So welcome everybody. This is our Cancer Rehabilitation Community Day. I think this year we're gonna keep it to about an hour and a half and then hopefully have more in the future in terms of a meeting. I'm Ekta Gupta in case you don't know me. And then Sam Shapar is my co-chair and we will be moderating today's community day session. Today we're focusing on advocacy, telemedicine and experiences during COVID-19. So let's see. This is a quick housekeeping slide. So just as a reminder to everybody, we are recording this webcast. Please mute your mic if you're not talking. For our guests, if you have questions, please feel free to use the chat, but we'll definitely be monitoring that closely. And if you have any questions, please chat the AAPM in our support in terms of tech support. So as many of you know, our subgroups have been working really hard towards the goals for our community. We've been focusing a lot on education research. This year, the goal of this presentation is also to talk about advocacy for our field. We're gonna be going through some of telemedicine and the effects on COVID-19. And last but not least, we're highlighting education with looking at some of our fellows and getting their experiences regarding not only fellowship, but the job search and how COVID-19 impacted all of this. We definitely like for more people to get involved as a group, the CRPC member community is always looking for ideas, ways to get involved, ways to make an impact for our patients as well as providers, not only in having oncologists and other interdisciplinary providers, like learning and seeing what we do, but also showing them the research in terms of cancer rehabilitation and how it affects their care and patient care. So I won't talk too much. And I think we can get started with our first few presentations. So the first presentation will be by Dr. Sean Smith and it's our role in an interdisciplinary approach. Can't talk properly. And then the next one will be advocacy and cancer rehabilitation medicine by Dr. Vishraj. So I think Dr. Sean Smith is on and I will stop sharing my screen, not scaring my screen, I hope. That's very spooky of you to scare your screen. So I kind of like it. All right. Hi everybody. I'm Sean, as Dr. Pooka said, I'm at the University of Michigan in cancer rehabilitation. And Vish and I are gonna be talking, it's sort of a joint presentation split into two parts, a bit of good cop, bad cop, maybe. I'm gonna be a little bit of the bad cop and Vish will be a good cop because he has needs. And so we're gonna be talking about, advocating for our field, our patients and what it is we need to do to do the thing we always talk about when we get together, which is getting the right patients into our clinic at the right time and sort of showing our value. And specifically, I'm gonna talk about how that works as far as what is the value on paper for what we, the physiatrists, the PM and our physician bring to rehabilitation along the cancer continuum vis-a-vis PT, OT, rehab psych, exercise, phys, nurses, et cetera. Okay. And this is not to diminish anyone's specialty, but I'm gonna kind of outline what it is that is known that we bring to the table and why we kind of need to know more. Okay. So I have no disclosures. I'm gonna start really simple and preach to the choir here and say what it is that we add that's distinct in the rehabilitation continuum compared to say a physical therapist. Okay. So we both, hopefully under both specialties, understand the musculoskeletal system, but there's a lot that we bring to the table that others in the rehab world can't. One of which being we can coordinate rehabilitation care. We can prescribe PT and OT. We can make sure it's properly carried out. We can refer to rehab psych, et cetera. And we can take that burden from the oncology group. We can order and interpret tests, look at MRIs and say, this is why you're feeling pain or you're weak here. This is why your personality changes like this. In studying a brain tumor, we can conduct EMGs, point-of-care ultrasound, that type of thing. Those are things that therapists can't. We prescribe medications. That's a no-brainer, but that helps facilitate rehab. Maybe we reduce the impulsivity of the brain tumor patient or the spasticity or pain. And we can also reduce healthcare utilization, right? These are patients who come out of months and months of cancer treatments and they're sick. The idea of going twice a week for eight weeks to physical therapy might seem daunting. It might be impossible with the co-pays and the driving. And we could give a home exercise program and we can guide these patients, especially with the advent of telemedicine, which my colleagues will get to subsequent to this. There are other things we do, procedures, et cetera, but this is just a smattering. But is there actual evidence that what I just laid out is helpful in terms of improving patient outcomes or reducing healthcare costs? Or are we just kind of shouting at the wind? And there's not that much. I'll get to what there is, but I'll start off saying that clinical trials, which is what oncology requires, that's sort of the threshold to get something into a guideline or become a standard of care. They're really lacking in terms of centering what we do, the physiatrist. And you look at a few recent clinical trials, there's the COPE trial out of Mayo that looked at tele-rehabilitation in advanced cancer. And it was compelling that rehab or function-directed treatments reduced pain, but they use the exercise champion, I think it was called, basically a physical therapist. And then they had one arm where a nurse was managing medication. So they didn't use a physiatrist and they found that the nurse managing medication wasn't terribly helpful, but it wasn't us. So if we go to the oncologist and say, hey, rehab helps these patients, they may come back and say, yes, the physical therapist helped, why do I need you? Similarly, and more concerningly, as an insurance payer saying that, because they're cheaper than we are. The PAL rehab trial is a palliative care trial that used a palliative care nurse to oversee rehab and basically say, hey, go do some exercises. Their outcomes weren't terribly compelling, but of course, rehab helps. Pretty much every prehabilitation trial, I've never seen a physiatrist be the center of that. It's an anesthesiologist or a surgeon or a physical therapist or an exercise physiologist. So why are we needed for that? And this is not, I'm not personally casting doubt on our value, but I want to really lay out a somewhat dire situation that there's not a lot of evidence for what we bring to the table, and that's a problem, okay? A lot of the publications on cancer rehabilitation are single institution, a lot of them are retrospective. So just as an example, JAMA and a lot of their subset journals won't even consider those for publication, right? So even if it's a really good, really high number patient and looks good on paper, we won't get into those big journals this way. So a lot of our studies lay out as a four and five evidence range. And to get into the major guidelines and the major journals, you kind of need a one or a two and potentially a three, depending if it's compelling, okay? And the randomized control trials are one and two. So what do we know? What do we have in our corner though, that supports this? There's a lot of evidence for the benefit of inpatient rehabilitation and cancer rehabilitation. This is probably not something that will be a randomized trial, and I think it'll just be accepted that this helps. This is a physiatrist centered approach, although it's obviously multidisciplinary. It improves function across tons of different cancer diagnoses with good SIM efficiency. And regardless of this, they're having active cancer treatment. There's other benefits to inpatient rehab. There's, if somebody goes to an IPR facility versus a SNF, they're more likely to go on to receive subsequent chemotherapy. Now there's obviously selection biases there who can tolerate inpatient rehab, probably the people are gonna live longer. And that's been shown that if the patients have more gains on IPR, they have longer survival. And if they have lower function, lower survival. There's also a benefit to symptom management in terms of fatigue, anxiety, depression, and potentially getting patients back to work with inpatient rehabilitation. This is all very good for us because we can say, hey, we're part of that. Now, what about others? So there's been a few other studies that are worth pointing out. What about how do we help clinical decision-making and patient flow? There was this study out of MD Anderson that wanted to see an outpatient sort of coordination of care. What is it that the physiatrist does? And I think reading between the lines in this paper and this study, they were really trying to get to one of those points I shared earlier that we can coordinate care and we can help push things further. And they found that when a physiatrist is involved in this outpatient oncologic care, there's almost two thirds of the time they're coordinating something or leading to follow-up visits for more surveillance and sometimes referring to other providers. Similarly, out of MedStar Georgetown, there was a tumor board study that found that over 40% of the time these breast cancer patients were discussed, there was a physiatric recommendation, be it for lymphedema management or something else. So this showed some help. Outpatient rehab wise, there's been studies out of Shirley Ryan about the multidisciplinary day brain tumor rehabilitation program that that improves function and the physiatrist was part of that. And Lisa Rupert published through ASCO the importance or the impact of having a physiatrist in a multidisciplinary prostate cancer clinic found that about 54% of the time there was non-cancer functional impairments or pain generators or some problem going on, that it wasn't just the tumor, meaning it didn't need to be radiated or cut, it needed some rehab. And so that's a pretty high number when you're talking about metastatic prostate cancer. So what does that get us? If we look at the guidelines that are out there, which is how we get referrals, there's the National Comprehensive Cancer Network and we're in a few of these, right? That's pretty good, fatigue, palliative care, et cetera. Now this, the NCCN, how they make their guidelines, for