like a pain doctor saying all they do is a steroid injection, right? And there's so many different ways to treat it comprehensively, you know, be it through bracing, splinting, toxin, cryo, pumps, phenol, surgeries, you know, knowledge of the surgeries, when to refer to the surgeon, also equally important. So I think for all those reasons mentioned above, plus just the gamut of procedures, the wide diversity of patients that you see during fellowship, you're not pigeonholing yourself into a spinal cord injury or brain injury population, you're seeing everything. And for those reasons and more, very thankful for training from both of these individuals and all involved. I think it's made me much more confident in what I'm doing as a new provider. The last thing I was gonna mention too, I think it really hones in on the idea, you know, during my residency at Moss Rehab, there's a lot of neurotoxin injections. The one thing I will say that I will be very much grateful forever for fellowship training is I think, you know, I left residency thinking I was confident with toxin injections, but I think what I was confident in is, you know, finding the tibialis posterior, things like that, right? Kind of doing the injection itself. However, as Dr. McGuire mentioned, you know, doing the injection itself is not the hard part. What the hard part is seeing somebody in your clinic for the first time, watching how they walk and say, ooh, what do I need to treat? How do I need to treat it? How much do I need to treat, right? And making sure you're doing it in a safe manner, but something that's gonna give them actual relief. So, Danny, unless you just have any other. I just, yeah, I just wanna, you know, jump, dovetail on all of that because it is, like I said, in the, you know, what's sort of happening in the world right now is that, you know, payers are sort of restricting what you can and can't do. And there are people that sort of dabble, dabble in it. And when you see what they do, they don't do the injections, right? And then they say, well, they did it, it didn't work. And that doesn't work. And you go, well, that's because, A, they did the wrong muscles. They did the wrong dose and they didn't localize them the right way. So they kind of did it, everything wrong. And then they say, well, the toxins don't work. And you go, well, no, if you do it the right way, it does work. And I think that's where, yeah, I mean, you're lucky at your program. And I think most of the residents that go, because they spent a couple of months with me, at least they get to see that if you do it properly, you can really help a lot of patients. And that's really how you build a practice. And that's how you show other people because people go, well, they say, well, they had an injection, it just didn't work. And they send them to somewhere and they go, well, it didn't work. So then they just don't send the patients anymore because they go, well, it didn't work. And that's because they did it wrong. And so I think the more people that we get trained that can do it properly can show, because I mean, it really, it helps a lot of people. And that's what for me has been really satisfying. But I think to learn how to do it well and do it, you just need to get a lot of, you need to do a lot of it. And like I said, for both these programs, you're gonna, you do a lot of it. And I think if anything, for me personally, if anything screams fellowship, it's doing this. And I think some of the other ones that's morphed into TBI or spinal cord, because I've talked to them and they don't get a lot of it unless they're at a place that does a lot of it. And because our number one diagnosis for pump is spinal cord injury. And I'm kind of surprised with these, some of these programs, they don't get much exposure to it. You go, wait a second, the pump is like the number one diagnosis here. You should know how to manage a pump at least. And even if you do dabble in the injections and so, but I have residents call me all the time and we give them helpful hints here and there. But the main thing is, is to realize that if you do it, if you do it properly, you can really help people, but you have to do it right, like anything. And that's what makes it, to me, has been very rewarding and very satisfying. And, but I think that's the value in a fellowship. And I just want to, for Kim, as far as the research part of ours, it's if you want to do research. I mean, it's like, I don't, I'm not, it's not like it's open season, you just come and do whatever you want to do. No, we lay it out. And so you will learn, you will get a healthy dose of outpatient and inpatient, and you'll get a healthy dose of clinical exposure to everything. But you got to kind of see, you got to be able to know how to troubleshoot these things. That means going to the ER at midnight or weekend sometimes, because that's when you get that, you have to learn how to do that stuff. You can't just, I mean, you can do the dirty laundry thing and say like a lot of people do and go, I don't know how to do it. So, but