All right, welcome everyone to tonight's Spinal Cord Injury Medicine Fellowship Training Session. We're really excited to have you here. This is a completely series that's voluntarily put together by AAP and the whole point of this is try to help you medical students, future fellows, current fellows, all to learn about spinal cord injury and why it's such an amazing field and why you should do it. We've got some amazing program directors here to explain everything today and just a shout out to AAP because we do have some future Q&A sessions coming up. We have the Pediatric Q&A Fellowship Session coming up August 14th, the Pain Medicine Fellow Series coming up on September 18th, and just a friendly reminder that this whole session is going to be recorded and we're hoping to post it up on AAP's website around September, October so that you can, you and anyone who's interested can review it for future reference. So without further ado, the amazing Spinal Cord Injury Program Directors. Jenna, thank you for that introduction. Hello everyone, my name is Jelena Svirchev. I am the Program Director at University of Washington up in Seattle, Washington. Just to offer a little bit of framework for our time together, we are a very small specialty. We are tiny but mighty. My colleagues and I all know one another, collaborate very closely with one another, and are a very informal group. So we thought that the three of us would each just briefly introduce one ourselves and share with you all our journey to SCI, why we chose SCI, and after we've each had an opportunity to share that, we'll go through a few slides that we have that describe the fellowship in a little bit more depth, and then we'll open it up for question and answer. So as I mentioned, I'm Jelena Svirchev. I'm the Program Director here in Seattle, Washington with the UW Program. I've been the Program Director here since 2012. I've been on staff here since 2006. I did my fellowship training here. I did my rehab residency at Stanford University and had an awesome, awesome SCI training experience there. At that time, most people in the field of SCI were not fellowship trained because fellowships were not ACGME accredited at that time, but we were just moving into the era where if you wanted to receive board certification, you needed to do a fellowship. So I chose to pursue fellowship training really for that. I valued having the extra year of training and board certification. Why I chose to go into SCI, I came to rehab medicine for the functional aspects of it, but when I came, I very quickly realized that while I thought I was going into a very narrow specialty, I came to realize that rehab itself is huge. And one can pursue many different avenues from pain, to sports, to spine, to palliative care, to electrodiagnostic medicine, PD rehab, brain injury. And I find myself, I found myself craving once again, a specialty, kind of a narrower focus. And I fell in love with the SCI folks. They offered me an opportunity to work with a specific diagnosis to capture the functional pieces that I craved. And when I came to SCI fellowship training, I fell in love with the lifelong care. So a good chunk of my training experience was at the VA where we do lifelong care. And that's really where my passion kind of came to light is that I love the fact that I could meet folks at the time of their injury and then follow them throughout the duration of their injury. So with that, I will pause and turn it over to my colleague, Dr. Amanda Harrington for her journey to SCI. Thank you. So I've also gotten to experience rehab at SCI at multiple institutions. I did medical school at University of Miami, residency at Carolinas Rehabilitation in Charlotte, fellowship in Cleveland, and have been on faculty at UPMC in Pittsburgh since 2009. And I've been the program director since 2011. And so my journey, I started out with primary care all the way. I wanted to do family medicine and have great longitudinal relationships with my patients. Then I found that sports medicine was interesting and I loved sports and then found, stumbled into adaptive sports. And as a medical student, I remember meeting my first patients with spinal cord injury thinking, wow, this is cool. I've never met anybody. I was a little, honestly, a little scared to work with somebody with paralysis. But after doing rotations and then experiencing an entire volume of patients in residency, really found that the subfield of spinal cord injury did allow that longitudinal continuity that I thought was interesting from a family medicine perspective, but also included managing a lot of sports related injuries from the adaptive sports side and a lot of opportunity to overlap that. So getting to follow patients really acutely from when they first had their injury and they're in the ICU in a kind of in a panic mode and follow them through inpatient rehab. And then longitudinally in the, in the clinic setting has really been a value to me. I also really enjoy procedures. And so managing spasticity, toxin injections, back up and pump management, and also joint injections, trigger point injections. I'm able to do a lot of injections as a component of practice. And so I've kind of felt that, you know, for me, at least spinal cord injuries allowed me to do inpatient rehab, outpatient rehab and tons of procedures, which is a little of everything and really kind of embodies the, the true like physiatric kind of essence of, of our patients. And so that's, that's kind of my journey. All right. And I'm bringing up the caboose. Good night, everyone. So excited to see so many people here. That's really, really exciting. I'm Felicia Skelton. I am the program director at Baylor College of Medicine down here in Houston. As of last year, I was the assistant program director for since 2015. And I took over as the director last year. So super excited to share with you all about the specialty that's near and dear to my heart. Spinal cord injury medicine is extremely small. I trained with Dr. Chercheff at University of Washington during residency. So we go way back. But I remember meeting Dr. Harrington at an AAP meeting for like the fellowship kind of meet and greet. So yes, you'll kind of keep seeing the same faces over and over again, which is really neat. And then you also may have seen my name around in places because I'm the current public policy chair for AAP. So I got interested in spinal cord injury medicine during medical school, I think. I kind of went into medical school knowing I wanted to do PM&R. Wasn't sure that I wanted to do spinal cord injury medicine at the time, but definitely wanted