So, thanks for all the introductions. You know, this panel is hosted through the AAPM NAR. Can everyone see the slides here? Okay. That's great. Great. So this is presented by the Cancer Rehab Physician Consortium. And this is a group of cancer rehab providers, both fellowship and non-fellowship trained. And our mission is to further education and cancer rehab medicine, further research and further networking through annual meetings at AAPM NAR and also through monthly meetings. So our agenda, we'll go over the current state of fellowship within the 10 minutes of my presentation, and then we'll have a panel discussion and a Q&A session afterwards. So there's a lot of cancer survivors in the United States, and that's projected to continuously increase over the next decade. And decade after that, you can see we have about 19 to 20 million cancer survivors currently. This is based from data from the American Cancer Society in 2020. By 2040, there's estimated to be about 26 million cancer survivors. And with that, there's also projected to be a trend, an increase in the prevalence of functional limitations for these cancer survivors. This was a study that was done from 1999 to 2017 and 18 to assess the trend of number of cancer survivors and how they identify with having functional limitations. So it just shows you how important this field is for the ever-growing needs of cancer survivors. And I do wanna outline the 12 different programs that are currently eligible to host the Cancer Fellow every year. And so we have, in no particular order, Memorial Sloan Kettering Cancer Center in New York, MD Anderson Cancer Center in Houston, Texas, U Michigan, U Penn Medicine, Kansas City, University of Kansas, MedStar National Rehab Network in DC, Northwell Health in Long Island, New York City, Rutgers New Jersey Medical School, Ohio State University, University of Miami, Atrium Health in the Carolinas, and University of Toronto. Just a little bit of descriptions of the fellowships. So this is a one-year non-ACGME accredited fellowship, although there are efforts made to change that, which I'm sure our panelists will speak to a little bit about. They take about one to two fellowship candidates every year, depending on the program. Currently, there's no standardized board exam for fellows to take at the end of their training year. And as we know, the ACGME is responsible for accreditation of residency and fellowship programs. I was looking at the statistics on how much percentage is tested on the American Board of PMNR certifying exam, and cancer rehab is lumped into general medical rehabilitation, which accounts for about 8% of the exam. Just some statistics here. And I do wanna outline all the important work that leaders in cancer rehab have done over the past few years to define what is important in cancer rehab medicine in order to really highlight our value to all the different stakeholders, including oncologists, leaders of healthcare systems, patients, caregivers, and facilitate in the ever-growing cancer rehab clinical programs across the country and really identify areas where we shine and provide value to patients. So I'm gonna breeze through these. I'll put links in the chat box to more detailed, an actual article in which these are outlined for your own review if you're interested. But these kind of just outline all the different areas in which cancer rehab physicians are able to treat different impairments in cancer. So this is a very comprehensive list, of course, including cancer-related fatigue, cognitive impairments, lymphedema, neuropathies, bone health, defining all the different cancers in which we treat patients, cancer-specific diagnoses, all the different procedures that cancer rehab physicians do. Comment, you know, really supporting the cancer patient throughout survivorship and wellness beyond just their physical health, including prehabilitation, sexuality, nutrition, vocational things like employment, disability, and areas of practice into which different cancer rehab physicians practice in, including inpatient rehab, outpatient, consults. And this was really exciting for me to learn about here, the fact that there's an actual cancer rehab medicine curriculum through the AAPM NAR. I can't imagine, you know, how many meetings went into this, how many people really scrutinize every little service and what is considered core knowledge and what's specialized knowledge, basic, intermediate, advanced. If you have a second, you just pull out your phone, take a look. It's a 66-page document created by leaders in cancer rehab to really outline, you know, what's important and what should be considered, you know, common knowledge or competencies that the trainees should strive to achieve for. So I'll just leave that up for another five seconds, but I'll also post it in the chat box for people who are interested. And with regards to fellowship, what I've been seeing is most programs are asking for earlier submission of applications on July 1st of the preceding academic year that you're gonna start as a fellow. So for those who are within residency and applying as a resident, this is the start of your PGY-4 year. And for materials, they're asking for, you know, the program-specific application, the personal statement, the CV, usually three letters of recommendation, USMLE or COMLEX scores, medical school transcripts, and a headshot photo. To my knowledge, interviews are still conducted on a virtual platform. And this is news for this upcoming application cycle for me that we're gonna be participating through the National Resident Match Program as opposed to what was done previously. So this is gonna be the first time we're doing that. And I had heard from a program director that potentially December of 2023 would be the new match date. And I just wanna highlight this research study that was published. Essentially, this was a survey sent out to members of the Cancer Rehab Physician Consortium of the APM NAR. You know, a lot of attendees here today, our panelists here, to get their thoughts on how they feel about different things, including whether fellowship is necessary, how they feel that their burnout rates are in the field. So I'll just quickly highlight some things here. So most agreed that mentorship early on in training is important, and that's primarily done through identifying an early mentor in training and continuing to attend the professional national conferences such as APM NAR. And about over half reported their burnout as low or very low, and more than half believe their burnout level was lower than physiatrists treating other rehabilitation populations. And I will also post the link for this study for the sake of time in the chat box here. But this is just some figures from the study showing where people who answered the survey outlined where they mostly practice. So mostly, primarily in outpatient rehab practice, about 40%, followed by 35% doing a mixed inpatient and outpatient. And this