you should know how to do it. And anyway, so I, you know, I'm very happy to answer any other questions. Maybe we should say a little bit more about the kind of residents we're looking for. I'm really looking for, cause you started to say that a little bit. I thought that was great. I'm really looking for, as John said, someone who really wants to do this stuff, really loves this stuff, will, you know, geek out with me and get excited about this stuff, you know? And that's what I'm looking for. So somebody who's driven and impassioned about it. And I am, and it doesn't have to be somebody who comes in knowing a lot of this stuff, right? We're going to teach it to you. I don't expect that you know it when you walk in the door. Maybe you went to a program where they didn't have a lot of it. I just want willingness. I want the willingness. And I want a person who wants to get those skills. And so is, as you know, you mentioned, John, willing to go the extra mile when a patient's in trouble and they're in the emergency room at the evening and manage it and learn what it looks like to sit at the bedside and take care of some of these problems. So, you know, not someone who's checked out at five o'clock and somebody that, because I spend a ton of time with a fellow, I'm looking for a person that, you know, I feel like I can really shepherd and form a very close bond and relationship with because it's really, it's for life, right, Ryan? I mean, our fellows, we've all stayed really close and it's a kinship, right? It's a brotherhood, a sisterhood, the people who do this work. We're a network for one another. And so we want to bring in somebody that, you know, that we can stand. I think you incorrectly said it. I think it's hashtag tone squad is the correct way to say it. Yep, yep. You know, I like to throw stuff like that out there because I like to know who my people are, you know? And when I spot one, that makes me feel really good about it. So that's what we're looking for. Somebody with a willingness, somebody with big eyes who is ready to suck in the knowledge with a sponge. And that's the kind of person we love to teach and we'll make sure we teach until you get it. How do people apply to your programs? So glad you asked. Would this be a good time to show my slide? Yes, please do, please do. Okay, let me do that. Okay, do you see a slide of me and our program coordinator? Wow. That's nice. Thank you. I like that. So what you can do is you could scan this QR code and this will take you to an informational page about the program. And from there, you can toggle through the options and see like the list of clinical objectives, et cetera. You can look at the faculty. And then if you would like to get more information, including the application is on that site, but we can also send you one or you can send us an email. This email at the bottom, spasticityfellowship at jeffersonedu is monitored by me and Catherine who is our education coordinator. And so we will be able to see your message and respond to it with whatever information that you need. Nice. And is there like a certain time of year that applications are open? Is it like rolling? Yes. Thank you for saying that too, for asking that too. So we will announce it shortly, but we typically open every year in May. It's usually like the first Monday in May. And we strongly encourage people to apply early because we have found that our most serious applicants have been people who apply right away. And so we start to look at their applications very seriously. New interview on the earlier side, we conducted interviews for our 2024-25 program year in August this year. And we gave our decision before, we gave our decision just a couple of weeks ago. And the reason that we did that is that, I have only one position right now. It is conceivable. I could have more positions in the future, but right now I have one per year. And so I know I obviously can't give that to all the applicants and we get good applicants. So I really wanna make sure that the applicants that we didn't select have a chance to go for brain injury medicine as medicine. And those fellowships that have a match coming up in, it's in October, right? Yeah, yeah. Later in the fall. Yeah. So we wanna make sure that we give them plenty of time for a good plan B options. So it would be May and then as early as possible. Not that we wouldn't consider a really good applicant in June, but it does help to know early. So just to clarify, it would be the PGY-3 spring, in the spring of your PGY-3 years when you would apply and have your application in by May 1st for this program? As early as possible in May for a curious applicant, yeah. And we hold our interviews online via Zoom just for equity reasons. We can sometimes accommodate visitors to our clinics for a peak, but I'm careful to say that, that would be for the applicant's benefit and we would not give less consideration to someone who could not make that happen. Yeah, yeah. Okay. And then I guess before I keep asking you more questions about your program, maybe