In part two of this series on pain management, Dr. Demetry Assimakopoulos returns to provide a more in-depth view of the work chiropractors do at the Comprehensive Pain Program at the University Health Network (UHN) and the Pain and Wellness Centre in Vaughan. Both these clinics were founded and led by Dr. Angela Mailis, a physiatrist, pain physician, clinical professor, and leading authority on the diagnosis and management of chronic pain. In Part 1, Dr. Mailis discussed her interdisciplinary approach for addressing pain, her experience and her work with chiropractors. In this episode, Dr. Demetry will share a case study about a patient who was given the full-blown treatment at these clinics. To help you and other chiropractors hone an expertise in chronic pain management, he will also provide tips and useful resources, including must-read articles you can start with today.
In part two of this series on pain management, Dr. Demetry Assimakopoulos returns to provide a more in-depth view of the work chiropractors do at the Comprehensive Pain Program at the University Health Network (UHN) and the Pain and Wellness Centre in Vaughan. Both these clinics were founded and led by Dr. Angela Mailis, a physiatrist, pain physician, clinical professor, and leading authority on the diagnosis and management of chronic pain. In Part 1, Dr. Mailis discussed her interdisciplinary approach for addressing pain, her experience and her work with chiropractors.
In this episode, Dr. Demetry will share a case study about a patient who was given the full-blown treatment at these clinics. To help you and other chiropractors hone an expertise in chronic pain management, he will also provide tips and useful resources, including must-read articles you can start with today.
Topics Covered:
Key Links to References/Resources Discussed:
About Dr. Angela Mailis:
Dr. Mailis is a specialist in Physical Medicine and Rehabilitation, has a Master's Degree from the Institute of Medical Science, University of Toronto, has served as Senior Investigator with the Krembil Neuroscience Centre/ University Health Network up to 2015, and became a full professor at the Department of Medicine, University of Toronto in 2005. She is a member of the School of Graduate Studies at the University of Toronto and is currently an Adjunct Clinical Professor, Faculty of Medicine, University of Toronto, Division of Physical Medicine. Since she started practising in 1982, her clinical and research interests focus on the diagnosis and management of chronic pain.
Dr. Mailis founded and directed the Comprehensive Pain Program of the Toronto Western Hospital, University Health Network (1982-2015) and continues to be a full member of the Division of Physical Medicine and Consultant at the University Health Network Comprehensive Integrated Pain Program.
She is a national Evidence-Based Guideline developer, Chair of ACTION Ontario since 2005 (a not-for-profit organization for education and advocacy for patients with neuropathic pain), and a highly respected medicolegal expert in matters of chronic pain across the country.
Dr. Mailis has published more than 130 peer-reviewed scientific papers; credited with “first publications in the world” on a number of pain conditions; recognized as an international expert on specific specialty areas; has trained numerous students and international trainees; and has lectured around the world on matters of chronic pain.
She is also a Popular Science writer (has written BEYOND PAIN published in the USA and Canada) and CARP-Advocacy electronic newsletter contributor monthly (2009-2014), while her new book “Smart, Successful and Abused” will be published in September 2019 by Sutherland House. She has appeared on numerous media outlets (print, radio, TV) over the years promoting understanding and advocacy on chronic pain.
She has participated in several hospital and university committees and serves as an advisor to the Ontario Ministry of Health since 2009 as well as federal committees and health panels.
Dr. Mailis was nominated to the 75 semi-finalists “top immigrants” in Canada for 2011. She is a recipient of the Hellenic Women’s Coming of Age Celebration Award (May 2004); Division of Physiatry, University of Toronto, Achievement Award (June 2005); the 2013 Canadian Pain Society Harold Merskey Award; and the Division of Physiatry Life Award in 2014.
As of September 2014, Dr. Mailis created an interdisciplinary best-practices community pain clinic in Vaughan (Pain & Wellness Centre). The Centre was proclaimed in October 2016 by the Ontario Ministry of Health the “Demonstration Project of Ontario” as the template for further similar community-based clinics, that connect the community to the academic hospitals. The Pain and Wellness Centre not only offers chronic pain consultations but serves as an educational hub for numerous trainees, and also a research centre studying chronic pain in the community.