is time spent on clinical care, most over 51% said that they spent about 76 to 100% on clinical care. And then this is time spent on research related to cancer patients. Over 76% of respondents reported they spent less than 25% on research. So that was the most popular response. And then I just wanna highlight, really cool things in cancer rehab, including Psycho for Survival. Did this recently with some members of my own residency program to raise money for cancer research. So I think it's a very rewarding field. I'm very pleased to be here and kind of learn from the panelists today. So I do wanna turn the attention over to our panelists now. Dr. Frick, you can certainly go ahead and I know you're tight on time. Yeah, no, thank you for that. I think it was a very comprehensive intro and a good kind of description overall of what cancer rehab entails as well as how the application process goes. It's definitely an evolving process. It's become a lot more formalized, which I think is a strength of the programs and how they're moving forward. And as was mentioned earlier, yes, there is a gradual goal for moving the program into getting ACGME accreditation nationwide. And so there've been good steps so far towards that end of getting residency and fellowship specific educational milestones established and agreed upon within the cancer rehab community and amongst all of us. And yeah, I think it's more a matter of time than it's more of, and I think it's more of a matter of when it's going to happen than if. And Dr. Riley can chime in on that a little bit as well, because I know she's involved in that process to a degree as well. Yes, thank you very much. And I know we only have a couple more minutes with you, so I'm gonna give you a question back at you. So Dr. Fricke has done a great job starting his program. And I think a big question for people considering this career is how do you start a program and how do you market yourself and tell people what your skillset is? So I think one big question that you might have as a trainee is how is this fellowship gonna prepare me to start a program and how is this fellowship gonna prepare me to be different in this field? And I think, Dr. Fricke, any insights you have or advice would be great. Yeah, absolutely. I think that's a fantastic question. So one of the things that I think is in our favor is a lot of the work that has been done by the titans in our field already has helped to get us into the NCCM guidelines, mentioned explicitly as physiatrists needing to be a part of the cancer treatment continuum. I think what fellowship really gives you is a kind of a en masse exposure to cancer patients and the cancer world. So really you can learn to speak the language of the oncologist. To really, I think, be successful in marketing yourself and starting a practice and getting a referral base established, you need to come to these oncology teams and say, hey, how can I help you? Where do you feel the pain points? Where do your patients feel the pain points and really do like a needs assessment in that way because that's really our goal overall is to have this mutually beneficial existence where we're helping not only the cancer patients, but the oncology teams as well, improving their outcomes, improving function, improving quality of life. And that I think is really what I've been somewhat successful on and being able to achieve here in San Antonio is going to the oncologist, going to the teams. And as I said, I've been pretty fortunate. I think the oncologists here have kind of already drank the rehab Kool-Aid, if you will. So it wasn't a very high bar to entry, but for those that were maybe a little bit more skeptical, which really wasn't very much, it's really coming to them with this kind of, how can I help you? How can I be of service to you? What are some of the things that your patients come to you about? And as far as symptom burden, as far as what's limiting their function, what's limiting their quality of life because the oncologists and by and large, their focus is to treat the cancer. And so our focus is very different than that. Our focus is on their function, their quality of life. And so coming in to be like, hey, when you're in that very tight 15 minute, 20 minute clinic appointment with a patient and they're describing to you their shoulder pain or their knee pains, or that they have trouble getting up the stairs or that they have trouble bathing themselves or getting in and out of bed, instead of feeling overwhelmed and you have to be the one as the oncologist to address all that, send them my way. I'm happy to take that off their plate and it'll be that much more benefit to the patient. So there's also, I will kind of clue you guys in. There was a talk, I believe it was recorded as well, that was given actually by my boss, Dr. Gutierrez, along with a couple of other folks, Dr. Whiteson and oh gosh, I feel awful that I'm forgetting his name. But there was three faculty yesterday who were talking about marketing in general and how do you sell your services to the different stakeholders that we interact with, to patients, to the media, to those in the C-suite to justify our value that we bring as PM&R as well as our colleagues. And so I think there was a lot of good strategies and tips that were offered in that discussion. So I would highly encourage everyone here, especially when you get to that phase of your career to look up that talk, it's really, really good. Awesome, thank you so much. I think you bring up a great point, which is that there are people who are gonna buy in and there are maybe people who are more skeptical. And I think Dr. Chang also starting a program or joining a program at Cedars-Sinai, maybe you can speak to your experience about making like multidisciplinary connections and working with different providers and getting buy-in. Yeah, absolutely. So yeah, my situation's really different. So Cedars actually has like the first fellowship trained cancer rehab doc there. So the director there is Rosh Asher. So he's been there building probably like the most comprehensive survivorship wellness resilience program in the country, honestly, that I'm aware of. So he's been building buy-in for like over a decade. So I didn't have to do much of that work, but I think kind of what David sounds like, maybe he'll be doing it UPenn like with the affiliate hospitals or other sites. It's kind of what I did at Cedars as they've just kind of acquired like a bunch of different hospitals in like the greater Los Angeles area. So I've been building clinics out there, but yeah, I totally agree with everything that Brian was saying that. I would say, you really just want to be prepared. You want to know what you bring to the table. Definitely, you want to make very clear what you can do that maybe they can't do. Because at the end of the day, I think the thing that makes you the most valuable is the things that you can do that no one else can. So you're