#11 Dr Mohammed Issa - Harvard Pain Fellowship

I'll tell you truly the one thing that I've noticed over the years now since I've been doing this the one thing that matters the most in Making someone successful Really is The App for Mention does not constitute medical advice and notice that it establishes any patient position relationship. The information and content on this website do not substitute for any professional medical diagnoses, treatment or advice. Seek advice from a qualified healthcare practitioner for any questions you have concerning a medical issue including treatment. Do not delay consultation with a professional or disregard their advice based on the information this website. The opinions, statements and views are that of my own and do not reflect those of my affiliated institutions, policy or entity. Hello and welcome to World of Pain MD Podcast where we discuss all things pain with the experts. I'm Dr. Derek Davis of Physician Specializing in Pain Management. So as pain medicine fellowship season starts to kick off in full swing here, I thought there'd be no better person to discuss their opinion on what makes successful pain medicine applicant in my program director, Dr. Muhammad Issa. Dr. Issa went to medical school at the University of Alexandria in Egypt. Then he completed his residency in psychiatry at West Virginia University where he was also chief resident. He subsequently finished three fellowships. First in Addiction Psychiatry at Yale, then pain medicine at Harvard through Brigham and Women's Hospital and then a forensic psychiatrist fellowship at West Virginia University. He is the perfect guest for this topic, not just because he's a program director with more than half a decade of experience, but also because he's so knowledgeable and incredibly insightful. I hope this gives you a perspective of the pain fellowship program director, but more largely into the field of pain itself. Applying to fellowship regardless of the specialty is a daunting and relatively expensive process. So don't be too hard on yourself and wherever you end up is going to be the right place. And frankly, it's just a year long, at least pain medicine is. So you can do anything for a year. The field of pain is a fascinating and meaningful endeavor and I wish you the best in its pursuit. All right, let's just jump into things, Dr. ESA. Thank you so much for your time. I really appreciate you coming here. Welcome to World of Pain MD. We're discussing all things pain. Yeah, thank you. Thank you. Thank you. Thank you for inviting me. So first and foremost, what got you interested and decided and why did you decide to pursue the field of pain? Yeah, that's a good question. I mean, I have to look back what, 10 more years, yeah, like more than 10 years now. So I did my fellowship back in 2012. So it was, it was almost 12 years, but I'd say probably my interest in painstark even prior to that. You know, medical school, there's always been some interest in a lot of things and then, you know, got more interested in psychiatry, maybe a little bit of anesthesia and then I just went into psychiatry just went in. Let's do it. I love this. I love talking to patients. I like the kind of report that you have with them. I like dealing with medications. And it was really exciting. And as, as I was going through the psychiatry residency, you start seeing a lot of, you know, addiction patients, a lot of these have chronic pain issues as well. And when you were, you know, trying to help those patients, trying to treat them, I felt there was something missing, especially with patients that had colmoir bit chronic pain issues. You know, you'd send those patients to the pain clinic a lot of times they come back and it's like, hey, there's not much we can do. It's all, you know, all the psychiatric stuff that's going on, that's what's causing the pain. And it's like, that just doesn't make sense. It's just much more to that. And trying to get those answers from other people, just it was hard. So it's like, you know, let me just go to the pain clinic. I'll spend some time there, see what's going on. And I did an elective for a month, I think like late in my second year of residency or early third year, and it's like I'm eye openers like so many things that I didn't even know existed. Right. You know, you send those patients to the pain clinic and you're like, not sure what they do. And you start looking at all these different tools that they have in pain from, you know, all these kinds of interventions and medications and therapy. And I was like, you know, this is really interesting. And you know, a lot of these things I can start offering my patients and talking to them about it. And it just got me more interested, more interested and went back. My residency was super nice. My program director was like, hey, if you need to spend more time, you can do it. And I actually ended up spending six months out of my residency. Which is unheard of. But it really consolidated my interest in it. And I was like, you know what? If I really going to help these patients, I need to really get formal training into it. And I was still very interested in addiction. So I did my addiction fellowship and went in and did my pain fellowship. And now I'm practicing, you know, pain addiction psychiatry, all of it together. And it's I would not trade that for anything else. And it's been a really nice journey and so many things to learn. And so many things, even in the future to kind of build in that kind of sub specialty of these patients that I feel have been underserved and under recognized and medicine so far. But there's so much to learn about it. And can you fill us in about you had some international experience too in your medical training as well. That is correct. Yes. So I say there's there's positives and negatives to that positives is, you know, a lot of times when when you go and train internationally, there's you get exposed to different things, you get exposed to different populations, you get exposed to different disease processes, you get exposed to even, you know, your your approach to different conditions is a little bit different. So we didn't have that much training in pain. And that's why I said when you go into into when I went into residency, a lot of, you know, kind of still naive and in regards to treating this and thinking about it and even exploring it. So even though I haven't had that much exposure prior to residency, I think it kind of intrigued me to learn much more during residency and pushed me into educating myself and training myself more. And I think that was like really the biggest driver in me pursuing that career. Sort of almost the lack of exposure helps propel you more so to seek it out for yourself in some ways you feel like absolutely. And the more you get into it, the more it opens up doors and you're like, oh wow, I didn't know this and it's just kind of in tricks. It's just learn more and more and more into it. And once you're fully immersed, it's like you just can't get out, you just can't learn more and educating you. And you know, that's the nice thing about the pain field is such a new, you know, era, it's a new field that's kind of growing and evolving. And I think that's one of the most exciting things is that even while you're still doing this, I'll say in the last 10, 12 years, there's so much that has changed that looking back. I've learned so much and so many things have changed compared to that. And that's the really nice thing is that you just keep progressing and keep evolving as the field evolves as well. How did you transition from, you know, a learner, a trainee faculty and now an administrative role? How did you get interested? How did you get interested in that as well? Yeah. I think that's kind of a big gap and I feel like sometimes when people make that plunge, they almost look back and think, oh, like I really missed just the patient care element. I don't know if that really resonates to you. No, absolutely. I agree. But I'll tell you something. First of all, I don't think at least in my case, I didn't plan it this way. There are people that may do that where hey, five years from now, I want to be, you know, PD 10 years, I want to be chief, you know, I did not. But there are things that I love doing. I love teaching. I love, you know, kind of educating. I love, I love my clinical practice. I love talking to basically. I love forming rapport. And putting it all together and I think that goes with anything in life. It's really doing what you love, kind of just feeds back into into what you do and gives you that really nice satisfaction and gratification, but also builds up your career. And it's, I think that's the really best part of what I do. So, you know, you start to do what you like, you do, you try to educate yourself, you work with colleagues that are very knowledgeable and love working with them. And, you know, these opportunities come your way and you take it. That's what I always say. It's like, you know, there's no harm in trying. And