those not aware, is expert consensus, okay? So there's people on a committee, they say, yeah, refer to PMNR when this happens and then other people sign off on it there. They don't need to have a clear objective threshold, okay? So sometimes, and some of you like me have been asked to contribute to this, we might say, hey, put PMNR in there or something like that. The American Cancer Society has us in the head and neck cancer survivorship guideline of which Michael Stubblefield was an author and that might be why it's in there, but that's good. We're in that one. And then there's ASCO and we are in nothing, okay? Because ASCO has the highest bar to clear. You basically need that level one randomized control trial and if you have a level two, like sort of muddy randomized control trial, you're mentioned, but you're not the gold standard, okay? ASCO is almost to a fault, really, really strict, but that's kind of what we have to work with. So what do we do? How do we overcome this? I'm gonna leave us hopefully with some ideas and hope before Vish takes the baton in terms of what we can do to advocate for ourselves. So we need, I think, and this is not an original thought that I've had, we need our PEML study. And for those who don't know, Jennifer PEML published this seminal article in Palliative Care that found that if patients with advanced lung cancer saw a palliative care physician and team pretty quickly after their diagnosis, they had a lot better outcomes in terms of symptom control, healthcare utilization was reduced. And in this particular study, they actually lived longer, which blew the minds of all the oncologists and was enough to shoot palliative care into the stratosphere. Now the survival benefit hasn't been reproduced and it probably isn't actually true, but the other stuff is, and nobody questions palliative care, right? They had these huge, really impactful outcomes that they found all by saying, hey, I'm gonna go see this patient, let's see what happens. And that's kind of what we need to do, I think, if we want to make a big impact. And obviously there's other impact to make. Now, an example within physiatry is not in cancer rehab, but it's this study that some of you may be familiar with. The West Michigan study that every time somebody was going to have a lumbar fusion, they were randomized to see if a diatrist or not. And they found that those who saw the physiatrist had improved or at least the same amount of function and pain control, but a lot less fusions were done because they said you can manage your pain this way, you don't need rods and screws. And so as a result, healthcare costs were significantly reduced. And now in our state, if you're getting a fusion and you have a certain insurance providers, you basically have to see a physiatrist. There's a lot less fusions going on. So this is really good. It's not cancer specific, but this is an example of seeing a physiatrist made an impact. So what are some ways that we can find our TEML study impact or our West Michigan study within cancer rehab? And I'm just laying out some of these to generate conversation. If there's time to talk online here or offline, I think this would be great. But I want to get people thinking about what we can show to cancer rehab patients and to the oncologists who are referring to us that we make a big impact. And so to me, geriatric oncology and advanced cancer patients would pretty well benefit from being stronger in less pain and having more mobility so that they could stay on treatment longer and have a better quality of life. We can show that we can keep treatment going. That's a pretty big impact, right? There's probably a survival benefit there actually. And there's data to show that geriatric folks actually, they reduce treatment or go off of it because of function, not because of like kidney failure or nausea, function, right? Which is what we deal with. Similarly, if we get people back to work in a survivorship setting, let alone reduce the long-term morbidity from some of these late effects, there's the benefit of us in fine metastasis management. And Lisa Rupert's study got to this a little bit. You know, if we brace or we say, hey, then epidural injection can help with this. You don't need to radiate potentially. Or here's some exercises, et cetera. That could potentially help us get some more referrals and show our value there. There's now some palliative inpatient rehabilitation studies coming out that could be randomized to show a benefit. Aromatase inhibitor therapy adherence, right? Just seeing one of us help women stay on aromatase inhibitor therapy longer, which has a survival benefit. We need that big outcome. And I probably shouldn't have said killer outcome. That's poor choice of words. But you get what I'm saying here, that we need to have these big TEML study impacts if we're going to make that sort of leap, if you will, that palliative care took. And my last slide is this, because a whole lot of you are probably saying, I don't know how to run a clinical trial. And to which I would say, I don't really either. You know, most of us don't. And we don't get the research training that a lot of other people in the cancer world do, right? Certainly not the PhDs who are conducting research. Oncology fellows are getting two or more years of research and radiation oncology is heavily integrated into their residency. Surgeons get one or two years off to do research in their training. We don't. We're given three years after intern year and we're thrown out there and then we're left scratching our heads wondering why there's no research to support us. So, you know, I'll say that there are things you can do. You can find people who've done this. You can, you know, talk to your department chair or your boss about what resources they can give you to make your life easier. You can have professional development that can, you know, teach you, you know, this is what goes into doing this. This is how to write a grant or this is how to get your team together. And oncology mentors have been particularly helpful to me and others when it comes to research. So I encourage you to go out and do that. And lastly, that last bullet point is about preliminary data. So all those retrospective chart reviews can build on to a randomized trial or something big to get to that level one evidence. They're not, you know, they're valuable for a lot of reasons, one of which is that it can lead to that. So on that note, I'm going to let Vish talk about advocacy on a broader sense and hopefully this sparks some ideas for you. All right, thanks, Sean. Let me pull up the slide here. All right, so hopefully you can all see my slides. I want to thank you all for giving us the opportunity to speak. When Sean and I were asked to do this, we were trying to figure out the right strategy as it relates to trying to figure out how to put PM&R in the position to advocate and how you, you know, justify our role. And so Sean's talk went over a little bit of, you know, what you need to get a seat at the table with many of the organizations and to get people to listen. But, you know, where Sean described himself as the bad guy, I might actually be the bad guy because I'm going to actually talk about advocacy and cancer rehabilitation. And I'm going to try to explain why it's so challenging for PM&R to lead the advocacy front in cancer rehab all by ourselves. First, I have no financial disclosures. And in this talk, we'll be fairly quick. So our goal is going to be to review the interdisciplinary nature of rehabilitation in general, understand principles and advocacy, and then describe the value of coalitions and advocacy. So when we look at the definition of cancer rehab, many of you have read this definition came out several years ago. Sean and I were part of the team that came up with this, but the critical piece here is that cancer rehabilitation is delivered by trained rehabilitation professionals who have it in their scope of practice to address the physical, psychological, and cognitive impairments. So in our definition of cancer rehabilitation, we already are setting ourselves up for interdisciplinary care. We're looking at different individuals who can provide specialty and expertise services to help the patient and may not all be physiatry. So the real question is, you know, can physiatry carry the full load for advocacy? You know, are we in the position to actually lead the charge and be the sole representatives for cancer rehabilitation? And I don't know if any of you have ever watched The Godfather, but I remember this is one of the famous quotes, keep your friends close, but your enemies closer. Now I'm over-exaggerating who our enemies are. I don't believe that other rehabilitation professionals are enemies, but only as I've gotten into administration, as I've done more work in advocacy, do I understand that it's important to keep the individuals close to you who agree with you. Like, so everyone in the consortium who we all get along with, who we all work with, we all see the problems the same way. We all see our roles the same way. We all support each other and we all believe in each other in terms of what our role should be. But it's really important to understand what other people are thinking. So it's important to understand what physical therapy is thinking and what their perspectives are, what occupational therapy is thinking, what neuropsychology is thinking, what rehab nurses is thinking. And when you put all that together and when you think about how you can help set the agenda, you really need the input from some of those folks who aren't in your circles because they seem to understand things in a different perspective and may give you a new perspective about what you're advocating for and how to do so. And when we think about rehabilitation in general, remember rehabilitation is based on the premise that we are interdisciplinary. So for us to provide comprehensive rehabilitation and care for a patient, we always have to focus on not only the physiatric component but the therapeutic components, the psychological components and other services like dietary, nutrition, nursing, social work, et cetera. And so it's in our core when we're physiatrists and it's in our core when in rehabilitation that we need to rely on other people to provide the most comprehensive care. And in the same way, when we're looking at advocacy, it's super important that we have