all physiatrists. So you have the expert physical exam skills for the neuromuscular skeletal system. You can do EMGs, maybe you can do Botox, maybe you can do ultrasound guided procedures. Maybe you're like an expert in prosthetics and orthotics. And these are things that most oncologists know very little or nothing about. So everything that you can do that everyone else can't, I would kind of put that front and center. And whenever you can match that up with guidelines, either from the National Conference of Cancer Network or the Commission on Cancer or from American Cancer Society or any one of these 50 organizations that they pay attention to and they know about, that's also really useful. So honestly, what I do, I have slide decks for every kind of cancer, for breast cancer, lung cancer, prostate cancer, lymphoma, leukemia. So you just make a 20 to 30 slide deck. And then I think I've met most of the oncologists like at Cedars-Sinai that are in my catchment area. So you just like, when you start off, if you're like in the academic area, you probably have a lot of time. Your clinic's not gonna be very busy. Just use that time, take like five to 10 minutes to meet every single person and tell them exactly what you do. If you can do a face-to-face, great. If not, then I think video is fine. And not just the physicians, we meet with like the nurses and the PAs and the nurse practitioners and any other mid-level providers and anybody that could be like a referral source for you just so everyone knows who you are, I think is really essential. Okay, now regarding like multidisciplinary clinics and like buying from multidisciplinary clinics. Yeah, I would say it starts with building relationships. So once you get to know all these people, then they like you, hopefully, you have to help the people that they're sending your way. So hopefully they get better. And then those patients like tell the referring oncologist that, and then you build that relationship that keeps sending you more people, you start talking about people. And then yeah, one day you, whatever, maybe you start a multidisciplinary clinic, whether it's your idea or not. So I'm a part of, I guess, technically, I'm part of three multidisciplinary clinics right now. So we have a multidisciplinary pancreatic program. I'm technically a part of that, but really I'm just using that more for research purposes because we just started a prehabilitation supervised exercise research study. So I'm really more in it for that, but that was, so that was my idea. So like my, literally my first meeting, like with one of the pancreatic attendings there, like I mentioned that, you know, prehabilitation was something that we do. And then he's like, oh, that's great. And then, I mean, it took three years to get off the ground, but we're doing it now. But that was something that started with literally our first meeting. We started, we started a multidisciplinary CNS clinic. So for patients with brain tumors, and that started because I'm really good friends with one of the clinical nutritionists and she's, you know, knows really well. She's been working with like, you know, the neuro-oncologist for a long time. So we all got together and we started, you know, a clinic. And then there's a comprehensive bone clinic for like patients with osteopenia and osteoporosis-related cancer. And that was kind of forced on me. And not, okay, not forced, but that was like somebody else wanted to do it. And they're like, okay, you're here. And I'm like, okay, yeah, that's fine. So I would say, especially when you're starting out, say yes to most opportunities. And then once you start drowning, then you can start refusing stuff. Awesome, thank you. And thank you, Dr. Fricke for your insight. Thank you. So now I think, you know, I'd like to hear from the current fellows who have chosen their attending positions about, you know, their process of fellowship and applying for fellowship, choosing a fellowship and figuring out how to find jobs? Whichever one of you wants to start. I can start, I'm happy to. Do you want me to start with a decision on fellowship or jobs or? Anything you want. Okay, in timeline order. So fellowship, decision to do fellowship, I think that's kind of a personal thing as well. I personally knew that I kind of wanted to go through the cancer rehab route, like in even as a fourth year med student, and that came from just exposure really, and just like personal experience, just liking the field of oncology. But, you know, even throughout my residency, I was still kind of mixed between, or like torn between wanting to do kind of like a sports medicine route versus neuromuscular route versus cancer. And I know that there are some people who have interests in two different kind of areas, but I think what it just came down to was just asking a lot of questions and trying to figure out, you know, what was the right fit for me and kind of having a kind of being forward thinking a little bit to see where I pictured myself and like how I wanted to use my skillset. And if I needed a particular skill that I wouldn't get from maybe a general cancer rehab fellowship, and I really wanted to do that, maybe think of something different. But I know personally that's, cancer rehab was really what I wanted to do and wanted to immerse myself in that. And I think particular type of fellowship, I think for me, it was a lot of location and just volume. I wanted a lot of volume and a lot of different experiences, and I'm really happy where I ended up. And also in future wise location, like where I wanted to end up and having those connections. So, and then that ultimately led to me decision to find a job kind of in this area, cause I've always knew I wanted to kind of stay in New York and building those connections and those relationships and creating those mentors and ultimately ended up finding a good position within the city. And I think a lot of that was, one, having the connections from fellowship was great. So that's one of the decisions that made it really easy for me to find jobs in the area. And the market is great. Like, I don't know if that was the experience with the other current fellows, but I felt like going to the AAP conference last, everyone was kind of like, oh, are you interested in coming here in this state for cancer rehab? And so it's been really good, but that's been my experience. So, yeah. So in my case, I came across cancer rehab by chance because I happened to be rotating with attending and PGY two year who was practicing cancer rehab. And it was something I had never like thought about before or thought I was going to be interested in, but I was still working with him that I was supposed to feel. And I just remember being so happy that day. Like halfway through the day, I was like, oh, actually I really, like, I'm really happy. Like I haven't felt this happy in a while. Like I love PM&R, but I really love cancer rehab. So like after two days of working with