113. Progress Note #10: The Art of Attendinghood - Navigating Challenges and Patient Care

Hello everyone, I'm Dr. Darsha, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined. A podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in healthcare. Our guest today is none other than our very own co-host Dr. Altamash Raja. So we're going to flip the script today in this episode and talk about his trials and tribulations over the last year. For those of you that might know, he has now been in attending for the last year at Rowan University practicing sports medicine. So we thought it would be an awesome idea as Altamash comes up on one year of practicing medicine as an attending to really talk about the trials and tribulations, the challenges that he's faced, how he's learned to grow, and even trying to balance out the business of medicine with delivering the best patient care that he can. We'll also talk about the art of medicine, how he views that, and even how he has started a lifestyle medicine group. So this is an awesome episode for those of you that know any pre-medical students out there, or even medical students' residents, this would be an awesome episode to share to them so that they can finally see that the light at the end of the tunnel isn't maybe what it seems like, and that we all have to create our own light as we go through this journey. Enjoy the episode. All right, listeners, welcome to another progress note. This one's going to be a little bit different, where I'm going to be interviewing Altamash here. You've been in attending for almost a year now, when did you start last year? August. August, so we're coming up on a year very shortly. Yep. Awesome. Coming up on a year, and this episode's kind of been in the work, it's been an idea that we've wanted to go through about your experience as an attending now that you're coming up on a year. For those who may not know their first time here, why don't you go through your roles and responsibilities of what you do, where you are, and kind of just overview of your training? Yeah, it's interesting to be on this seat right here in the hot seat. Yeah, so for, I think most of the listeners are familiar with our journey in the sense that we're both physiatrists, right? So I've finished my PM and R training in 2021, subsequently did a primary care sports medicine fellowship, which we can certainly talk about, because I think people still don't quite understand the different types of sports medicine, but anyways, it's non-surgical sports medicine, finished that in 2022, June 2022, and the nine years of training in the books, that was a very emotional thing, and only because that one year was the best year of my life, but also it's just, you know, the culmination of nine years of emotions coming in. And then now I am in attending an assistant professor at a medical school in South Jersey, Rowan University, Rowan, Virtua, School of the Lasty Pathic Medicine, where I have clinical duties, academic responsibility as administrative responsibilities as well, and, you know, we have tons of trainees at every single level, from medical school to interns, and most recently we have our own PM and R residency, so it's been amazing being a part of that and also help establishing a new program, and yeah, we can dive further into it as you please. Cool. I didn't realize, Rowan just added a residency program for PM and R, just new or brand spec, and you had a first residence first class start last week. Oh, wow. For as a PGOI-2 class, or both, both we have three interns, and we have three PGOI-2s. Oh, wow. I did not know that. Yeah, there's, there's random residency spots in PM and R, kind of opening up. I didn't realize Rowan was one of them. Very cool. Okay. Why don't you take us through then a little bit about the sports medicine journey? You did just mention that many people don't know the differences between, you know, people just think sports medicine, they think you work with athletes. What is it truly? That's a good question. Yeah, I think, so let's back up, right? So sports medicine, I think for most people, it is working with athletes, but majority of the time sports medicine professionals are working with people who are active individuals and have musculoskeletal ailments, right? So they're going to be taking care of everywhere, anything from somebody who's a weekend warrior could be your true athletes at every single level. You could be elementary, medical school, high school, collegiate and professional level, but most of the time those sports medicine providers who are fellowship trained, maybe even non fellowship trained, but have that type of practice, we'll be taking care of just bread and butter, musculoskeletal ailments that are just accumulation of trauma throughout people's lives, right? So these chronic overuse injuries, much like everything else that we talk about in medicine where the chronic disease burden of cardiovascular disease, diabetes, et cetera, et cetera. It's also the case for musculoskeletal medicine, it's quote-unquote wear and tear, osteoarthritis, overuse injuries like tendonosis, tendonitis, that kind of stuff. And so that's probably the majority of the stuff for even the most robust, true sports medicine practice, and I put that in quotes where they're taking care of athletes. With respect to how somebody can get into sports medicine, really you have two tracks, and I tell my medical students this, is you have to decide whether you want to be surgical or non-surgical. If you decide you want to do a surgical, there's really only one route that I'm aware of, and then you're going to do orthopedic surgery, and then you want to go ahead and operate. And what's interesting about that is even the best surgeon will tell you that most of the musculoskeletal ailments that see in clinic, we've talked about this before, really about 10%, I think Dr. Tufik