Dr. McGuire, do you also have applications like by May 1st or how do people apply to your program and by when? Well, our clock is not quite as fast as Dr. Heckert. So we go a little bit later. And so we usually take our applications actually through the end of October and then we try to get all our interviews done before the end of the year and make our decision then. And so it gives people a little more time if they kind of, not everyone knows right away. And so, but usually we know a little ahead of time but we give them a little more time. And I also actually did this also now, whether or not I can actually do this share screen thing would really be kind of amazing. You know, if I can figure this out. You can also, yeah, sorry. Oh, you can also email it to me if you need me to share it for you. Oh no, I think you got it. Does that work? Yeah, good job. Look at that. Beautiful. We can do that today. Good job. You guys keeping, you both keeping up the times with the QR codes. This is great. It actually works. So that little scan thing, you know, cause we have a spinal cord fellowship, a spasticity fellowship, a pain fellowship and a sports fellowship here. So then you have to click on the spasticity one to kind of get into ours. And so we would actually accept your application through the end of, we'd like to know about it because they're coming in. So the sooner you get it in the better, but, and you know, once we, you know, but we will probably, we probably won't make our decision probably until the end of the year, but we're not gonna leave anyone hanging. If they need to know, we'll let them know. Okay. So people need to make decisions. And so it's sort of a, but we'll probably have to move it up like you guys did at some point, but for right now, we, and we'll do, if people want to come here, we can certainly do it in person. Otherwise we'll do it, we do it over Zoom also. And so, so we like to, you know, we've always, I always kind of like to use the Academy meeting, but now everyone's making their decisions a lot earlier than that. And so, so historically I always kind of thought, well, I'll meet people at the Academy meeting and then we can talk then. But those days are, you know, that's like old school now. I mean, everyone's making their decisions so much in advance. And it's kind of like, like my daughter, when she was in high school, you know, where are you going to college? Where are you going? And she goes, I just want to finish high school. And I, you know, you're a sophomore in college, in high school and they're making you decide where you want to go to college. And she goes, yeah, I just want to enjoy high school. I just want to enjoy residency. Do I have to make all these decisions right now? Yeah, kind of. You kind of have to, you know. Kind of do, yeah. And you know, I, I really love in-person. I really liked in-person interviews. I liked walking the candidates around the campus. And when we switched to Zoom interviews in the pandemic, I really didn't love it. And then Jefferson decided to adopt as a policy. We did it even before they, they made it a policy, but we kept our Zoom interviews for equity reasons and they made it a policy for equity reasons. And I think that that is the right thing to do. And so I support it, but I do really like the in-person interaction. And I wouldn't think that the Zoom would work as well, except Ryan, I never met in person until he started the fellowship. I met him just this way, as I'm seeing him now, this is how I saw him. This is how I invited him to the fellowship. And it was, I didn't meet him in 3D until his contract was signed. So, and it worked out incredibly well. So it's not to say that you can't have, you know, you can't select and, and train a great fellow based on a Zoom interview and application process. So. Yeah, I must've had my ring light on for that interview and my eyes were just shining or something. I don't know. Yeah, glammed it up. Something like that. Yeah. I just want to highlight that sort of, as Dr. Eckert said, it's sort of for us, we're just, we're looking for people that really have a strong interest. So usually if you're really that interested in it, we usually, usually they, the people that are really interested reach out to me much sooner than that. And so the sooner you know, the better we will. And then if we're pretty sure who we want, then we may have to shut it down because we can do up to two, but they have to be good candidates. And so, um, but I understand some people, you know, have other, you know, you need it, you need to have plan A, plan B, plan C, no matter what you do anyway. And so, uh, but, uh, I want people that really are interested in it and want to make it, cause I think it's, I think it's special. I think both our fellowships are very special, uh, um, because we have that flexibility. I think that's what actually makes it a strength in a lot of ways that you can really hone in and, and spend time doing the thing that you want to really learn more about. And you're not going to get a chance to do that really ever