so these different things come my way and I'm like, hey, you know, I want to try this and see how it goes and and it's it's been such a nice journey so far. So, yeah, I definitely grown throughout these years, I've added more and more. And I think over the years, it's really opened up again, my vision to a lot of new things and made me learn a lot of things. And, I see now like, you know, new fellows and new residents and everyone that comes out and it's, it's, it's. extremely, extremely satisfying to see them grow and, you know, and again, comes back truly to the kind of gratification, satisfaction that you feel as a clinician as an educator as an administrator. What is your favorite part if you have one? Is it working like, well, like, well, if you, like, looking back on, you know, this, what it is in being a clinician versus being like this administrator role, do you have a favorite part in the administrative role? I mean, that's a fair question. It's the paper. Yeah, I know. It's, I mean, I'll say my least favorite part is going through the applications and reading them. Really, really. It's, it's just, because really the, the one thing I love the most is kind of be, form that personal relationship and someone and sitting down and talking just like we're doing right now and getting to know you. And so my, I think my most favorite part, especially as the PD is the interview part. It's just, it's so nice. Like, because you have a picture of someone, you know, you, you kind of form a picture and it can be, right, it can be wrong. Yeah. And it's just like a, like a presenting history from a patient. You read it in the chart and then you walk in the room and you're like, this is not it. I said to you to be like, you know, far sicker, but you look great, you know, it's exactly exactly. And it's the same thing. Sometimes you read these applications that it's like the most amazing person you would ever meet and you go in and it's like, oh, wow, that was like not what I expected. Exactly. And sometimes it's completely the other way around. Yeah. So, so that's really my most favorite part is like really going and doing this, these interviews and all that. My least favorite part is like just reading that because it's, sometimes it's really hard to read through the lines and, you know, you try to pick here and there and see and I just feel so bad that maybe I'm missing something and I think that's really what kind of makes me, you know, feel a little bit more stressed out when I do it. I'll put it that way. Because a lot of times I feel like I don't want someone who deserves to be in here to miss that. Yeah. And just not give him that opportunity. But I'd say from an administrative perspective, that's it. The clinical, you know, I love my clinic work and I'd say still that's my top thing. It's, you know, working with patients, seeing them feel better, even if not better, keep working with them, giving them hope that things will get better. And I think just giving that hope is really what matters the most. So still I put probably my clinical work still as number one, but definitely working with our fellows and kind of educating and seeing them grow throughout the year that's, that's unmatchable. That's great to hear. Speaking of fellows. So just jumping into kind of, you know, why we're having this conversation to begin with, is understanding your perspective on the application cycle. So are there key qualities or experiences you look for an successful pain medicine fellow applicant? Or like perhaps like when you look back, what are like, when you look at the very successful graduates that have come from this fellowship, were there any key themes or characteristics you saw? Yeah, I think that's a great. And I love how you kind of change the question a little bit because it kind of makes you think about it in a different way because I agree with you. When applicants come in, you may have a little bit of a different set of qualities that you're looking for. But when they go through the residency, you're, you know, kind of finish, I'm sorry, the fellowship, if they finish their fellowships and you kind of look back and look at the class and be like, oh, maybe this person, I didn't expect that, but see where they are right now. Right. Maybe a little bit of a different perspective. And I'll tell you, truly the one thing that I've noticed over the years now since I've been doing this, the one thing that matters the most in making someone successful really is how receptive they are to feedback. It's a huge thing. A lot of times, fellas get into their training or any kind of training, even residents when they get in. It depends on how open they are to learning, you know, and it's like we have those fellas that come in and they're just even if they know a ton of things, you're in residency. These are some of the smartest people out there, right? I'm really surrounded by such intelligent people all the time, it's really me too. I mean, until now, I mean, it's like I work with the fellas and I all the say, I learn even more from them than they learn from me because they're so extremely smart, extremely knowledgeable, extremely, you know, they want to go out and inquisitive and they want to learn things and they want to share it, super nice people to work with, but really how open are you to also open up and learning and not just learning from me or learning from other faculty or learning from, but also learning from your colleagues, learning from your patients, even patients can teach you a lot of things as well. When I truly feel this is the most important quality I've seen, fellas who are more open to learning from others and opening up to feedback are the ones that do the best, not just during the fellowship, but also throughout their careers after that. And I think if you had to pick one quality, I definitely put that. Is there a way that someone can work on that or express that when they're doing their interviews or when you talk to them, I suppose in the application or when you do the interview? Yeah, I mean, you can try and again, going back to what I said, it's, you know, the application is just paper, right? It's like there are things in your control that you can put in others, there are not and sometimes it's really hard to read through these and really know the person unless you sit down and sometimes even like really work in a spending time with them and that's why, you know, when you read the applications and you go through it and you see that someone maybe, you know, have some of the qualities that are, would be a good fit to put, it's really good to kind of pick up the phone and talk to people who are working on that. That's something that we really try to do. So we're divided, you know, there's usually somewhere around eight to ten faculty that review the applications with me and we divide the work and be like, hey, if you know person, can you just call him in that hospital or that universe, just ask, like, just plain, how do they do? How are they doing there? How are they working? How's their, you know, are they open to feedback from faculty? Are they, how do they work with the team within their colleagues? How are they doing all? Because this is really what matters at the end of the day. This is really what matters the most, not just for a person to grow throughout the fellowship, but also for the whole fellowship to grow because you as a person, as a fellow within it, it's you're a part of a unit. And if the whole unit doesn't grow well, if there is, you know, kind of something that's broken and it just breaks the whole thing and everyone gets affected, not just you, but everyone else. And I think that's what we've tried to put emphasis on over the last few years since I've been here is how can I get, and it's a big fellowship. We have ten fellows every year, right? It's like trying to get that kind of harmony because these are fellows that come from all over the country, from different disciplines, from different backgrounds, from different everything. How can I make it as harmonious as possible and get these fellows who can learn and grow and educate into all of these things? And at the same time, hopefully become leaders in this field as well. And it's a really fine balance that you can try to do. And every year, I keep my fingers crossed, the start of the year and the end of the year. I just help this year, we just don't have, because it just needs one person that just doesn't fit too well. Let me just destroy the whole thing. It is funny how I think at least this year, every one of us has fallen into, you know, I don't know if I can really speak to myself looking out, but at least the people that I'm surrounded by, it feels like everyone fit into their puzzle pieces very well. And it made a hole that, you know, I'm just surrounded by people that are so intelligent and that are, you know, inquisitive like you had said. And then, you know, I just feel like every single day, I look forward to going to work because of the people I'm working with. And it's huge. I