the whole team on board so that we can provide a comprehensive view of what we're advocating for. And here's an example of interdisciplinary collaboration. I know the print's a little bit small, but a few years ago, several of us were involved in a major presentation at the NIH when we were talking about cancer rehabilitation in the future of the field. And in this presentation, we talked about clinical care models. We talked about evidence-based medicine and practice clinical trials amongst other things. And what we came to realize is that in order for us to accomplish our goals, we really needed everybody at the table. And this is evidenced by just simply who are the authors on this paper. For those of you who don't know Nicole Stout, Nicole Stout is a huge advocate for cancer rehabilitation trained in physical therapy. But then as you go down that list, you'll notice that several folks on this list are MDs, several folks are therapists, and then there's other people with other roles. So it's super important to understand that even the work that we've done to set the agenda for cancer rehabilitation has been interdisciplinary. All right, so then the question is, if we're going to go into advocacy, you know, what do we do? How do we advocate and what is our role as physiatrists and how do we incorporate others in the discussion? So, you know, I bring this up, I don't know if any of you are Star Trek fans and if anybody in the chat can name who the actor is, I'll buy you a cup of coffee at our next meeting. But, you know, don't forget, we're all doctors, right? We train in residency three, four years depending on our subspecialty in PM&R and when we train we're focused on our core competencies. We're focused on clinical care, we're focused on how we can become the best clinicians possible to serve a patient's needs. We do get experience in research, we do get experience in other areas of administration, but advocacy is not necessarily one of the primary focuses of our training. And then when we go into practice, we don't always learn the tricks in terms of advocacy, in terms of language, in terms of communication, in terms of how you go about advocating for the agenda item that you want to advocate for. We're not politicians in general and so that's a hard thing for those of us in the field to try to navigate. But one of the key components of physician advocacy is first to remember that it always starts in context of individual patients. So, as you get experience and as you learn more about what the deficits are for patients, whether it's regulatory, whether it's insurance based, whether it's clinical care, you have to figure out what the problem is and you might end up doing a root cause analysis. And for those of you who don't know or aren't familiar with the root cause analysis, the idea there is you identify what the problem is, you try to come up with an algorithm to solve that problem and as you identify the steps, then you can go back and say, well, here's where we're having a challenge and we can go back and try to solve that problem. And then all of a sudden you become an advocate for that issue. But the key thing to remember is limitations exist on advocacy based on the expertise of the advocate. So, even as physicians, even though we have a lot of fervor and we want to go in there and advocate and say that we can represent a whole field of cancer rehabilitation, we have to really be comfortable with all aspects of cancer rehabilitation. You know, if you're in a cancer committee meeting or you're in a tumor board with surgeons, you often see surgeons who are very emphatic and very quick to share what they know with others and to share their expertise. And it's very quick to see how they might debate each other on what the right course of treatment are, what the right surgical approaches are, and they like to do that kind of thing. But with PMNR, it's a little different. We're not as adversarial. We're not looking to show that we're the best. And I think that it's in our nature to be interdisciplinary because we realize that we can't carry the burden by ourselves. So, having some expertise from other areas can get us along farther. And so, when you look at how that happens, well, you have to look at how you advocate. And when you advocate, there's probably four different levels. You can advocate at the patient level. That might be something we're super good at, especially if we're treating patients and we're really focused on the clinical questions. But then you can also advocate on a practice level, maybe in a departmental level. If you think that you need to grow cancer rehabilitation within your department, you might be the best person to present that to your chair or to your administrators and to try to grow service lines. But then when you continue to look at where you can advocate, this is where it's more important to have other people helping you. When you look at your system, your healthcare system, and you're trying to advocate for cancer rehab, you need the help of other providers, whether they be folks in the oncology world, whether they be other folks in the rehab world, to try to put a program together so that a system can understand the value of cancer rehab and understand what they have to do to advocate even beyond their system at a more national level or at a state level to get support, funding, and things of that nature. But then finally, where advocacy is probably the ideal state is when you can advocate for an entire population. So when we're advocating for cancer patients throughout the country or even internationally, we really have to understand the systems of practice. We have to understand the laws. We have to understand the regulations, what Medicare is doing, what Medicaid is doing in the state. We have to understand how different governments, if you're going internationally, treat rehabilitation, treat cancer. And to do that, you really need the help of several experts. As a single physiatrist, it's a very, very challenging thing to try to address. So when we look at collaboration and advocacy, it's important to have diverse and effective and comprehensive skills. It's important to have many different people. And they may not all be clinicians. It might be politicians. It might be academics. It might be activists. But you need people at the table who understand that there's something that needs to be accomplished. And you need people at the table who can address things that you cannot address. It's important to have partnerships so physicians can achieve more by advocating alone, like we talked about. Having those experts at the table only solidify the argument. And then teamwork is more effective when you have interprofessional training. So even as a physician, if you're advocating, it's really important to get some experience in other areas of advocacy, like things like social work, things like therapy, or maybe it's regulatory stuff. So it could be laws. It could be legal issues. It could be government officials that you have to speak with. It's good to have some training to understand what it is you're advocating for and how you can cross-train to help push those arguments forward just as much as other professionals can cross-train with you to help push your arguments forward. And then, you know, as a gold standard, when you look at advocacy and health care, addressing Medicare, which for a lot of us is going to be the individuals on a national level that we advocate to, it's important to know that you need coalitions to accomplish your agenda. And so this is a publication by a group that actually did specify how you advocate to Medicare. And one of the, you know, three of the critical pieces are that you have to have a willingness and ability to work collaboratively. You have to have the ability to connect the dots among the missions of the different groups. And you have to have a willingness to share resources and power. And if you can do that as a group, you can make great accomplishments as a turn in terms of advocacy and the ability to move an agenda forward. So finally, I'll end here shortly with value of collaboration and advocacy. And the importance of advocacy and building a coalition is that you have a stronger voice. You have a unified voice that's going to address multiple issues in cancer rehab. You have more resources because different organizations, different individuals may have access to different resources that can only benefit the argument. And there's power in numbers. So the more folks you have, the more legitimate you come across, and you can build better relationships, both the community and other interprofessional groups. And it just strengthens the need to move forward the agenda forward if multiple people, multiple groups agree with it. And here's an example of institutional advocacy. This comes from the website of Spaulding Rehabilitation Hospital. And for many of you who know Spaulding, Spaulding is one of the top facilities in the country, a great research institution, great academic institution, great clinical institution. But even on their website, when you look at advocacy for patients, they agree that they need support with other organizations and other groups to move their agendas forward. And here's a list of the people listed literally on their website to show that they've partnered with others to help move the rehabilitation agenda. And so my point is that even if one of the great rehab hospitals and great rehab institutions in the country understand the thing to partner with others, I think us as physiatrists also need to learn that lesson so that we can move our agendas forward. And finally, there's strength in numbers. And so I think that for anyone interested in advocacy, it's really important to understand that you can go at it with a lot of fervor, a lot of passion. You can go into any government official's office and try to make your case. But if you have a bunch of other folks with you and you're all unified in your approach, what you'll find is that you can chew off a lot more than you could by yourself, and you have a lot more strength and power with people being compelled to listen to your arguments and being compelled to trust in what you're saying. So I guess if there is a take-home point on this, I would just leave you with the fact that advocacy is super important, but because of our field, it lends us to be more interdisciplinary in our nature, not