again. And you can, like I said, you can spend time. I mean, Ryan came here. Um, no one's, we haven't shipped anyone your way yet, but, you know, We're happy to take them. We're happy to take them. I know they're just, uh, well, the last one was what she, I'm not sure. I thought she was going to do it. I don't know what happened with that. I'm not sure exactly what happened, but yeah, suffice to say, um, we would do it. And I think it's great to see how different people do it. Ryan was like sending me photos from your clinic when he visited you with like this looked like a deck of cards with like 15 syringes of dysport. Um, but yeah, you know, that whole serial deletion thing, they got going on there, but yeah, kind of pushing the envelope here a little bit, but that's what you learn, you know, but, um, yeah, I think we do it slightly different, but we have success. So that's what works. Um, Dr. McGuire, I see here on your side, you have a personal statement and three letters of recommendation. Do you prefer that one of those letters of recommendation come from the program director for the resident? Um, I, they can, well, yeah, I mean, someone, yeah, that would be nice. Um, not, not like your, uh, golf pro or something, but that'd be okay. Or just like, you know, three people that you like that know you well. Yeah. Okay. Or people that I want the people that now the program, if you've never rotated with your program director, a lot of times you get that canned one. I want, I should probably add that people that know you clinically, you know, know you, that you've rotated with that can make some sort of judgment on, um, on, on your interests and you as a, that, that, that worked with you. I prefer someone that you've worked with now. I mean, cause some people don't work with their program director. Yeah. They don't really, they haven't really seen you, um, in, you know, uh, at the bedside, so to speak. And so I want people that actually kind of know and work with you. Gotcha. So three quality letters of recommendation. I appreciate that because some, some fellowships, they, a lot of them say three letters of recommendation and it, but it's like understood that one of the letters is from the program director without it coming forward. So it's good to know that for this program, it's just three quality letters from people who really know you as a physician, clinician, uh, educator person. Um, and then you're saying for you, Dr. Hecker. Okay. Okay. So three letters of recommendation that just show you as a quality applicant, quality person, physician, and then also a personal statement for your program. Yes. We have a personal statement to, um, the QR code will take you to the, um, the standard Jefferson, uh, house staff application. And then there's a supplemental application for us that just has a couple more questions. One of them has to do with the teaching experience. And the reason that we, uh, regard teaching experience highly is that in this fellowship, there is a teaching component. There's, um, there's an expectation that the fellow is helping to teach residents who rotate through our clinics. And, um, uh, there's an expectation that the resident helps us with some spasticity courses. So I put on a spasticity course yearly for our residency program. Um, and then I'm involved in some other spasticity education within the, uh, regional community. And there's an expectation that our fellows participate in that, um, as well. And, you know, one other thing I was just thinking about, um, is, uh, you know, aside from the flexibility piece, which I think we've both mentioned, the other thing that's great about a spasticity fellowship, and I'm sure you would say the same thing, John is like, you know, my faculty and I, we were all doing this before we had a fellow six years ago. And so when the fellow is not there, it's not like we cannot function. So you're not in this position in our fellowship of this incredibly high burden. Like you have to be there to be doing like the scut work of the service or something like that. I mean, it almost feels like we have a spasticity service now, doesn't it, Ryan? We really sort of built up, we get a lot more inpatient spasticity consults, but there's no spasticity service per se. There's no, um, high, you know, burden there. I mean, we do treat some complicated cases and, uh, there are some injections that, you know, are a little bit more, uh, I don't know, is physical the right word, Ryan? Yeah, I think parkour, uh. Parkour human innovation. Yeah, we teach that. We teach parkour human innovation. Uh, but, you know, aside from some of the jobs being a two person job, maybe a three person job, um, it, it, it's, it's not a tremendous burden. It's really about the fellow getting their hands dirty and learning these procedures. Yeah, that was good. I would echo the same for us. We don't, uh, we, we function with and without a fellow and the fellow has value of course, but it's not required to run the clinical machine. And so, uh, and, and we do have a large team because we have