About Dr. Demetry Assimakopoulos ('Dr. Demetry'):
Dr. Demetry received his specialized honours undergraduate degree from York University in 2008. He concurrently earned a specialty in Fitness Assessment and Exercise Counseling, and the title of Certified Exercise Physiologist (CEP) through the Canadian Society for Exercise Physiology (CSEP).
Dr. Demetry graduated from the Canadian Memorial Chiropractic College (CMCC) in 2012 and immediately began practising in midtown Toronto. In 2014, Dr. Demetry became the Clinical Coordinator for the University Health Network (UHN) Comprehensive Integrated Pain Program at The Toronto Rehabilitation Institute. In the hospital setting, Demetry works with a team of physicians, nurses, occupational therapists, and physiotherapists to adequately diagnose and manage chronic pain.
He earned his diplomate in chronic pain management through the Canadian Academy of Pain Management in 2015. He has since been hosted by several provincial associations across Canada to lecture to health care providers on the conservative and interdisciplinary management of chronic pain. He was happy to finally join the fabulous team at the Pain and Wellness Centre in November 2017.
Dr. Demetry was voted to receive the members' choice 2022 Dr. Michael Brickman Heart and Hands Award from the Ontario Chiropractic Association for embodying a generous and giving spirit (the heart) with remarkable passion and dedication to chiropractic care (the hands).
Episode 14 - Managing Pain with Interdisciplinary Care: Part 1
Introduction:
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Welcome to ON Spinal Chat, where we explore what O-C-A is doing or supporting to help enhance your patient care, grow your practice or advance the chiropractic profession.
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I'm Leslie, and today we're hearing from Dr. Angela Mailis and Dr. Demetry Assimakopoulos for part two of this series on pain management. In part one, we spoke extensively with Dr. Mailis, a physiatrist, pain physician, clinical professor, and leading authority on the diagnosis and management of chronic pain. She discussed her interdisciplinary approach for addressing pain as well as her experience establishing and directing the Comprehensive Pain Program at the University Health Network, or U-H-N, and the Pain & Wellness Centre in Vaughan. Dr. Mailis also outlined the role that chiropractors like Dr. Demetry play in her interdisciplinary approach.
In today's part two episode, Dr. Demetry returns to provide a more in-depth view of the work chiropractors do at each facility. He'll also share a case study about a patient who was given the full-blown treatment at U-H-N and later at the pain and wellness clinic. To help you and other chiropractors hone in expertise in chronic pain management, Dr. Demetry will provide tips and useful resources, including must-read articles that you could start with today.
Main interview
Leslie:
Last episode, we spoke with Dr. Angela Mailis about her work, her Pain & Wellness Centre, the value of interdisciplinary teams and her experience with chiropractors. Let's start today's episode with Dr. Mailis sharing a couple of her key values.
Dr. Angela Mailis:
I'm a very big believer that each professional has something unique to offer to the others. Each profession has something to learn and something to teach all of us, interprofessional cross-pollination. Collaborating is the best way to deliver better pain management and better management in everything, being health habits, life changes and all of that. You deliver that much better in a collaborative model, and always, always science-based.
Leslie:
Let's turn now to Dr. Demetry Assimakopoulos, who's worked with Dr. Mailis at both the University Health Network's Comprehensive Integrated Pain Program, as well as the Pain & Wellness Centre in Vaughan. Dr. Demetry, how does your work at the University Health Network, or U-H-N, differ from your work at the Pain & Wellness Centre?
Dr. Demetry Assimakopoulos:
The biggest difference both at the hospital and at the Pain & Wellness Centre is that all the chiropractors do assessments side by side with physicians, either the anesthetists or medicine rehabilitation or physiatry specialists. There aren't any other chiropractors who do that at the hospital, so that's just me. I think Dr. Mailis said this best. When you work collaboratively with an open mind and in a congenial way with another health care provider, you really start to understand that based on your scope and your training, we as chiropractors don't have all the tools to help every patient. And the greatest thing about the physicians that I've worked with is that they acknowledge that they don't have all the tools that either. So there's this really wonderful opportunity for cross-pollination, as Dr. Mailis says it. And from that standpoint, it's allowed me to develop my diagnostic skills.
