Hi, good morning team. Apologize for the late start, it was rounding. I wanna welcome everybody to AAP Virtual Didactics today. My name is Sterling Herring, I'm a PGY3 at Vanderbilt. As always, we want to recognize and appreciate those of you who are on the front lines of the COVID-19 pandemic to recognize that not everyone has had to shoulder the same burden. So we appreciate those of you who have been affected either professionally or personally more than the rest of us. The goals of this didactic series are to augment ongoing didactic curricula at your home institutions, to offload overstretched faculty, to provide additional learning opportunities for off-schedule residents. Again, we know some of the logistical challenges associated with COVID-19 have been hard on some programs and harder on some programs than others. To develop more digital learning resources and support physiatrists in general during COVID-19. As always, we're gonna keep everybody's video and audio muted throughout the course of this lecture, except for our presenters. So if you have any questions, again, you should be able to find the participants list either up near the top or at the bottom. If you click on that and then scroll up near the top somewhere, you should see my name, Sterling Herring. If you double click my name, you'll be able to send me questions which I can then pass along to our presenters at appropriate times, usually at the end of their lecture, but as invited. If you have any general questions, concerns, suggestions, please feel free to reach out to Candice. Her email is there on the screen, or you can find us on Twitter, AAP. So without further ado, we're excited to have Dr. C. Michella and Justin Bishop here with us. Thank you so much for joining us, both of you. Are you there? Yes, we are. Thank you. I was gonna let Elga start first. She's, I basically just do whatever she tells me to. So I was gonna let her kind of run the game of the show. Can you request for remote control? Are you, who are you referring to? Me. Justin, there. Yeah, okay, sorry. Got it. Okay, well, thanks for having us today. Dr. Bishop and I will be discussing the intersection of physiatry and advocacy, and we just think it's a natural combination since we advocate for our patients on a daily basis. But first, just a little bit about us. My name is Ellie C. Michella, nothing to disclose. In elementary school, I was a recycling advocate, even before curbside bins even existed. I graduated from Cal and was in the marching band, and I received my Juris Doctor from GW. And then I left my well-paying job to get a medical school diploma in Las Vegas, and I completed my PM&R residency in Houston. Now I'm a spinal cord injury fellow in Salt Lake City. And, you know, my name is Justin Bishop. And so for me, as you can kind of see, there's a big fish right here. Both me and Elle, we, you know, slightly non-traditional paths. I think all of the alphabet soup behind our names, none of it doubles up, and we've all kind of, we've done something different. So, you know, I think me and her kind of, you know, per a SNL skit, see things a little differently in a sense. We try to explore ideas, and I think a lot of PM&R docs do as well. Initially, I got into advocacy. You know, I went to Texas Tech, didn't know what I wanted to do, so I was like, I'm just gonna scoop dive all the time. So I started hanging out with this alligator gar, his name's Steve, and I did some bio telemetry and some rearing young a year research. And then once I decided that really wasn't for me, I ended up getting an MBA and then, you know, going into PM&R. It was in the middle of that that I found my really kind of like for advocacy because it was able to try to help people outside of just the inside the walls of the clinic. And so these are some of the roles that I've been doing, and it's obnoxious, I get it, but it just wanted to kind of show you that there's a lot of different opportunities to be had. And so I was on the AMPAC board and I was on the TMA board, and I currently am doing the Medical Society Consortium Vice Chair for that. That's a lot of fun. But so there's just a lot of opportunities for you. And I'll kind of talk about how later on, about how that's really kind of important to make sure when an opportunity presents itself, make sure you seize it so you can further advocate for what you want. So for this talk, we're gonna talk about three different things. First, we'll discuss advocacy and how it relates to our traditional patient physician relationship. And then we'll discuss advocacy in the realm of healthcare. And then finally, we will close with a case study of real life upstream advocacy that we have done in the context of gun safety and complex rehab technology. With an emphasis on really how you can make a positive impact on the lives of our patients through advocacy efforts. So let's first look at the advocacy spectrum. First, there's self advocacy, and we're pretty familiar with this. This is like bargaining for employment contracts. And then individual advocacy. And this is what we do for our patients, like when we try to get them a wheelchair. Community advocacy, for example, teaching medical students about disparities and disability. And then policy advocacy, like when you work with specialty organizations to apply pressure in the political process. And then there's systems advocacy, such as a social movement to overcome patriarchy. We're not really gonna talk about all of this, but let's first talk about something you're familiar with. And that's the traditional patient physician relationship. The strength in this is really in that it emphasizes individual advocacy. In this role, we often advocate for high quality, safe, well-coordinated patient care across the healthcare system. We also organize appeals for coverage and advocate for patient and family in complex situations. I hope this sounds familiar to you because this is actually part of the ACGME PMR milestones, specifically system-based practice within the larger context of systems. Essentially, the graduating resident physician is expected to be knowledgeable and apply individual advocacy. And then the best of the best graduating residents have been given the opportunity to appeal coverage. So I really think residency programs do well in this aspect in teaching individual advocacy. But often we can't see the forest from the trees. So let me just explain a parable. Once upon a