to do PM&R. And then kind of started PM&R residency for my experiences in medical school thinking I wanted to do brain injury. But I quickly realized that brain injury is messy and spinal cord injury is neater. And so I was a neuroscience major in undergrad. And I was like, okay, the spinal cord is organized beautifully and therefore fails predictably. And there is something kind of comforting about that to me. But then you also get to kind of treat the whole patient because they've had this catastrophic illness, this catastrophic disability happened to them. And now you've got to figure out kind of how to pick up the pieces and how to live your life. So there's something just kind of really rewarding about that to me. So I enjoy the clinical care. I'm actually at the VA down here in Houston, and I do something a little bit different in that I'm a primary care physician for people with spinal cord injury. So I oversee our home-based primary care program here, which is somewhat unique to the VA. But again, the easiest way to describe it is I'm a primary care doctor. So in addition to their rehab needs, I'm treating their diabetes and their high blood pressure and their high cholesterol. And I didn't think that that's something that I would want to do, but I actually really, really enjoy it. And every once in a while, I get to kind of focus on preventative care and wellness, which is something near and dear to my heart. I am only a part-time clinician. I kind of have my educational roles, but I probably spend the majority of my day or my week doing clinical research, which is another avenue that you can do should you pursue fellowship. And it's probably one of the other big reasons I did fellowship specifically. I wanted to kind of be an expert in the clinical care of people with spinal cord injury so that I could take that expertise that I had at the bedside to kind of ask thoughtful questions research-wise. And so it's definitely, definitely a field that's amenable to that. We need more clinician scientists in our field. So if that is something that interests you, we need you. We need you here. So that's just a little bit about kind of how I got to to do what I do. Every day is a little bit different for sure. All right. Why don't we go through a couple of our slides and then I will do a small commercial break right now, because in hearing the three of us talk, it reminded me of something that I'm hoping that Amanda and Felicia can each address. And it's in looking back at the three of us, each of us seems to have a slightly different emphasis to our SCI careers. So Felicia, as she just mentioned, has a large research component. I have a large admin component with some serving experience that I'd like to share. And I think Amanda has a very large education component to her career. So I'm hoping when we wrap up the slides, perhaps each of us can kind of discuss how we chose to integrate those pieces into our SCI careers. That while we're all SCI clinicians and we do some patient care, each of us has a focus within that that brings a slightly different flavor to our professions. So when thinking about SCI Medicine fellowships, this is taken straight from ACGME program guidelines for fellowship experience. Spinal Cord Injury Medicine emphasized the prevention, diagnosis, treatment, and management of traumatic and non-traumatic myelopathies. So we capture folks who have congenital disorders, such as spina bifida, MS, ALS, Guillain-Barre, stenosis, cervical, both cervical and lumbar, in addition to folks that we think of as classic spinal cord injury, the traumatic folks. And in addressing the injuries, we emphasize the medical, physical, psychosocial, and vocational consequences and complications throughout the life of those individuals. The specialty has been certified since 1998. Since the board examination has been offered, 788 individuals have received initial SCI board certifications. Currently, we've got about 470 individuals with active certificates. So folks will retire and not renew. Folks will choose to initially receive board certification and not maintain board certification for one reason or another. So right now, we've got 470 individuals who are actively board certified in SCI medicine, which is tiny, tiny, tiny. We are looking to grow the field, and we are hoping you all out there will consider fellowship training so that you can continue to support this small field, but this very critical field when delivering care to folks with spinal cord injury. Next slide, please. When we look at what does fellowship training look like, it is a 12-month program. Folks who are eligible for SCI fellowship training come from a variety of different BCGME accredited programs. So highlighted is physical med and rehab because most of the folks who are pursuing SCI fellowship training are coming from physical med and rehab, but we have colleagues who are in anesthesia, ER, family medicine, internal medicine, these surgical subspecialties, and pediatrics who are eligible to participate in SCI fellowship training. Granted, folks in emergency medicine and anesthesia are few and far between. I don't think during my time in this field I've seen folks in those two specialties pursue fellowship training, but I know of colleagues who are from internal medicine, from family medicine, and a couple of folks from neurology, and I can think of at least one urologist who chose to pursue SCI fellowship training. So the field is diverse in that we are starting to, particularly the last couple of years, include individuals who are coming to us with non-PM&R backgrounds. That just makes the conversation that much more robust when moving forward with clinical practice with our colleagues. And next slide, please. When we look at what the structure of that fellowship training is going to look like, it's quite flexible. The bare minimum requirements, one is going to have three months of inpatient, three months of outpatient, and aside from that, programs can be very flexible and creative in developing opportunities for the fellows that they're coming. So that allows you as the fellowship candidate to really dig into what that program has to potentially offer you and find a program that's really best suited for your interests and for your needs. I will pass over the next couple slides to Amanda to share about. Just to talk about, you know, the bare minimum of three months of inpatient. Some programs often would have more months in that given year of training for fellowship, but where the inpatient care occurs will vary across institutions, across the different fellowships. So this is something