only in our clinical care, but in our advocacy efforts. And with those multiple perspectives and multiple vantage points, we're in a good position to move agendas forward, especially like cancer rehab, but it's important to develop those coalitions, both within the field of rehabilitation and even external to rehabilitation, so that we address all the aspects that are necessary to make for successful cancer rehabilitation program development in the country. So with that, I will end and hand the presentation off to the next group with Mary Vargo. Thank you. Thank you very much, Vish. This is Sam Shapar. I know as we're doing this transition to the next group with Mary Vargo, Amy Ng, and Philip Chang. Mary, as soon as you're ready, you can start pulling up the slides. They're going to be focused. We've had, obviously, a telemedicine subgroup that has been more active, obviously, over the last, what, now two years since COVID's kind of put us into forced telemedicine. So they have a lot of great info, I think, for the group here. Just talking to them, preparing for this, we've already gotten a lot of info from this. So hopefully this is very helpful and informative for the team. And Mary, are you ready? Are you seeing my slides? Are you seeing my slides or no? Not yet. No. Okay. So welcome to the telemedicine portion of the day. We have three speakers. I'm Mary Vargo from MetroHealth Case Western Reserve in Cleveland. And I will give a brief overview of the activities of our group. And then Amy will give sort of the hardcore part of a review of some literature related to telemedicine in rehabilitation. And that's Amy Ng from MD Anderson Cancer Center. And then Phil Chang from Cedars-Sinai will discuss a survey that we're doing. And he'll actually talk about two surveys. So the telemedicine subgroup is relatively new. We did form pre-pandemic, just barely, at the 2019 AAPMNR meeting. And here's a list of our inaugural members. And probably about half of this group has continued to be pretty involved with this subgroup. And you can see the image there. It's a famous painting by George Seurat. But the reason I picked it is because telemedicine, you know, seemed like sort of a walk in the park at the time, like we would be able to, you know, grow and, you know, meander at our own pace. And like in retrospect, it feels like back in 2019, we were sort of in this era compared to where we are now. So a few months after that, we started meeting a whole lot more. And I list a lot of sort of initial discussion points that we were having, but they actually organized around a couple themes. There was a lot of just, you know, especially early on, pure comparing notes. You know, what are people doing? Are people doing video in person, both? Are people going into the office to do their telemedicine or purely staying home? What sorts of electronic visit platforms are being used only for outpatient, only for follow-ups, or, you know, what are the variations on, you know, what's being done? And then secondly, we just started talking about some more meaningful points to, you know, what's working well, what's not working so well? What about efficiency? And then, and this sort of still remains an enigma, I think, what about, you know, cancer rehabilitation in particular with regard to telemedicine? So we did have, you know, some initial thoughts about this. On the pro side, you know, it seemed that the medically vulnerable cancer patients can stay home and still have their visit with us. So of course, you know, that's desirable. And then also telemedicine is an opportunity to main contact with our patients more frequently, and especially especially with physiatrists at the tertiary centers that have patients coming from quite a distance for their appointments. It could be even, you know, advantageous compared to usual care from the past where we're not reliant on having our patients physically come in as often. And then it could be a conducive model for long-term survivorship needs and perhaps other phases of care, such as prehabilitation. You know, on the con side, obviously, you know, telemedicine affords a limited ability to evaluate changing or unstable situations, which of course we do have. And then there's patients, you know, with clinical barriers to telehealth visits. So, you know, what to do? That was, you know, a question. And pretty quickly, we decided we did want to survey our membership. There was just so much going on and assess, you know, what are some recurring themes. Also just getting as many ideas on the table as we could. So we've been putting some work that way. We started a box file with telemedicine literature, and we're also interested in what was going on in the academy, you know, outside of our group for telemedicine. So as not to be, you know, duplicating work and also to be informed by what else might be going on. So Carolyn Millett, by the way, is the academy staff person involved with telemedicine. Long range, you know, we're thinking we would like to look at ideas for strategies for implementation and have listed some thoughts about it. You know, honestly, we have not settled on, you know, any particular direction as of yet. And also to identify best uses for telemedicine. So we're hoping with the survey results and just, you know, continued, you know, discussion that we can organize around, you know, a particular focus. I'm going to skip this slide. This is what's going on elsewhere through the academy. To get back to the survey, we did a preliminary survey just amongst our small group to inform the design of the larger survey, which many of you have probably already taken. And this is just a screenshot of the results of the small survey. And I liked it because it was done by Christina Kleinkuro is one of our members, and it seemed like our own little pointillistic work. I showed you the painting originally. So here's our work. And then we have spent quite a lot of time to like rework the larger survey, you know, for the cancer rehabilitation community. And this is going to be my last slide. Our other big focus, it's a pretty big thing. We realized we would like to do a study. It's a retrospective study among our various centers, really looking at what is going on in a real world context with respect to telemedicine. So we will be looking at cancer rehabilitation, physiatry, outpatient visits, comparing the type of visit, i.e. in person, and then telemedicine, phone or video, including comparing phone versus video. And with respect to two major types of variables, first of all, disparities variables, such as race, age, zip code as a proxy for median income and insurance type. And this is, I think, especially interesting for the phone versus video question. And then also looking at the types of interventions during the visits. For example, the frequency of ordering different types of consultations, medications, labs, imaging, DME, or procedures. So it ties a little bit towards, you know, what Sean was saying about the value add of what we're doing. So we're hoping to get some good information, you know, looking at differences, if there are any, between the different types of visits. But we'll also get some big picture information of the total tapestry of what is being done in cancer rehabilitation visits. So we're really just getting going with it. So more to follow on that. And so with that, I will transition to Amy for the literature review. Thanks, Mary. All right. So I'm Dr. Amy Ng. I'm from MD Anderson Cancer Center. Just going to go over some of the telemedicine rehabilitation literature that we found. Of course, I'm limited with this time being able to present the number of articles, of course. There are lots of articles, but we'll highlight some of the more relevant articles. I do not have any disclosure, financial disclosure conflicts of interest. And I wanted to just start by saying that when the pandemic hit, I mean, when we first started this group, we had no idea that COVID was going to happen. We were all just kind of interested in advances in technology, telemedicine, and then the pandemic hit. And all of a sudden, healthcare just shifted into this whole virtual visits. And even though reimbursements were uncertain, how was the hospital getting paid? We all just suddenly went to telemedicine. And by mid-March to October of 2020, we saw CMS reported 24.5 million people of 63 million eligible Medicare patients as 39% received a telemedicine visit during that time span, almost seven months. And at its peak in April of 2020, about 42% of all outpatient visits were telemedicine visits. Once we were able to use telephone and for this first time, actually, we were able to start using telephone and video conference visits for all patients, regardless of disability or diagnosis. And also they were able to do it in their homes and we were able to do it from our homes. And once this started, then Medicare, once this started, Medicare started paying for it and then other insurers started doing it as well. So of course, there's been an increase in literature, like I said, in telemedicine and due to time limitations, I'm only going to be able to highlight some of the recent publications that I think would be useful for us cancer rehab physiatrists. In this article by Dr. Verduzco Gutierrez, she highlights how to conduct an outpatient telemedicine or prehab visit. Ideally, how this would work, you know, we would start by identifying patients, we go to scheduling, testing, the call, connecting, delivering care to the patient, giving instructions, next steps, and then completing the visit with documentation and billing. This article, I also like it because it does give examples on how to document your exam in the virtual setting and most of it can be done with observation. Everything from the general to neuro to musculoskeletal can be documented and also this article gives examples on how to document the exam in your note. Examples of some special tests, sometimes that we don't think of, can also can be performed without assistance and then also if there's family members or a caregiver present, also we can do some of these special tests. Some of these, you know, testing the cervical spine, lumbar spine, the hip joints, knee joints, any of these joints that we might think of. Finally, in this article, I like the fact that the billing codes were given to those of us who had questions about billing and also documentation on how to write, you