don't know. I'm glad that this culture exists because I'm really happy to be a part of it. And I'm amazed to hear that. That's good. This is exactly what I want to hear. You know, at the end of the year, this is exactly what I want to hear. I want to hear a fellas come to me and be like, you know, I had a good year. I enjoyed it. I feel sad leaving. I think that's really, and that's what I've been hearing over the years now. That really, for me, tells me everything. It tells me that we have done a good job because, I'll say, you know, one year is just so hard to learn so many things, right? Right. And it's like you have to put so many hats on. I know. You know, when I meet fellas during the interviews, I tell them that you got to put on hats as a surgeon, as an neurologist, psychiatrist, as an internet. There's so many things that you need to learn. And you're not going to be able to learn whatever you do. Even if you work 24 hours a day, you're not going to be able to learn all of that, right? Yeah. Throughout the year, there's so much learning that's going to happen after that. But I want you to kind of get the wide concept of all of these things together while you're still enjoying it. I want you to, at the end of the year, you feel confident that whatever walks through the door, you'll be able to handle it. And I know that I'm still going to learn. But I know that I'm going to do it in a safe way because I know all my bases. That's really what I'm looking for at the end of the year. Someone that feels this way, but at the same time, they've enjoyed that year as well. Are there certain things that you're going to be able to do? things at the beginning of the year that you, that residents ask you, what can I do to improve my competitive, see, competitiveness to enter into the fellowship? Right. They do. I mean, I always tell them, and you know, I always say, just first of all, like our brains are like a spawn, right? And especially when you're coming into training and you're coming into a fellowship and you're working with these super smart people around you, you know, other fellows and faculty and everyone around you, it's like so much resources around that just keep yourself open to all of that. Just keep your ears open, just learn, try to learn as much as you can because these are different people with different backgrounds and so many things to learn. So I always tell them, just, you know, sometimes all we need to do is just sit back and just listen and learn and read. I mean, as much as you can, whenever you have time, just open up a book. There's no bad folks just open up, learn, there's going to be so many opportunities around you. There's going to be workshops. There's going to be things. Just go to as many as you can and just, you know, keep that sponge absorbing as much as you can. And that's really what matters the most. And that's what I tell them. It's like, don't like try to have fun while you're doing it. But at the same time, it's a sharp, sharp learning curve. So just, you know, just accept it. Don't feel stressed about it because that's how it's going to be. You just accept and learn as much as you can. And you'll see that sharp, that sharp curve is start starts to flatten out. You know, the first third of the year may be really sharp and then starts flattening and starts flattening and the last third is going to be almost flat where you're just absorbing and learning and tweaking all of these things. But you will get there. You will get there. Just be open to all of that. That's encouraging for me to hear right now. Oh, you're doing great time. Don't worry about it. I am not worried about you. Oh, good. Thank you. What are some common mistakes that applicants make during the application process and or during an interview as well that you could give some advice on just how to avoid? Yeah. I think really the biggest mistake is focusing too much on the paperwork and how your application looks and not putting too much into how I am as a person and how I fit within my team. So I've seen sometimes, you know, applicants that come in that have published 30, 40, 50 papers. Right. Yes. But you sit down and talk to them and you just can't even have a conversation. Yeah. Or even during the residency, you talk to people who worked with them and it's like, hey, we don't see this guy at all. He's like doing this and doing that. Or if we ever ask him for, you know, to help out here, they just don't want to do it because they're busy. Which I understand. I mean, they're probably because of the things they're putting it. Yeah. So trying to really divide your time and being efficient as much as possible, but also at the same time, really very important working within that team. I think it's, you know, I, we always hear it all the time, teamwork or teamwork or team work, but really understanding what that means and really working within a team. That's the, that's the gold egg. That's really what matters the most. And it's not just throughout your training, but even as a faculty, even after training, this is what employers are going to be looking for. This is what they are going to pick up the phone and ask hey, doctor, he's that that fellow that graduated. How do you think he works? Is this their main thing? Are you going to be someone that is going to be dependable? You're not going to be, you know, missing half your work days or things like that. But also at the same time, are you going to be able to work within the team and not be, you know, a burden to that health system or whatever it is? So this, this is a quality that you carry on forever. And if you start putting that emphasis when you're putting in your application and showing that even during your interview, I think that makes a huge, huge difference. And I'll say looking back at, you know, five, six years that have been doing, you know, as PD and during these interviews, the one thing that I feel especially during interviews that is a big no, no, where faculty that are interviewing you know, like no, we is showing, you know, kind of like, and I'll put it frankly, you kind of arrogance. Yeah. Yeah. It's just a big thing where, you know, even if like I said, even if you're the smartest person, even if you've done so much research, even if you just, and it's sometimes a little bit of a fine line, right? Finding that fine line between self confidence and showing that, which is good. But crossing to that arrogance and be like, hey, it's me, me, and I can do everything by myself. I don't need anyone else. This whole team thing is that's a very fine line that you have to walk if you're going to do it. Yeah. But that's what really throws you off completely and can be a huge negative thing during your interviews. Yeah. You know, and I, I think two things. One is it's so challenging for us as medical students and residents, I think, to try to balance that when it comes to having what it takes on paper to get your foot in the door to then prove that you're a good team member. And I think that, you know, that's when kind of the letters of recommendation come into play. In some regards, I think that then if you can have people vouch for you, not only, you know, has this person done a lot in terms of their academics, but also working with them is really a pleasure. Is that what you see from letters of recommendation? Is that what you look for in letters of recommendation? And then I, the other thing I was going to mention is that I'm so blown away by some of the people that I've met here about how they are not arrogant. You know, we have a co-fellow that was giving a lecture on, I think, monastic eating. And I was like, what? And, you know, and, you know, it's just, they do incredible things all the time. And I just think walking right, you just feel really inspired by people like that. So I will, you know, it's such a testament to people when they can do both, you know, right. I totally agree with you. And it's not just like, and, you know, residents, I mean, I have residents that I've met that I'm impressed by. I'm like, wow, I wish I would be like you one day or, or fellows, you know, or faculty and they walk around just like, you know, like they haven't done anything at all. And it's really impressive. I wish we all could be like that. We strive to be like that. We could learn to be like that. And I always say there's so many of these qualities. They're not like, hey, you're born like this. You learn to be like this. And it's always, again, comes back to just being open looking and learning how these people act, how these people do and just trying to kind of be, as if I look at what I've done and be like, oh, wow, you know, I've done so many things and just shout myself and just be there. Or I can open up and say, hey, look at this person. I've done way more than I did. And look, there's just nothing. And it's really looking and learning from them. And I do it all the time. I learn from people. And I mean, I wish like all, you know, all the residents and trainees who come in and fall asleep comment, they do