Jalde, who's going to be a upcoming guest in the very near future, when we publish that, we'll talk about about 10% of those musculoskeletal ailments that they see are going to be surgical cases, right, aside from maybe trauma and stuff. And so if you decide that you like that bucket, fantastic, your path is laid out for you very easy. However, if you decide, hey, maybe that's really not your cup of tea, and you want to do the non-surgical management, which is really 90% of everything else we talked about, then you've got lots of different avenues. The five primary ones that are most popular would be emergency medicine, family medicine, internal medicine, pediatrics, and physical medicine rehab, and I did PM&R. I think those are really the main med-peeds is another one too that people do, but that's far less common. So I did PM&R, then did it sports medicine, and here we are. Awesome. So what type of patients are you seeing? Because you're not, as a physiatrist, you're not just seeing your bread and butter sports medicine, like you're doing more than that in your clinic, right? For sure. Yeah, I think it is mainly all of musculoskeletal medicine, I would say 99% of that, but it's just really about, and most people's chief complaint is pain, right? I think I've had maybe two or three people who've come in with just dysfunctional or lack of performing up to their capacity, and those are actual athletes, but most of people will come in and pain is limiting their function. And so, how do you manage pain? Well, we have a ton of different tools, right? We talk about oral medications, you have topical medications. We use osteopathic malignant medicine. I am a DO by training SOAR U, so I refer back to, I think, episode six, if anybody doesn't know what that is, go listen to Dr. Alex King talking about what OMM is all about, and then you know you have, I do a ton of diagnostic and interventional ultrasound as well, so you can use different types of injections after you've made the appropriate diagnosis. And you know, you have your oral medications as well. I also do a lot of spasticity, and that's another area where people might come in with not pain necessarily, but they have limitations and function because no spasticity for those who don't know, it's when you have a neurological insult to your body, classically somebody would cerebral palsy or a spinal cord injury or after a stroke where they have almost a rigidity, but that's maybe not the best word, but they have tightness and increased tone throughout their body, right? And so it's, it's velocity dependent, which is a buzzword for any medical training testing and view for your boards. And so in those instances, interventional treatments like Botox and adjacent or analogs of Botox are indicated. But yeah, that's pretty much it. Very cool. So now when you talk to your students who are interested in sports medicine, and for those who don't know, I mean, go into a DO school, I remember my class being at VCOM. I think like half of my class probably went into family medicine. And in regards to sports medicine, that was probably our largest interest group. So those just like who go into a DO school, I feel like have this propensity to gravitate towards sports medicine, OMM, hands on type of training. What do you tell your students though about how to get into sports medicine? You did mention there's five different avenues. Do you say there's a preference for one of them? I mean, obviously being a physiatrist, I don't know if you're thinking that might be the best or... It's very independent, right? I mean, you and I've talked about everybody's got their own journey, right? Sure, I'm a little biased, but I'm much more interested in getting the person to the road that's going to be the best path for them. Just because the path that I chose with PM&R doesn't mean that everybody else should follow along with that. I do think there's advantages and disadvantages to the path that you choose, but it comes to that primary question that I mentioned earlier, it's like do you want to be surgical and not surgical? Right, again, I think once you answered that question, you decide to, hey, I actually want to do it with a non-surgical aspect, that's what appeals to me more. That's the lifestyle you'd like, which is an interesting point. We talk a lot about this. Majority of the people are in such a surgery. The students that I've spoken with over the last year, but I think that turns them off as a lifestyle, especially my female students that are with me because they're like, you know, family planning and whatnot, things that we've been talking about in some capacity over the last two and a half years, right? But once they decide that they want to do non-surgical, then it's like, okay, well, what are the trade-offs that you're willing to give? I do think specialties such as PM&R are more catered towards musculoskeletal medicine, which is what osteopathic schools are as well. I think DOs come out probably with better training. There might be some data out there. We might be able to find that to support that, but I also think physiatrist will come out with better muscular training, which is the main reason that I actually went towards that route. I think that anecdotally, I felt that and with my colleagues coming into training and also now, but there are things that physiatry training doesn't prepare you as well for, that family medicine or pediatrics do for. It's really asking yourself about, hey, where do you want to be 10, 20 years of what kind of patient population you want to take care of? Then you can reverse engineer or backtrack in terms of which path might be the best one for you. Yeah, I think that's the key, reverse engineering, what your end product wants to be. Because I remember me going through the hospital, me working with sports medicine here at Penn State, that's through family