Like the other day, Dr. Mailis and I saw a very motivated patient who was diagnosed with fibromyalgia and over the years has seen many clinicians. We didn't agree with the diagnosis. We started in our interdisciplinary program, and then boom, her presentation completely changed. And I was just like, no, this is inflammatory. And if it wasn't for the fact that I worked with physicians like Dr. Mailis and the other great physicians and health care providers at the hospital, I never would've picked this up. Truth be told, I found out today that this patient has rheumatoid arthritis and she's had it for all these years. It wasn't until this patient was in my office, I picked it up. I said, "You're going to make an appointment with Dr. Mailis." Dr. Mailis looked at my assessment, she looked at the patient, she goes, "Demetry, spot on. We need to get this person to a rheumatologist." Sure enough, there was the diagnosis.
So that's one thing. Another is because of our exposure, our diagnostic skills might be a little bit different than the average community chiropractor just by virtue of the fact that we see different things and we have different experience, and we learn a lot about medications. We learn a lot about psychology and psychiatry, and we learn a lot about various forms of diagnostic imaging and other diagnostic testing that might allow us to make a better diagnosis and prognosis that we might not have access to or have been exposed to in another scenario. So the beauty of our program and of our clinical setting is that access to our fellow members is at our fingertips. I'll be sitting in the session with the patient who's on opioids, and they might be having problems like a narcotic bowel or they might have features of obstructive sleep apnea that are way out of my control, but I'll just be like, "Hold on a second."
I'll open up my Slack channel and I'll message Dr. Mailis or the other physicians who work with us right then and there. And they'll be like, "Yeah, make an appointment for this patient to do this with me. I'm going to see them on this day, yada, yada yada." So right in front of the patient, we have an action plan for what to do. At the hospital, the visits were a little bit shorter because the patient volumes were larger. I only had two afternoons where I could see patients, but we had really high volumes, and then when my hours changed, I had a single afternoon just to treat patients, so I can only see them for about half an hour at a time. Whereas at the Pain & Wellness Centre, my treatments are an hour long. I also have a full gym at the Pain & Wellness Centre, which I unfortunately didn't have at the hospital.
I was actually doing far more assessments at the hospital than I am at the Pain & Wellness Centre. Much of my time at Pain & Wellness is dedicated towards patient care, not necessarily towards the interdisciplinary assessments that I do with the physicians, whereas the bulk of my job at the hospital is doing these initial assessments with the interdisciplinary team.
Leslie:
So how have you seen the interprofessional model at U-H-N evolve or change over the past eight years?
Dr. Demetry Assimakopoulos:
It's been very similar across the scope of time. In 2014 when I started, all the way to about 2019, I was only doing assessments. I didn't do any treatment at all. And I was given this wonderful gift of being able to start treating based on all these corporate changes. Recently, they went through a little bit more restructuring, and it was decided that chiropractic services would be moved to another program. So thankfully, this other program has three other chiropractors who have been hired, Dr. Glenn Harris, Dr. Doris Mertins, and Dr. Nick Moser, and the advertisement actually went out for a chiropractor, which is another pretty amazing thing. And those three very gifted chiropractors work as part of this new program who are going to be taking over chiropractic services, and I'm really excited to see how things evolve for them.
Leslie:
Now, you left U-H-N to focus on your work at the Pain & Wellness Centre last Spring. Do you want to share some thoughts on this change and what you gained from your experience at U-H-N?
Dr. Demetry Assimakopoulos:
Well, the first thing that I can say is that I have a lot of gratitude towards the individuals that I've had the great fortune to work with, especially a good friend and mentor, Dr. Flannery, who really went to bat for me for many years. And if it wasn't for him and Dr. Mailis, I wouldn't have had this opportunity. I'm really glad that, one, they didn't let me waste it, they pushed me, and two, they really had my back. The other thing is that both Dr. Flannery and I and all of our partners as part of the program worked very hard to build chiropractors into the corporate infrastructure when they decided on how much chiropractors would be paid. When I was involved in writing the scope of practice, that now all chiropractors must adhere to, I think that they recognized that over the years they had trained someone who had really great neuromusculoskeletal skills to have many of the skills a pain physician would have.
I think with me having a place there, they then open the floodgates for other talented people to come in and provide the program and patients navigating through that program with an amazingly good service. It was that we want people to have these diagnostic capabilities. We want to have this very complementary relationship with excellent clinicians so chiropractors can fill that role. And I think that really has beared fruit because you now have three amazing chiros where there was just one before who are providing an amazing service, and that program is now working with C-M-C-C to try and create more opportunities for patient care and research and so on. And I genuinely hope that it works out for them. I just needed something new. That was it. I saw this amazing opportunity to grow as part of the Pain & Wellness Centre and really develop a different skillset and work in a way that I very much enjoyed. I just had to follow my heart.