time, a riverside village, a woman noticed a shocking sight. A baby was crying his lungs out, being washed down river. She rushed to save the baby, rescuing the baby just before it went over the fall at the edge of town. The next day, there are two women at the edge of town. The next day, there are two babies. And then the next day, three, the next day, four. But with the help of her neighbors, she was able to save all of them. The babies kept washing downstream, but the village banded together and they even set up a 24-hour rescue watch. So the neighbors are saving each baby one by one. And this is similar to how we help our patients by getting them a custom wheelchair or manning the IC unit full of COVID patients. In this case, just like our patient population, the babies will still keep coming. So the community installed an elaborate alarm system. They strung safety nets across the river, but they were still overwhelmed with trying to save the babies. This is really the perfect setup for burnout. Finally, they asked the village wise man who had the solution, let's go upstream and see who's throwing the babies in the river. If we stop them from being thrown in up there, we won't have to rescue them down here. So the village wise man was really thinking about upstream issues. And this is what really I'm talking about. And that is upstream advocacy. When I talk about upstream advocacy, I often say that I'm advocating for patients that I'm not even seeing. This is really because it's a community impact. And you can do this through various means. Basically anything that affects a group of individuals. So back to the advocacy spectrum, what I'm really talking about is community policy and systems advocacy. But the question is, does ACGME expect residency programs to be teaching this? And if you look at the milestones, it doesn't look like it. It does provide that graduating residents are aspirational if they advocate to improve care provided through healthcare, social community and governmental systems. But really aspirational is not a graduation target. But I believe it's essential to learn and apply this in residency because if you don't start early, you're unlikely to do it later. And if you haven't learned it yet, we need physicians at the forefront of healthcare advocacy to prevent the never ending exhausting causes of burnout. Now the question is, can a resident fellow junior attending even a senior attending make an impact in advocacy? And the answer is yes. We'll give you two concrete and real examples of what residents, what we have done in this arena. All right, so that comes down to me. So, when I went to clinic, this first sort of problem, I was super excited about the day, looking at the charts, they look normal. I made an inappropriate gesture and then someone, this TBI patient decides to put a gun on my face. And so here I had two funny pictures of guns to kind of lighten the mood. But if you kind of really think about it, because I mean, if I put a real picture of a gun to your face, that would feel inappropriate, but it's very much real in our practice. When we're going into the clinic and a TBI patient is sitting before us and they are having severe issues. They're talking, saying, hey, if you don't do what I want, I'm gonna shoot you. It's because of that lack inhibition and all the other things. I'm gonna take a real fast point to what Elle was talking about before, about the ACGME points. I talked to my program director about it and she's been very good about me being able to do the things that I've wanted to do and that was to see just as a, if it was me and I hadn't really got into it and I had a program director that was on the fence about it, I would contemplate cutting that out, printing that out, cutting it out and just sliding it under their door and circling step five. And that may kind of edge them into helping you out. All right, back to gun use and motor use. So just some little bit of what TBI and physician oversight looks like. It's just some of the facts. So we all know what TBI is. We've done the residency. Some of us are gonna do fellowship. We know what the book says. If you're curious, go back to it. If you have any questions that aren't on your brain, just come and just talk to your attendings about any sort of holes are there. We know that there's inhibition with driving or all actions driving the visual cues are problematic because you have decreased vision, other medical impairments. And some just simple facts about how many TBIs are occurring are really important. Facts are really important when you're talking about anything with advocacy because anecdotal evidence, everyone always falls back on anecdotal evidence. And by evidence, I mean just experiential stuff. So something happened to them in the clinic like I did with the thing, but it's a part of the puzzle pieces. And so knowing these things are very important. Not only does it important to know and talk about it, but when you start actually moving forward with paperwork, you can't just say because I want to. I don't think kiddos do too well and adults. Some politicians do it very well, but not for us in order to really make real change. So here's some of the facts about how TBI goes. I have this little funny thing about, remember the Alamo, I am from Texas. So it's kind of one of the things we, it's in our memory bank to use whenever we need to. But just for a quick instance, remember epileptic patients. So physician oversight, what does it look like in general for us? Well, we see it in the hospital because they're sitting in the bed. And then when they come to the clinic, how are these TBI patients? How are these medical impairments and disabilities? How are we going to be able to see them? So, there's 37 to 50 states have medical advisory boards. There's boards where have physicians on them. They, in essence, not a lot of states know about it. And I'll kind of talk about some of the fights I've had or heated discussions, if you will, about what they are and how we can use them. But the physicians on these boards don't actually make any decisions. So what happens is they get reported either through self-acknowledgement box on a report, through a physician report or from law enforcement. It goes to the board, the board then sends it to the DPS or in Texas, it's the Texas Department of State Health Services. And then they decide what is appropriate to move forward with. The fact is, is if you look