being with neuro, you're PM&R, you're the one whose exam is going to be better than everyone, right? I mean, that's just the perception that people have with PM&R is that your musculoskeletal neuro exam is going to be thorough, it's going to be detailed, you know exactly what you're looking for. I think back often, both of us are very into lifestyle medicine and so we're not just looking at musculoskeletal, but you're very interested in cards. I'm going to sit in GI. So we look at the whole gamut of things and I think sometimes, man, I wish I did have that family medicine training, right, to really understand the medications and side effects and interactions. But then I go back and I say, well, I really like PM&R because there's so many different avenues within the field itself, right? I mean, you can be a generalist and even to you being a sports medicine fellow, you can or being trained as a sports medicine fellow, you can go into brain injury still in spinal cord. And I think that's the beauty of the PM&R residency is that you're able to be an interventional ist, but also a generalist and kind of makes a match and that's kind of why I chose that. But yeah, I think it's true to say that it really just depends on people's goals. So I like that. I want to stop back, I'll return back to students. I do want to get your opinion on teaching students and their perceptions as far as medicine goes. But you've mentioned nine years of training now. So four years of medical school, four years of residency, one year of fellowship. And oftentimes in medicine, we are accustomed to hearing light at the end of the tunnel. You know, it's almost there. It's almost there. Where was that light for you at what phase and what did you see? Was it truly light or was it not what you expected? And I wasn't ready for this question. We're going to get one. Yeah, yeah, I'm not sure, I'm not sure I believe in the light at the end of the tunnel. I think I think you have to light the tunnel yourself, you know, I really do believe that. And I think partly the way that I did that, I think we did that as honestly by starting this podcast two and a half years ago, which we've talked about offline. There were some good and some bad, right? It opened up our eyes to different ways of practice. I think our initial purpose was, hey, let's, let's help educate and let's spread the good word out there selfishly. We did want to learn. But I'm not sure if like that when I made that phone call to you, like that was the primary reason. But when I learned shortly after about four to six months in, I was like, oh my God, like the opportunity out there, the possibilities out there. So that's when it, you know, I started like that tunnel was getting brighter and brighter for me. I think coming up to the end, it was just, it was just checking off a box like, okay, training done. You know, with that saying about light at the end tunnel, it's almost suggestive that your journey's come to an end and I'm not really sure I love that, you know what I mean? I think that it has to, it's like a stepping off point, kind of like we talk about a lot of the, the physicians who've come on and they've finished their medical training or, you know, gotten their medical degree and then use that as a jumping off point to open up different opportunities. So I do think that in a sense that you don't have oversight, which can be good and bad, like you get to call your old shots, you do have more freedom, right? Make a little bit more money, which is very nice, right? Considering the amount of debt that we're in. So I think those aspects are quite good, but there are some negatives to it as well. We can talk about. You've been exceptional at this, which is kind of what I've told you that I, I mean, you do an X, I think in terms of lighting the tunnel throughout, like you do a great job, you know, doing, I'm not going to wait for that day to graduate, right? I'm going to make the most of the moment that we have now, right? I mean, as far as your intern year, like traveling, we've talked about this, right? You know, not to be too tangential, but this, the concept that we talk about how we have to be physically fit so you can kind of earn that freedom. So when you vacation and you can, you know, climb the Great Wall of China or Everest or Machu Picchu, whatever it is, I, I've, you know, for those who don't know, I was recently, you know, across the pond and traveling in Europe. And I truly got to appreciate for the first time after that conversation. I was like, wow, because usually I'll do around 10 to 11,000 steps. That's my daily goal. And I was the couple of days I was out. I was consistently over 22,000 steps, yeah, 24,000 steps a day. And I was like, holy moly. And I was, I took a picture for you. It was like dad rucking where I had a pack in front of me and a packet behind me. I'm just like carrying and I got my toddler on this side. And I'm like, you know, I've got nothing on this. And I was just like, man, we just walked like 14 miles today. And if I wasn't exercising and training consistently, like this wouldn't be manageable. So I take that little, you know, that little transition. It's just because I do think it's, you kind of have to continue letting that tunnel as you go along. Yeah, man, it's a very good point. And I'm glad that we're both there in terms of learning from people like Bill Perkins, right? Attia had Arthur Brooks on and like Naval Ravi Cutt and like, you get these perspectives from people who have done it. But they're all about living in the present moment and lighting that tunnel, whether they're in business, whether in your law, dentistry, medicine, whatever it might be, I think it's important to figure out those things that bring you happiness and joy and really try to work at those, right? And I think in medicine, we're not taught that at all. And so many of us go into