him, I told him, hey, like, I think I really love what you do. And I think I'm interested in doing the same thing. Can you give me some advice about that? So kind of like follow my heart situation. And so I ended up applying to a cancer rehab fellowship because in my residency program, I didn't feel that I had enough experience seeing cancer patients. Like there just wasn't enough volume. And this goes back to what someone else was saying earlier this evening and that doing cancer rehab fellowship, it really gives you that volume and diversity of experiences and seeing different cancer patients and the different pathologies and things like that, that really helps gives you confidence to practice as attending independently later on. So I applied to cancer rehab fellowship. And then in terms of the job hunt, I absolutely agree with everything Chanel said that the market was great. I'm also very geographically good in terms of looking for a job because my is from like the New York, New Jersey area. So when I was looking for a job, I didn't even look in other parts of the country. I only look in that one small area and there were tons and tons of job opportunities. And it was definitely good for me to be able to have a variety of choices in deciding what kind of job I wanted. And even while I was in that process of looking only in one area of the country, I heard from multiple people about other institutions nationally who are looking for a cancer rehab physicians. And they said, you should apply, this place is great. And I said, well, I don't think I can move there, especially since it looks like I'll be able to move into my preferred geographic area. So I didn't even look, but I'm sure if I had opened myself up nationally, there would have been endless opportunities. For me, so my fellowship journey, or when I decided I wanted to cancer rehab, started a little bit later, I think. For me, I was thinking back to, what sort of patients do I wanna work for? And not that other patient populations are not as inspiring, but I felt particularly inspired working for cancer patients. I just remember being so touched by the patients that I saw, particularly in our inpatient brain trauma unit, and just dealing with not only the medical issues, but talking to families and just seeing how much of an impact the disease had on patients' quality of life. And so I knew that that's population I wanted to work for. And as I did more and more research about the field of cancer rehab itself, I discovered that it is a growing field. And I really wanted to have the opportunity to take on perhaps a leadership role in either developing a program someplace else where there hadn't been a program before, or helping build a program that already exists. And so I recognized that there were those opportunities, and because I wanted to take on a role in that regard, I thought cancer would be a really great fit for me. Yeah, in terms of looking for jobs, I also was looking for this particular area, mostly because my wife's from the area and she had always talked about living sort of in the Northeast, like Philadelphia, New Jersey. And so I was mostly looking in a couple of places, but I think ultimately I'll echo what everyone else said in that there seems to be a lot of interest in cancer rehab nowadays. And even if a job isn't publicly advertised, I think that there are avenues where if you just reach out to oncology, or you just reach out to certain hospitals and you explain like, hey, these are the services that I can provide, I think that you'd be able to justify, just as Dr. Pericchi was saying, what value that you could provide for cancer patients. And I know I've heard of some people doing that and sort of getting the ball rolling on finding positions that way. And so I really do think that the time is ripe right now for cancer rehab to continue growing, and I don't anticipate that there'll be any shortage of opportunities for anyone going into the field. So yeah, I would suggest even if something isn't publicly advertised, if you have a location that you wanna go into, it doesn't hurt to reach out and sort of try to see what connections you can make. Awesome. So I'm gonna put Sammy on the spot because Sammy's applying to fellowship. What questions do you have as an applying fellow for these panelists? Hi. So one question I would have is, how can a candidate begin to, I guess, see what a day in the like is at each different fellowship program? And I'm sure you learn a lot about that through the interview day and potentially just talking to, I guess, other fellows who had recently graduated from the program. But for some people, it's like a move from where they're used to living to an entirely different location, how they begin to, I guess, get an idea of how that year is gonna go. I think talking to the current fellow and recently graduated fellows is probably the best route to go. Generally speaking, everyone in the field of cancer rehab are incredibly friendly and are really excited whenever they hear that someone else is interested in joining the field. So if anyone's interested in a specific program, feel free to reach out to the program directors. In my experience, they're all very friendly and very excited and very happy to help. And they can definitely connect you with the current or recently graduated fellows so that you can hear from them. Yeah, I agree. Everyone in our field has been really approachable and open, and I think that that's been from the beginning, even when I was applying. I mean, I remember when I was a fourth-year student and I met Francesca on a whim on an interview, and she really just facilitated a lot of things because we were both really excited about the field. And I think that what's beautiful about our field is that people are just really excited about people joining in and buying in and wanting to grow this subspecialty. And so I think anyone is probably willing to chat with you about their experience if you reach out. And I think the best way to do that is you really don't have any connections, maybe reaching out to program coordinators or directors, like Ying was saying, and see if they can put you in touch with the current fellows to get kind of the experience of what it has been that year. But yeah, I mean, we're all really friendly. I think I had heard that there was something in the process of being created for listing contact information for different recently graduated fellows from different programs. So I was wondering, is that something that would be publicly made available, like on an AEM PM&R website, or how is that going to be distributed or access for applicants or candidates who are interested? Yeah, I think that that's one of the objectives of our CRPC subgroup is to develop some type of contact list, especially as the fellowship programs continue to grow, it's gonna be helpful for people interested in applying to know everyone and to maybe figure out who their closest geographic