that some people like to consider when they're thinking about where they might want to train. So there are freestanding rehab facilities, just like there are for PIM&R residencies. Some of those inpatient rehab beds are freestanding, and some are rehab units within a hospital. And oftentimes in those inpatient rehab settings, whether it's at a freestanding facility or in a hospital, you would have both acute spinal cord injuries, but also perhaps chronic spinal cord injury patients readmitted with a new problem, whether that's a flap after, you know, somebody's had a pressure wound, or after a rotator cuff repair, or after some kind of, you know, chronic illness, say COVID, and then they just need a tune-up. So often you will see chronic spinal cord injury in addition to acute spinal cord injury on that inpatient unit. Another model, you know, when you think about where this can occur is either a rehab unit that will have a mixture of patients. So there may be patients with spinal cord injury, patients with traumatic brain injury, patients with stroke, so that there may be a mixed unit with patients with SCI kind of admitted to that unit. Some facilities have a spinal cord injury specific unit where the entire populace of that, you know, unit is our patients with spinal cord injury. Now the VA often will have a spinal cord injury unit that can accommodate both, you know, acute and chronic spinal cord injury, but also subacute, and sometimes there can be patients who, the VA has a little bit more flexibility with how the bed status can be assigned, and so sometimes some patients may be more of a subacute level of care within a VA spinal cord injury unit. Children's hospitals often will have pediatric spinal cord injury patients admitted to the children's rehab unit, and so some fellowships will have an opportunity to interact with pediatric spinal cord injury. And then consultation services, so the ACGME doesn't think that, consult doesn't count as inpatient or outpatient. It's kind of a vague definition, and so often as a spinal cord injury fellow, you would have an opportunity to do a consult on patients with new spinal cord injury or with chronic spinal cord injury as it relates to managing their care while they're admitted to, say, a medicine service or a surgical service, or prior to coming to a rehab unit. Now, from an outpatient perspective, there is a huge variety of how outpatient clinics can be set up across various training sites at different fellowships. There are often spinal cord clinics where people with chronic spinal cord injury will come for follow-up forever, you know, after discharge from inpatient rehab and then ongoing annually. There are also general rehab clinics, pediatric rehab clinics, and some, whether it's, you know, potentially VA or, you know, pediatric, often there'll be some interdisciplinary clinics where people may be able to see multiple providers in one sort of clinic setting, or kind of they get to have one clinic visit and potentially work, see different providers. Some sites have specific clinics for ALS patients or patients with multiple sclerosis, pediatric or adult spina bifida, or separate neurodevelopmental clinics. Most places have some sort of spasticity clinic where, as a fellow, you may be doing spasticity management for people with spinal cord injury, but other diagnoses for spasticity, particularly when working to learn and, you know, to fine-tune injection management or, you know, back-up and pump management. Seating is something that people often get a little bit of exposure to during residency, but during fellowship may have an opportunity for more robust experiences, learning how somebody with a spinal cord injury should have wheelchair modifications, initial wheelchair prescriptions, or somebody who perhaps had a change in their status and might need a different type of wheelchair, that can all be addressed through a seating clinic. Unfortunately, many people with spinal cord injuries may have pressure injuries, and so wound clinics can be a component of spinal cord injury care and therefore a fellowship. And then other kind of things to think about in terms of ways a spinal cord fellow might interact with patients is potentially in a long-term care unit, either at an LTAC or at a skilled nursing facility perhaps, or via telemedicine, which has certainly gotten more robust post-pandemic. And one thing to kind of keep in mind, regardless of whether we're talking about the inpatient experience or the outpatient experience, is there's a lot of collaboration with some of our subspecialty colleagues. And so as we talked about in the beginning, spinal cord injury tends to be a very collaborative field. Everyone tends to get along well, and so we find that that collaboration extends to the other services that are often we're working with. And so most spinal cord injury fellows are going to have interactions with neurosurgery and orthopedic surgery, kind of the post-operative management of acute spinal cord injury, obviously urology and neuro urology when it comes to management of neurogenic bladder, urodynamics testing, treatment of the bladder, neuroradiology, plastic surgery, neurology as it results to our multiple sclerosis patients, and then all different varieties of therapy, kind of very similar to what we see across physiatry, but certainly in the setting of comprehensive care for people with spinal cord injury. So lots of opportunity to collaborate within the subspecialty. All righty. So one of the great things about spinal cord injury medicine is that you truly are practicing medicine. You are going to use every bit of your training from medical school and residency to take care of people with spinal cord injuries and disorders. So you've got acute trauma, you know, from the time they hit the ER, that go to the ICU, you're probably doing ICU consultations. That's becoming more and more frequent, early mobilization in the ICU. So if you're, you know, interested in taking care of the critically ill patient, you can do that in spinal cord injury medicine. Musculoskeletal medicine, shoulder pathology is almost ubiquitous in every level of spinal cord injury. Your shoulders were never meant to be used as your hips, your elbows were never meant to be your knees, and your wrists were never meant to be your ankles. So pathology galore. I tell all my PGY2s that come through and rotate with us, I'm like, I don't care for you to ever want to do spinal cord injury ever again. Examine your patient's shoulder. They're not going to care, you know, they're getting hands-on, they're getting extra TLC from the physician, and