medical school thinking, okay, I'm going to be able to shape the practice that I want. And I'm going to be able to treat the patients I want. But in residency, you're so bogged down by one, not knowing anything, two, your attending is teaching you. And then as you get out, you're kind of just like, well, I can only go back to the level of my training, right? There's always that quote. You don't really rise up to the occasion, but you fall back to your level you're training. And I think so many people's quote-unquote hopes and aspirations and dreams die through residency because they don't know how to light that tunnel for themselves. And so I think it's important as people go through medical school residency to be alert at things outside of medicine and that what other people might be doing because we're totally in a market and era right now where so many physicians are switching careers, right? Or switching jobs. And the tough thing about being a physician is unlike nurse practitioners and physician assistants. We don't have that laterality, right? Like we can't just switch from Piment art, dermatology to family medicine where they can. And sometimes you'll feel pigeonholed. And again, this kind of goes back to why I chose Piment art because I think we have more of that option than other specialties do. But it's just a long way of saying, you know, kind of what you are about living in that prison moment and trying to figure out what it is and those things that you can add in. I did want to bring up a point too. You know, there's so many people that I know that are in business who are bankers or work at hedge funds and things like that, a lot of my friends and they'll say, man, I was pre-med at one point. And I wish I kind of stuck with it because I would have job security, right? And it's funny because I think in any field you go into, there are going to be things to complain about, right? Whether you're in business and things that it's going to be job stability, right? You can, today's market, you can get fired at any moment. They're going to always be set someone better than you. Whereas the physician, yeah, that's not, that's not the biggest worry because worry is kind of the autonomy and practicing the way we want and, you know, going into something that you thought was going to be your truth and ends up being a lie. But Alia Gupta, you know, one of our former guests is really good at this and really get us sharing her perspective on social media about how to find happiness and joy. You know, she's been a family medicine practitioner now for, I believe, about 21 or 24 years and she wasn't happy at first. But then she went out and created and got those missing pieces, right? For her, it was the autonomy. It was really just practicing the way she wanted, finding the right patient population. And so I think no matter what career you're in, you're going to have to go out and find those things, find those missing pieces to add on, right? And I've been now solely transitioning or, I should say, slowly switching my mindset because I was always like, I don't know if I do this again. I don't know if I do medicine. Yeah, I could always do consulting and stuff. But as you mentioned earlier in this podcast, it's a launching pad, right? I think this degree as an MD or DO is such a blessing because people do take you seriously. You have that authority. You have that grip. People know that you're willing to work hard. And I think with that, there's a lot of opportunity out there to shape it, how you want, and you just have to be willing to kind of go out and learn those things. So yeah, that's a long-winded one. Yeah. I mean, it's necessary though, right? I think a couple of points that I wanted to follow up on. You mentioned these prominent podcasters that we often reference that we listen to. What are the interesting things, lessons that I've learned from them, despite all the successes they have? And it's not necessarily the financial pearls that I've gotten from them or maybe even the philosophical, but it's time and time again, all these people who are quote unquote successful. They'll talk about the importance of being in the present moment, which is so incredibly hard for me. Interesting note though, I'll tell you, having a child, especially a really young child, I can't think of a better way of somebody to be in the present moment just observing a child. I don't have this to you offline or not, but part of the reason that this trip was so incredibly enjoyable for me is, you know, I asked you offline, hey, where do the spots to go when I was planning this trip? I even had chat JPD planning for me. But what we went there, we were going through these museums and we were just going through these moments and just watching my daughter just take it in and be there and just watching, like looking at it through her lens and kind of like, it was, it was beautiful. I digress. The other interesting about that cliche though, about light at the end of the tunnel, you know, medicine, as we know, is not what it used to be 30 years ago, right? That golden era of medicine that Dr. Standard is going to talk about in a future episode coming up. And I think that, you know, people 30, 40 years ago and they were going through that, grinding through the residency and training years, they knew that they're going to get to the back end of it and they will have much more autonomy. They will make more money. The business won't be so burdensome that it truly would feel like this glowing light at the end of the tunnel. And that's not the case anymore. Medicine is a completely different ball game, right? With the implementation of social media, with the business of medicine and, you know, there are so many more opportunities to kind of have that glowing light earlier on. We've had lots of guests earlier in their training who have come in and are doing, quote, much