the same thing. And I think we've been lucky that we've seen that over the years now that those are the people that we're getting. And I think that's what really builds up and makes this program a really strong one. And then just touching base on the letters recommendation, what do letters recommendation mean to you? What do you look for in them? Yeah. So again, you try to reach between the lines, right? And sometimes it's better than anything. It's just picking up the phone and just talking to this program director or something like that. But definitely when you go through the letters of recommendation, you're trying to look for words that mean these things that we talked about, teamwork, compassion, working with patients and forming report with that. You know, kind of how their relationship is with their colleagues, how their relationship with faculty that they work with are the accepting feedback well as they should or not. So those are the things and those are the things that kind of build up a character. And those are the things that will make you a very valuable person, not just right now during your training, but also as as faculty later on. And that's what we want to see. We don't want to be graduating people who go out and, you know, be for a better word cancers and wherever they go, right? So those are the things that you try to read through through it. But sometimes, you know, like I said, it's just it's all embedded there and you can't figure it out. Best thing is just call the person like, hey, how do you think of this person as a person? How have they done? What kind of relationships they have with everyone around them and how have they shown it? But those are really the most important things that I look at when I read letters of recommendation. Doesn't matter if the letter comes from a pain provider or whoever in your, you know, in as our field sort of changes, we're going to have, I think, a broader specialty, you know, I guess, swath, including people from, you know, Bailey medicine. I've seen general surgery. I've seen. So it doesn't matter that they come from pain specialist, specialist specifically. It's not a must, but we do recommend it. And again, I think a part of it is not just like, "Hey, I want to see how you do within a field." But one of the things we're always looking for is how genuine are you in this? How are you one that, "Hey, there's really nothing else I want to do, so I'm just going to pick pain." Or is it really, "I have strong interest in this?" Because this is what we want to build on, right? We want people who are truly interested and have a passion for this field because those are the ones that are going to grow. Those are the ones that are going to go out and become leaders in this field. That's what we want to be associated with. We want to give them those tools so that they can build. We have so many of these tools. We want to give it to the people who really deserve it and go. My recommendation would be for people to try and work with a pain, physician, and get at least a letter of recommendation, doesn't happen all the time, but if you could, I would definitely recommend that. Excellent. Speaking of working with pain specialists, how much familiarity should residents have with pain procedures? Should they have done all of them, the medial branch blocks, the epidurals, the RFLs, RFAs, or is just a familiarity with them such that they know about them. They know how they're done and why they're done, or not much at all. What spectrum are you looking for when you're talking to people? Definitely I'd say to be familiar with as many of them as possible. You do not and we do not expect people to do like 10, 15 procedures or 20 or that of everyone because we know that a lot of these programs, they have already fellows or they have faculty that do it. That's not our expectation. If someone is really interested in this to be at least reading and seeing some of these as much as they can. That's our expectation and that's what we want to see. Yes, of course, we would love for them, especially if it's from a specialty that's non-interventional, like let's say psychiatry like myself or neurology is to get your hands wet and go away and do some of these procedures because again, it's one year that you're going to learn a lot of things. So many things. We don't want to spend two, three months at the start of the fellowship just teaching you how you're going to put in, you know, lidocaine and do these things. We want you to at least know those. Again, it depends on what kind of subspecialty or specialty you're coming from and I agree with you. This is what we're seeing over the years now is that more and more of non-anesthesia, even non-piminar, and those are the two primary specialties that go into pain. More and more of these subspecialties are going in. So we want to see more of that involvement of like learning more of these technical skills, at least the basics of them, not for anything, but just so that they don't waste their year in learning those basics and just kind of jumpstart and do the more invasive things and more complicated things during the fellowship. Moving from the practical side of things to the academic side of things, what sort of research experience are you looking for in potential fellows? Are you looking for any research experience? If you are what sort of research experience? Yeah. Yes. So do I look for something I do. And it's not the basis off, you know, we live in a reality where we know that not everyone that's going to graduate and not everyone is going to be in an academic place. If you look, let's say in the last 10 years or so for fellows, I'd say maybe about 50%, they go into academia about 50%, plus or minus, every year is different sometimes. Yeah, but it's about half going to academia and half going to private practice. So just to have that assumption that everyone I want to get into the fellowship, I want them to be, you know, it's not. And this is not what we're looking for. There's actually sometimes more benefit in graduating, you know, fellows who will go to these places where, you know, there's just no other pain doctors at all. I want them to do that to go do, spread the word, learn, provide patients with the care they need that there's just nowhere else. So we want to do that. We want to graduate people that even just only provide clinical care. But having said that, there's so much to kind of be involved in research because it's, you know, once you start looking into something, you just broaden your perspective. You learn how to review an article in a, you know, in a meaningful, critical way. And this is something that you're going to carry out even if you're going to do clinical work after that, right? So this is really important. I want to, I want to see someone who's like open to that. I want to see someone that's done that work. I want to see someone that understands all these concepts when they come in. So the question is how much and all that kind of truly even if I see that they've been involved in, you know, a couple of research, that's totally fine. Yeah. It can be case reports, can be things just to show me that they're able to do that part. But also at the same time to really show me that genuine interest in pain too because it tells me that if someone has done that part and has put the efforts into it, has put the work into it, they really genuinely have some form of passion towards doing that. That's a good sort of reflection of what research means. I think, I think these days, in addition to USMLE scores, we are so caught up on numbers. But the reality is that research reflects strong interest in things sometimes. Sometimes people just kind of crank out numbers, I think. But I do think that research has allowed me at least to look into things in depth more or so than, and then especially it allows you to pursue an interest to the eighth degree that just reading a textbook went. Absolutely. when you are reading personal statements. What are some things that stand out to you that you think really impress you in terms of certain themes you've seen, and then the follow-up question will be, what are some things that you would say to avoid in putting in personal statements? That you may have seen. And believe me, there are so many things that you read and so many things that I'm like, "Oh, wow, they should not accept that." I mean, we get something around 300, 400 applications every year. After a while, we start reviewing applications and you're like, "It's almost the same thing just being said over and over again." Definitely there are some of them that catch your eyes. And truly, if you try to look back and see why, why are some of them really catch your eye and some of them do not, and some of them, you want to kind of keep reading instead of just cleaning the damn. Right. A good story, I'll just. Exactly. I really think what makes it that way is how much of a true story have you put in, how much have you really looked back deep inside you and thought, "Why? Why do I want to