you're getting really, really good at doing the shoulder exam, and you're going to find some pathology. Pain, so much chronic pain, nociceptive, neuropathic, dysthetic at-level pain, all sorts of pain from every single ankle, and you can be really, really effective and really, really helpful in trying to help that person out. EMG, ultrasound, injections, you can do all of that. Again, ultrasound and side injections for all of the musculoskeletal pain that they have. Sports medicine and adapter sports. This is a very, very huge field and something that we, is very, very, very, very, very, very, very, very, very is kind of at a fellowship level of training, getting involved with, again, I'm most familiar with the VA system, so, you know, the wheelchair games and adapter sports that we do with our patients here, but there's, you know, Paralympians, there's all sorts of wheelchair rugby. I know I did that when I was up there in Seattle. There's all sorts of avenues that you can get into that. Internal medicine. You need to be very strong in internal medicine because, again, you're treating the whole patient. The spinal cord injury affects every organ system within the body, and so you're going to have complications and secondary complications and medical complications that come from spinal cord injury that affects the entire body, so you're going to need to know that. Again, the option to play the role of the primary or specialty care provider because I promise you, you're going to be probably the most common, even if you're not an official primary care doctor, you are going to be the de facto primary care doctor because you're going to be the physician that the patient probably sees the most often and, to be frank, just feels the most comfortable with because you're going to understand their condition and understand what's going on with them more than any other physician they're ever going to see, so they're going to kind of lean on you to play that primary care role, even if that's not your official role. Long-term care. People with spinal cord injuries are living longer and becoming injured at older ages, and so the geriatric aspect, the kind of aging in place aspect, is something that we're really, really having to become very familiar with, and end-of-life care. Palliative care and hospice care is something that we see not infrequently in our field for newly injured people and also, you know, folks that have been chronically injured, so that's something that you'll have the opportunity to become very comfortable with, and again, true longitudinal care. Again, we follow our patients forever. Again, it's just that familiarity. They want to go to someone that they don't have to kind of reinvent the wheel and tell their whole story to every single time, so they're really, really going to lean on their spinal cord injury medicine doc for their care throughout their life. So, next slide. There's lots of things that you can do. As Dr. Shirshef was saying, we all did something different. You know, we all did spinal cord injury medicine fellowships, but we all are now doing something very different with that. So, inpatient, outpatient, you do consultations. Spinal cord injury medicine is very, very prime for academic career, because like I said, there's a lot of different things that you can do within spinal cord injury medicine, and we need all of it. You know, we are such a tiny field that we need all these people doing all of these great things. If you see yourself being a program director or a fellowship program director, if you see yourself just being kind of more of a clinician educator, educating residents and medical students like yourselves one day, spinal cord injury medicine is a great path to do that. Academic research, again, you can do everything from basic science, working with mice and, you know, spinal cord injury models to pretty much anything. We need help. We need bright, engaged people that want to do spinal cord injury medicine research in a rigorous way. We need you. We need you, and there's so much work to be done. The harvest is plentiful, but the workers are few when it comes to spinal cord injury medicine research. So, pick a question. Pick a clinical question. I'm sure you can answer it, and we'd love to mentor you and get you the expertise that you need to answer that question. The VA does a lot of data, but we have so much data on people with spinal cord injury from years and years and years just sitting there waiting to be used in a meaningful way that can affect clinical outcomes of the people that we're taking care of right now. So, any sort of research that you're interested in, you can do it with us. Program leadership, again, if you're more administratively minded, this is a great path to do that because, again, if you can take care of somebody with spinal cord injury, you can take care of an independent person with spinal cord injury. You can take care of anybody. You can take care of any rehab patient that's going to come through your door. And so, I think leadership is going to feel very comfortable that you can take care of anyone that comes through their door. And so, you're in a prime position to do those type of jobs. Program review. Utilization review. It's a needed job. It's a needed opportunity. And you really want to be talking to your peer. To your peer. A lot of times in rehab, we're talking to somebody that doesn't know anything about rehab and doesn't know anything about spinal cord injury medicine. So, if more of us were in these kind of utilization review type positions, we would truly be talking to our peers when we're trying to do some of these appeals and medical justifications and things like that. Life care planning. Again, how much time and effort and resources is it going to take someone with, you know, a C5 complete spinal cord injury to live X amount of years? That's something that you'll be uniquely positioned to answer. Next slide. So, SCI fellowship highlights. I think it was mentioned before. The fellowships, again, besides the kind of basic inpatient and outpatient requirements, the sky's the limit. A year long, it flies by. It's really fast. But it's also just enough time to really kind of take a deep dive into anything that you want to know about spinal cord injury medicine. So, again, if you see yourself as more of a clinician, you take a deep dive into all of the little nitty gritty clinical aspects of SCI care that you didn't maybe get exposure to in your residency. If you're more into education, you teach as many lectures as you can to residents and medical students, you know, while you're there. If