Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And we have three physical medicine and rehabilitation specialists for you today from Northwestern Medicine Marianjoy Rehabilitation Hospital to highlight Elevating Care: the Impact of Fellowship-Trained Physiatrists. Joining me is Dr. Anton Dietzen, he's fellowship-trained in Pediatrics; Dr. Ishaan Hublikar is fellowship-trained in Spinal Cord Injury; and Dr. Julie Witkowski is fellowship-trained in Brain Injury.

Doctors, thank you so much for joining us today. And Dr. Hublikar, let's start with you. What drew you to Physiatry and motivated you to pursue a fellowship?

Ishaan Hublikar, DO: So, Physiatry, in general, attracted me because of my upbringing. My mom actually was a pediatric occupational therapist. So, I grew up around Rehab, and it really opened me up to the field of Physiatry as a whole and rehab as a whole. So when I knew I was going to medical school, one of the first people that I shadowed was a physiatrist and helped me understand how Medicine and Rehab are integrated. So, that was getting into the specialty as a whole.

And then, as I was in residency, I really was into Spinal Cord Injury because of the amount of different types of care you can provide, the unique aspects that a spinal cord injury causes a patient in terms of their physiology of their body and the longitudinal care you get to provide really lifelong for those patients.

Melanie Cole, MS: Well, thank you for that. Dr. Dietzen, same for you.

Anton Dietzen, MD, FAAPMR: Yeah, it's interesting to hear your perspective, Ishaan. I didn't know that about your mom. I kind of had a similar experience. My brother-in-law has spastic quadriplegic CP. My wife and I were high school sweethearts. And so, in the summers, I was kind of his caregiver and just sort of got immersed in the world of going to East Shields and taking him to therapy and being around that. And ultimately, I was kind of introduced to Dr. Keen, who's one of our other Peds Rehab doctors here at Marianjoy. And so, after the first time I met her, I was like, "Well, this is what I want to do, the specialty that I want to do," even before I was a medical student. So, it was an early, early interest definitely for me.

Melanie Cole, MS: Dr. Witkowski, tell us your story.

Julie E. Witkowski, MD: Yeah. That's so interesting to hear, because I have a very different story than both of you. I had absolutely never heard of Physiatry until I was halfway through medical school. I went into medical school with some other interests that do overlap with Physiatry, but I didn't actually even know that it was a specialty, like a lot of people, until I think I was a second-year medical student. And one of my eventual mentors had come and given a lecture to our medical school class on what is physiatry. And I kind of learned throughout the process. And as I was going through my different rotations, that it had a lot of the facets of different specialties that I liked, that I had heard of previously, incorporating some Neurology, knowledge of the central nervous system, some peripheral system knowledge. Also, I had had a previous interest in perhaps something like Orthopedics, but it had some non-surgical Orthopedics knowledge, like musculoskeletal system, and how the nervous system and the musculoskeletal system integrate. And then, I also had a big sports background growing up, so I knew there was a good amount of Sports Medicine and just a whole bunch of things that went into making the specialty of Physiatry.

So, it was interesting. As I was listening to his lecture on what is physiatry, I was sitting there thinking to myself, "This sounds right to me." And about four people came up to me after the lecture and said, you know, "This sounds like a good specialty for you." I said, "I was thinking the same thing. " so, I looked into it a little bit further, did a couple rotations in Physiatry, and eventually decided on that as my specialty.

Also, as I was going through my residency program, I have a lot of interest and I was drawn to a lot of subspecialties within Physiatry, but it really kept coming back to Brain Injury. I loved Pediatric Physiatry, but I realized that I really loved the brain injury patients that I was seeing on the Pediatric Service. I really liked Spinal Cord Injury as well. I really liked the Neuro Rehab aspect. But what ultimately drew me to a fellowship in Brain Injury was just that every patient I saw would present in a different way, because brain injuries are variable and they affect every single person differently. And so, at the end of my residency training was when I finally settled probably a little bit later than some others on absolutely pursuing a fellowship. And I decided to ultimately pursue a fellowship in Brain Injury, and be a Brain Injury-certified physiatrist.