residents instead of a resident and student with me, you know, we pretty much have medical students and residents on, on the rotation pretty much around the year, around the, you know, the whole year. And so there's a lot of, uh, we, uh, we don't specifically say that, but I should add that, that that's, it is a big part of it, but I think that's also good. It's sort of like, you know, see one, do one, teach one. And that's how you really learn it when you start teaching too. And so, uh, uh, we also, they also participate pretty much all my fellow we've hired. I mean, we've hired four of my fellows right now. And so, um, we, you know, we, um, we do a fair number of workshops and, you know, both with the academy and, um, outside of the academy and, uh, uh, but that's, it's good. You, you just want, you want to learn from people that know what they're doing. And if you, like I said, if you learn how to do this the right way, I mean, it can really, you can really help a lot of people and it's very satisfying. And so that's the kind of spark you want to see in, in, in the person when they get excited. And, um, I can, I, you know, I joke around with the residents a lot, but I just tell them, I said, look, if you, you know, after you block somebody and they, all of a sudden they just, it just like melts away their spasticity and all of a sudden they can do this or do that where they couldn't do before. And, um, you know, and I say, look, if you're not getting excited about this, I say, you just, just go home. Yeah. Yeah. It's like, you know, cause it's these people really need it. And if you do it the right way and you can help them, it's very, it's very rewarding. And if that doesn't get you excited, I think you should, you know, well, well, and you probably get a lot of those cases. Yeah. You probably get a lot of those cases like I do, John. Right. You get like, you know, cases from other physiatrists in the community that, that they're not sure what else to do. And it can be very satisfying when you can make a difference there. Oh yeah. I call it the clinic of last resorts. And so, um, they come to me and yeah, they kind of go, well, this is it. I've, you know, they've had every fricking pain procedure done and every, you know, freaking surgery done and everything, everything done. And they kind of go, well, you're my last hope. I'm the greatly, you know, the great white hope or whatever. And I kind of go, well, yeah, exactly. Totally. But I mean, you know, some of these people, when you get these guys walking again, when they've got horrible, you know, this or that, and all of a sudden now they're doing a lot more, I got one guy, he's like the poster child. He goes, I came in in a wheelchair and now I'm out there cutting the grass and doing all this stuff. And it's, it's kind of neat, you know, when you can, when you, I mean, you can't fix everybody, but you know, you fix a few of them and it actually, it's kind of neat when you do it and no one else was able to fix them. And, and that's, that's very rewarding. So, you know, I had no idea how we were going to talk for an hour here, but I guess I underestimated you, John. Oh, come on. You know, we can talk for hours. We can, nothing. This is like a drop in the Ryan here with Ryan and Kim. I mean, we can go, you know, people that like this stuff. I mean, you know, days, we can talk for days, weeks. It looks like there's a question here. Question. Would it be okay if I asked like a question? You can ask anything. So I think I mentioned, I'm a PGY2 currently interested in like spasticity management in neurodevelopmental disability. So kind of trying to figure out if I'm interested in like a pediatric fellowship versus spasticity. And was just wondering if you had any recommendations as far as, you know, being this early on in my training as to things I should be doing just to help figure out what's a good fit, especially being at like, you know, a smaller program where there maybe aren't as many spasticity related like research or clinical opportunities. I hope that question makes sense. I was a little rambling. Great question. Yeah, I think that's a great question. Yeah. Cause we have both here. We have a pediatric fellowship and also spasticity one. And one of our, you know, she did the fellowship and now she's basically doing PEDS. And so, but she does bridging that gap between PEDS and adult, which is really important because a lot of the PEDS people, you know, they, they got these, this huge adult CP population that they just go, God, now these kids got these adult problems because they grow up, you know, they grow up and, and, you know, when you're doing PEDS, you're just all about growth and development, which is really important. So, and some PEDS fellowships are going to be heavy into spasticity and some aren't. So you have, you have to kind of see where you're mostly interested in. So I, so I tell everyone, just look at, look at the whole thing and, and then decide, cause this, cause like, at least for here, you know, you would have the flexibility to do as much