you're into research, again, you start getting some basic training in that. So, it really, really allows you to kind of tailor your experience to where you want to go. Lots of interdisciplinary learning. That's the hallmark of spinal cord injury medicine. We interact with a lot of different people in a lot of different parts of the hospital. Everybody knows us. And in general, they like us because we're kind and responsive. Observe surgeries. Again, flap surgeries. Tendon transfer surgeries. If you see it, you're not going to get another opportunity to do that. So, you want to take advantage of it during fellowship therapy sessions. Sit in the gym. Talk with therapists that have been probably doing this longer than you've been alive to, you know, just get to learn that knowledge and learn that, get some of that expertise and see things from a different perspective. Go on home visits. I encourage every single fellow and resident that I work with to go on a home visit. It will change the way you practice. Hands down. When you see what people are trying to do at home with the resources that they have, it will change what you ask them to do in the clinic. It will change what you ask them to do at the hospital. It is a practice changing experience. Highly, highly anticipate that. Plus, it's just fun. And patients are tickled. They love when the doc comes out to the house. They're very, very tickled with it. Try some adaptive sports. Again, get in an active wheelchair and see how much work it is to push those chairs around and do what those folks are doing. And like I said, I like to think we're pretty cool and that we're friendly and that we're nice and fun to be around. And it's a very, very small field. Like, our meetings are so much fun because it literally is just like a little reunion and you get to kind of see people from across the country that you haven't seen for forever. But you've either worked with them or trained with them or done something with them. So, it's a really, really neat field. So, I think that's the slides. Awesome. Thank you so much. That's just been a really informative and very fun session so far. And I'm so glad you guys are here to share about the beautiful world of Spinal Cord Injury Fellowship. At this time, you know, we just want to open it up to everybody that has joined us tonight. If you want to be brave and turn on your video and ask a question yourself or just unmute yourself and ask a question, please go ahead and do so. Otherwise, I'll start reading questions off from the chat as well as we have some prepared questions, myself and the panel, that we thought might be helpful to you. But, you know, throughout this whole Q&A, I really want to encourage you to unmute or turn your video on and ask your own questions because, you know, we're all here doing this to support you, the medical students and residents that are interested in spinal cord injury. So, we'll get started. And so, one of the first questions we have, oh, unless, Sarah, did you have a question? Yeah, I do. First of all, thank you so much for presenting. This is really enlightening and just a really great experience. One of the, I'm very interested in spinal cord injury and I think that, like, you know, like the longitudinal relationship is amazing. I think my biggest fear in a way is just, you guys talked a little bit to this, but almost the job opportunity compared to brain injury, you know, brain injuries are so ubiquitous, especially strokes and all of that. Can you talk a little bit to the job opportunity in a place that might be a little bit less populous and you might not get as many spinal cord injuries? So, I think it depends on your market. Obviously, if you're very rural, you might not have a lot of patients with a spinal cord injury. So, I would say most people that are practicing a hundred percent spinal cord injury are probably going to be somewhere in one of the, you know, a bigger city. So, you have a catchment of people coming from all over. I know some people do get fellowship training and then they go to work more in a smaller area. And so, they may be managing patients with other diagnoses in addition to spinal cord injury. And if some people have geographical preferences where they might want to, you know, they want to move home, right? And their home may be a smaller place. I always have told people that that additional year of training, it also, it sells you more too, right? So, you're not, you didn't just do a physiatry residency. You also are spinal cord injury trained. So, you're bringing something extra to to a, to a smaller community, even if your volume's low. I'll add a little bit. Go ahead, Felicia. I was just saying, I just second the, the smaller, you know, going back to maybe a smaller market. You know, the last few of our fellows have both, have all gone to smaller places, but they took the ex, you know, the SEI expertise and the knowledge that they had to places that barely have any rehab, you know, and let alone spinal cord injury medicine. And that's the nice thing about spinal cord injury medicine is like once it's, it's bread and butter rehab. And so, if you can take care of somebody with a spinal cord injury, you can take care of pretty much any other diagnosis and do it well. So, yeah, that just, like Dr. Harrington was saying, the pure spinal cord injury, yeah, it's kind of hard outside of the bigger markets, but I promise you that if wherever you go, there's going to be, they're going to be like, oh, you do spinal cord injury medicine? Okay. And I'll, you know, all those patients are going to become yours now. So. And I think this is an area that has the potential for tremendous growth, particularly now that we have the telehealth abilities. I think that there are folks in very rural locations who are simply not aware that there is this specialty called SCI and that there are experts in SCI. Many of them do not know about rehab medicine that's out there. So, being comfortable setting yourself up in, in a medium size location with a plan to develop a strong outreach into those rural smaller communities would be a tremendous asset to them. Even in centers where you would expect there to be somewhat of an SCI presence, it may not be there. They may have rehab, but do they have SCI, which means that the smaller communities outside of that midsize area probably does not have access to an SCI expert. So, I'm thinking creatively when looking at job opportunities at the potential to develop outreach clinics, providing care to folks who are way, way out there is certainly there and right for development. That was great. Thank you so