better than 10, 20 year physicians who are in their practice, right? Who are supposed to be in the middle of that, like where it's shining bright on them. So, yeah, it's just, it kind of shows like medicine has completely changed, maybe not completely, but it has drastically changed. And, you know, I do think we have to continue to adapt with that and actually be up to speed. I mean, we're going to talk about AI in the very near future of what that means for us and our job security stability, so to speak. And so, um, so yeah, I think you just have to get on board. Let me ask you this, right? You said, um, or we started this podcast, 2020, you were a final year of your residency. We've probably done one, maybe about 50, 60 episodes until you became an attending, maybe even a little bit more. And you heard throughout this time of your training, the glaring kind of mishaps that are happening in medicine, right, preparing you for what you will actually see when you are in attending. Now that you're in attending, looking back at our podcast and the things that people have shared, the common themes, what are like two or three of those downsides of health care that are really noticeable for you in this last year? I think in the system, the way that it's constructed right now, makes it really challenging to quote unquote, do the right thing, you know, and I know that's a very bold statement to take. Like as you'll see, as the listeners will see with, you know, we had Dr. Chris standard come on, he developed these comprehensive spine based fellowship at UPMC, talking about how it's one of a kind fellowship with very much a value based care system. And the fee for service model, it's, it's very challenge of practice and also be outcome driven when the system isn't based on that. And the reimbursement model with terms of how the business profits, how, you know, your incentives are aligned with that, it makes it really, really challenging. And sometimes, you know, there could be a little cognitive dissonance because you know what the patient needs, right, but the patient, you don't have the time to maybe educate the patient or you're not incentivized or set up in a system where it's the perfect opportunity to, to educate the patient. And maybe even everybody around the patient, we, we kind of spoke to Jim Ubanks about this as well. Again, I'm kind of giving people a little preview of what's coming the near future about how it's not just the patient, but also the answer staff needs to be educated well enough so we can set up for success, right? So I think that's really, really challenging. But the business of medicine, if you understand really well, like things that we didn't really learn well, at least I didn't learn a lot in my training in terms of how to bill and code appropriately, there are ways to go about that, right? It might not be the most efficient way to do it, quote unquote, but there are ways to go about that system where you can salvage and be more outcome driven. And the other interesting thing that I've learned is like, for instance, now I'll share that with people that there is something called time-based billing, but how much time you spend with a person, you can bill for that. Whereas the other real way for people to do it is this problem is based billing, right? And every single encounter that you bill for is a side of specific code, and depending on how many problems you care for or how much time you spend, you can, you know, bill up or down or a higher level code or low, low code, and the higher level of code is the better you get reimbursed. And that's, that's easily accessible information for everybody. The challenging thing is when you are sitting down and trying to address so many different things with a person, you, it can take a toll on you emotionally, especially because touchpoints that we've talked about, I think one of the things that we've talked about is, you know, specialties and our allied health professionals, such as physical therapists and psychotherapists and nutrition and stuff, they might be more successful because they have so many touchpoints and that key phrase that somebody's used, Jimmy used actually was engaging in behavior change, that requires a lot of touch points. I think seeing somebody once every six weeks or once every three months, if you're interested in making outcome driven change, that's not enough. And so what does that mean? How are you going to cater your practice? Like are you going to see people more often, you know, how often and stuff? And so that's the piece that I'm kind of working through, honestly, and trying to find the happy media in delivering that, but also being available for as many people need me to be available for them. How long do you have per visit with your patients? It depends. It depends, and for me, you know, it could be anywhere from 20 minutes to a 40 minute set appointment, but I will, of course, take as long as I need, right, to be able to achieve the desired outcome. What I'm finding challenging and I need to get better at is learning that you can address everything in one visit. It's just not going to happen, right? If somebody comes to you with years of trauma, whether it's physical, micro trauma, or just emotional, you're not going to be able to unravel it in 45 minute visit. And it's just going to, you're going to have to chip away at it. I mean, for multiple reasons, why you shouldn't even try to. I was recently having a conversation with one of the new staff members that we hired talking about sometimes when I inherited a new patient because from a previous provider who's left and, you know, we've had some changes. The first couple of visits are just about establishing a rapport and just, hey, getting to know people, sometimes it's not even asking about what their chief complaint is. They'll share that with you. Sometimes it's just getting to know them. Where do you work? What are you doing this summer? It's just basic human interaction, right? And once you gain that trust, once you establish that rapport, then you can earn the right to probe these more sensitive topics, these more difficult conversations. And so, you know, technically on the books, it could be anywhere from 40 to 45 minutes, but that's never enough. Both of us know that. Right. So how do you balance being your authentic self versus the metrics you're up against? I mean, it's a business. There are metrics like RVUs. There's going to be patient satisfaction. There's going to be time it takes to get new patients through the door. I mean, they track almost everything. And for they share that with you, I don't know if they compare it with other attendings out there too, but they're metrics and it's almost like playing a game. So how do you balance playing the game versus being, you know, Dr. Roger, the one that you want to be your whole life? Well, I'm still figuring it out. I don't know if I've quite gotten the balance yet, right? But I think it'll for every person who's listening, at least a medical professional who is going to embark on their attending a journey very soon, it's going to very much depend on what kind of system you're in and what type of practice you're in, right? So I am at a large academic center. And so the expectations of me are drastically different than somebody who's in a private practice, right? And so maybe I get more time, maybe the expectations in productivity are a little bit lower for me. And that's usually the case for somebody who's in an academic institution, who has in private practice, it's all about productivity in the sense of, you know, the fee for service model that we talked about. And so I'm still continuing to develop that and also learning the practice and also learning that I have to be patient, just like we tell everybody else that they have to be patient. And we haven't even talked about how we're incorporating trainees and educating them and telling them like, what's the important part of this visit? Like what's the information that we need to extract? But I think the one thing that I've realized that I work significantly harder as an attending than I did as a trainee, which I didn't think was going to be the case. The case. Why do you think that is just from paperwork or just from how much you're trying to improve patients or is it the students, you know, responsibility to? It's all the above, I think, probably not as much paperwork to be honest with you. I think that's actually been good, especially since we got a better EMR system, right? We now have a band which is one of the better ones. I think a couple of things in terms of when you're a trainee or at least when I was a trainee, you have that oversight of somebody telling you how a procedure should be done. You have that guidance that you could bounce ideas off of, right? You don't have the final say, usually, right? And so when it now, it's pretty easy, certainly you can look things up yourself. You can do the research and you can read the papers and stuff, but you can always bounce on ideas off of the attending. Like, hey, this is kind of what I said, this is what the evidence suggests. And they'll say, yeah, I agree or I disagree. And you can talk through them stuff that when you are that last person, the buck stops with you. Really, there's really no person to bounce that off of, right? You have colleagues and stuff that you can do that, but you can or burn them with every single patient situation as well. Nobody's co-signing your nose, nobody testing your notes. So now that pressure of, you know, getting it right, also doing right by your patients early on is very high. And so I've, like I think I mentioned to you, I prepare for a clinic a lot more than I did as a, as a resident or a fellow in advance, chart reviewing, sometimes reading papers in advance or telling a patient, hey, I need to kind of check in with some people reaching out to my network and saying, hey, what's the best approach for such and such? The other thing is that, you know, I am also doing a lot of things in terms of the types of procedures I'm doing and the things that I haven't gotten exposure to before throughout my training. And that's both good and bad. You know, I think part of the reason for that is because I did residency in a certain location in Baltimore. I did fellowship training in a completely different environment in Pennsylvania and now I'm practicing in such urgency. When you hop around different geographical reasons, you get different patient populations and they have a slightly different set of problems that you might have to care for. And so I didn't get, I didn't get exposed to everything that I'm doing now in my training because I was taking care of a slightly different set of patient population. And so now I also have to learn some of those things on the job, right? And I have to teach myself some of those things as well. And yeah, like, you know, that's both good and bad. Had I stayed and if I went back to Baltimore, I'd probably be seeing the same things and maybe I wouldn't have as much opportunity to grow, right? And we talk about the medicine is like physically practicing something, but I look at it as like constantly learning and evolving. And for me, I'm going to be much better forward five years from now. Yeah. Yeah. So let's talk about students, right? So you're obviously teaching medical students, residents. Do you see that their mindset about the future of medicine, right? Now that social media is everywhere. I think social media really blew up maybe when I was like a second or third year med student, right? So for you, probably just starting out in residence, your intern year. But now that they have so much access to what's wrong with healthcare, right? I mean, they see medicine