cancer rehab physician is to go shadow. So we're working on that. And until we get there, anyone on this call, feel free to just email us or find our contact information somehow. And like everyone's mentioning, everyone in this field is very friendly. And we've all been in your shoes where we had no idea what to do. And so please feel free to reach out. So I think that another question has been, what's gonna happen with the potential ACGME accreditation of these programs? And so, in my opinion, I think that this is an exciting time for us. And when I applied to fellowship, I think there were four or five fellowships and now we have 12, and that's been, I think, a five year process. So with the growth of these programs, and as we graduate more people from these programs and you all start to build your own programs and hopefully build your own fellowships, we wanna hopefully standardize the curriculum so that anyone who graduates from cancer rehab programs in the country is gonna have the same skillset. And so, we're not ACGME accredited now, but hopefully in the next, I don't know, five to 10 years it'll happen. And I think what that gives us is more credibility with the oncologists. So they, seeing us graduated, seeing us have a fellowship that has a board exam that has an ACGME accredited or accreditation, I think will help us establish ourselves in our field and maybe provide us with more resources for research and collaboration with other specialties as well. But yeah, Hannah's putting a shout out in the comments to help her with her project, but I think it's an exciting thing and I think it won't take away anything from what we're doing currently. I think if I were an applying fellow, I might wanna know about what these graduates have thought about the differences between the programs. So we have a couple of people who have done fellowships at different places. So Michigan, Miami, MSK and Penn. So I'd like to hear more about kind of what you thought in terms of your programs and what you were looking for in terms of balance of inpatient, outpatient procedures when you're applying to your fellowships. Phil, go ahead. Oh yeah, thank you. So I've only been to one fellowship, so I guess I can't compare directly, but I'm pretty sure it's the best fellowship that there is. I think Dr. Fadu who's on the call would agree. More biased. Yeah. I'm just kidding. Or yeah, I'm sure they're all great. I'm sure everywhere has their strengths and weaknesses. Like I'm from Michigan, so I kind of wanted to go there. But at Michigan, I thought they had a really good, I guess, I honestly can't think of anything negative that I would say. So I'm just gonna list off all the positives. Their inpatient, outpatient balance was really, really good. The number of like ultrasound guided procedures was really, really good. Like I wasn't even like that good at ultrasound injections like coming out of residency, but I did like a ton of them like during my fellowship in Michigan. So that was really good. I don't know if they're still doing this, so don't quote me on this, but I think 20 or 30% of your time there is basically your own like autonomous clinic where you're like billing yourself for those patients. And I thought that that was really, but your attending is there if you like have any questions or wanna talk about anything. So I thought that was really good because it was like a really good transition for being like a real by yourself attending because you had to learn all the billing yourself and stuff. And for anybody, I guess, who's like going to academic medicine, because I was technically like an attending there my first year, that counted as like one year of like being a clinical instructor. So it's like less minus one year, depending on where you go, like towards becoming like an assistant professor or so for anybody for whom that's important. But no, I literally have nothing negative to say. It was like a really, really good experience. And I think the training was really, really well-rounded. Yeah, I really enjoy my fellowship here at Penn. I have outpatient clinic and then I do inpatient consults. And just like Dr. Chang, I also have my own fellow clinic as well, which I'll echo and say that it's been a really great experience just in terms of knowing how to bill and how to do billing. And I think that's really, really important. And I think that's really, really important just in terms of knowing how to bill and knowing how to do, and gaining the confidence and doing a lot of the medical decision-making. I have my attending with me to, you know, if I have any questions or anything, but it's really myself who's making those decisions, ordering all the labs and tests and bring up those additional workup. And I think it's been great. Just in general, when I think about, you know, I was in residency, I'd never really had that kind of autonomy. And, you know, you quickly learn what you don't know once you're thrown into the fire. And so it's been really, really great. I think there's been a great mix of procedures as well. You know, like I do a lot of Botox. We have a lot of patients get referred from our head and neck oncologist. And so do a lot of Botox injections for cervical dystonia. Do ultrasound, we do ultrasound guided procedures as well. Yeah, it's been a really great mix of different things. I think for me, Penn was really attractive just because, you know, it obviously has a wonderful comprehensive cancer center. And I knew that I would see a lot of complex cases. And, you know, I really wanted to see much of what, I think, as much difficult, quote unquote difficult patients as I could, just so I would have a better handle as I'm attending and know how to deal with more complex issues. So that for me, you know, I thoroughly enjoyed Penn and I'm, you know, very excited to continue my work here. I guess I'll comment. Yeah, I mean, my experience was very similar to Dr. Lee. I think for me, I was looking for a fellowship that would really give me something very well-rounded. I wanted to see a lot of, as much complex cancer cases as I could to feel a little bit more competent and confident. So when I come out and be in an attending and say, okay, I've seen things like this, what also really attracted me to Sloan was the fact that they really had a lot of different attendings working there. They had like maybe some eight or nine attendings and they all kind of do their own kind of subspecialty within cancer rehab, which I thought was really unique and interesting and got to see how they use their unique background and how they applied those things to cancer rehab. So it was a true like bread and butter rehab like on steroids in cancer. And I just, I really loved that. And then what I got here, what really surprised me with the fellowship that I really learned, like came to love is that you get a lot of autonomy. And not only that, the culture at Sloan, they really just embrace trainees as like fellows, as