PEDS as you want it. Cause there's, we have a huge PEDS program too. And so it's, we kind of offer that as far as, cause we have some like our spinal cord fellows too. They spend a lot of time with me just cause they want to learn more about spasticity and they should. I mean, and so we, we try to, we try to accommodate that the best we can because I want people to do it right. So either way, I mean, you know, you want to find a place that sort of fits your interests and your needs. So I would look at both very seriously and see, you know, kind of weigh the pros and cons. And so I think our program and Dr. Eckert's program offers some flexibility to kind of design it more tailored to you. But if you find that you really just want to do more PEDS, I mean, you're not, you're probably won't get as much spasticity depending on where you do your PEDS just based on what I know about them. If you want to do more spas related things, which is morphing into a lot of, I mean, it is a lot, you will learn how to do a lot of, you'll get really good at like, like I said, phenol, you'll get good at cryo, you'll get good at ultrasound and EMGs and doing neurotoxin injection and pump management. And so, which can kind of go a long way in the PEDS world too. And so. I think, yeah, I think, I think a consideration if you're between the two, if you did a PMNR residency and then you came and did our fellowship, it's unlikely you'd be treating kids. Now I will say the largest growing area of my practice personally is adults with CP and intellectual disability. So we, you know, we see those patients as they're transitioning. At Jefferson, we have a dedicated team for that transition to adult medicine. And we've got some really brilliant minds over there in the department of family medicine who are doing this. So they're, they're my referral source. And it's nice for me to partner with them because I really am just doing the rehab and spasticity management. But, you know, you wouldn't be treating PEDS then in your practice, depending on your state, because licensure is probably not going to allow you to do that. On the flip side, as John was saying, if you decided to do a pediatric fellowship, you will do some spasticity management for sure. But it probably, you know, the scope of what you would be learning in that fellowship is so broad. Spasticity would be probably a relatively small part of it, I would imagine. Just for my own education, if you do a spasticity fellowship, are you able to do spasticity management on PEDS or no? It depends on your state licensure requirements. And me personally, I just don't have the comfortability with PEDS. Okay. But then again, I treat a lot of these, you know, 20 to 30 year old adults who were never neurologically normal, who are small people, who I dose with pediatric doses of neurotoxin, for instance, you know, I still use weight-based dosing for them because they're small. So, you know, I'm not saying there's no overlap, but I'm getting them out of the pediatric hospitals. And because the pediatric hospitals around us are, they, they're so well done. They do things so well in the pediatric hospitals. They're coming to me pretty well packaged. They've all had a new wheelchair within like the last 12 months, they've had all the surgeries they need. And, you know, that first visit is just really kind of a, usually a getting to know you visit, um, and along with whatever, um, you know, uh, uh, there's usually very little equipment needs at that first visit, but you know, any spasticity needs that they have, if they're already getting regular neurotoxin injections or pump refills or something like that, then we're getting plugged in for those services. Yeah. I think, yeah, I mean, the same sort of thing here, it's sort of, uh, you know, in the pediatric world, it's, it's like when I first got here, no one was doing the PED, so I was doing everything. And so you, um, it's what you feel, like I said, if you want to do kids, you can like, like I said, it's sort of whatever your license, but you would, you would certainly, if you want to do kids, you could learn how to do, I mean, you could do the kids here too. It's, um, it's, it's just a matter of dosing. It's all the same. It's, it's the same idea as far as getting good at making the right assessment and, um, how you do that. And so it's, it's seen a lot of kids. And so, um, if you're interested in that population, I think you have to, you'd have to decide if you're interested in just seeing more kids, or if you want to see a mixture of kids and adults and that sort of thing too, because I mean, there's a huge need for these people that kind of can go on both worlds because it's sort of that transition. And every time I talk to the PEDs heavy people, they kind of go, God, I got all these adults. I don't know what to fricking do with them. And they also got adult problems and you kind of go, yeah, but I mean, uh, that's my number. My number one diagnosis for toxin is, is stroke. And my number one diagnosis for pumps is spinal cord. My number two for pumps