glamorized, but they also see the downside of it. Do you feel like those students are very different than kind of what we were when we went in, at least about the things they think about or the things that they want to pursue? Some, very few to be honest, I think most are still looking at that next hurdle to jump through, rather, or the next hoop to jump through. It's so interesting how short-sighted we can all be, and we're guilty of this, maybe not you, but I certainly was guilty. You're just looking at that next hurdle. You're like, I got to get through step one or level one, and then it's all by step two level two, and it's about the next exam, and very few people look at big picture, you know, five years from now, ten years from now, is because the system is designed for you to only look at that next thing, that look at that next carrot, right? And so, you know, that's kind of written the challenge because sometimes we're having these conversations, and I'm trying to teach these lessons about, hey, establishing rapport, how that's much more critical about engaging in behavior change, than maybe arriving at the exact diagnosis about, you know, as much of a sickler as I am about getting precision medicine, both we are in terms of ten United States of ten and doses, but when it comes through some of these chronic musculoskeletal issues, it might not matter as much as like the overall global risk to be able to zoom out and look at the big picture. That can be really, really hard. I have had a few of them, and they're certainly the ones that are like outliers, but I would say it's so interesting when you look back and everybody's just kind of looking at that next thing, and they're just so incredibly stressed about it that they can't see beyond that, you know what I mean? Yep. And I was there too, so. It's funny, man, that's why I really think everyone should have a PEMINAR rotation in medical school. Some schools who make it mandatory, I believe Rutgers is one of them, but rehab has really opened my eyes, especially now being on a consult rotation, as far as thinking about system change, thinking about down the line, thinking about what's going to happen in the next week, year, four years, right, for these patients, because you're looking at disposition. You're not just looking at, okay, this medical hospitalization that they currently have, but what's going to happen after, right? What are those things that we have to think about? And I remember being in medical school and being like, oh, they're patients in the hospital, and then they go home, right? And every, like, even occurred to me that they would have to go to rehab or they would have to go to a skilled nursing facility and thinking about the challenges that they just went through, you just assume that they get better in the hospital until they're ready to go home, and then they go back to their lives, which we know is definitely not the case. And it's funny, because I had a medical student who was with me this last week, and which is very, like you said, very just that tunnel vision, as you would, as a medical student, because you're just focused on the things you learn, and you're focused on, okay, this patient has pain, they just went through a laminate to me, but then why is it not having this pain? And that doesn't make sense with this note, and I was like, oh, you got to back up, like, as physiatrist, that's all good, and we can talk to the patient, but let's back up and think about his function, right? Which we always talk about buzzword if you're interviewing for PIMINAR. Let's think about his home setup. Let's think about actually what's going to happen down the line with this person, because in the end, that's what's important, and I dress a little bit there, but I wanted to move on to... No, I think that's a key point, though, and I've wondered why that's the case, right? Why is it that we have to focus on that specific mechanism of action for a drug, or the specific type of pain, as a no-susceptive versus neuropathic? And I think part of the reason is, because those are the concepts that are testable. That's what I can write into a test question, right? That's what our exam questions can be. That's where the board examinations can ask you about. It's really challenging to ask somebody about the art of medicine, which is a lot... I don't know, it might be sometimes even more important, and at least with these lifestyle medicine topics that we often talk about, right? Which are very, very important with respect to the chronic disease that everybody is suffering from. Not everybody, but most people are. And so I think that's part of the problem, and so until we were just revalued how we test and how we test for competency, the way that we're doing is at the best way, I'm not sure you're going to... You can expect students or trainees to think differently, right? If you don't incentivize them to do so. Yeah. No, absolutely, and I like that you use the word art every time a medical student on my consult rotation, you know, as I pull up the plan, I say, okay, our first line is going to be that initial diagnosis and the right disposition. This whole portion right here is about the art of medicine. You've got to think not about the medical stuff, not about the science, short, that's tied in, but you've really got to think long-term. And then everything else after that, right? The right having a pre-sist, insomnia, whatever. Yeah, we're going to be looking at it more medically. But again, everything is going to go back to that art too. We're looking at the medicine to go back to the art of medicine. That's why I love PM&R and it's just been nice going through this training to really realize that. But yeah, I just think our training is really focused on knowing facts, right, and black and white. And then you get to it and that's just not the case for any specialty, honestly. So