Melanie Cole, MS: What great stories, all of them. I'd like to ask you each how your fellowship training shaped your approach to patient care. So Dr. Dietzen, you're in Pediatrics. How did that training help you to work with these children in a much different way?

Anton Dietzen, MD, FAAPMR: Yeah. Well, I mean, the Pediatric fellowship, I think, is unique in that a lot of the other fellowships within Physiatry are kind of condition specific. You have like brain injuries, spinal cord injury, pain. And so, you're kind of focused on one, you know, really building your expertise in one kind of very specific niche within Physiatry.

But in Pediatrics, we see every basically congenital-acquired disability from birth injury, genetic conditions, burns, the whole kind of spectrum and then you go into it having already completed your adult residency. So, a lot of times we've had the ability to, you know, kind of see how people age with these different conditions. And so, I think one of the things that's really valuable is being able to start with a child early on, maybe you're seeing them when they're two, three months old, even like at a NICU followup appointment, and trying to think, "Okay, what are the things that I can do to help this child really achieve their max potential and avoid complications and things down the road?"

And so, as a result, I think Pediatric Physiatry in particular is a lot of pattern recognition. Because every day, there's a new kind of genetic condition. I see a patient almost every day that I'm like, "Oh, I never heard of that condition before. There are three in the world, six in the world." And so, we spend a lot of time doing kind of pattern recognition. Is there truncal hypotonia? Is there ataxia? Is there increased muscle tone, decreased muscle tone? Maybe difficulty with swallowing? Is there a vision component? And so, I always do a really thorough kind of review of systems and kind of go like top to bottom. And then, pull from that the things that I think are most important. And then, try to match that up where their idea of the most important kind of things to focus on are and make sure that we're kind of creating a plan together.

Because obviously, when you're treating a child, you're treating the parent as well, because they're the ones who have to do all the things that you're asking them to follow up on, all the other appointments, all the other tests and therapies and things. So, I always try and make sure that my vision for what I think, especially where the child aligns with, what the parents says. And so, I think those are kind of two sort of unique aspects of Pediatric fellowship, is that kind of like working on that early pattern recognition and using all the tools that we have at our disposal, medications and therapies and injections and bracing and all these types of things, to kind of look down the road and say, "Okay, how can I use these tools to really help this child to achieve their max potential?" And then, really, to kind of partner with the family, with the parents, and even the siblings and trying to make as much of what often is medicalized fun or engaging in things for the child.

Melanie Cole, MS: Well, it's certainly a comprehensive approach, especially as you said, when you're working with parents, because we all know how we can be, right? And when our child is ill, it's a tough time. It's a terrifying time. So, thank you for explaining that. Dr. Witkowski, how about you? How has your fellowship training shaped your approach to patient care for patients with brain injury?

Julie E. Witkowski, MD: Well, actually, it's an interesting segue because in the Brain Injury world, again, kind of a little similar to the Pediatric world, in the Pediatric world, as Dr. Dietzen mentioned, we're treating the patient but also their family. And in the brain injury world, we're often also working with the patient and their family. Brain injuries come in all shapes and sizes. I see all kinds of patients, especially on my brain injury rehab unit. And so, that could be anything from a traumatic brain injury, so a fall with head trauma, brain bleeding. Also, we see non-traumatic brain injuries, which can be from encephalopathy or from, say, a tumor resection or a brain surgery or VP shunt placement, or other kind of alterations in someone's mental status for a variety of reasons.

And one of the things that's pretty unique about the brain injury population is most of the time when someone has a brain injury, some measure of cognitive impairment also comes along with the brain injury, at least for a period of time afterwards. And so, one of the things that I got to practice a lot during my fellowship was being more the leader of the team when working with brain injury patients. You get to do that a little bit more in your fellowship training, than in residency training, and really learning how to integrate not just the medical care for the patient themself. Because brain injury patients have a lot of complex medical needs as well. But also, incorporating their family, loved ones, caregivers, other people who are going to be assisting them after their rehab discharge, whether that be cognitively, physically, or both.