at any of the other states or all states, this is like free work. I personally, you know, I'm like a bazillion dollars in debt and I know all these other positions are, you know, time is money. So it's a lot of work for no income. So the fact that there's a lot of work put onto them isn't really fair. And the fact that the states don't utilize it and ignore it, it's kind of a problem. So let's see what this slide says, is it moving forward? Okay, so this is what the normal, at least in Texas, how it works. You know, like I mentioned, the self-referral law enforcement, physician referral, then the DPS office referral, it goes down and basically does exactly what I just said. So reporting laws overall, we have, is it forward? Here we go. So in certain parts of the reporting is not legally required, but then there's certain aspects that are. So here in Texas, there is a health and safety code. And in chapter 92, it says you have to report brain injuries to the brain injury reporting registry. So you do have to do that. Also for the mental code, you know, if a patient is at risk in Texas, and I'm pretty sure that's another state too, where if a patient has some sort of mental issue and they're at risk to themselves or others, they also have to be reported. There is mandatory reporting in other states. And then I don't know. Okay, so here are overall some state, and mainly I think these are federal. I think these are all federal laws I put in here, except for this Texas subchapter here that I thought was really important. So on the right is a, from, it's federal law. And it says, if you are considered educated as a mental defective, which is by a board court or commission or lawful authority you cannot own a gun so that means if you're danger to yourself or others lacks mental capacity to manage your own affairs found insane or is incompetent to stand trial so that that's pretty broad and that's federal law already and so you just have to get a court board or commission well the Medical Advisory Board is a board you just have to send the DPS so a lot of these things are already there they're just not connected or known which I have a feeling for my time the last eight or nine years of doing some advocacy that's a lot of the case these laws are there they just kind of get lost and you just have to remind people they're real and you have to make a big hullabaloo about things some other things that are I think are really interesting like here on the bottom of the left on section 172 D if you in Texas if you are a default on a loan or delinquent in tax payments or child support you can't own a gun so therefore and also in the above on federal government if you've ever done been dishonorably discharged with mental conditions these are things where I'm like okay so I defaulted on a loan I can't own a gun but I can been hit in the head and be you know have the inhibition and anger or other things that possibly might be there and I can own a gun without any sort of physician oversight that's it's interesting to me so this also is a normal medical examination board you can see up here on the top right where it says if you've had a head or brain injury check yes seizures and epilepsy that's also on there and the reason why I highlight that is I'll kind of talk maybe about a hair about it later is that with some of the conversations are like well you are stigmatizing a population of patients of ours and that is unfair the American Psychiatric Association did not like that and so we had some discussions but then at the same time you have we already have these laws that already in place for people who are delinquent on loans that's a population of people that you know maybe socioeconomically aren't doing too well and they also have people with seizures and epilepsy who clearly are going to be putting other people at danger while driving I would think the same thing with people with the brain injury who have problems with their vision but also so this one will kind of what to do so I have all this stuff I've done my research I've looked into everything and I want to put some stuff to action so what's really the kind of the first thing to do well you get angry you get real angry and then you kind of calm down get some new clothes on and maybe take the green spray paint off your body and then you put all you connect all those dots that we were kind of talking about earlier you kind of come up with a game plan research you could come out and get a JD's right here on the right this is really interesting there's a actual I'm diverging for a second there's an actual whole historical context for kissing babies there's a history to it I thought that was absolutely ridiculous but there is and it's really interesting if you want to read about kissing babies you can go to that website get to really know people rub elbows it's really important to rub elbows so people know what you're talking about if you can't talk to people then they're not going to be aware of it but who do you want to talk to well you know I already kind of talked about the different levels of where you start I thought that was those were some perfect analogies you're going to start off with your patients you're gonna start off with your clinic your hospital and you're gonna move on up and then you're gonna talk to anybody who will listen at the end then when you start getting into these societies once you get up in this area where you can actually make things move you can go that way or you can go through your legislators or you can go through both or you can go through like a thousand points of light and try to hit this from you know a blitzkrieg sort of thing and get it from all angles you know on the county side you'll get some ears but I don't know if you're gonna get a lot of action but that does help you get your your idea up to the state level whether that's you know for me that's Texas Medical Association and then that can move on into the American Medical Association or my special our specialty society with the AAP or AAPMNR or whomever else that you may have if you're going into other subspecialties also with PACS you know if you don't know what a PAC is that's a political action committee that is a 5013 5016C I believe not a 3C and these are things that it's all about just being active and trying to get into roles I'm gonna kind of diverge again for a second because I think it's really important in general for advocacy because me and Al