do this and why do I want to spend my whole life doing this?" And taking back from your past into the future and really trying to reflect that as much as you can, that really matters the most. A lot of times I see candidates just getting caught into like, "Okay, I'm just going to write just facts, facts." This is what I've done. I've done so many things. I've volunteered. I've done so much research and that's, you know, I want to do like in five years, ten years, this is what I'm going to be. And it's all facts, facts, facts. And I don't need that because I can get that from the application, right? I want to get beyond that. I want to get to the real you. First, that story comes from and it can be from, you know, a story like when you were just a kid and kind of working or doing, or it can be something that started during, during a medical school. It can be something that started. I had no interest in anything. I just went through the process, which is totally fine. And you know what? Sometimes it's refreshing. Just sometimes reading this like really true like, "Hey, I, but then during residency, this is really what kind of clicked with me and kind of like made me really start thinking differently." So really what I'd say and it's really not an easy answer, but sometimes it really needs for you to kind of sit down and just think and think and think back and really think deep into yourself and be like, "Why did I do, why did I become where I am right now? And why am I even thinking of doing this?" And trying to put that in words, which is the hardest thing. Yeah, leave me. Yeah, trying to put that in words as much as you can. And it really, the more you put into it and the more it comes from deep in your heart, reflect into the paper and it comes to us and you can read it. And you'd be like, "I start reading and I'm like, oh wow, this is new. Like I want to see what's going on." And you finish it and you're like, "This really had an impact on me." It carries a lot kind of doing that. And I'll say, personal statements can really carry a lot or carry nothing at all. Yeah. So just try to spend time thinking about it that way. Does one aspect of an application, is that what hinges on a candidate being bumped up or in what ways do you look at applications comprehensively? - No, not one aspect at all. And when I meet with faculty to kind of tell them, and we probably will do this meeting like in the next week or two. Like I said, it's 10 of us that review those applications. I'm lucky that I have so many people that do the initial ones and then I do the secondary ones after all of them, but I review all of them at the end of the day. And I sit down with them and I say, do not, and this is exactly what I said, the point that you said, do not depend on only one thing. Please do not depend only on, 'cause you may look at certain things and you may see like glowing parts. It can be their letters of recommendation. It can be their research work. It can be their use of semoles. It can be, but try to look at it all together from their medical school kind of, you know, evaluations to their academic work, to their scholarly work, to their letters to this, and we kind of grade all of this, and kind of almost doing points to all of these and then adding them together and then coming up with an average score of eight. We come up with that score, depending on application, and then we go and each one will have and we'll say, okay, these are, for example, that's the score that above that, these are people who will be granted interviews. And usually at least two or three faculty score them and we get average on them. So it's not just dependent on one person's scoring, so there's at least there's two, including myself, or maybe even three. So I always try to be the even person throughout, all of them to kind of just even out those scores. And then I'll take that score and we'll go into the interview and either go up on it or go down. So it's not like we're doing a totally different scoring in the interview, so we take that score and we either go up or go down on it. So what we've been doing that in the last several years, and we feel it's really been, it gives a very fair reflection because you're now looking not just at the application and being evened out throughout it, but also the, or building your interview on that application as well, so taking that and incorporating it into the full picture. - That's a great way to look at things. I didn't know it was so comprehensive, but I really respect that because I think, like you said, I mean, just paper is just one thing. When you sprinkle on someone's personality through an interview from that, then you actually get the full idea of who someone is and whether or not they'd be a good fit for a certain program. If a potential candidate was to ask you what a typical day looks like for a fellow, and I suppose I could answer this too, but what would you usually tell him? What do you think? - You don't want to tell me. - What is a typical day? - My perspective is we see, dependent on what rotation you're on, you would see your either in a clinic day, you're in a full procedure day, if you're, let's say you're on the inpatient rotation, or if you're in a clinical rotation, you would do half day clinic, half day procedures, which I love because it really keeps things fresh. - So that's kind of like a very brief representation of I think how I see my day to days. And then inner mix with that is academic days where I focus on whether it be research, reading, or doing podcasts, video sort of stuff. That's my typical day. And that's exactly how most fellows would spend their days. And things have changed over time. I mean, it didn't always used to be half days, half days, it used to be even when I did my fellowship 12 years ago and now it's used to be just throughout the day, you'll be like seeing patients running it. And it was so chaotic. - Wow. - I feel like it was a huge impact. Kind of switching. And really one of the biggest things was feedback. And I always say it's really important kind of listening to the fellows at the end of the year and be like, "Hey, what do you think we have?" And it's something that I always put a lot of weight on is these exit interviews that we do for fellows. And we've seen it over year, over years, like they just kept saying it's like, it's chaotic. Like we learned a lot, we know it was great year, but I wish there was more structure to it. And you can't imagine switching to those half days, half days, how, 'cause it's all to your brain. It's just so hard to kind of jump from, sync patients doing the procedure, sync, it is, but it also makes you so strong. Right? It's like at the end of that, because then you can take on anything. So, but that being said, I am glad we have structure such that we do now. I think it's the perfect sort of balance between the two. - Absolutely, absolutely. So how would you like to communicate the weight value of clinic versus procedures to applicants and to us fellows now? So, I think one thing is we are really caught up now in the pain sphere as I'd call it, of doing more and more advanced procedures and more and more of wanting to call ourselves pain surgeons, which may be an app title or not. But regardless, how do you see the value of clinic versus procedures? - I think that's another great question. It's, and I see it over and over again. I'll put it since you've asked this question of actually, remember the earlier question you asked and it's like during the interview, what are the things that applicants should avoid saying? And I think the second thing other than arrogance that I really hate seeing applicants say is, I just wanna be an interventionist. I just wanna learn the interventions I want. I think I wanna be a great interventionist or I wanna be a great surgeon or I wanna do this. And you have one of the biggest surgery kind of programs or pain surgery programs in the country. And I wanna learn from the best and do it. And why it is? And it's true. I mean, do you tell them there's IR? - Yeah. (laughing) - There's IR, there's, you could be a surgeon. It's like if you really wanna do this, you could be a surgeon. But it's not that because pain is not that, right? I mean, even in the definition of pain, I mean, when we talk about the definition of pain, what is pain? I mean, there's a sensory component. There's an emotional component to it. So if really all you wanted to, like, you know, I wanna be an interventionist. And even like you'll see them saying, interventional pain, you know? - Yeah, yeah. - Because they just wanna specify that that's all we do. Then you're really not doing yourself or you're doing patients any favor, right? Because you're really focusing on that sensory part but you're not focusing on the emotional part. And that's what chronic pain is all about. You have to focus on all of that. And that's where the whole concept of multi-discipline and comprehensive pain and all that comes from that. It's like, how can we integrate all these different treatments? It