part of the team, part of the treatment team, part of the, like you're really one-on-one with oncologists, with neurosurgeons in one of our multidisciplinary clinic. I'm literally sitting shoulder to shoulder to the neurosurgeon and he were reviewing slides and they're asking me questions and my advice as a fellow. And so I thought that that was amazing and unique and I really come to love that kind of culture where we can all learn from each other no matter what level you are on. So I just really loved that and it made the learning environment just that much better. So that's something that I didn't expect coming here that I like really came to love, so. Like everyone else, I'm also having a fantastic time in fellowship and I love my fellowship. And it's also a very well-rounded experience. So for my fellowship in Miami, I have inpatient time on an inpatient cancer rehab service where PM&R is primary, time on outpatient, time in consults, consulting on cancer patients within the acute care hospital. And actually two different acute care hospitals, one that is a private cancer hospital and one that is a public county hospital. So very different patient populations in those two hospitals. And then time spent with specific oncologists, time spent with palliative care, and then also elective time, which I use to spend doing some additional procedures specifically with Botox and ultrasound guided injections. And I also had a similar experience as Chanel where when I was with like Guyonk, they really valued my opinion when it came to their patients. The attending, if she saw a patient, she'll be like, oh yeah, this patient's been having trouble walking. Can you go see her first before I see her? And she would give me individual time with that patient. I actually have one experience where I saw a patient at Guyonk clinic without attending, I evaluated her, I gave her my medical recommendations, and I saw her again in PM&R cancer rehab clinic two months later, and she was so much better because she had done everything I had asked her to do. So by the time she made it into the cancer rehab clinic, she was like doing well. Like she just needed maintenance. She didn't need anything new to be done for her. So that was like a really good experience. And it's when you're with those other physicians that you realize like how much expertise you have as a physiatrist on things that they have no idea about and how much they really value you and the care you add when taking care of these patients together. I think these are all great points. And I think as physiatrists, it can sometimes be intimidating when you're speaking with oncologists and you're like, I don't know what these acronyms are, but this person has a frozen shoulder. So I think as you do your fellowship and start your programs and start your careers, like everyone here is mentioning, just rely on your skillset and know that you have a lot of value for these other teams. And it may take some education. It may take several emails and introducing yourself and reintroducing yourself, but just continue to persist. I think we're coming towards the end of the discussion. So I think the last 10, 15 minutes, I'd like to ask you guys what has been the most difficult part or what would you wanted to know as a fellow or as a trainee before you started fellowship in your career? I can start. I, I think that, I mean, we kind of knew that this, this year was a lot of work, and I think in any fellowship during this year you know you have things like boards, those things, you know you have your part one you have a part two later on, you have a lot of fellowship projects you're trying to do well in the clinic and consults. There's a lot of like follow up you you're trying to learn as much as you can, but at the same time try to pass your exam so it can get overwhelming and I think that, you know, I was lucky enough to have people surrounded by people that give me some advice and support and everything like that but it is a year that's going to be going to test you and challenge you both physically emotionally mentally so just really taking things day by day and learning as much as you can, and just knowing that you're it's okay to just ask a lot of questions, and this is your time to kind of learn and. Yeah, yeah, that's really just what I wanted to say and I didn't expect it to be that rigorous and challenging but I think it makes you a better person coming out of the other side too and you have a lot of support here in the community itself and like I've reached out to just some colleagues today just about things that I've been feeling and, you know, and just feel really great and supported in this community so yeah. Yeah, that learning curve from residency to fellowship is like exponential. So, it's very overwhelming, and at the same time you're setting for boards and then once those are over you're looking for jobs so it's a, it's a wild year but you all can do it. Yeah, I would love to hear, you know, as a trainee, how everyone's experience was looking for their first job, like coming out of fellowship and how that process when like what, at what point were you beginning that process and how did you ultimately, you know, make that final decision with the institution that you chose or. Yeah, like, I guess. Yeah, all the processes that went into that decision. I can start. So yeah so I think for me when I was looking for jobs. It was important for me to be close to family and so I, you know, reached out to a couple places that were close to, to my parents and then also my wife's parents and then our respective families and so, you know, when I, as I, as I went through this process I realized that, you know, there were a lot of places just looking for people that have been trained to help with cancer patients and you know their quality of life issues, and I think for me there was never a point in time where I felt stressed about finding a job. So I wasn't too concerned about, about that it was really just finding a place that I thought would be a good fit for me and my family. I ultimately ended up staying here at Penn, which I'm excited about and yeah I you know I would say that, you know, throughout the process. I found myself not having to market myself as much as I thought I would I think a lot of the groundwork and sort of been laid out especially at the major academic centers where I think there has been some exposure to physiatry and the good work that we do. So I personally can't speak about really, I never really looked at a place where I would have to start my own program I don't know anyone else in common on that but for me, might be a little different compared to what other people are looking for. So I started looking for a job last fall so honestly like it had only been a few months into my fellowship. So I started looking. Thankfully AAPMNR was around the corner and I figured I can go to AAPMNR all the programs will be there I can go talk to the programs and