Leslie:
What steps do you recommend other chiropractors take to prepare for opportunities to work collaboratively with physicians in interdisciplinary clinics?
Dr. Demetry Assimakopoulos:
That's a tough question. For instance, when the jobs opened up for the three new positions at the hospital that were filled, there were an unlimited number of applicants. So I don't think that the average chiropractor will have a problem finding these opportunities should they arise. I really think that it's just chiropractors need to be confident enough and willing to throw their hat in a ring and be ready for a big change in practice and a big change in their day-to-day, because working in these settings, they're long hours. From a policy perspective, things work a little bit slower, and you have to be willing to work in a team, and you have to be willing to understand that there's no room for ego, that everything happens for the good of the program and for the good of the patients. So I think it's more those soft things rather than the hard things that chiropractors need to be prepared for.
The other thing is that we're excellent at manual therapy, but we also need to be ready and willing to prescribe a really good therapeutic exercise and be prepared to implement these things in real time with patients. Because when you're working with chronic pain, in particular, telling patients to do exercise without guiding them through it can often make a patient feel really uncomfortable and unsafe. So if you're with them going through these things and convincing them that these things are indeed safe and that they can do them without you, the chances of compliance and success increases. But there are other things that need to happen. We wouldn't be working at the Pain & Wellness Centre in this capacity without us getting funding from the Ministry of Health, and that was all Dr. Mailis' doing. What I think needs to happen is that other opportunities like this need to come from the Ministry of Health, and then chiropractors need to be there and willing to work in these teams and develop them.
The other thing that I'm really quite passionate about is if we want more chiropractors working in hospitals, there are two ways to do that. The first is to have independent contractors, and many hospitals, like Mount Sinai, North York General, et cetera, have independent contractors that work there and provide chiropractic services. That's like a typical fee for service model, or it might be part of W-S-I-B or Altum or something like that. It's a third party payer. But if you want chiropractors being part of government funded programs, there are institutional changes that need to happen, and that is the corporate human resources infrastructure at hospitals, many of them actually don't have a job title for a chiropractor. So that's one. And then once more chiros are working in these settings, then it's a wildfire. Then people really start to realize the benefit of having chiropractors as part of these health care teams.
Leslie:
So tell me, how can chiropractors enhance their relationships with physicians?
Dr. Demetry Assimakopoulos:
I really genuinely think that taking the time to communicate with physicians is very important. I've never had an instance where a physician refuses to talk to me on the phone, maybe a handful of the hundreds of letters I've sent out to physicians where they're unwilling to entertain something that I've asked. And I think that if chiropractors look for more opportunities to work together with physicians, just go out on a limb and do it. And it doesn't necessarily mean, "Oh, let's go to lunch and discuss sending me patients." I think that just sending physicians information about their patients and saying, "You know what? This is what we're doing, just to keep you in the loop." The more and more you do that, there's more and more trust that can develop. But with regards to creating these interdisciplinary environments, that's a top-down challenge. It's not necessarily something for chiropractors to solve. I just think they need to be ready to pounce. That means creating relationships with government and other professional partners from an advocacy perspective.
Leslie:
I agree, and O-C-A is doing this advocacy work on an ongoing basis. And members can learn more about this work by checking our 12th and 13th podcast episodes on ‘Advocacy to Advance the Profession.’ Let's go back to your work on pain management. Tell me about a memorable scenario about a patient who was given the full-blown interdisciplinary pain management program at the Pain & Wellness Centre. What was this patient's experience like?
Dr. Demetry Assimakopoulos:
So there was this one patient who is really near and dear to me, and what this person achieved is nothing short of amazing. And this story involved both sites, at the hospital and at the Pain & Wellness Centre. This patient initially saw me at the hospital. I believe he was a mixed martial arts fighter, so he used to cage fight. He has a whole whack-ton of amazing stories. He was working as a welder, sitting in the passenger seat of his work van, and I believe his work van was rear-ended. And the inertia of the movement drove some of the gear forward that was behind him, and the latch on his seat was broken, so it kind of folded him in half. That was about 10 to 12 years ago. He gradually developed low back pain with greater frequency, intensity and duration. Gradually he also developed leg pain, and he went on multiple bouts of short and long-term disability.