And again, making those care plans and helping them shape the next steps of what the recovery and the rehab are going to look like after they leave the hospital, making sure they have all the followup appointments and everything that they need. So, I think my fellowship training really gave me a good comprehensive overview on how to navigate those difficult situations. Also, sustaining a brain injury is not typically in anyone's plan for their day, right? So, this is usually a big life-altering event or, you know, an accident, incident, illness, an injury, that led someone to come be under my care. And so, there's a lot, not just medically, but socially, psychologically that goes along with that. And so, I think really learning to guide patients, their families through that process is really a big part of the specialty itself, and also my fellowship training.

Melanie Cole, MS: So important, the points that you made. And Dr. Hublikar, what about you and Spinal Cord Injury? How did your fellowship training shape your approach to patient care?

Ishaan Hublikar, DO: Yeah. So when I was finishing residency or as I was going through residency, I really found a connection to Spinal Cord Injury. My personality is such that I really like to delve into like every nook and cranny and understand why does this work, why do certain aspects of the body work the way in which they do? So, I really felt that I wanted the extra year to explore all the smaller areas within a spinal cord injury. Truly, spinal cord injury affects almost every organ system. It can affect your cardiovascular function, your respiratory function, bladder, your bowel function. And other types of upper motor neuron conditions such as spasticity, very similar to brain injury in a lot of ways.

And so, I wanted the opportunity to have extra time and extra exposure to all these patients dealing with these issues within their spinal cord injury, also in relation to their rehab impairments as well, and have the opportunity to go into each of those areas within a fellowship. And that's really what it allowed me to do. It helped me increase my exposure and my comfort level with all of these types of patients. In my fellowship, I was also helping to manage patients on ventilators as a result of their spinal cord injury. I got to do specialized clinics, for example, in spasticity management, where I focused on how to discern between different types of oral medications, injections or interventions such as a baclofen pump. And then, I get to work with specialists that we work with very closely in spinal cord injury. So, I got to have the opportunity to do clinics with Neurosurgery and Urology and really see the aspects of the care that they get from the patients as well. So overall, that and the increasing amount of patients you get to see over time in a fellowship was really important to me.

The last thing that I found really important was having the opportunity to have more mentorship within the area that I was specializing in as well. So, I got to see the different practices of a multitude of Spinal Cord Injury specialists during my year in fellowship, and still really keep in close contact with them. And that really helped me see aspects of different attendings that I got to take pieces from in terms of their management, in terms of their practice, and really help me adapt what I wanted to bring into my own practice, coming into this first year as an attending.

So overall, you know, I think the one-liner would be, it helped me to anticipate their needs a little bit better in terms of what not only is going on right now with their injury. But over time, as their injury evolves, what can I anticipate that they're going to need into the future, and how can I help that in the current state?

Melanie Cole, MS: Very well said, Dr. Hublikar. And Dr. Dietzen, after you completed your residency at Marianjoy, what factors influenced your decision to return?

Anton Dietzen, MD, FAAPMR: Yeah, that's a good question. Dr. Hublikar and I and one of the other brain injury specialists other than Dr. Witkowski all came back after. And so, I was kind of thinking about that as I was preparing for the talk today. And I mean, I really wanted to go and train outside the system because I wanted to have something unique to bring back.

But ultimately, I think Marianjoy in particular, it's a very mission-focused organization and patients here really get wraparound care. You know, when I was in my fellowship, I actually reached out to the Spiritual Care team here at the time because they were doing prayer shawls. And I had gotten a couple prayer shawls here for patients, you know, as a resident. And I had a patient in Maryland during fellowship who, you know, I just knew the mom would really appreciate it. And the spiritual care person here at the time actually sent a prayer shawl out for us out there. And that was the kind of thing. I felt like the culture here at Marianjoy is really just to go above and beyond for patients and their families. And I think that was the thing that most drew me back was just that everybody's on the same mission and the mission is just to try and get the patient better as much as we're able.

Melanie Cole, MS: Same question to you, Dr. Hublikar. After you completed your residency there at Marianjoy, what factors influenced you to return?