and toxin is CP. And so I have a huge adult CP population and also weirdo neuro developmental stuff that just no one knows what the hell they got. And so you kind of go, okay, this is a weird thing, but anyway, so they, but they've got problems with spastic dystonia or co-contraction and they've got these, you know, overactive muscle issues that are a big issue. And so usually we can help them with that, but it's transitioning into that. And so, I mean, if, if I were you, I just try to decide, do I want to live in the PEDs world or I kind of like a little bit of both. And I think, I mean, not, not take, I mean, PEDs is wonderful. I mean, it's great. I mean, they, like you say, they get, they're packaged. I mean, they have the interdisciplinary care down to a T. The adult world is cruel. It's, it's the a la carte sort of fend for yourself. And you know, they're used to being coddled in this pediatric world. That's just fabulous. And all of a sudden they have to find that, you know, there's no more interdisciplinary care. There's no more interdisciplinary clinics anymore. I mean, you're, you're, you're, you're kind of out there in the big world now and it's hard. It's hard for a lot of these kids and they need that. And so, and, and, you know, sometimes there's like this expectation that we're going to do all these procedures under anesthesia. And I look at the patient and I think, no, really, we can, we can do this in the office. I think we'll be fine. And, you know, caregivers are surprised by that. And we do have a very small number, a handful of patients that we still will treat under anesthesia, but, you know, just even some of the way that we care for them is different than what they're used to. You know, they would have these procedures and x-rays and everything twice a year under anesthesia when they were doing other things, because the kids couldn't, couldn't be still for it. But, but it's, you know, it becomes a little bit different as they age. Wonderful. Well, we actually gone past our 9 PM, but it's just been a wonderful time chatting with you all. And I, even though I'm a sports med fellow, I was very interested in this. You really got my attention. Any, I just want to open this up to let you guys do any final closing remarks that you would like to say about your fellowship or spasticity fellowship in general before we close for tonight. I will just say, if you clicked on the link to watch this later, or if you tuned in, thank you for your interest. The world needs you. You clicked on this for a reason. The world needs you listen to that, that, that small voice telling you that this is something you want to do. It's something you want to do, whether you do the fellowship or not, there's two fellowships. You want to learn these skills somewhere because the world needs you. And when you can offer treatment for these problems, you're offering someone hope and hope is the most powerful medicine of all. That, I mean, that was beautiful. I mean, I'm going to say echo that and just say that there's a huge need for this. And if you do it well, you will help a lot of people that need help. Neuro this neural rehab thing is not going away and it's, these people need your help. So yeah, if you click on this and you have any interest at all, pursue it. I mean, learn it, get good at it. You'll provide a great service to people that really need it. And that's, that's what's made it satisfying for me. And that's, that's why I wanted to train fellows to get good at it and, and do it well, because you provide a great value to people that really need it. And they're very underserved and it's not sexy, not sexy in any way, but you're going to help a lot of people. My, my last thing is, you know, especially from people in my perspective, kind of coming out early career and everything like that, you will most certainly have a job doing this afterwards. It's not necessarily, you know, always advertised, like say like a interventional spine positions that seem to be all across the country and stuff like that. But I've had more than a fair share of individuals from around the country ask me, you know, where are these spasticity fellows? We are looking to hire aggressively. We need to build this program up. Where can we find these fellowship trained individuals? So also, again, if you're watching this, you will most certainly have a job. You will most certainly be compensated for what you do and enjoy while you're doing it. Awesome. Awesome. Thank you so much, everyone, for coming. Thank you, Dr. Hecker, Dr. McGuire, Dr. Hafner. Very, very educational, very intriguing talk. Thank you so much for your time and listen to what they said. If you clicked on this and you're interested, go out there and give people hope. All right. Thank you all. Thank you. Have a great day at night. Look forward to our next meeting.

spasticity fellowships

spasticity management

trained physicians

treating spasticity

hands-on experience

diagnosing spasticity

flexibility in tailoring

application process

experienced physicians

quality of life