we're kind of betting how many people would show up to this talk because not a lot of people are passionate about advocacy even though they're always asking why more people why more isn't happening for them and that's because people have to do stuff for themselves you can't expect other people to do things for yourselves we have to be talking together because if you look at the American Health Association Hospital Association the nursing with the mid levels and the other issues associated with that they have a strong backing with themselves and so anytime I would advise anytime you get an email read your entire email at there because there's positions and at any time you can take a position you can either see that position on as a committee or something like that you can either see that as ambitious and moving up a ladder I don't really care what you're doing it for in that case I mean I'm glad for you you could do it to learn seriously just learn and hear and grow as a person you could do a little bit of both but you know the whole aspects of the inner workings of things is super important in anything and that there's no different in advocacy especially in this sort of very political convoluted sort of situation and how getting things done works and then when you go to these conferences I think it's really important too because every conference is totally different APS or from the APM and our AMA is totally different than TMA or your state society but these advocacy societies and conferences are very focused on certain topics you know some are very focused on fair payment for services some are focused on fracking I didn't want on fracking at one point you know public health and some could be on such things as return to gun and driving use so when you're doing these things make sure you are being heard don't be quiet and just keep don't just sit there and let things other people run the things because they will they'll they'll they'll try to take things and pretend like they're the end-all be-all I've heard that many times on the TMA where they try to say certain therapy issues weren't necessary all that important which you know from a PM and our aspect is totally different so my goals were with this were these below to make sure that we're doing good on time I'm gonna start kind of not reading things but I wanted to make sure I expanded the role of medical advisory board because I could tell that no one knew in tarnations what that was and to make sure that there was a better understanding of how to oversee TBI patients with gun use so this is just what the after I submitted my resolution which was about this long this was the return of the discussion from about six committees that it went to specifically in the TMA and I will move forward with their conclusions so I actually brought this to instead of just starting in TMA you know I know that the workings of how it works the APM are was going to get it to the AMA faster than the TMA but I wanted everyone to be aware of what was going on so I could use this later I also recognized that one I wanted to set legis advocacy and resolutions in place so I could build on them later even if I didn't get everything I wanted here so the TMA said that the variability of what exactly constitutes as a symptomatic TBI patient may pose potential difficulties in implementation regulation and enforcement of state statute and then if TMA supports this it does it doesn't like the idea of eroding physician professional freedoms and seeks to limit the increasing excessive paperwork imposed and it could be this could be an issue later on they thought there may be some unintended consequences that may be a deterrence and individuals reporting their own brain injuries and lead a potential patient distrust a distrust and strain on the physician-patient relationship so this different than epileptics though I don't know it's it's ridiculous so when it went to the science and public health I talked to them adept because they kept on calling me the chair of the commit council it actually lives in Dallas so we went to coffee three or four times which was really nice because she paid and it was fancy and she was like I really would love to give you everything but there's some just some people here that just aren't really quite getting it and so this was their recommendations and for me I was like okay at least you recommended something a positive and I will annoy you to no end after you pass this and just keep on hammering because it's not going to hurt anyone but me to hammer and it's going to help the patients overall this also went to the AP MR and the AMA the AP MNR got it to the AMA faster and they like watered they they accepted it more much more but they still wanted watered-down version of a verbiage which was fine because by the time it was the AMA I was able since I'm a delegate I was able to change the wordage verbiage a little bit back to a little bit more original language but both at the AMA and the TMA I had to go up in front of people and argue vehemently not not inappropriately but like that they just didn't understand the concept because when an ear nose throat person's coming in or you know a podiatrist talking to me about this I'm like I'm sorry this I think this might be a good time for you just to sit down and just not have an opinion on everything so with that I will pass this back over to you thanks so you can really see that advocacy is a long and adaptive process for dr. Bishop there's still more to do but he definitely got a good beginning there for me I had a special interest in complex rehab technology being a spinal cord injury interest and I saw that improving access to CRT was really important I noticed that my attendings were actually jumping through hoops to get patients their wheelchairs for example but you saw that advocacy can be a daunting process so I really took it piecemeal and think that trainees can do the same I use the problem-solving model and here it is so first you define the problem and then you explore ideas third select options and then fourth apply and evaluate and recycle so this really looks similar to the PDSA cycle of quality improvement so in this case let's define the problems with access first what is CRT it's medically necessary devices that are individually configured to meet the person's unique needs for people with qualifying diagnosis and you know that's such things like MS ALS Parkinson's spinal cord CP the