Ishaan Hublikar, DO: Certainly. So, Dr. Dietzen, me and him share in common, in addition to being residents here, is we were both chief residents in our fourth year of residency in the program. And so, there was this intrinsic motivation I felt to come back here and help give back not only to the community, in the patient community, but also to the residency program as well in terms of going to another institution in a different region, picking up skills and knowledge, and coming back and bringing some of the aspects that we learned back to a place that we knew really well, and growing not only the patient population, but also the residency program as well.

There was one other spinal cord injury physician who's still here, Dr. Kou. And so, she was one of my mentors in residency and I really look up to her. And so, I really look forward to the opportunity to working with her and under her mentorship and growing the Spinal Cord Injury program. I think that's been a goal of ours overall. We have the unique opportunity that outside of the city, we're really the only SCI program here, all the way out basically until Iowa and up until Wisconsin. And so, having the opportunity to catch more patients and bring more to our spinal cord injury patients, and also being able to mentor the residents here and bring that knowledge back was some factors that I really couldn't pass up.

Melanie Cole, MS: I would like you each to answer how your fellowship training prepared you to tackle the challenges in your specialized fields, because you are all working with these very complex patients. So, I'd like Dr. Hublikar for you to start first, and how have you worked on tackling these challenges?

Ishaan Hublikar, DO: Yeah. So, I think, ultimately, having the extra year of fellowship really helped me be challenged in terms of the most complex patients that I could possibly try to treat. I think that was one of my goals going into fellowship, is I want to see the most complex and potentially like the hardest patients to manage from a medical standpoint and from a rehab standpoint, while I was still under the fellowshiphood of being able to ask my attending any questions or seek guidance at that standpoint.

And so, that's what I was able to bring back, is I really feel confident that, in many ways, I won't be surprised by hopefully too many cases where I feel at least confident with the training I've got to start the management. And I also have the benefit of having partners that I can bounce ideas off of. So really, that's what I've been able to bring back, is a lot of confidence. And in terms of knowing that between my residency, between my fellowship, that I've seen some of the more complex situations that I would likely deal with on a day-to-day basis.

That being said, you know, medicine is unpredictable and you always get some surprises and challenges, but I think that's also why medicine is a lifelong learning field as well.

Melanie Cole, MS: Dr. Witkowski, what about you? How have you really learned to tackle the challenges for brain injury?

Julie E. Witkowski, MD: Well, one the nice things about staying for an additional year of training and brain injury for a fellowship, I actually stayed at the same institution where I did my residency. I was a little different than Dr. Hublikar and Dr. Dietzen. I was at Mayo Clinic for my PM&R residency, and I ended up staying at the same institution for another year for my brain injury fellowship. And then, coming back out here to where I was born and raised in the Chicagoland suburbs, to work at Marianjoy, which is always one of the goals of mine, since growing up. I'd always heard of Marianjoy or had friends or family members that had been to Marianjoy. So, I was really excited to be able to come out here and use some of the skills I learned in my residency and fellowship.

And when I really stayed for that additional year of fellowship, I was able to be more fully immersed in the brain injury world. That's really across the entire continuity and spectrum of care areas in which you might see a brain injury patient. I got to spend more time in three different places really, first, on the consult service, so I was doing a lot more brain injury consults. So, I was seeing patients in the acute care hospital following, monitoring, assisting with their care there. Also, weighing in on their candidacy appropriateness for something like an acute rehab program or other levels of rehab care. And then, getting more of the opportunity then to also follow them on the inpatient rehab setting, so on the inpatient rehab unit, which is something that we have here at Marianjoy in subspecialized units. Then, I was really able to immerse in just the inpatient care of these patients' brain injuries. There's a lot of complex medical management that goes into brain injury care at times, different complications, electrolyte imbalances, things like SIADH, autonomic storming, spasticity, different medication titrations, agitation management, which is something that happens not uncommonly after brain injury. So really, getting to then experience a full panel of brain injury patients over multiple months on the inpatient side and really fine tuning my skills and managing those conditions.