By the time he saw me at the hospital, he was kind of kinked in half like a pretzel. He was using a cane. He had been on long-term disability for quite a long time, really unable to work, racking up a whole bunch of debt. I started working with him at the hospital, got him off his cane, but he still had significant leg pain and back pain. I think at that point he was on 50 micrograms of fentanyl, so he was using the fentanyl patch. We did some electrophysiological testing. We identified that there was an acute on chronic L5 radiculopathy. We gave him a steroid injection that really brought his pain down but didn't abolish it, still intensely painful. And then we decided, you know what? Let's bring this person, a very strong man, up to the Pain & Wellness Centre because we thought that setting in the gym and working with psychologists and all of our team would've been very helpful for him.
He came up to the interdisciplinary program. We worked with him. He went from a guy who was scared of picking things up to working out in the gym nearly every day. He started to realize how strong he was. But the most fascinating thing is that when he started the program, he was on 50 micrograms of fentanyl every three days. He was on 600 milligrams of Pregabalin. He was on Baclofen. He was taking a few Percocets a day on top of that. And by the time he finished the four-month program, he was in the middle of getting a new degree to start a new career. He was off all of his medication. He was off all of the opioids. He was back to working out, lifting really heavy weight, and no pain. It was gone.
And this one is so inspiring because he was just an amazing guy. He was the epitome of a motivated patient. If you have a motivated patient with a team that cares about them genuinely and has no ego, patients can move mountains. We needed to bring out the beast in this guy again. And if it wasn't for having the gym there where I could work with him, I wouldn't have been able to do that because this guy started pushing some really heavy weight again. Dr. Mailis did an amazing job at progressively weaning his opioids and all the other medications. The contact with our mindfulness teacher, with our psychologists, with our massage therapists and our naturopaths really did a good job of helping him to cope with the withdrawals from the opioids and the other medications.
Leslie:
Can you elaborate a little more on how this patient's background and mental health affected their neuromusculoskeletal condition?
Dr. Demetry Assimakopoulos:
Many people with persistent pain come in with adverse childhood experiences or adverse life experiences, but they're not relevant. We need to determine, is this relevant? Is it changing this person's behavior? Is it not allowing them to be readily engaged in care? Is it integrated into the whole processing system that the cortical-subcortical brainstem structures are responsible for and woven into that, and it impacts processing? So that's where the challenge is. That's where you really need to have an astute clinician because in the chronic pain population, you'll actually find, for one reason or another, that the prevalence and the incidence of some kind of D-S-M-5 disorder, the Diagnosis and Statistical Manual, Fifth Edition, might be present. Whether or not it's relevant is another story, and that's why I said beyond a certain intensity. So the vast majority of individuals who come into my office might have some degree of depression and anxiety, but usually it's not relevant until it passes a certain threshold.
The other thing was is this patient had a lot of trauma in their past, and as I've said, that adverse life experience and childhood experiences can negatively affect the way a person experiences pain, even if it's not an underlying cause of pain. It increases vulnerability, even when they have a bonafide reason, like a lesion that is causing the pain. So helping him process his past and come to terms with it and giving him a safe place to rediscover himself was really key because you had to think about this person not only as someone with a chronic L-5 radiculopathy, but as a whole person, and this whole person had been suffering for a long time, and these things compound each other. So it's a very humanistic type approach, to paraphrase Peter Stilwell.
And this one really stands out in my mind because we fear opioids, wonder where we are in the scope of health care, and we have whole continuing education opportunities to learn what the chiropractor's role is in helping to wean opioids. But this guy was on as much opioid as you could imagine, and if it wasn't for the team working together, not just me and the patient being truly motivated and feeling safe, nothing would've changed.
Leslie:
Is there a current research document on pain management that you recommend all chiropractors read?
Dr. Demetry Assimakopoulos:
So there was one article by Slater published in Pain 2022, and the title of this article is, ‘Listen to me, learn from me: a priority setting partnership for shaping interdisciplinary pain training to strengthen chronic pain care.’ It's about learning to listen to your patient and learning from your patient. Rather than taking the role of the expert in pain management, we need to understand what our patient's needs are and then learning how to help that person have that need realized, or can we get them to a person who can help them fulfill that need. That's one really good article. Another article that I really like is by Joao Paolo (J-P) Caneiro in Physical Therapy 2022 called, ‘From Fear to Safety: A Roadmap to Recovery From Musculoskeletal Pain.’