doesn't mean that you need to do all of these things. You need to do the psychotherapy for the patients or you need to learn chiropractor therapy and spinal manipulations and acupuncture and all of the, you don't need to learn all of these but you need to be knowledgeable about them. You need to talk to your patients about them. You need to know which patients that you shouldn't be sticking needles in and you should be focusing more on, you know, these treatments. Who are the patients that you would talk to them and say, hey, I think you need therapy because a big part of this is central pain and this or that or talking even about the basics of just chronic pain to them and saying, or which ones that you think medications are gonna help or which ones that you think therapy are gonna help. So you need to have a big, that big picture. And I'll tell, I've had one of my mentors during Foshpon is still stuck to me until this time is truly chronic pain is third. There is a third where, you know, you see patients and you follow up and do these things and you think about medications and you think about and there are third, so it's mostly medication aspects with maybe therapy or so. There's a third that needs like a form of full comprehensive therapies and you have to think outside the box for these and then there's a third where interventions are great for them and even those interventions, there's much smaller percentage of those that will need like these advanced interventions and search and you have to think of that. If you really wanna focus only on that third then you're leaving about two thirds of patients that are not gonna get better and if they don't get better, believe it or not, that's gonna get back to you because you're not gonna feel satisfied at the end of the day. And if you don't feel satisfied and that's the number one thing why you see these high levels of burnout among physicians is it's not because they're working along. It's just because they don't feel satisfied that they're doing and if you don't feel that way you're just not gonna have that compulsion to kind of continue to make what you're doing. - Yeah, that's really insightful. Yeah, I think that there's like an existential void of meaning and a lot of jobs and I do wonder why are doctors getting burnout? Like this is the most meaningful job you could possibly have helping people in the most vulnerable times. But I think that if you miss the point, if you think that the reason I'm here is to use needles or to do, you know, quote unquote pain surgeries, then I think you'll get burned out very quickly because like you said, it's not for everybody and if you do it for the wrong person, they'll maybe not get better, they'll get worse, you know? So yeah, that's really insightful. What are in addition to sort of maybe misinterpreting what the field is, What are some. common challenges that fellas face during the training and how would you advise or prepare them for that? Yeah, so I mean, I'd say really the hardest thing is the first few months when you start the fellowship. And I always say it really, that's what makes you continue and learn and grow as a fellow or not. And it comes back to that point that we talked about about how sharp off of a curve it is. So the more the fellows are open to learning, the more the fellows are open to listening, the more the fellows are open to getting that feedback from faculty and learning and incorporating and growing on it and all that, the better they do. So really the biggest challenge that I see fellows sometimes struggle with is doing that is going in and be like, hey, no, I know how to do these things. This is how my institution did it or this is how I learned or this is how my mentor taught me and I'm just not too open to like, you know, whatever you're taught me, why are you even telling me this and all that. But really like if you open up your mind to learn and kind of, you know, tie, even people that you don't expect to learn from, I mean, there may be, you know, even non physicians that work with you and have been doing this is just learning. There's so many things that they've been doing over the years that there are little things that you can learn from each of them and building up. So I'd say this is really the most important thing and if fellows do that and if trainees in general do that, I think they're going to grow and they do very well during the fall ship. Yeah, I'll echo that. I have learned so much from just rad texts. Like, you know, just like, you know, even reps like, you know, coming in with different, you know, spinal cord stimulators and perforationators and all that. There's so much things you cannot say. All these are non physicians that just, there are so many things that they can teach you as well. They can incorporate into your own practice and build up on it. So just be open as much as you can. I'd say that. How can a program achieve a balance between the academic clinical and procedural aspects in a paying fellowship? I think that that's a really unique thing for each paying fellowship because they're so different. You know, you interview around and some won't do, you know, spinal cord stem trials, even trials. So, yeah, no, I agree. And it's, and that's exactly what I was going to say, really different between one place and another. It doesn't mean that one place is inferior to another. It's just, you know, this is how it is. And a lot of times it's always good for you as an applicant to also look at these and while you're interviewing and I've seen, you know, fellows and I love that applicants who would like make a graph and be like, Hey, this is a program that like, okay, academics is like high, this may be a little bit of lower clinical load. Oh, this is a very high clinical fellowship in this and that. And thinking about yourself, where, where do I want to be? Where am I like really want to focus on research during my fellowship and I want to, so this is a good place there. It's hard. It's hard to find that balance. And even like in a place like ours here, it's a very high clinical fellowship, right? And we like it because our fellows like it and we can, we can always change if we need to, if we find that the interest of the inner fellows, but a lot of our fellows who come here, this is what they want to see. They want to do high clinical work. And I see a lot of advantage for that. I always say, you know, sometimes an example is, you know, CRPS. Sometimes it's, it's better for you and you can learn much more seeing 10 patients with CRPS and doing different interventions and different treatments and seeing their progress than reading a whole book about CRPS, right? These things will stick in your mind. These patients will stick in your mind forever. 10, 20 years from now, you're going to remember them. So there's definitely good advantages. But of course, if there is a high clinical volume, then there's less time for doing scholarly work and academic works and things like that. So we definitely take that into consideration with changed over years, with given more, you know, nonclinical days for fellows to work on some of these things because we also, like I said initially, I said, you know, it's also important for them to do that work. And we're modifying it. We're kind of getting feedback year after year to try and find that fine balance. We're still want to keep it as a high clinical fellowship, but also at the same time, given them that opportunity, especially if someone is really highly interested, let's say in research and things like that. How can I carve it their fellowship a little bit where I can give them a little bit more time in that? But it's definitely working progress every year. We have to work on it. I mean, I really commend you and Jason, Dr. Yong, about allowing the flexibility to some of the fellows to, you know, maybe tweak things just a little bit based on their, you know, pretty significant interests. And I think that that's just awesome. And I think that it, you know, finding that home in a place like that has just been so great. And then also allowing me to interview for a podcast. So the field of pain medicine has rapidly changed over the past five, two, five years. Like a lot of, a lot of programs in fill, like over 30, I think this last cycle. And then like there was, I think, 60 unfilled spots and last, last cycle. So where do you see the competitiveness now of pain medicine? Which is crazy, right? I mean, it's like, if you asked me five years ago, I would never even think about this. I mean, it was so competitive to the point that you can't imagine like how many emails I would get from people. It's like, I didn't match. I don't know where to go. And it's really, I mean, it's a reflection of how the market is. And we've seen it years and years, you know, it's like, if you look 10, 20 years ago, it's, you know, the primary specialties, how, you know, for better terms, how hot are they, right? And pain, still a big part of it is coming from anesthesia, right? And it's not just pain, it's