know, how to document consistently with what we're billing. Of course, these changes have been, or these codes and some of these statements had to change throughout our time with COVID and so, you know, of course, this article might not be relevant in say like a year, but as of right now, it's still pretty relevant and what we're using currently to document as well. This next article, Laskowski et al., dedicated to the MSK exam in telemedicine and I really like this article because it shows pictures of how to do the special exams and for you to show your patient, and then have the patient do them themselves. So some of these, you know, such as the Faber test, the Hawkins test, showing the patient. And then, of course, like, I guess you could also take these pictures and show the patients themselves if you're not able to physically do them yourself. So now that we know how to do telemedicine, you know, the next question is really how do patients and practitioners like telemedicine? And that's something that our group is trying to find out currently. We're, again, of course, Mary already mentioned, but we're trying to poll our own cancer rehab physiatrists about our telemedicine experiences. In this article, Cianforte et al surveyed 119 patients with a response rate of 41%, and also 14 physiatrists. Patients rated overall that their telemedicine experience was excellent or very good, and about 93% of the physicians themselves rated their experience as very good or excellent as well. The key barrier, of course, was technical issues, which we've all experienced. Lopez et al published their experience during their first 90 days of COVID, and they were able to shift successfully to virtual formats to deliver their cancer rehab care. Interestingly, they noted that only 11% of the patients needed in-person appointments, and that was due to a musculoskeletal issue or a neuro issue or some kind of lymphedema that needed hands-on. In this, they were also able to show that pre-COVID versus after COVID hit the virtual visits, they were able to see just as many visits virtually as they did pre-COVID, if not in all areas of cancer rehab. And they also break it down to days one through 30, 31 through 60, and then 61 to 90. And we see, again, that the care virtually continued across all types of services, therapist, follow-ups, lymphedema, nutrition, social work. In this article, Zolman really highlighted what virtual care has given us, this surprise look at sometimes our patients' lives, how they live, what their living conditions might be, their support systems, their food and medication safety. And I think that's one thing to take away from this, that we are given a special look into our patients' lives with telemedicine. And finally, I'll end with this thought-provoking slide, thought-provoking article, really what happens next. When the pandemic ends, or COVID stays with us, we don't really know, how will we pay for this? What will we do? How are the governments and insurance companies going to fund this going forward? Currently, funding is based on outcomes and value for the money. And right now, we don't have a great deal of data, really, to inform the decisions, which might lead to how payments are going to be tied to telemedicine. And if certain parameters are put in, that will influence how we practice and how we do our telemedicine. So, we are looking into doing our own kind of research and in our telemedicine group and for cancer rehab physicians. And we're looking to make sure that, telemedicine can give the same comparable safety, effectiveness and care as a traditional visit, respecting the patient's preferences and values going forward and not trying to increase or cause any additional healthcare disparities, but rather to decrease it. So, with that, I'll end this research and I will let Dr. Cheng take over. Thank you, Amy. I'm just throwing up my slides here right now. And hopefully, that's showing to everybody. So, I'm Phil Cheng. I practice cancer rehabilitation medicine at Cedars-Sinai Medical Center in Los Angeles. And I'm going to be taking the next few minutes to discuss the Cancer Rehabilitation Telemedicine Survey. So, as Mary was alluding to earlier, this is actually a prior survey that we did just at the really beginning of the pandemic. And this was just assessing patient provider reported satisfaction with telemedicine visits during that time. And as you can see, along with a lot of the data that Amy was just sharing, that satisfaction with cancer rehabilitation telemedicine visits was high for both patients and providers. Although we did notice some discrepancies and some certain trends when stratifying by visit type, so whether by phone and video. So, as kind of everyone's been talking about so far, we've kind of been thrust into this new era of telemedicine. And it's basically new for all of us, much like the Mars Rover on the left, we're exploring new territories and much like the Mariana Trench on the right, we are navigating these uncharted waters. And it really feels like we're kind of operating kind of by ourselves in the dark, not really sure what other providers are doing and practicing it in regards to their telemedicine practices. So for that reason, we want to gather more information and we created a survey and the goals of that survey were to explore opinions on the types of visits being used, whether video, phone or in-person, to explore how telemedicine visits can be optimized, to explore perceived disparities in the application of telemedicine and finally to explore specific considerations related to telemedicine for cancer rehab. So the survey has 19 items, it takes about 10 to 15 minutes to complete. And there are two parts, the first of which consists of check all that apply single best answer and one ranking Likert style type question and the second part consisting of a few qualitative type questions. And I really wish that I would, I was really hoping that we'd be able to share the data with you here today, but instead we opted to actually use the opportunity of this meeting to give kind of one last push to have anyone who hasn't completed the survey yet to please do so to boost our response rate so we can hopefully get as much data as possible and just really have it be more meaningful and hopefully helpful to all of us here. So with that said, thank you to everyone who has completed the survey, your responses are incredibly appreciated and you can kind of tune out for the next couple of minutes as in lieu of data, I'm just gonna kind of be going over the survey itself. And we have posted the link to the survey in the chat. So please save that so you can complete the survey following the meeting. So to go into it, we just wanted to get some basic information on telemedicine usage. So we want to ask what percentage of your telemedicine visits have been inpatient versus outpatient and what percentage have been through phone, video, and in-person. To explore the utility of telemedicine, we wanted provider perspectives on for which clinical situations they feel that phone visits and video visits are typically adequate versus for which clinical situations in-person visits are preferred over video or phone visits. And as you can see, we've kind of stratified the answer choices by the various services provided by rehabilitation physicians, as well as if patients are presenting for new versus stable or worsening problems. To explore the appropriateness of telemedicine for specific patient situations, we've asked for which patient situations are phone and video visits typically appropriate here. A question that I think is particularly interesting is which parts of a physical exam are you performing during video visits? We've also left others comments section for anything that we may have left out. To explore the disparities in telemedicine, we're interested in provider thoughts on perceived changes in disparities with the application of telemedicine and to kind of elaborate on their thoughts. And certainly we've all experienced the drop call or the inability to connect to audio difficulties when using telemedicine visits. So we want to ask what percentage of video visits are being converted into phone visits due to either patient or provider factors. And kind of moving on or going in the vein of satisfaction with telemedicine, just what has your overall satisfaction with your current telemedicine practice been? And with reimbursement considerations aside, do you prefer video visits, do you prefer phone visits or do you dislike both? And then for those who have both kind of like a mixed practice where they're seeing both cancer and non-cancer patients, we are interested in finding out if you feel that the telemedicine for your cancer patients is more appropriate or less appropriate or the same as telemedicine for your non-cancer patients. And then for the final question of this first part is just kind of stating the level of importance of the various driving factors in determining what kind of visits type you'll use, whether video, phone, or in-person. So of course, there's patient preference and a lot of patients just prefer telemedicine visits just because they're so much more convenient. Institutional policy always plays a role and at the onset of the pandemic, a lot of institutions were telling their providers that they can only do telemedicine visits. Then there's, of course, provider preference, patient logistical issues like transportation. And then finally, clinical indication of, you know, what kind of visit type, whether phone, video, or in-person is most appropriate to actually diagnose and manage the patient's issues. So the second component is a few qualitative questions, and these are just to kind of give an opportunity for more open-ended answers to kind of flesh out some of these ideas more. So the first question is just, will you continue to have telemedicine be part of your practice after the pandemic and why, as well as what you've experienced to be the most important advantages and disadvantages of telemedicine visits? And then to explain how the change in the way you conduct or don't conduct a physical exam has altered your management of patients through telemedicine. And then finally, what steps your practice has taken to streamline and optimize telemedicine visits and finally, along that same vein, how can telemedicine be used to improve cancer rehabilitation medicine beyond everything that