much. I really appreciate it. Yeah. And thank you so much, Sarah, for hopping on and asking the question. Really want to encourage anyone and everyone, this is a stellar opportunity to talk to spinal cord injury program directors and ask your own questions. So, and I'll go back to the chat. So, we have a question from the chat says, do you feel spinal cord injury is one of the few PMNR fellowships that PMNR in a sense owns in comparison to brain injury or sports medicine? Yes, I think this is one that we absolutely own. We are happy to share it with the other specialties, but it kind of came out of us as a specialty, meaning PMNR, and we have maintained it and supported it. We welcome all of our other colleagues and other specialties, but we are the, we own it and are proud of it. Proud and proud. Okay. We have another question from the group chat. Do you feel it's better to do inpatient rehab or outpatient for a career of spinal cord injury or good to do both inpatient slash outpatient compared to general physiatrists doing inpatient rehab or outpatient? What additional skillset do you obtain during the fellowship that sets a difference? Right. I was muted. I think that's a great question. I think it's going to vary from individual to individual. There are some people who do only outpatient. There are some people that do only inpatient. Yelena said we could talk a little bit about what we do. I do a full inpatient service 12 months out of the year, 10 inpatients kind of round in the morning, and then I have clinic in the afternoon. I, at one point in my career, I had four half days of clinic, but as I've gotten further along and done a lot more administrative work and educational work, I've cut down to just one half day a week of clinic. And so I think it just depends on the person. And when you think about compared to general physiatry, doing inpatient rehab, that additional skillset, I think some of those harder conversations regarding prognosis and what to expect, I think the fellowship really helps you kind of gain your confidence as somebody who can really have those difficult conversations with patients specifically related to their spinal cord injury. So I think although you could potentially take care of a person with spinal cord injury after completing a PMNR residency, that extra knowledge and skill is just really helpful to build that knowledge that you're really able to share that information with patients. I'll offer the flip side to Amanda. I do 100% outpatient care. And the question of do I think it's, do I think it's kind of easier to do one versus the other, and am I losing any skills by only doing outpatient versus inpatient? I think for myself, it's more the administrative pieces that I'd be challenged with if I was going back to the inpatient side. So I'd be pretty comfortable still managing all the issues that come up in more acute SCI practice, meaning HO, the autonomic instability, autonomic dysreflexia, some of those issues that we see kind of in the acute slash subacute period, but it's just the mechanics of how do I get this study done on the inpatient side versus the outpatient side, some of those issues that really have nothing to do with the SCI medicine per se, and more just of the admin. And I think that my out, my inpatient colleagues here at VA would feel similarly that it's just kind of the mechanics of admin within the institution that you're working in, that would be a bit of a stumbling block if you were to go back to that flavor of practice and not necessarily that I'd lose any sort of core rehab skills by limiting myself to either doing all inpatient or all outpatient. Felicia, I don't know if you want to speak to that. It only in that it just really depends on your practice setting, where you go. I also, like again, I'm only part time clinical, but in within that I'm all outpatient. Home care has some unique kind of regulatory or administrative things that as Dr. Zvershev was alluding to. So like I have to have like a weekly interdisciplinary team meeting and, and some other kind of unique regulatory burdens, opportunities. But again, it all just depends on your practice. Some people are like inpatient medicine versus outpatient medicine. I know, again, as the younger person on the panel, the less experienced person on the panel, I it took some time to get used to, OK, I'm triaging things at home versus, OK, no, I need to get this person into urgent care or I need to get this, you know, that definitely took some some getting used to. I think our most residency training is more geared towards that kind of inpatient, you know, acute inpatient rehab model. So just depends on what you're interested in and kind of where you land. Awesome, great, great, great. More questions compared to general PM&R, any increased remunerations after spinal cord injury fellowship? I think that could be negotiated. I was going to say, I think that's institution specific, and that's something that you absolutely should advocate for yourself when going into practice. Oh, and Tricia, I think that's how I say your name, I'd love for you to ask a question too. Thank you so much for taking the time from your really busy evenings to speak with us all. I think something that I heard during this presentation, which is really interesting to me, is the opportunity to be this longitudinal physician with our patients. And I was curious to know, what are some of the challenges that you face when you're a longitudinal physician? What are some of the challenges that you face as perhaps the primary physician for a lot of our SCI patients? And what are some strategies or resources that you use to circumvent those? Lack of resources. Lack of resources. A lot of people say a lot of things about the VA, but spinal cord injury medicine, I think, is one of the things that gets really, really right. Because I don't know where some of my patients would be without some of the kind of wraparound services and resources that we provide. It's expensive to live with a spinal cord injury. I don't care what your background is, what you did before, it takes resources. People hours, money, equipment. And I think that's probably the biggest challenge that most of us face. And again, that's where systems-based learning. I know you get tired of hearing that as a trainee sometimes, but that's what it is. You learn about what system that you're working in, the health care ecosystem of where you're at, because it's different from hospital to hospital, state to state. And so you just figure out how to get things done. You figure out how to jump through the flaming hoops that it takes to get