all fellowships, right? You'll see that, hey, they're, they can just graduate from residency and make so and so, why do you have to spend an extra year when you can make more even just doing this? And then the kind of market kind of cools down a little bit and then you start seeing the applicants starting to think about, okay, I can invest an additional year in, you know, whether invested in my education, my career, things like that. So right now that's what we're seeing. We're seeing the kind of hot market and specialty and you're seeing less. I truthfully see it as a positive. I don't see it as a negative because what happened is it opens up more exactly like you mentioned, opens up the door for more of non anesthesia specialists to come in. And that's exactly what we've seen. This class that we're getting, the new class that's going to start next year, actually half of them, I think either five or six out of 10 are non anesthesia. And I'm really excited about it. I'm like, because this is really how you grow the field. Just like opening it up to all these different disciplines and all these different specialties. It makes you, I mean, when someone from, let's say you said it, like family medicine or surgery or emergency medicine, they're sitting down and it's like, oh, I'm just not going to have a chance going in or someone else is like, hey, I heard like there's more openings. You start thinking about it. You start being investing time, investing energy, investing education, and doing it and applying for it. And then we start seeing like more of these non anesthesia applicants applied. I know time is going to come where it's going to change again. And we can, you know, evaluate and see how things go. But I'm not too worried about it. Of course, there's other reasons to, and this is not again, just for pain medicine within insurance changes and approvals and all that. So it's getting a little bit harder. But truthfully, I think the primary reason it comes back to how hot these markets, primary markets get and you'll see that shift as it happened before it's just going to happen again. Yeah. The cost benefit analysis is a little perplexing to me because if you were interested in doing pain and you decided not to pursue it because you were able to make more money, I suppose that maybe like the interest of that later on in life could help. But at the same time, if it's just a year and you have the ability to then go to one year of training about something you're interested in, I would say that just do that first because you always have the opportunity to do your primary specialty. But going back and doing one year of training after you've done, you know, X amount of time in the field. I would suspect to be harder. And I think pursuing something that you're interested in, you always then have the ability to do this thing that you did for a year in your future. So it's just kind of interesting. I could not say better than that. And this is exactly what I tell residents when we talk about this. This is exactly what I tell them. And it's much, much harder. I'll put like five lines under that. Much, much harder to go back again and do it. And it's just even if you cannot imagine every year we see applications from very high, achieved personality, but they graduated years ago. And there's always a lot of question marks that come with it. And I think one of the biggest question marks is like, why now, why are you thinking about it now? What's the real passion that's driving you to do this? So it's much, much harder. If you really have a good passion, if you have passion for anything, you want to do it, please invest that year and do it now. And it's going to pay off just holding one year. You've been in training for 15 years. Right. One extra year. I have a whole life. Yeah. Something I just wanted to mention too is that I think that people are a little hesitant out of the field because of the reimbursements, the insurance bets. because they're worried they won't make, you know, quote unquote, is much money. But the elements of pain are like threefold, like you said, you know, it's the it's the clinical aspects of building that like the rapport with the patient. It's not just the interventional thing. So if they're not reimbursed, you're still like a primary care physician for pain for for people. And maybe that's not appealing to some people, but maybe that's part of the reason why people aren't coming to the field. Correct. I totally agree. And what we've seen is even if the reimbursement for intervention has gone down, the reimbursement for visits has gone up. So it's always balanced. Yeah. So if you're really doing the right thing and you're treating the patients the right way and doing the components of treatments and care for the patients, where you're balancing all of these at the end of the day, balances out. Right. But I 100% agree with you. People who are not interested in that just want to be intervention. Yeah. They are the ones that maybe not as interested in doing this. That we truly don't need to have. And that's why I kind of started with all of this by saying, I am interest. I am intrigued and kind of excited about things. And I don't feel it's a dark cloud in any way. I think it really now even makes my job easier in selecting people who are really interested in doing the right thing rather than just coming in for the wrong reasons. That's awesome. So moving forward, what career opportunities do you see I suppose for pain medicine graduates now that you've seen in the past and what you expect to see in the future? Yeah. So I mean, again, I think pain is not going away. There's a human experience. Yeah. I always think that like, you know, these people will still be here until they're until they're uploaded on the internet. You know, absolutely. I mean, it's like we are getting older as we get older. There's more wear and tear that happens. People are just doing more things. They're becoming more active. They're living more active lives for longer periods of time. So we'll see the chronic pain kind of being there. And people want that to be treated. We're not in a society where people are just sitting back and saying, hey, I know this is how it is. I'm just going to be in pain. I'm just going to live my next 20 years, 30 years in pain. No. They want to be in their 67s. They want to feel better because they've been working their whole lives. And they want to be now. Want to go travel and do these things. So it's not going to go away. And the career will always be there. And with that and with more and more patients, there are becoming that we see are kind of going in and seeking these treatments. More of the pharmaceutical companies and more of the interventional companies are developing because you have more of these patients. So the growth of the field itself, I just see that it's just going to keep growing. And we see it. Like for example, let's say in the last 10 years, most of the growth has been what has been mostly interventions, right? Spina-court stimulators, all these minimal invasive procedures and these minimal surgical procedures. That's where we've seen a lot of the growth. We haven't seen a lot in the drug industry. But there's so much right now that's in the pipelines that we're going to start seeing. So we'll see that pipeline also opening up. And I'm really excited to see a lot of these drugs coming out. And we'd be treating patients with selective sodium channel blockings, with TNF, with all these other things rather than just non-surorders and talon or a couple of neuro-pathic medicines. So that's where I see things. There's going to be more demand. There's going to be more things to grow. We're going to see more of all of these different treatments. And we're going to see more patients. And I just think we're going to be in demand forever. I just don't see that that's going to go away. Absolutely. So what has opened up my eyes being here is that I've seen and heard, pain fell is wanting to be part of the biotech industry and pharmaceutical industry, like you had said, and the medical directors for potential device companies. So I think that the opportunity seemed kind of endless in many ways. So I think despite sort of maybe not the negativity, but the suspicion of the field, I think it seems to me like there's more and more opportunities like you said. So I'll just second that. So how can one make themselves more marketable as a pain specialist after completing fellowship? I think really the most important thing is, first of all, I mean, making as much of the social connections as he can. And throughout the fellowship, you're going to have so many opportunities to do that. Go to the meetings. Go to as many meetings as he can. And I always say, really, there's so many things to learn from these meetings. And these, especially if it's like national meetings that you go to. But more important than the learning part of it is forming those social connections. And the more social connections you make, the more opportunities you open up to