list goes on and CRT can be a myriad of things but for now let's just look at some seating systems here's a quick comparison on the left you can see the CRT manual wheelchair compared to the one on the right which is the standard manual wheelchair and CRT is really customized to the individual for positioning orthopedic issues pressure management and is really intended for long-term use in the home in the community at work during recreation anything really compared to the standard manual wheelchair and then just to show you side-by-side as well there's a CRT power wheelchair on the left and then the standard power wheelchair on the right with similar customizable features of the CRT so what is the barriers to access and in terms of Medicare it's really the numerous time-consuming administrative requirements such as the face-to-face exam the five element order certificate and medical necessity detailed written order home assistant and delivery documentation but it really goes further than that and that's the requirements of DME itself which means that it must be needed within the home so equipment that is not needed within the home but needed for work or in the community really has no bearing and doesn't get you your CRT in addition since DME is paid by Medicare Part B the person must not be institutionalized so for example we send a lot of patients to Smith's and they're expected to provide the DME but CRT is customized to the individual it's expensive and it's likely not going to pass on to the next user so sniffs probably won't provide the CRT and then our patients end up going there without the proper fitting equipment and are for example could get pressure sores and back in the hospital again and then who's affected by this it's really two people well two set of groups it's end-users like our patients and clinicians the end-users our patients go through the system and it causes them delay and frustration and ill-fitting equipment this results in secondary complications readmissions and poor quality of life and then for the clinicians this process causes a lot of issues the current process is complex and confusing everything must be done in proper order by specific people otherwise the process must be restarted the taxing documentation is difficult for those not well seasoned in the process and then the current process requires many disciplines and many people for example physicians therapists social workers suppliers all must be coordinated at the right time this eventually leads to burnout moral injury really whatever you want to call it and because of this process there's often a difficulty between our patients and clinicians having issues at the end so really the million-dollar question is how did we get here why are we having issues with DME and the short story is that we really just shoved a square peg into a round hole and you can really see that by looking at the timeline in 1960 before the advent of Medicare federal government spending on national health care expenditures was only 11% and health care spending itself was just 5% of the total economy in 1965 Congress established the Medicare program specific for the needs of the elderly 65 and older and created both Part A and Part B this is when DME was created under Medicare DME was first developed for the elderly and it was to be used in the home and not used for a non-medical reason generally it was readily stocked on the shelves with minimal customization and then in 1972 was when Medicare was amended to also include coverage for those under 65 who had long-term disabilities and ESR D so after having received disability income for 24 months they're eligible for Medicare and then as you can see by 2013 that spending mostly due to Medicare and Medicaid expansion has increased the federal government spending has increased to over 26% and then if you add a layer onto that and that's Medicare fraud I'm not sure if you guys have seen this commercial I think it was the one that got me interested in getting my scooter. Oh, yeah. So that's the scooter store and Medicare started investigating the scooter store in 2003. And by 2013, they lost their federal contract. It was estimated that between 2009 and 2012, that the scooter store had overbilled Medicare by at least $108 million. And then even recently in 2019, there was a federal indictment of over, of 24 individuals involved in a telemed DME scandal that estimated to be responsible for over $1.2 billion in Medicare losses. So with this background under our belt, we need to come up with some approaches to solve our problem. There's really two that I thought of, and one is to continue what we're doing with carve outs and special rules on CRT through the DME payment category. But this really hasn't been working. So the other approach I had was to create a separate CRT payment category. And that's what really I was going for. So why would this work? Well, CRT is really not DME. It's meant for chronic and progressive illnesses, not just to get over the hump to get back to working. It's supposed to be used in the home, in the community, out at work, on recreation. And it's really customized to the individual and essential for daily life. And by creating a separate CRT payment category, it would allow for different rules. Well, this idea is actually not new. It's been in Congress since at least 2015. In its current iteration, it's HR 2408, also known as Ensuring Access to Quality Complex Rehabilitation Technology, Act of 2019. Currently, there's 36 co-sponsors, and it has been referred to Committee on Energy and Commerce and Ways and Means. There are over 51 organizations who support this bill. But when I looked at the list, there are really only two physician organizations, AAPMNR and ACRM, that supported it. So I thought increasing physician support in this important legislation would improve its momentum and hopefully get it out of committee. So my goal was to gain both state and national physician support. I did this first by submitting a resolution to the residents and fellows at Texas Medical Association, and that's really where I met Dr. Bishop, and we exchanged emails back and forth. The RFS adopted the resolution and sent it to the Texas House of Delegates. And then the residents decided to send various residents to the county medical societies to garner support. I was an alternate delegate to the Harris County Medical Society, so I went there, and I provided testimony in support. I