what you need for your patients. And you just keep doing it. You just keep doing it. But yeah, it's every day. I'm just kind of like, oh, man, this patient needs like a hundred thousand dollars. I can't prescribe that, though. But I can, you know, I can get them the you know, I can I can put I can piece together as many other resources as I can to try to to try to get it done. Great, awesome. Did that answer your question, Tricia? Anything else? Yes, thank you so much. Okay, great, awesome. Thanks so much, Dr. Skelton. All right, more questions from our chat. We've got, can you speak to any pros, cons, differences you see between practicing spinal cord injury medicine in the academic slash VA slash private settings? I think that's a perfect question for our panel. I can take on the VA piece. One thing to preface is that even if you are a provider who is practicing at the VA, very often that institution will have a... relationship with an academic institution. So I believe that that's the case for Dr. Skelton. It's certainly the case for me, where I'm 100% VA employed. VA pays my entire salary. I have an academic appointment at the UW. So I'm an associate professor who is on the clinician educator track with the university. And my academic appointment and fellowship director piece falls under the UW umbrella. So just because one is in one institution or a salary being paid by one institution doesn't mean that you are only affiliated with that one institution. Kind of pros and cons of being at VA. VA allows me the luxury of doing, of offering that lifelong care. And certainly the benefits that I'm able to offer my veteran population far outseed, far exceeds anything that's available in the community. If my veteran needs a power wheelchair and a backup manual wheelchair, and now decide they want to do some adaptive sporting, if I can justify it, I very often am able to provide that for them. What the downsides of working at the VA can be, I am much more of an administrator than many other people. So I do a lot of my own faxing, photocopying, recycling, a lot of those tasks that other institutions have built in administrative support for. That oftentimes falls on you at the VA. But on the plus side, I'm allowed the luxury of time to be able to do some of those things. VA may not offer as high of a salary as a private institution does, but we have tremendous benefits when it comes to leave. And when it comes to pension, if we're in the system for a good number of years, generally 20 years. So there's certain, and then the last kind of downside is you deal with a lot of VA hoo-ha. But once you've been in the system long enough, you learn how to deal with the hoo-ha that comes your way. And you know how to navigate it in order to best advocate for the veterans and for yourself. Administrative, perhaps burden is higher, luxury of time and ability to provide as comprehensive of care as possible to that specific population. That's the plus side. Yeah, and I think, you know, as a non-VA doc, I think you're gonna have pros and cons with any type of practice. Certainly less VA red tape, but there's more red tape when it comes to getting certain things covered because when you talk about equipment and things like that, you can get that for your veteran patients, but not for your people with certain insurance plans. You know, interestingly, I'm not a VA doc, but I will care for patients that are veterans acutely. And then we will often discharge them to follow up with the VA. So even the non-VA practices often are collaborating with their VA counterparts to collaboratively take care of patients. And things, you know, related to compensation, that's gonna depend on your market and cost of living and kind of a lot to do with, you know, your academics. You know, I don't see there's a lot of like pure private practice spinal cord injury. There are certain institutions that are maybe have higher levels of foundations and they have a lot of foundation support, but that usually means that that money is going towards the patients and great programming for patients and less likely into, you know, the physician pockets. I did see one question in the chat. Tim put about, he's heard that you don't need to do an SCI fellowship to practice SCI for someone on the edge of whether to pursue a fellowship or not. What are some reasons to learn towards doing fellowship? That's a great question. And I can tell you that I've had residents that have decided to do fellowships and I've had residents that have decided that they don't need to do that. They don't wanna take another year off. And I think some of that may depend on where you want to practice. If you have your intentions of being an academic spinal cord injury doctor, then you probably need to do the fellowship. If you wanna have research funding, also, you know, to do the fellowship. But I've had a couple of people who geographically knew they wanted to go to certain parts of the country and they knew that there was no great spinal cord there. And so they knew that they could become the spinal cord doc and kind of build that within that practice because they knew that there was nobody else there to do it and they had that interest. And so I know of at least two off the top of my head that opted not to do the fellowship. Of course, we're 100% biased as the fellowship program directors because we do think that that fellowship adds extra knowledge and tools in the toolbox to provide the best care for the patients. Awesome, thank you so much for answering that, Dr. Harrington and we actually have a question from our group. Taylor, did you wanna unmute and ask a question? Yeah, thanks so much. Thanks to everyone again for being here tonight and giving us this in-depth talk. I'm not sure when I logged on if it was directed more towards medical students or residents, but I'm actually applying the SCI fellowship currently. So very excited to hear all of your perspectives. But quick question, going off of what everyone said, great things about the VA, which I'm also familiar with. I know that we take great care of our SCI veterans in this country. Did you feel that it was important to prioritize VA exposure in fellowship when you guys were looking at fellowship programs if you knew that you had aspirations to one day work at a VA and do you think that that really matters? Well, I don't think I knew when I was looking, I just kind of applied everywhere and honestly, I just kind of ended up going where I felt like I meshed with people. People ask me that a lot because I don't have a VA as part of our fellowship. And I know there are other programs around the country that don't have VA built into their fellowship, but I can tell you out of my last four fellows, two of them got VA jobs and are working successfully at a VA. So at least that's, I have in the last four years, a 50% VA rate, and they would say that they were capable of working in a VA even though they didn't have VA training as part of their fellowship. And I know that there are other programs across the country that are kind of, that are similar. Obviously for people that are training in the VA, they've got that experience kind of built into their fellowship. I'll back Amanda up on that. I'm coming from a program that does have VA built in, but if you are choosing to go to a program that does not, that doesn't mean that those months that you would have been at the VA, you are not doing anything. You will continue to see patients. You will continue to see a wide spectrum of disorders and simply having that volume in not the VA, but in those other clinic settings will make you very well-served for comfortably working at a VA, even if you hadn't trained there during the fellowship year. Thank you so much for asking that awesome question, Taylor. More questions from our group. So thanks for inpatient spinal cord injury. Are you, oh, thanks, sorry, thanks, comma. For inpatient spinal cord injury, are you usually the primary team versus consultant? As an attending for inpatient rehab, are you able to do home visit at a patient's home, house with the therapist per regulation? So the first part of that question, yes. Most of the time you, I think, I don't know anywhere that you're a consultant on inpatient rehab for spinal cord injury. I'm sure that model exists, but I think most, I'm not sure where. I know all the training programs I've been at, you're primary when they're inpatient on the inpatient acute rehab. I do not know if most payer sources will support home visits into a patient's house with the therapist. My understanding is that that's why one of the, why the VA is one of the few places that does it, just because it's not reimbursed at all, or definitely not at the rate to where it's cost for you to slip out to somebody's house, unfortunately. But I'm sure- I agree, I think that's usually in the VA. Most of the private insurances don't cover it. And then there also becomes a liability risk. Some places will not allow home visits because of insurance off the premises, both taking the patient or the therapist or the trainee going. So sometimes that's an issue. I'm gonna put in the chat real quick, just because we're, I know we're running out of time, but in case anyone is curious about the application process, I will put it into the chat, but the ACGME Spinal Cord Injury Fellowships is sponsored by the Academy of Spinal Cord Injury Professionals, or the ASCIP, who collaborates wonderfully with AAP, one big happy physiatry family. But information about the Spinal Cord Injury Fellowships is housed on the ASCIP website. And that is where the common application is uploaded every year. We currently do not participate in ERAS. It means that it's a free application for people applying for SCI. And so there's a common application that is available annually and updated annually on the ASCIP website. So people applying to fellowship can go on, get that common application, and then send it to each of the programs of interest. And that website is where all of the program information is listed, where you can find out, links to the websites and things like that. Even though we don't participate in ERAS, Spinal Cord Injury Fellowship does participate in the NRMP match process. So most of the time people apply in the PGY-3 year, starting April is the earliest. Most people apply kind of, I would say, May, June, July through August. Interviews are typically usually July, August, September, and then the match occurs in October of the PGY-4 year. I had to think about that for a second. Awesome. We have super, super helpful information. Thank you so much for sharing that, Dr. Harrington. I'm sure a lot of people who are just learning about spinal cord injury fellowship world would find that very, very helpful. Any other last-minute questions from the group? We'd love to answer them. Just in case the chat doesn't get recorded for those who are just, like, watching and listening, one question that we did have was regarding visas. If any fellowship-sponsored visas, the answer is, like, it's very unique to each program, but yes, like, many programs support certain visa types. And one question was, like, any research projects that need to be tackled? The answer is, yes, all the things. All the things need to be done. All the things. In the injury world. All the things. Yes. Like Dr. Skelton particularly mentioned, pre-uroprocedure care. But yes, any other last-minute questions or comments at all? I'll give about 20 seconds. Hopefully you don't want to wait. I just want to encourage folks to reach out to the spinal cord injury specialists in your community or nationally. Certainly reach out to Felicia, Amanda, and I. We are all approachable. We love talking about the specialty of spinal cord injury medicine. We would be happy to speak with you one-on-one. We would be happy to connect you with other individuals in the SCI community who may have interests that align with yours. So know that we are resources to you. Use us as resources. And we look forward to seeing all your fellowship applications in coming years. Really excited. Thank you so much. Friendly reminder that the fellowship Q&A series will continue on August 14th with the pediatric rehabilitation medicine, as well as on September 18th with the pain medicine fellowship series. And I just want to give a big personal round of applause to our wonderful spinal cord injury program directors for coming and just giving us so much of their time and wisdom tonight. And just the world of spinal cord injury is very special. We really, really do need more spinal cord injury doctors. So many patients really benefit from just the unique and amazing skills that spinal cord injury podiatrists have. And we need more of them. So thank you so much for coming. And huge round of applause to our amazing program directors. Yay. Have a good night, everyone. Good night.

Spinal Cord Injury Medicine

SCI Medicine Program Directors

Fellowship Training Program

Importance of SCI Medicine

Benefits of Fellowship Training

Career Opportunities in SCI Medicine

Job Opportunities in Smaller Markets

Practicing in Academic, VA, and Private Settings

Challenges of Longitudinal Physician in SCI Medicine

Guidance for Medical Students and Residents