see kind of where they're at where their headspace is whether there are positions available. Because for me personally I was always interested in a practice in the academic center so I knew I wanted to be able to talk to those, you know, big AAPMNR, big academic AAPMNR departments in the area that I was looking in. So that's just like a very convenient way and yeah at the career fair you know every program has their table so I just made my rounds and talked to all the programs in the geographic area I was looking at and everyone was very friendly and a lot of them were indeed looking for a cancer rehab physiatrist although no one had posted any jobs, they were all looking for it. So definitely reach out to the programs in the geographic area you're looking interested in, if you're interested in looking for a job, and definitely start early, rather than later because the interview process took a while, that took like a few months, then like when they make an offer, it takes like another weeks to maybe a month. And then you know you want to negotiate your offer right because you want to make sure you're doing what's right for you and your family so then that takes like another month or two or three. And then you decide what to accept it and that takes some time too so it's a long process. I think after, I think my first goal was to get over like part one of boards. And then after that I started thinking about putting out feelers. Again, I was kind of location limited I knew I wanted to stay in New York and kind of getting a sense of what the programs were in the area that had established programs. And it was a lot of word of mouth, actually, because I think New York City and New York area. Everyone knows each other and know, like, what positions are kind of available so that was helpful but also, you know, going to AAP MNR was really really helpful because you got to kind of introduce yourselves and see you know who, who was out there that didn't actually like post anything, and then just got a sense of exactly like if they're if they're even as available positions open or any interest at all. I knew that I wanted to be in an academic environment, because I feel I personally feel like those positions can really help, like, have you like hone in and the cancer rehab piece. Otherwise, I've talked to a few people in kind of the private area and they were like, you know, I do some I see some cancer patients but I also see a lot of like general general PM and R as well which, you know, in, in some positions you might still be doing but I really wanted to build cancer rehab programs. So, those are all going to be different experiences and different challenges in itself, but kind of trying to decide on what avenue I wanted to take there and if you had a particular interest within the field. One of the questions I've always asked all like places I was interviewing at is, is what is the interest among the, the different types of oncologists and surgeons and kind of get a sense of the people that are already trying to work with me. So, that way I know like I'd be putting my interests, you know, to use but all around it's been really good and it's been really easy to find people who are interested in even making a job opening so yeah, go to a human are. And I think I wanted to add to I don't know if any of the attendings here can comment on, it was really kind of difficult for me to when negotiating kind of salary contracts to find specific cancer rehab specific like numbers in terms of like salary or RVU targets and all of that, you know, I don't know if obviously our field is new but also people in our specialty kind of practice differently. Some are more procedure driven and some are other so there's really not one cancer rehab bucket for knowing like what to negotiate for and I think that that was the most challenging too. I don't know if you know anyone, any of the attendings can comment on how you know if there's information out there, if there's going to be any information out there about ideal targets and salary and all that. In terms of RVU. There's no information like that I think you kind of hit the nail on the head when you say that, like what we do is really heterogeneous. Not one of us really practices like anyone else, I don't think. But I would add that it really depends and this is something like if you're looking for jobs or whatever when you're looking for jobs that you should ask and look into, like what department, you're going to be under. Like, are you working for the cancer center directly or are you going to be under the Department of PM&R, because they will both have very different expectations of like what you should be doing, who you should be seeing, like, how much, like in general cancer if you're working for like a cancer center, like the money that you bring in it's so little compared to what they get from like chemotherapy infusions. So if you're like under like the rehab department, you know, the RVU targets may be higher. So it just ask like, you know, who's paying your salary basically and who you owe your time to. I think, you know, some people are comfortable sharing their salaries, we don't have to do this on this call but, you know, you develop relationships with other people and you can reach out to your mentors and ask, you know what they feel inappropriate starting salary would be and it also depends on what your role is, are you starting the program, do you have a title of director of cancer rehab or, you know, what are the expectations that they have of you. No good answer for this but I think, you know, just reach out to some colleagues and try to get some feelers as to if the offer that you're getting is appropriate or if you should be asking for more. So we have 10 minutes so if anyone has any questions from the group here, you can feel free to put them in the chat I know Evelyn when did you start reaching out for jobs and I think it sounds like early fall after boards is the recommended time. I guess never too early though so. So that's that answer. Any other questions or anything else that the panelists want to say, Dr. Koenig recommend also just having your program director look at your contact track yes for sure. And they will continue to be great mentors for the rest of your life so keep reaching out to your program directors forever. I'd like to hear if anyone also participates in, like a cancer group outside of a PM or I've been seeing things from like a CRM, like a cancer group and community there but I personally have never attended one of their conferences so I'm just curious if anyone does other, you know, networking groups outside of a PM there. Actually, yeah, so I'm not actually a part of it so ACRM, they actually have like a huge cancer rehab, like program. It's not just physician centered ACRM is a lot more multidisciplinary so usually with like skilled therapists. I'm going for the first time this year but yeah they have like a huge, pretty huge network. Yeah, outside of that other like rehab, you know organizations I'm not sure but I would say ASCO, they have a specific. Somebody correct me if I'm wrong but they have like a quality of life, like conference. And that is like a lot of people like kind of, you know, not necessarily just rehab but like supportive care medicine like clinical social work, clinical nutrition, but I would say that would probably be another big opportunity and something that, you know, us as a field to probably maybe start branching more towards or greater visit, like greater direct visibility. Another question for Dr. Chang. So can you speak to a little bit about your experience with the palliative care fellowship that you did. I guess there's a lot of overlap between cancer rehab especially with end of life metastatic cancer and dealing with transitioning to hospice and how that ultimately may be translated to how you practice today. Yeah, that's that's a really good question. So, yeah, I think it really depends on where you are and like you know who you're working with. So for me, um, yeah, it's. Yeah, it just depends on how things are set up. So, you know, you've never wherever you go, you know, you want to try not to like step on other people's toes or like you know, like stay in your lane or whatever or at least you know have it be, you know, at least know that there should be like an understanding. I mean at where I am right now like I'm really fortunate like we I'm technically there. We all work under the Cancer Center and we're all a part of the same group essentially so I know all the supportive care medicine palliative care doctors in my institution really well. Like when I first started there was like helping them with all their consults for like the first year, because they just hadn't lost somebody. And these days, you know, I do think it whenever possible like, you know, especially the patients that we deal with, they see so many doctors like they have doctors visits and therapy visits like every other day it's honestly kind of ridiculous. And, you know, especially if you have advanced disease like is that how you want to be spending your time. Like, I don't know. So, like, if ever you can cut yourself out and sometimes it's me sometimes I'm like, you know, you don't need to be seeing me right now go like see your oncologist and radiation oncologist and like call me when you need to. You know, whenever I do a lot of my own palliative care still and like transitioning people to hospice. So, like, yeah, you try to do less referrals when possible and anything you can take care of yourself like try to take care of yourself, I guess. And I'm not sure if that answered your question. I just was curious how you're, you know, working with your co workers and palliative care and how much of that you're currently doing but yeah I think you really did answer the question so thank you for that. Yeah, when I like have my own patient I'm seeing for cancer rehab I don't take palliative care referrals anymore but for my patients who do like progress more advanced disease then I yeah continue to usually do their palliative care. Another question I had for our panelists. How comfortable are you in managing long term opioids for your cancer patients. That's actually a point and one of the surveys I had outlined in the slides earlier about, I think, I think most agree that it's important for cancer rehab physicians to feel comfortable doing so so I just wanted to hear your thoughts about that. So personally, I do feel that for cancer patients, I would be comfortable managing their opioids. However, I know at the institution I'll be going to. There is a great palliative care service there who works very direct closely with oncologists already and they manage that. And so I, as long as that group exists, I would prefer to send the patients on high dose opioids to them to manage further. If I ever ended up somewhere where that palliative care physicians weren't available and I was like the only person who could fill that role for those patients, then I would be happy to do that myself. Yeah, I agree. I think, you know, having some knowledge of just opioid management and equivalence and stuff like that is important, especially if you're having, you're seeing some post op patients or patients with just, you know, biologic cancer related pain. But I also think it does depend on what kind of practice setting you're in and if you do have palliative or supportive care colleagues like available because they do it day in and day out and I think what Dr. Like, you know, knowing your role and like kind of what you bring to the table and not having too many, like, hands in the pot of someone managing opioids I think if everyone has their own role if someone's managing those medications and I would kind of defer to As, you know, as Ying was saying, we can step in and help with at least refilling medications if needed or, yeah. Yeah, I mean, I agree. I think I'm lucky here at Penn as well that, you know, we've got great palliative care and a lot of the patients that come to us already might already have seen other physicians for management of their opioids and so, you know, that being said, though, I definitely have a lot more confidence now than I did during residency just because, you know, you work with these patients and even though sometimes, you know, even though I'm not perhaps on prescribing patients, these open medications, I do see how their pain is being managed and what works for them, what sort of dosing they're on, you know, things to look out for and so I definitely feel a lot more comfortable doing that and I feel like I've learned a lot throughout fellowship. So, yeah. Awesome. So we have one minute left of this panel so I want to say thank you so much to our panelists. You guys, I appreciate anyone giving up an hour and 15 minutes after work and I really think that this is a great start to this hopefully annual panel, and, you know, just hearing everyone's experience and enthusiasm I think also is like revitalizing for me. So thank you all for sharing your experience and I hope that everyone here found this helpful. We'll be welcome to feedback and feel free to email us in the future if you have any questions. I'm just going to put my email address here and if you have an email, or if you have a question for a specific panelists, I will put them in touch with you. So thank you all and hope to see you all at a conference soon. Yeah, thank you everyone really appreciate you for joining in on this evening. Appreciate everything and all the words of advice and yeah the support in this community is great. Thanks. Thanks for everything. Thank you. Yeah, Sammy, Julia, thank you for putting this on in the panelists and good to see you guys in chat. Thanks guys.

Cancer Rehab Physician Consortium

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Cancer Rehab Medicine Curriculum

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