yourself. And you can kind of open up all of these different opportunities. That's one thing. Second thing is in your training, opening up to learning as much as you can. So again, future employers don't want to just kind of get someone that has done like 1,000 epidural source, 1,000. They want someone that whatever walks through the door, they can treat those patients. If someone comes in, they have an infected interethical pump or they have tried 100 things. And there's nothing that worked for them. What can I offer these patients? How can I treat these patients? Sometimes can be simple as, and this is something that you learn at the end of the fellowship. Sometimes it's just sitting down with the patient and listening to them for 10 minutes. That's all they want to hear. So having all these tools and learning and building up your toolbox and listening and forming rapport with patients and knowing who would be good candidates for what? I think that's really what matters the most. And that's what employees will be looking for. And the more of these tools that you develop, it can be again. I've had fellows over the years be like, especially when Suboxone used to have an x-license for that. They would get there and say, you can't imagine how many times the employers are like, oh, can you treat addiction patients? Can you do this? You don't know where or how or what kind of patient population there is out there. So the more of these tools that you build up through your fellowship, the more marketable you're going to be. That's good advice. I think sometimes I struggle with the idea of going to workshops because everyone says, go to the workshops. But then there's like 10 people around the station that are trying to learn something. Everyone wants to get in there. And then by the time it's your turn, the clock's up, and you're going to rotate. So what I've learned, though, is you go to the workshops and you make connections. And for instance, making connections or the representative, I learned about the accelerated program through Metronic, which you get opportunity to more workshops after you graduate from fellowship. So it's not just about-- for me, in order to learn something, I need to repeat it 10 times and hopefully in a row. And so I'm not going to get that opportunity to workshop. And I'm just kind of talking to maybe people that aren't in the programs that get a really high level of procedural volume. And so I'll just echo your point is to, I think, going to all these meanings, something else might come up that's not just like you're supposed to intend an idea behind it, like going to this rotation where you're going to do maybe a spinal cord sim trial. And then do you have advice on pursuing an academic career versus a private practice career? I really don't. I mean, there's an advantage to each of them. And there's pluses and minuses like we do for everything. And even myself, like when I started this, I even myself kind of struggled to think about this. Like do I want to be an academia or do I want to-- and when fellas come and talk to me or, you know, Trini's come and talk to me, I'm always like, what do you want to do? The one thing I'll say is, if you're kind of in the middle between this and that, I think it's always better to maybe start an academia, see how it feels. You're going to be most likely working within a whole team. You're going to have the support there. You're going to have your colleagues. You're going to be learning from them. Because like I said, after you finish your fellowship, there's a really sharp learning curve that you're going to have for, you know, 1, 2, 3, maybe even five years, so they're still learning a lot, right? So it's always nice to have that kind of support around you and learning from everyone around you over those, you know, first few years or so. So if you're on the edge between them, maybe just do that. And it's always easier to go from academia to private practice rather than the other way around. But if you feel like, hey, this is what I want to do. I want to kind of provide clinical care for patients. I want to go just to, you know, practice and do the absolutely go for it. And we're always here. I always say like here, you know, your mentors are here. You can always pick up a phone and just ask and do these things. But, but there's truthfully, there is no plus or minus-- there's always plus or the minus to each of them. So I have heard a lot, and I also agree with, but I don't know why I necessarily agree I just suspect. Why is it easier to go from academic to private versus private to academic in your mind? I mean, again, I'll say maybe this is changing a little bit than it used to be. Definitely used to be hard. I'd say five, 10 years ago. Now I think academic places are more open to accepting people who have gone. And I think the biggest reason is before they coming back to what we talked about with, what's your potential for teaching? And they just don't want people that just go into academia and they're just not interested in teaching trainees, not interested in being involved in any scholarly work or things like that. And now with seeing more and more people that have gone for one reason or another, I mean, there are so many people that have gone from private practice to academia because it's just has not been as profitable as it used to be with insurance as kind of clinging down and reimbursements have gone down. So we've seen more and more and it doesn't mean that they're not. We've seen them come back and they're super interested in teaching and research work and all that. I think this kind of phenomenon have changed a little bit. Maybe there's just a tiny bit of a, you know, kind of a lag in that. But and that's why I say sometimes it's a little bit harder but definitely it's much better than it used to be and it's not as hard as it used to be. So if you want to do it the other way around, absolutely. You can go to private practice and go back. I think there's now at this time there's a very high chance that you can do that. Yeah. I've heard of this idea of the private dynamics model too now. It seems like academic institutions are implementing where they have some sort of, where they have some sort of financial incentive based on, you know, the volume that you see. Yeah. It's an interesting world now. So our last question here to wrap things up, what are two books you'd recommend on the field of pain that you be there like educational, fictional or otherwise that have influenced you as a pain physician? Yeah. I think that's a great question. There was a book by Skurry and I think I'm butchering that name. It was I'll send you I'll send you the name of it. But it kind of talks basically about, you know, the beyond what what neurobiology is of pain and beyond what the physical part of pain. But also talking about how pain affects your relationships, how pain affects your interaction with people, how pain affects your entire life and it's and the consequences of pain within that and I when I read that book, I think even myself understanding and talking to patients and working with them, it's a different perspective that gives you and different perspective of, you know, what truly these patients are going through. And it really affects them in every aspect of the life and that goes back again to why sometimes the smallest changes that you do for these patients can have a huge impact on their lives and they will show that to you and they will come and talk about it to you. There is another book to and I think maybe we can I can get you the names of it to yeah. I'll put them on the video. I'll put the yeah. I think it's the other one is called the Essentials of Pain or something like that and it's also by David something but it's also another book that I feel also had a huge impact. It's a little bit different. This one basically really like kind of talks about the evolution of pain and you know, kind of the neurobiology but it really kind of digs deep into that and why do we have pain and kind of the mechanisms behind it. But I'll get you the names for these two but I feel those are really nice books beyond you know those textbooks that we know about. Yeah. Like hey, these are the drugs. These are the things. There's so many of those. Yeah. This kind of really opens up your eyes on thinking about pain in a different way and what kind of impact pain has on our patients and you know, in general. Yeah. I see this concept and how I see my patients. Yeah. I think that's a really interesting topic. I often think about the historical context of pain because back in the day when they're you know, your dentist was your barber was your surgeon sort of thing, you know, and it's like were they just pulling teeth out and was that but you know, so but anyways, this has been so helpful, so illuminating and such a pleasure to talk to you. Thank you so much for your time Dr. Eza. I really appreciate it. And I truly, truly enjoyed it as well and thank you for giving me that opportunity. Of course. Thank you. Thank you.