yeah. All right, let's transition now to lifestyle medicine. So you recently have created a lifestyle medicine group at Revan. How's that going? Yeah, we started in Elmig here, like somebody's interest group, really awesome. And so to your point earlier about students getting more involved and more in the know about some of these topics in social media, I have to credit social media to that, right? I think the person that I reached out to a few students were shadowing me a clinic and just the conversations that we were having, I felt, hey, these would be good champions for this. I remember reaching out to our president, shout out to Amanda Miller. And I asked her, I was like, hey, you know, what are your thoughts about getting this started with me? And interestingly she had mentioned, hey, I've been thinking about this for six months because I follow ACLM on Instagram and her and another person, you know, Marley Friend and who's a vice president, they've really just taken that baton and they've been running with it and just kind of exceeded my expectations with every regard. So I'm lucky to have such a large group of students who are interested in this. That first meeting that we had, I don't know, we had maybe 30 students show up to that and really big turnout. And it was awesome because of the conversations we were having. I was so incredibly impressed because the students were bringing up different topics in terms of the nuances of nutrition and communicating and the social disparities and things that I would have never thought about, right? And I was just thinking about how the biochemistry of nutrition, essentially what we learn about. But I think people are talking about, right, we talked about, hey, it's like health that every size movement and about how BMI is not the best predictor and maybe not even the best marker in terms of looking at. And so, you know, I'm excited to continue working with these students. And I think, I think that, you know, we've got a really special group. So just lucky man, lucky to have invested, invested students. So I think it makes the whole process of being a mentor, being a faculty member, much more fun. Yeah, absolutely. That's awesome. That's awesome here. Yeah. That's like the most, I think, excited thing I'm looking forward to as attending is just having hopefully students in res and shadow so that we can teach, right, about our doings and the things that we've seen. But it impresses me that I think this next generation of physicians, and as we know, like Gen Z and millennials, we do care more about passion and purpose in the workforce and also having that life balance. And then if we can also give that energy of those topics to our patients, you know, I think that's what eventually can hopefully make health care even better than it is now. So that is definitely what I'm looking forward to as years go on. Cool, man. Well, any other pieces of advice that you have for maybe any of the pre-health students listening or even the old time physicians might be listening, anything else you want to share? No, it's something that I drastically changed my perspective on. I went through, when I was a medical student, I remember having, I mean, we all know this. We all had our preceptors who really inspired us and changed the way that we thought about medicine in a positive light, right? But we also had attendings and preceptors who were like, holy moly, this is the worst preceptor ever. I remember having quite a few of those, but what was interesting about those working with those preceptors is I really cherished my time with them because I remember extracting those lessons and those memories and just banking them and promising myself, hey, when I become a preceptor, I am not going to do X, Y and C because of this. What I can tell you is I have a much more empathy for those people today because being on this side of the coin, you can start to get an understanding of, oh, maybe they were behaving this way because of X, Y and C, right, things that you just didn't understand. I mean, that lesson can apply to anything else in life, right? You never understand what somebody is going through until you walk in that person's shoes, right? So, you know, whether or not some of the behavior is still excusable or not, different story, but I do think that I have a lot more empathy for some of those people that I was like, oh, my God, why would this such person behave that way or why wouldn't they do this or why wouldn't they listen to this? You know what I mean? And now she's like, oh, it's not so easy. It is quite challenging. And so just tell people to be more open minded and have empathy even for your attendings and your trainees and just really for everybody, man. It's a good point. I like it. Cool. Well, Altamash, thank you so much for being a guest and a host today. My pleasure. Okay, appreciate you all for taking the time to listen to this episode. Again, if there are any pre-medical students, medical students or residents that you know that would find this episode valuable as they continue on their journey to becoming an attending physician, please send it their way. Our hope is that we're not only teaching everyone to provide better care for their patients, but also that we're able to help those that really need it, which are our young learners. And you know, medicine is not really what it seems like. And I, we can both attest to that Altamash and I as you can hear from this episode. So please do share it to those that you think would benefit. As always, our medical disclaimer, everything in this podcast is for educational purposes only. It is not constitute the practice of medicine. We are not providing medical advice, no physician patient relationship is formed. And anything discussed in this podcast is not represented by our employers. 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