we're currently doing? So hopefully, you know, as I was discussing all those questions, you've kind of been answering them in your head. And, you know, if you took the survey now, you'd be able to do it even faster than 10 minutes. So if you haven't already completed the survey, we kindly ask that you give your input so we can get as much data as possible. And hopefully, we'll be able to share that with everyone shortly. And again, the link to the survey has been posted in the chat, and there will be also a final email reminder sent out through FizzForum. So look forward to hearing your answers and sharing that data with you and appreciate your time. Great. Thank you so much, Phil. So our next section will actually be Q&A with fellows to discuss their experiences during COVID-19. So we'll ask them to join us on video and introduce themselves, tell us a little bit about them and how they came about with their careers, their next steps, and then their experiences in fellowship. And then we can open it up to some questions. All right. I guess I'll start us off, Dr. Gupta. So my name is Brian Fricke. I was a fellow at MD Anderson last year. Right as the pandemic was coming about, I graduated in 2019 from fellowship there, and I'm currently the cancer rehabilitation physician at UT Health San Antonio, the Mays Cancer Center here in San Antonio. It was quite the change for us kind of halfway through. My elective time was kind of backloaded, so that more or less evaporated, which was kind of unfortunate. But we kind of took the opportunity to really take those first scary steps into telemedicine, like was being explained during the last presentation, putting together a lot of the templates and making sure the clinical workflow went well. One of the things that I thought was really interesting and what we engaged in early on was also doing the inpatient care using telemedicine, doing inpatient consult using telemedicine. So that was probably a unique perspective that I don't know that many other places got. I'll be very curious to hear the other fellows' experience here, too. Hey, I'm next in introductions. I'm Hannah Oh. I completed my fellowship in cancer rehabilitation this past academic year at Memorial Sloan-Kettering and just joined the faculty at the Department of Rehab Medicine at University of Washington and medical director of cancer rehab at the Cancer Center here at Seattle Cancer Care Alliance. A little bit about my experience as a fellow was unique in that I had done my residency at New York Presbyterian, but kind of done the rotations or rotated in the clinics with the faculty that had eventually became my faculty in fellowship and saw what it was like to be in these interdisciplinary meetings and collaborative meetings, like tumor boards in person or an interdisciplinary pain conference, and then saw the transition as a fellow once these things went remote. And in doing that, I think it was a transition, but also seeing how cancer care is going to change. I can't say that I'm hearing a lot of talk about tumor boards going back in person via Zoom, and I think the dynamics are different, of understanding how different services communicate with one another, how we play a role as psychiatrists in these meetings, whether it's in person or remote, but I do think it's the start of an overall change in how collaborative cancer care is going to continue forward. Hello, everyone. My name is Azrahan Salahuddin, and I completed my cancer rehab fellowship at the University of Kansas in 2020, so just when COVID was starting. And same thing, we had a lot of electives planned for the last couple of months, and obviously those definitely got affected, but at the same time, I think this was definitely a lesson in adaptability, and just seeing how so many things that we thought were not possible in the way we practice medicine. I mean, it was just, everything was flipped all of a sudden, you know, everything that we were taught that you can't do, you know, you can't treat these, you know, you can't see patients like this, and you can't practice medicine like this, and everything just kind of got flipped over. And all of a sudden we were, you know, doing telemedicine, and we were even doing, you know, some limited physical exams over video, and you're doing phone calls, and you're, so for example, in our palliative care rotations, everything got switched to virtual, and so, you know, someone's literally taking an iPad into the patient's room on the inpatient floors, and then, you know, you're facilitating family meetings through the iPad, and just, you know, the heartbreak that comes with that, and then, but still managing to, or learning to manage all of that, that was, those were all just very big things that we learned. Other than that, also, you know, of course, the job search was affected all of a sudden, on all the interviews, or on the phone, and through video, and again, you know, you never would have imagined accepting a job without actually going and visiting the place, and, you know, doing interviews, or dinners, in person, and that definitely changed as well. I'm at the Indianapolis VA right now, and I'm setting up their cancer rehab program here at our VA, as well as, I have a background in interventional pain, and so, I'm the first physiatrist in this VA to hold a joint appointment with the Anesthesia Interventional Pain Clinic, as well, which has been really nice for the cancer rehab side, because now we have, not that they weren't being seen there, but it's a little bit more of an in, with a little bit of a rehab approach, as well, so it's all been really interesting. So, I'm Ezin Zane, I was just a recent fellow at MD Anderson for their cancer rehab position. I just finished, I'm in June of this past year, so, I guess I kind of just echo what the prior fellows also discussed. I found that it was a little difficult just to adjust myself, especially with like the video, Zoom, patient evals, especially like a new patient. I definitely wasn't a fan of Zoom, probably throughout the whole year, I didn't like new patient evals, I didn't like follow-ups, I felt like I'm just too hands-on, I like to evaluate my patients and just talk to them in person, I feel like it's what makes us human, just from our tone of voice, to our posture, to how, you know, if you're checking someone's spasticity, so I feel like that kind of took a little bit from me, but I also, luckily enough, MD Anderson had a ton of resources, so I tried to take advantage where some things might've lacked. I have a ton of appreciation and I really liked doing EMGs, so I did a ton of EMGs, I worked with the director of the neurophysiology lab pretty extensively, I got to get involved in some leadership courses and things like that, so I think overall, I learned a lot, it was a great experience. I think the limitations that we experienced during COVID, I feel like already have kind of started to diminish, I think that, for me at least, from where I'm working, it's kind of just coming back to normal, per se. I feel like at the larger institutions, it's a little harder for them to kind of remove red tape or loosen some restrictions because at that scale, it's just a little more difficult, but I feel like where I'm at now, I'm able to do just a little more to how things were before the pandemic. Thank you. Thank you, guys. I know Ekta just posted in the chat to please post any questions that anyone has, but I actually have some questions for the group a little bit, appreciate the introductions, obviously. Why we asked you guys to kind of be part of this is because no one around has had the experience you had, obviously, it's a unique experience. Is there anything now that you guys kind of look back that some of you may be training new fellows that although some of the stuff that happened last year was out of necessity that you think was a good experience, although, like Monson mentioned, it's a little bit tougher at times and not necessarily ideal that can develop your skills in a certain way that you said, okay, COVID goes away, but are there certain things that, as some of you mentioned, that you've kind of learned how to adapt that it will be good to kind of, as we have new med students and trainees kind of move forward, anything that you think that you wanna move forward regardless of our infectious disease pandemic issues? And yeah, Azra, jump ahead. I was just gonna say, I mean, I think telemedicine obviously is here to stay, it's not going away, obviously. There's gonna be some issues, I'm sure, with reimbursements and figuring, I think at some point that'll be figured out. For our cancer patients, I think it's just been such a blessing. I think my follow-ups have definitely increased substantially because they have this option. These are patients who, well, at least at the VA, I mean, a lot of them live far away and then they're undergoing treatment, they're already here multiple times. And a lot of patients who maybe would have preferred not to make that extra appointment, once you say, hey, you can actually do this at home, you don't have to come in, they're on board all of a sudden. So there's just a lot more continuity of care, a lot more follow-up and a lot more education advice and different things that you can do for them with this. And so I would definitely say for fellows, I love that slide, the telemedicine physical exam. I think that's just fantastic. There's a lot you can do without having the patient right there. And a lot of times, of course, you'll end up having to bring them in for a physical exam or maybe coordinate on a day they're already being seen, but at least you kind of have an idea of what's going on and you can start getting that ball rolling of what needs to be done. I think also, I saw a lot of the attendings I work with take ownership over prescribing a home exercise program that would have maybe fallen into the realm of therapy, but in-person therapy was not an option due to decreased space capabilities or patient preference to not see another in-person provider. So just being able to collaborate with a therapy team, which is what we're doing here, just to have some sort of input from the therapy, therapist, but provide those home exercises or stretches as a provider, rehab providers. I think it's something I didn't see a ton of, just because it's so frequent, but also just the volume wasn't as great as it would be because of the lack of in-person