Many times when I see patients with persistent pain, there is an underlying fear and avoidance of movement. I don't like using the language kinesiophobia or fear avoidance beliefs. I just think people are fearful and learning how to dispel that fear, helping people to learn that they can be safe, and getting people back to doing the things that they love doing through some form of exposure is a skill we need to master. And this article really paints an excellent roadmap for how that works.
Leslie:
What final recommendations do you have for chiropractors who want to develop an expertise in pain management?
Dr. Demetry Assimakopoulos:
I think that chiropractors have some cursory understanding of pain management, but I don't think we have a very comprehensive understanding of pain management. I think that more about eyeing and treating chronic pain differently is coming down the pipeline at our educational institutions, but my perspective is that it's not nearly enough. So if we graduate people who understand that patients with chronic pain might need a different form of treatment, and they understand that through and through, that when they hit clinical practice, they'll either say, "You know what? This is a chronic pain patient. I know what to do with them. I know how to treat this patient differently from someone else," or they can say, "You know what? I ain't interested in treating chronic pain. I'm going to refer this person to the chiro down the street." I think that more about chronic pain and how it is different from other types of pain is very important.
Selfishly, I'm going to plug my own course through RRS Education, ‘All Aboard the Pain Train: A Chiropractor's Guide to Chronic Pain’ is really a labor of love between Dr. Shawn Thistle and myself, and it's been very successful, and people seem to really like it, and I think that it's a good start. So I think that chiropractors need to just put a little bit more time into learning different things and understanding that their practices need to evolve. And then when you identify a chronic pain patient, you probably need to give that patient more time because those cases tend to be a little bit more complicated. Doing a shorter patient visit is probably not going to be as effective, which is why the treatments that I provide are anywhere between 30 to 60 minutes for patients with chronic pain. I just need that much more time.
So developing some different skills to help those patients is very important. And I think we're pretty good at developing a good therapeutic alliance, but where I think many allied health care providers, chiropractors included, need a little bit of work is developing some skills in the identification and management of the psychosocial variables that can be involved in patient care. I was actually talking about this with Peter Stilwell the other day, that there's some literature demonstrating that many allied health care providers don't feel as if they've been properly trained to provide a comprehensive bio-psychosocial assessment or treatment, particularly from the perspective of the psychosocial factors. This is a very easy target for chiropractors to develop their skills and for educational institutions to facelift their programs. Not every patient is the same, and you have to choose the appropriate tool that's necessary for that person. What that means is that we need a bigger tool belt and we need a better understanding of when to use which tool.
I think that continuing education on chronic pain is where it starts. There are many courses out there, like my own. I think that developing your skills and understanding that there are many roads to Rome, manual therapy isn't the only tool in our toolbox, and we need to understand that treating chronic pain patients is different than treating your acute pain patients. And if chiropractors want to be involved in the opioid solution, then we need to understand that we need to make some changes as well. That takes developing more skills and learning new things. And understanding how to phenotype a patient, how to help them set goals, and what outcome measures to use and how to communicate that movement is safe, and how to educate a patient on pain without scaring them or without having a nocebo effect is really powerful.
Chiropractors are the perfect profession to help patients with the opioid crisis, but we need to develop skills and we need to develop relationships, and we need help from key organizations all the way down to the individual chiropractor upgrading their skills. I think that we're well poised, and if we all follow that evidence-based or evidence-informed paradigm, then the future is bright. I think we'll survive. And I think that things like integration with medical professionals and working to together in a collaborative fashion is in our future. We just have to do the hard work to get there as a profession together.
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Outro:
Leslie:
Thank you, Dr. Demetry, for walking us through one patient's journey from debilitating chronic pain to a fulfilling life thanks to comprehensive interdisciplinary care. Thanks also for sharing your insights on how members can prepare for an opportunity to work in interdisciplinary clinics, should one arise, and what to expect, as well as how to hone chronic pain management expertise. We'll be back later in the fall with another episode of pragmatic insights and tips to help you and your practice. I hope you'll join us.
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