was very interested because they actually fully depended on my rehab expertise, and I was only a PGY-3 at the time, and they unanimously supported the resolution. Not only that, but they wanted to amend the resolution so that we would send it to the AMA. So that's what we did. And then as a delegate, I went to the Texas HOD and provided similar testimony, and it was unanimously supported, and they agreed to send it to the AMA. At the AMA, it was actually referred to the Council on Medical Services, and while they were deliberating, I was able to get the residents and fellows at the AMA to support it. And then by the next meeting, the Council on Medical Services recommended adoption with some minor changes, which I was really happy about. So by the end of that, we had both the Texas Medical Association and the AMA fully supporting this, and it became their policy. There's still a lot more to go on this, and that's to get them to actually act on their policy, and that may be the next hardest goal right now because as a fellow, I'd be moving into the young physician section, which doesn't seem to have a lot of ability to do this, but I'm working on that now. So in conclusion, really, I think residencies should provide advocacy, training, and opportunities. And just like we push our residents to do scholarly activity, they should consider advocacy as scholarly activity. And advocacy benefits you, your community, your profession. You can get involved big and small. You don't have to be specifically physician groups. It can be your local football league or anything else. And then who are you gonna work with? You can work with your patients, physicians, hospitals, medical, non-medical organizations, local, national. And really, like Dr. Bishop said, networking is key. Going to meetings in person and virtual, social media, Facebook, Twitter, all those other type of things really help. And Dr. Bishop also mentioned, emails are important, scan for opportunities. You never know what's gonna happen. I had no idea that there was ability for residents to be part of APM&R, but I saw the email applied and I actually joined what's now the FIT Committee, but before it was called something else. And so you really can find your opportunities there and then get to know your politicians, the local ones, the federal ones, pretty much anybody can help you. And to give you an idea of what you can talk about, it's really anything that interests you. For Dr. Bishop, it was brain injury, guns. I think he's from Texas, so guns a big issue over there as well as everywhere else. And then for me, I'm really interested in spinal cord injury and getting equipment is a really big thing, so that was for me. Research is key, you should Google everything. Anticipate questions because you need to know those answers. You won't have time to respond with researching. And then focus on facts. They'll wanna know facts, especially physicians. We wanna know where you got your information from and how it was come about. And you can talk about experience and anecdotes and that really opens up the talk, but you really have to base your information on facts. And don't burn bridges because you never know when you'll meet those bridges and be loud. So for me, I'm not a loud person, but when you get me into something that really interests me, I'm pretty much pushed through it until I can see some changes going on. So here is some of us in action. it's really you that can change things. So now we wanted to kind of give you guys an opportunity to brainstorm with us. If you want to give us any ideas you have, we can come up with a little bit of how to go about doing it. Thank you, I think it's a great idea. Just to kind of throw in my two cents here, I want to thank you both for this. I have to say I was pretty excited. I want to come back to your questions. I think that's, you know, the what now step is the most important part of this conversation, I think. I was super excited. Personally, I was super excited to see this come up on the AAP lectures. Just FYI, we don't have a ton of people on today, but most of our lectures now are watched on a delayed schedule. People are kind of rolling back into clinical schedules, and so we're actually getting more views later than we are getting live. So I anticipate a lot more people seeing this than are currently here. But again, I was super excited to see this come up. I fully support advocacy. I'm a big fan. Like our presenters here, this is my second career. I did my master's and doctorate degree in health policy, injury policy. The school motto was protecting health, saving lives millions at a time, and it kind of inspired me to kind of take a similar approach. So I worked in that field. I worked at the local, state, federal levels, and then overseas before coming back to medicine. I found that many, many, many times I'm the only physician at the table when policies are being made that affect everyone, and that should not be that way. So I think, again, to support our presenters today, I can't emphasize enough that I think we should all be involved in this. This is an everyone issue, not just when you get around to it or people that are into it issue. My two cents to kind of underscore some of the things that they said here. Find something you're passionate about, you're most effective when you really care about something. A word of caution, be aware of your environment. In my former life, and just in the six months prior to residency, I was in the New York Times two or three times. I was on the Today Show talking about injuries and injury policies and some policy interventions that we should be addressing. And then after coming to residency, I was in the ER during a school shooting that was obviously a terrible experience. So again, circle back to kind of my old career and went back to, I was again back in the New York Times, NPR, and other groups. I got a lot of pushback here at my institution from certain people in my institution. I won't say the institution as a whole, but from certain folks in my institution. So political realities are in fact reality, so it's important to kind of keep aware of what's going on around you so you can navigate that appropriately. Just kind of be aware of your environment. Our presenters did a fantastic job of showing a peek into the process of how this works. So I tell policy students, I give a talk on this, and I say when you get angry, if you're still angry three