visits with lymphedema, so before I started my position here, I decided to take the certification to become a certified lymphedema therapist and kind of learn it independently, and I think just like a roundabout way of also learning how to treat and assess for something that we didn't see, may not have seen a lot of in training. Any other thoughts, Brian or Mo? I mean, I would echo what Azra and Hannah have mentioned already, that, yeah, I think it was very, you know, it gives us a unique window into what these patients' lives are, and I would say in my practice currently, I'm not doing a ton of telemedicine, but certainly with a lot of the follow-ups after I established care with patients, ones that are more routine, just wanting to check in, I'll offer that as a convenience and patients will tend to appreciate it, and I've had a number of patients even, you know, continue to suggest or request doing telemedicine visits. I think early on and during fellowship, it provided some, it was a good opportunity to kind of, you know, take advantage of the fact that we were still being supervised and to some degree, and that we could kind of, kind of learn how to swim on our own with that instead of just being thrown into the deep end and trying to figure it out as I would imagine many of you guys had to. So that was something that I think was helpful during fellowship, for sure. I would just add- Oh, go ahead, Heather, sorry. I was just going to build on what Hannah mentioned as well about tumor boards, you know, a lot of them not being in person anymore, and that was really one of the biggest ways, you know, where we could be visible and I guess self-marketing, self-promoting, and so what I would urge fellows is to come up with a game plan, you know, because you might end up with a job at a place where tumor boards aren't in person, and so what are your strategies going to be as far as becoming more visible? You know, what are things to push for, like clinic in the same space, you know, physical spaces, the other oncologists, or radiation oncology, and also, you know, more frequent meetings, one-on-one with some of the key players, or trying to get people or different departments to buy in, and, you know, it's a very ongoing process. You're going to have, you know, times when you're very visible and, you know, you're getting referrals, like, every single day, and then, like, after two weeks, all of a sudden it drops and you're wondering what happened. It's not really anything. It's not that they're not happy with you. It's just when you're not constantly visible, I mean, consults can definitely start dropping down, so you just need to have a game plan as well, and that's something to talk about with your attendings when you're in fellowship. I think that's a great point, and I think there's a few things, and Dr. Smith has a question in the chat. I think when I started, one of the big things was, like, get over to the tumor board, show your face, go give a talk. Are you guys still finding, especially now that a lot of talks are via, like, telemedicine or Zoom, has that been integral in terms of how you get your visibility? I know kind of set up the meetings, but I also know it's tough to get on a lot of people's books to get people's meetings, especially when they don't know who you are. Is there any techniques you guys have learned, and this is going to build off Dr. Smith's question of what extent telemedicine should be part of fellowship training, but I think that's a patient care thing, but also how we do Zoom and other things to make your visibility in place. I think we've kind of done it in a necessity, but, like, should this be part of our curriculum that you need to know how to leverage technology and other aspects to build your practice, but also patient care? I personally think it's a huge advantage and definitely should be a part of the fellowship experience. I was fortunate enough to end up at an institution where there was a lot of hunger for cancer rehab when I got here, so a lot of doors opened pretty early, but I would say that just the same way that Asra mentioned, you know, not being able to attend the fellowships in person, or the tumor boards, excuse me, in person, I found that attending them even virtually was all the more beneficial. You know, the flip side of that can be very helpful, too, because I was able to, you know, chime in here and there a little bit more easily. There's a little bit less pressure being the one to, like, stand up in a room full of strangers that you don't know and say your piece. You know, I distinctly remember even seeing, attending a GI tumor board here recently there, where they had a patient that I had never seen before. They were talking about considering surgery or no surgery, and noticed that the patient had very small psoas musculature as they were going through the abdominal CTs, and that's not something that they look at during tumor boards because they're focused on the cancer, and so I chimed in and asked about, you know, hey, is this patient very debilitated? They seemed like they would be, have very poor mobility and poor functional status. Is this someone who might benefit from prehab? And got a referral there, and the oncologists and surgeons were, you know, very, very appreciative and to some degree impressed that, you know, here I was, this stranger, this strange voice in the chat that spoke up and, you know, got to drop a little PM&R knowledge on them. So definitely something that I think can be leveraged to your benefit, too, if you're, you know, creative enough to kind of take advantage of that. Anyone else want to chime in about how we could potentially integrate telemedicine as part of the curriculum? Hannah, it looks like you came. Yeah, I was just going to comment. I mean, here in Seattle, telemedicine is still a pretty robust part of my practice just because I think the location and a lot of patients who aren't living close to the city aren't ready to make that drive or that commute. Just yet. But in terms of in training, I think what I remembered about telemedicine, I think it depends on the platform and if the attending or kind of who's in the visit, too, especially early on. Something different from an in-person visit is being able to answer questions or provide information about prognosis or next steps without someone being right there is a little bit challenging for me versus, you know, a little bit challenging for me versus kind of stepping out of the room and saying, oh, I'm going to ask my attending and then we'll come up with a plan together versus kind of like hanging a call, hanging up a call and then discussing and going back. So I think the telemedicine overall just became a lot more comfortable later on in my fellowship once I knew a little bit more about how to treat common things in cancer rehabilitation. So definitely has the utility, but I would say the oversight and the teaching aspect would be more challenging in the first few months. Yeah, I agree. I mean, depending on the clinic that I was part of, there were different ways that they handled trainees. There was, I think one of the best ones was where they had like a breakaway room. So you did your interview with the patient, you went to the breakaway room, you discussed with the attending, and then you go back to the original room and you talk with the patient together. But that's like, you have to have people who are really technologically savvy, depends on the program the hospital's using and so on and so not. I'm sure not every center is going to have that availability. I've seen it where, you know, you just go in and the attending's kind of doing the whole session and you just kind of, you know, obviously they introduce you, but you've kind of feel like a stalker, you know, just kind of listening in. And then the other way as well, where you're doing the entire interview with the attending's there, and so you're just doing it in front of them. So different ways to handle it. I think the breakaway room was the nicest if that availability's there. I think I kind of enjoyed having the attending with me personally. We kind of just chimed in together, approached the patient. I kind of took a lead and, you know, as HPI kind of just directed, you know, a quick physical exam or, you know, certain questions, kind of broke down the plan and then my attending would kind of chime in. I thought that was very helpful. Also just gave me a little more confidence in myself that, you know, I'd be able to direct this kind of care since I didn't get formal training or anything like this before. So I felt like that was pretty helpful for me. So I think one of the things that I found difficult when we first transitioned is I think a few of you mentioned about discussing about prognosis and those other aspects. I deal with some inpatient and I think some of you during your training did, but, you know, sometimes they were in rehab and we had a telemedicine, the oncologist to talk about prognosis and all these other things with visitors. I think some of those things have calmed down, but I think it helped us learn on the fly, but I think a lot of us who are past, you know, no longer a junior, how we gauge this as we have new trainees coming in of how we integrate, but also how we train. And I thought you did a good kind of breakdown of the different processes. And I think obviously we'd be looking more to you and the new people coming in about what would be probably the most beneficial and probably a mix and match. I always think about when we talk about telemedicine, there was a study by Dr. Shaville, I don't think she is on, from some years ago where they kind of did, it was pre-telemedicine was a thing where they did phone calls to check in with patients. And it seemed obvious compliance was much better. And I think Hannah, I think you mentioned this about followups and things like that. Do you feel that we need in building off Dr. Smith's talk about research and other things, as we talk about some of these outcomes, do you feel by leveraging telemedicine and our engagement that may help us to integrate more into the team, to build whether it's in research or just get more into the team, to have us more integrated and have that research and be part of that? And I'll open to that. I mean, I think, yeah. I think there's an overall interest from primary oncology providers. I think Dr. Smith mentioned that geriatric oncology including functional assessments and mobility assessments throughout the cancer care continuum. And I think with that ongoing conversation amongst oncologists and surgeons, that's like a perfect kind of segue for us coming in as experts in that to figure out the time points and knowing how to best integrate which ones might be translatable to telemedicine, like something that involves the defense versus something that is better suited for an in-person evaluation. Anyone else? I think one of the things I think about when in terms of research, and I think Dr. Smith, the one piece that I would be thinking about, we've had our metrics group that have done issues with patient reported outcomes. And oftentimes it's a form the patient may fill out and sometimes it's through the EMR, but potentially leveraging that as we get information, just like Brian, you mentioned, you saw something on a CT, you never saw the patient, you didn't have any other info, but are there things that we can leverage that whether through telemedicine or otherwise that can start funneling in who we see in person and otherwise, and I think that's a potential area. It looks like Anne has a question and I'm gonna read it out loud for the group. How has your experiences with the telemedicine consults for procedures and physical medicine intervention? So how has your experience been for actually doing the procedures or other physical medicine stuff? And I'll bypass Hannah's experience with her training for lymphedema, which would probably be different than outside of fellowship, but do you guys feel comfortable whether that was in fellowship or otherwise in terms of how things have come about? That's a great question. So I personally, I got a fair amount of procedural training during residency. And so I felt like I brought a fair amount of that to fellowship to begin with. The volume I would say did, especially early on when things were first closing down and we didn't really know what we were dealing with quite yet. The restrictions were pretty significant. And then the conservation of PPE initially really just volume of procedures took a nosedive. And so that made things a lot more challenging, especially at that phase of fellowship to really kind of build your confidence in terms of being able to do a lot of those procedures. I think it's better now and here in San Antonio, a lot more we're able to do these procedures almost effectively to the same way that we were doing them pre-COVID. Patients still masked, I'm still masked, but everything else otherwise is pretty standard. So I think that these days, it's probably a little bit less of a concern. The evaluations, like for evaluating a patient over telemed to see if they're an appropriate injection candidate. I think that there's, I have mixed feelings about that, putting a needle in someone I've never put my hands on, but I think that there are a number of some patients who can describe a very classic pattern who you're able to do some of those non-contact physical exam maneuvers and provocative maneuvers over telemed that can give you enough information to appropriately recommend an injection of some kind for them. So I think that there's a lot of room for, and fellowship to be able to explore that a little bit more too, how far can we go in terms of evaluating some of these patients and making recommendations based on what we all recognize to be a more limited version of the patient encounter. I'll take the flip side of that. So the other side of being out of fellowship, for the most part, if a consult is for a physical, a specific physical complaint, especially one where they're really wanting to see if they're a candidate for procedures, I'll really push very hard for that to be an in-person evaluation. If it's a situation where it just absolutely is not working out and it's a difference between the patient just not being seen at all, then we'll do telemedicine, like a virtual visit. And even then, sometimes it's just to kind of, again, just get an idea of what's going on. And you kind of have an idea in your head what it is and what the procedure it is is going to be, but still then you're obviously eventually going to see them back in clinic and you'll just confirm your diagnosis before you put a needle in the hole. I know Brian, you had mentioned you got enough procedure experience in residency. Do you feel that your experience was adequate enough for you guys to do what you needed to do from fellowship versus residency? I think personally, yeah. My residency experience was a little bit different, I think, than most, just because I, so I did my residency at Georgetown in DC. And so Dr. Wazowski, Dr. Power up there, they do a fair amount of procedures and I spent a lot of time with them. And so that's really where I put a lot of my, that's really what I often will look back to in terms of procedural training and experience with that. So that really was beneficial to me in particular, but yeah, to Asra's prior points, I agree, and the reality is these, we haven't quite figured out how to get a needle in a patient over a Zoom call. So they definitely will have to come in at some point, but in seeing them that day, you can certainly confirm a lot of what your suspicions were in terms of saying exactly where the injection is going to be. So I think that that's a very fair point. Thank you, everybody. It looks like we got another question for Dr. Smith. So I'm gonna pull up kind of our closing slides here and then ask actually, let's stop this share, cause it looks like I am here. Dr. Smith, are you around still? Yep, I am. Do you see in the chat, the question for you, if you wanna take that lead? Yeah, about randomized control trials. So it's a good question about, how do we turn one randomized control trial into a multi-center trial or for phase three? And essentially there's two ways to go about it. One is you start with the single institution study, phase one or phase two trial, and that's what somebody is doing. And I think the more we talk, the more kind of people will be in the loop about what's going on. And a lot of times we don't know until it's published, but I think we could probably, if there's enough interest, we could have somewhat frequent meetings to discuss research and ongoing trials. But the other, to make it a big multi-institution study, you would have to kind of start it that way. So I think having us all sort of talk and if there's a shared vision for a trial, that's doable and can be funded, then it can be done. One way to do multi-center research or one thing that helps, I should say, a proposal is if you show a track record of working together. So to the more senior folks on the call, if you get invited to write a paper or review or something, bring in people from other institutions and who are maybe less senior in their career so that you have that track record all of a sudden. And if you do decide to come up with a study together, you could submit that as proof that you can work together and accomplish this. So I'll put my email address in here if anyone is interested in talking more about that. Okay, thank you, Dr. Smith. And you guys can all see my slide hopefully up there. Thank you for all attending and where I know we're a little bit over time. I think a few things that we wanna close is, as we transition, I wanna thank Dr. Ekta Gupta for kind of leading the way over a very challenging few years that was an unexpected, not really getting to meet in person with a lot of people. I probably didn't help her as much as I probably could have via virtually, but we do have some new leadership within this. Appreciate everyone who participated and volunteered to be a nominee. But myself, you'll see the names through there. Myself, Dr. Begay, Dr. Power, and Dr. Shrivano. And then we have the subgroups that we're working through as well, hopefully to add on. We will be hopefully having another meeting outside of AAPMNR to kind of introduce everybody and start getting a flow and a plan for the next year or so. Though it may be at some point, 2022, we can get together in person. We tend to get more active then. A few other reminders. I wanna tell people to check your email for that telemedicine survey. Contact us through PHIS Forum or reach out to us individually if you wanna get more involved or if you have some ideas. I know Kelly Shrivano, who's our co-secretary this year, is pediatric trained, and so we're gonna probably hopefully look to do some more integration with the pediatric team and potentially, as that may lead into survivorship-related issues that I know a lot of us kind of deal with as well. And then lastly, we have in closing, obviously for the CME link, everyone to kind of fill it out and get your feedback. If there's any other last questions, thoughts, concerns, Dr. Gupta, if you have any thoughts, let me know. I know Mary's talking about a happy hour. I think that'd be good for everybody these days, but we can talk about that. I don't think that's gonna be okay. Oh, Sean started it. Oh, Sean, sorry, I just saw the last one. I did. But I think a happy hour is good, whether you have any spirits or not. And as Ekta was sharing her scary screen before, hopefully everyone's doing okay. And if there's no other questions, I think we are good to end the session. Appreciate everyone's time. I know it's tough during the week and everyone on different time zones busy during the day. Any last comments, Ekta? No, it's been fun. Two years flew by, mostly related to COVID. So I'm hoping in the next couple of years, we can keep accomplishing more. Thank you all so much. Thanks, Sam, for taking over. You will be a great chair. And Leslie's gonna be awesome. And she has so much experience as well. I'm looking forward to our co-secretaries, but thank you all. Thanks everybody for joining us today and taking the time out too. And please reach out. I know during Zoom and the Zoom error, we often miss emails and other things. So I always say, if someone has a question that doesn't get answered, ask again. No one's gonna get mad. All right, thank you very much.

telemedicine

cancer rehabilitation

research findings

American Journal of Physical Medicine and Rehabilitation

Journal of Telemedicine and Telecare

increased access to care

care from home

ongoing support and monitoring

interdisciplinary care

collaboration among healthcare professionals

physical therapy

functional improvement

quality of life