And then, the other nice thing was having a really comprehensive outpatient brain injury clinic throughout my fellowship year where I was able to follow a full panel of brain injury patients that really became my own patients. Some which I saw once or twice or a couple times in a consult, but other patients who I followed regularly throughout my entire fellowship year, and really was able to work with them as they transition from the hospital setting to the outpatient setting. There's a lot of other things that go into rehabilitation medicine in general, but a lot of tools that we utilize probably a little bit more in the brain injury world, like working with neuropsychologists and learning more about neuropsychometric testing and how to review that, go through it with patients. And also, really helping folks if they able and ready to transition back into other roles in the community, like working on things moving towards return to work or return to school, return to driving, and the different resources that are available for that. So during my fellowship year, I really got to be fully immersed in kind of that entire spectrum of brain injury rehabilitation and practice those skills with a large number of patients.

Melanie Cole, MS: Dr. Dietzen, you're up now. How has your fellowship training really prepared you to tackle the challenges of Pediatrics?

Anton Dietzen, MD, FAAPMR: The Pediatric fellowship is unique in that it's the only two-year fellowship out of the Physiatric fellowships. And really, that's because as I alluded to earlier, it's the patient population that we see is so broad. So, we see so many different types of patients. And so, like Dr. Hublikar mentioned, I wanted to train somewhere with a big inpatient unit and the sickest kind of kids on the spectrum. So, I took care of kids who were on vents and kind of learned the vent weaning.

Johns Hopkins sort of pioneered the early mobilization. So, we would help kind of get patients ready for rehab really early in their hospital stay. And so, I think it was helpful for me to kind of stretch my mind in terms of when the rehab sort of process begins. It wasn't uncommon to see patients, you know, pediatric patients in the PICU at Hopkins, walking on ECMO, up walking intubated, and ventilated. Things that, like if somebody sort of described you, you'd be like, "That's not possible." You know? They have a team of like eight people behind them making sure everything was working. But movement is medicine and the earlier we can get patients up and moving, whether that's after something traumatic that's happened that's interrupted their life as they're starting out with challenges. And so, I think really being able to be exposed to people who are thinking outside the box and trying to push those limits of how we can do that, and trying to bring some of those ideas back. And then, also realizing that two years, even though it's long on the fellowship side for PM&R, it's really just kind of where education begins.

And so, I think, coming back to a place like Marianjoy, where I have Dr. Keen and Dr. Pavone who are both just tremendous mentors and kind of pediatric rehab legends in the community to continue that mentorship, and sometimes I'll be in clinic upstairs and have one of them on each side. And I'm like, "Oh my gosh, this is like--" You know, I'm so fortunate because between the two of them they've seen so many different things. And so, it's just an incredible kind of team to work with and to be able to kind of exchange ideas with.

Melanie Cole, MS: This is really such an enlightening eyeopening discussion. You all have so much knowledge to share for providers that are thinking about going into these specialties. And I'd like to give you each a chance for some final thoughts. And Dr. Hublikar, what advice would you give to those considering a fellowship in spinal cord injury in your specialty? And what do you see? What do you hope, and what do you see as the most exciting advancements on the horizon in your field?

Ishaan Hublikar, DO: Great question. So for part one, in terms of advice, I would say I find that Spinal Cord Injury really is a perfect hybrid of rehab and medicine. So for those that have those types of interests, it provides, in my opinion-- obviously I'm biased-- but the best of those two aspects, as well as having that longitudinal care just over the course of their lifetime and really being an expert on specific pathology that can affect everything really for the patients.

As far as the second question, where I see the field going, really the new frontier is neuromodulation in terms of the spinal cord injury population. There's a lot of different studies going on around the world in terms of how can we help some of their recovery in different ways. So whether that be motor recovery or helping their spasticity or helping their cardiovascular function, that's really going to be the exciting kind of next five to who knows how many years going in the future of what is available to our patients and what might really change the expectations and the ceiling for what the rehab could be over their whole lives. So, only time will tell, but that's why the whole field of rehab is really exciting.

Melanie Cole, MS: It certainly is. And Dr. Witkowski, same question to you. What advice, if you were talking to other providers, would you recommend that they listen to when it comes to thinking about joining Brain Injury? And what do you see as exciting happening in your field, technology, innovations in the future?