days later, call me and we'll address this. Because it's easy to kind of come across something and get upset about it, but I mean babies take months to gestate before they're viable and ideas are often the same. So get angry about something. If you're still angry about it a few days later, that's when you're like, all right, I need to do something about it. But allow these ideas to gestate. Start bouncing things off of people and seeing how you can improve this idea, how you can improve this solution to your problem. I'm gonna advocate for turning down the volume on our overhead thing here. Know your tools. Justin was talking about going through local medical associations, the state, AMA, AAP, AAPMNR. There are a lot of different tools at your disposal. Know what they are, talk to people, and that's kind of how you find out what those tools are. And as Dr. C. Michele mentioned, data makes you believable, stories make you memorable. That's something that I try to remember. I worked a lot with members of Congress and Senate and kind of the state legislature level on a number of policies, but that's something I found to be true. Nobody believes you if you don't have data to back you up, but nobody remembers you if you don't have stories to tell them. So yes, I think we should definitely move on to this next section and say, hey, what next? CDC NCIPC priorities. Some of you may have heard this spiel before. I think I've given a talk once or twice on this, but CDC NCIPC priorities are falls, NBCs, TBI, overdose, and violence. And to me that says PMNR, PMNR, PMNR, PMNR, PMNR. There's no reason that we as an institution and we as colleagues should not be addressing each of these things and we should be on the front page talking about these things and we should be knocking at people's doors, members of Congress, or again each of those schools talking about those things. Please send me questions. We have a first question here. Do you believe this advocacy, education, or empowerment needs to begin at the medical school level? Yes. Yeah, it does. I'll keep mine brief so I can talk about it. Actually, the one thing I wrote down just to make sure that I said no matter what sort of topics we actually get to because me and her have a couple of ones that are very new that if we get to we can talk about like the new CMS inpatient guidelines or you know sometimes it works in your favor or like the getting rid of the past. You know that sounds, or not the past, the paper. Yeah, but starting earlier is the better. I can't tell you how many times I've heard like 50 or 55 year old colorectal surgeons or whatever type of physicians state that they wish they had got in earlier because at that point they're seeing some sort of, you know, they're seeing their bottom line get huge chunks taken out of and then these are people that are actually probably more active and more gung-ho about things but it takes a while. Like I know for mine, just my resolution, not even me getting enough clout to kind of walk, I mean I don't mean arrogant clout, but just enough to actually talk to people and them hear me fully. It took like, that took a while, but just this resolution took about two and a half years to get, you know, to where it is now and so it takes a while. Yeah, I definitely think starting earlier is better. I was particularly talking about residency because I feel like that's even a deeper hole that we're not addressing. A lot of medical schools do allow medical students to advocate and they're doing a lot of it. If you go to AMA, it's kind of like to forget that advocacy is important. And as we move further in our career, we find that advocacy is in the back burner. And sometimes I hear physicians say, oh, they don't have time. They got to see their patients. And I was just trying to make note that, you know, you're helping more than one patient by doing advocacy. I also think if you kind of put things in slightly in perspective, let's just for giggles say that, and I'll put it in a somewhat probably realistic number that 1% of each specialty is active in advocacy. And I think that may be generous. It may be even less than that. If you have 1% of, you know, emergency medicine doctors, you know, you have 3,000 active voices in that role actually, and the resources that come along with it. But for PM&R, you know, 1% of us is only going to be like 90 physicians or that's 60, no, it's 45 physicians that would be active in advocacy on some level across the entire United States. So that means what is, how are we actually pushing the needle, you know, for rehab? And so we've got to find ways to be more vocal because, again, if we let nurses or mid-levels or pharma or business kind of dictate how medicine is growing or how rehab goes, we are going to be out of luck. And also, you know, I see other residencies are really strong in advocacy, like pediatrics, OBGYN, ER, they're really good. And then we go to PM&R, we have a very vulnerable population residents to do that, and we don't give them time to do it as well. I couldn't agree with you guys more. I never understood the argument of I don't have time, I'm taking care of my patients. It goes back to, again, Dr. Cimichelli, your parable of the throwing the kids in the river. You're so busy scooping the kids out that you can't run up a river and stop it. That is an argument I never understood. Certainly in the aftermath of that school shooting, I'm like, how about we step out of the EOR and start talking about preventing school shootings instead of just being happy to sew them up. A question that came up, maybe that was a bit aggressive, sorry guys. A question that came across, I was very interested by this talk. I want to propose an example for the group discussion. Dental care is often difficult for patients to access. Indigent patients with tooth infections may have many ER visits without fixing their root problem. That's a good pun there. What initiatives are out there regarding this issue? This is a big question. I think I wrote a paper on this once. But it is a big question. I think the lack of access to dental care is certainly a big issue. It's interesting because actually there are laws to require that places be accessible. And unfortunately, they're just not being implemented. And I think that by pushing those current laws, that would actually help. Right now, you don't even have to make something new. Yeah, it'd be about connecting the dots. Because again, the dollar rules. And when you're looking at your DRG or whatever, you're getting paid for that group. And they're like, sweet. So now we have to worry about how this is going to impede into your three hours a day. Or I mean, it's one of those things where you have to be aware of like Waddell and I said together about connecting all the dots, but then looking at the system that's in the hand and seeing all the cogs, how they interwork. So then you can disrupt it because, you know, disruption is fantastic. But physicians aren't really a big fan of it. So nor are they fans of light either. We're big fans of efficiency, right? These things turn off by themselves. So I agree with all those things. We have a few minutes left. Do you want to, Justin, do you want to talk about some of those issues you were talking about with the PAPE and? Yeah. So I would say the, I'll start off with the mid-level thing. So when I was on the, I know this is the AAP, but so when I was on the AAPMR board, one of the things we had an issue. I know what that is. I don't know if you're, I'm just. We had an issue with, there's always going to be an issue with mid-levels, like what's appropriate for mid-levels, whether you're primary care or us, you know, scope of practice. Scope of practice in the entirety of organized medicine is an issue. So there was trying to figure out what mid-levels can do. So the conversation within PMNR, the family of PMNR has been kind of fresh lately. And so I know that organization has wanted to include mid-levels so they could be taught and educated appropriately. And that was the total extent of it. Well, then CMS decided very, oh my gosh, holy moly. So within like, I was thinking about like eight months, the CMS put out guidelines where inpatient rehab, the facility themselves could dictate what is defined as a rehab physician, and that rehab physician definition is just someone who does rehabilitative care. It doesn't mean it's a PMNR doc. It could be an internal medicine doctor that they just deem appropriate. Well, then within a, I would say within a year, I can't remember the exact date they did that, but it was recent. Just a couple weeks ago, they said, well, how about we just, you know, the medical, the facility can deem a mid-level competent in all ways as a PMNR physician. And the point that's really, I mean, beyond the fact that that's insane, you know, the CMS right now is when they were reaching out for conversation points, all of the conversation points were kind of funny because they were the opposite of what we were saying today. A lot of it was anecdotal or people were saying it was fact and it sounded like CMS took it as fact without actually validating these statements. They're saying, oh, mid-levels can totally do everything appropriate as a PMNR doc. And so that's something that's currently going on this very moment and is, in my opinion, a huge deal, and I think a lot of people also think it's a huge deal. What do you think, Elle? Oh, yeah. Well, you know my stance. I was pretty vocal at PMNR's online thingamajigger and didn't really think that we should be training non-physician practitioners by providing them membership. And then this comes out, and they say that this is because of COVID because apparently all the rehab physicians are so overwhelmed that we need other people to take over our jobs, and that it seems like it's actually permanent post-COVID as well. And apparently after COVID, we're going to still be overwhelmed and need this assistance. And I don't think they really understand that we provide a specialty that isn't just trained in a couple months. And, you know, we go through residency for four years, and even, you know, as a first-year attending, you're not, you don't know everything. You don't know how to order a power wheelchair still and make sure your patient gets it nine months later. So I don't know what they're really thinking about this, and it just makes me think again that physicians aren't advocating for themselves, but nurses are because they have one big organization, and we have 100, and we're not really stepping up to the table in masses. We're just talking about certain things that are important to a specific specialty. Yeah, I think we're right up against the end of our hour. I couldn't agree with you more. I think this is a great example. We have to, in medicine, 21st century medicine, we have to toe a line between corporate perspective and a patient perspective and a societal perspective, and there are a lot of pieces of that puzzle. And I think my read on the CMS response to the comments is that it seems like the corporate voices, now that most rehabs are being incorporated, at least a percentage of each rehab is being incorporated into a larger corporate institution, a couple of specific big ones, those voices are then kind of dictating a lot of the conversation. So I think all the more important to get back to what you guys are saying, which is to get involved and stay involved. Thank you guys so much. We appreciate having you on. Your comments have been spot on, and we appreciate the expertise that you bring to the table, the experience you bring to the table. Thank you both for joining us today. If people have questions, can they reach out to you directly at these email addresses? Absolutely. Yes, that'll work. Excellent. Thank you both. And for anybody who saw this, was inspired, I hope everybody that saw this was inspired, please refer your colleagues to this website right here, physiatry.org slash webinars. You can see this and all of our other virtual didactic series there. They will be hosted through at least the end of 2020. So if anybody is currently on clinical schedules and unable to watch it now, encourage them to come back and check this out. Again, thank you both for joining us today. Thank you. Thank you for having us. This was great. All right. We'll go ahead and get started in just a second with our next lecture. Yes, it's Didem Inanoklu. Perfect, thank you. All right, let's go ahead and get started. Again, welcome everybody to our AAP virtual didactics for today. My name is Sterling Herring, I'm PGY3 at Vanderbilt. We will skip through the goals, but we will address some of these housekeeping issues. We're gonna keep everybody video and audio muted except for our presenter. If you have any questions, my name is Sterling Herring. If you click on your participant link,

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