Julie E. Witkowski, MD: Yeah. So actually, this is a fairly easy one for me to answer, especially the first part, because I mentor a number of residents and medical students, and I get asked this question a lot. One of the things that I like to share with people who are considering doing a Brain Injury fellowship is really anywhere you practice as a physiatrist, whether or not you decide to specialize, you're probably going to encounter patients on your service or in your patient caseload that have a brain injury in one shape or form.

So when I was deciding on whether or not to do a Brain Injury fellowship, there are multiple possible outcomes that can come out of that. One could be doing something like what I'm doing now, which was obviously one of my goals, where I'm the medical director of an inpatient rehab unit with a locked brain injury unit with a high proportion of brain injury patients. So of course, I'm seeing a large number of brain injury patients, inpatient, outpatient, on consults.

But that being said, that wasn't certain when I was applying for fellowship where I was going to end up working later. And so, a lot of folks in physiatry end up going into a whole variety of practice settings, a lot of times practicing more as a generalist in PM&R, we all have general PM&R training. But I knew that really any practice setting that I'd go into, say a subacute rehab facility, a general rehab unit, a subspecialized inpatient unit, more of an outpatient practice. Patients who have suffered some form of brain injury, either traumatic or non-traumatic, are always going to end up on your patient caseload because folks often have a brain injury or have some cognitive impairment when they're in the hospital for one reason or another.

So, I really felt that the brain injury training that I received was going to be really helpful and marketable really anywhere I worked in any practice setting. And that I could always hone in on that subspecialized knowledge for certain patients when needed. And similar Dr. Hublikar, there's a lot of up and coming things and exciting things in research and technology for brain injury and spinal cord injury. I think during our careers, as we're all relatively early practice physiatrists, we're going to see a lot of changes in how medicine approaches recovery from brain injury and spinal cord injury, and other neuro rehab. I think there's up and coming things like using complex imaging studies and more sideline testing for faster testing after concussive head injuries, really spanning the entire spectrum from a mild to a more severe traumatic brain injury. There's always advancing technologies on how to work with folks who have sustained a brain injury.

One of the things that's not necessarily new and up and coming, but we're excited to have here at Marianjoys, we recently got a balance tutor. I think we're one of the only facilities in Illinois or the surrounding area that has a balance tutor. So, it's been really helpful for a lot of my patients to work on their higher level balance here, both inpatient and outpatient because it's a machine that incorporates both forward and backwards and side to side perturbations of someone's balance. And that can be done while stationary or also while walking or running. As we're trying to gradually improve the mobility of our patients, being able to use that tool to kind of give them some higher level balance challenges, I think has been really great and something that I'm really excited we were recently able to get here at Marianjoy. So, I think there's going to be a lot of advances in technology and diagnostic imaging, neuromodulation treatment, and also some technologies to help patients recover just their functional status.

Melanie Cole, MS: Thank you so much. And Dr. Dietzen, last word to you, what advice would you give to those considering fellowship in Pediatrics and what's exciting, what's coming up on the horizon, technology, innovations? What would you like the key messages and takeaways to be from today's discussion?

Anton Dietzen, MD, FAAPMR: I mean,

I think in terms of advice, you know, just use your elective time and try things out. And once you figure out what you're passionate about and what you want to do, put everything into, making yourself the best at it that you can be. In terms of peds, because it's so broad, there's some areas where there's a lot of innovation and technology happening, and there's other areas where we're using the same medicines and same tools that we used 20 years ago.

I think one thing that I hope changes is more like the kind of equitable access to care for my patient population in particular, because you have some patients who can have resources, they can go to other countries and spend thousands of dollars on stem cell injections. And then, I have other patients who can't get therapy because there's nowhere that accepts their insurance plan, their Medicaid plan, or whatever it is. And so, I think really we know what helps kids develop and make those gains in therapy. And it's really just good old fashioned bread and butter therapy. And so, I hope that the innovation or kind of improvement with time is just being able to get that to all of them.

Melanie Cole, MS: I want to thank you all so much for joining us and sharing your expertise for other providers that are considering these very unique specialties. Thank you so much again for joining us. And to refer your patient or for more information, you can always visit our website at breakthroughsforphysicians.nm.org/rehabilitation to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole.