All right. So, I know Ekta introduced me. This is Sam Shapar. I'll be kind of introducing the next case for this team here. And then, so, the next case here is a 44-year-old male who initially presented with a pathological hip fracture in July 2019. Subsequent went an intermedullary nailing of the fracture and was diagnosed with a diffuse large B-cell lymphoma on Stage 4a. Underwent six cycles of RCHOP, followed by a consolidated high-dose methotrexate, completing in January the following year. Unfortunately, the fracture was complicated by nonunion, requiring the nail removal, proximal femur replacement, and hemiarthroplasty in February 2020. The course was further complicated by a DVT and PE with a thrombectomy, as well as the initiation of Lovenox. And we can go to the next slide. And then further complications was the development of left lower extremity weakness, numbness and edema, and found to have significant large thigh retroperitoneal hematoma, as you see the picture on the slide here. The Doppler's did show a chronic DVT with common femoral and acute DVT in the popliteal vein with the hematoma drained by IR, and pathology did confirm residual disease. Next slide. The plan was to consider a future cycle with immunotherapy and chemo with possible autologous bone marrow transplant. However, at the time, the patient was not deemed to be a candidate due to a poor performance status. They were total assist with all ADLs and mobility, and really the discussion was hospice versus inpatient rehab. So we'll go to next slide, which brings us for this case. Do you recommend inpatient rehab for this patient? We'll pull up the poll and see what the group thinks. And we'll give this another 15 seconds or so. Make sure your vote is counted before the polls close. All right, we'll end polling here, and it looks like 67% of the group is thinking inpatient rehab, with 33% saying no. So this will lead us to, let's switch over to our video screen, we'll go back, where we will bring up our debaters again, and then Brian, if we can start up the clock. We will let team one begin their presentation, who's going to be taking the first shot of what they think? Of course, we are saying that this patient really needs to come to inpatient rehab. There's so much medical acuity here. This patient is a young patient, 44 years old, has a lot going on, PE, tachycardia, medical management from a physiatrist is needed, can't send this patient just to go home and die. We know that having cancer actually increases your risk of having thrombocytosis, thrombic events, VTE events, by up to 20% in certain cancers, and this guy needs us to help him with his, you know, doing his therapies, getting better functionally, and he also has some cognitive deficits, prolonged stay. So again, we would be needing daily physiatric care, the speech therapy, physical therapy, occupational therapy, to help this young guy out and get him a little bit better shape before he can go home with his family. I think the statement going home to die is quite harsh in a way. Thinking about hospice, palliative care, there's so many ways we can assist a patient with metastatic cancer and focus on quality of life. We've seen in some advanced cancer research articles that the earlier you institute palliative care, maybe even hospice, that that does not lend them to dying faster. In some cases, it actually gives them a longer length of life and an improved quality of life. This guy is total assistance, so going from total assistance to being able to do a significant amount on his own is a far jump, so I think promoting possibly going home with some quality of life measures could be, could serve him well, so to speak. I'm not advocating for his goal to be independent, but more of less burden to his family, less care for his family. At this point, if he's a total assist, I would talk to the family and say, perhaps we might not get him to mod I, but we could definitely get him to possibly minimal assistance level, or we continue to work on other ways to bring in equipment to help, alleviating some of the burden to help with the transfer, such as using sliding board, Hoyer lifts. Again, this guy is young, he's 40, prognosis, yes, might not be great, and if his, at the same time, his quality of life can be affected, improved with inpatient rehab, giving him more confidence for transfers, giving his family more confidence to help him, and overall, we know that inpatient rehab, even for advanced cancer patients, can improve their symptoms, improve their quality of life, as well as improving the FIMS and caregiver burden. Well, I would say, you know, we're talking about sending the patient, you know, home to die. I would argue that sending, if sending the patient to inpatient rehab is where they're going to die. This patient has, is highly immunocompromised. He's prone to a lot of hospital-acquired infections, and I would argue that sending him to a hospital, particularly at this time, or really any time, would be an absolutely disastrous thing to do, and something that, ultimately, I think we'll regret, and, you know, home, at this point, for this patient, is a safer place for him to be. So I'm going to, oh, sorry, I'm going to bring up two points out of the discussion. So palliative care is not, doesn't mean that it can't be with rehab, like they are not exclusive of each other. So we can work very closely with palliative care to make sure that the patient is comfortable and have a good quality of life, while at the same time, we are improving their function, which ultimately is also going to improve quality of life. So that's one of the first one, I want to make the fact that the patient comes to acute inpatient rehab doesn't mean that they cannot have good quality palliative care. And then, secondly, yes, there is a risk of infection, and maybe hospitals, you could think that, oh, well, it's better just to send the patient with comfort care home, but we have to take into account what are the goals of these patients. Is this patient ready to transition to hospice? Is the patient has exhausted all therapy or oncological treatment? Because in this slide, they were saying that the patient was actually candidate for more treatment. However, his performance status was limiting him. So it wasn't like the patient didn't want treatment or the oncology didn't think there were other treatment options. There were, but the performance status didn't allow that. So this is why that the limiting factor here is function. So function is what we need to be focused on and what needs to be improved. I would want to bring up the point about he is such a high risk patient going to acute rehab. This guy has had this significant bony lesion that required operative intervention. How are we sure from last scans to now that he doesn't have additional bony lesions that you put him through aggressive rehab and he would have the potential of a pathologic fracture while you're putting him through rehab. Another thing is, he's already had one pathologic fracture, right? So yeah, the non-union of that pathologic lesion, right. And then he has such a tenuous hematologic status in the sense that he had DVTs. He was on anticoagulation. He proceeded to fail that because of the retroperitoneal hemorrhage, which is risky in and of itself. So you're kind of like walking on thin ice with this guy from a pathologic fracture risk, from a bleeding versus clot risk. No doubt he's pancytopenic too, so I'm sure his endurance is going to be low. And there has been a study looking at patients who went to acute rehab with significant cancer burden and about half of them unfortunately passed away within 180 days after rehab. And this guy has aggressive, aggressive lymphoma, which Dr. Fu also noted that male with lymphoma has an increased rate of transferring back to acute care as well. So I think we're just, we've got a really, really risky guy going to inpatient rehab and would we serve his quality of life better elsewhere? Right. I agree with that. I think the central question is, are we really going to do this patient more harm than good than subjecting them to inpatient rehab? Don, at the same time, he's a young guy. He wants to come to inpatient rehab and his treatment kind of depends on his functional status. So if he were to give up on inpatient rehab and he goes home just with hospice at that time, then that's it. He won't get the treatment. We would have failed this patient because he didn't get to even try. So yes, there are definitely some danger red flags on this patient's chart, but the skill set of therapists should know about how to handle pathological fractures, weight bearing precautions. If you're afraid, please call the ortho person as well and just make sure that there's no more pathological fractures or impending fractures that could be possible as well. And then as far as infection rates, it would happen if he came to the hospital for outpatient. It could happen out in the community. So I don't think that's a, at this point for him, he would, I think this patient would rather take those chances to give him that chance to improve and get his treatment rather than, you know, go home and not know what if he didn't try. But even if this patient is already at such a low level of functioning, I mean, like we discussed, you know, he's total assist for everything. Do we reasonably expect a patient like this with so many issues to have any improvement, right? To me, that's one of the biggest issues. And you know, going home with hospice, you know, there's, you know, there is dignity in that and spending time with your family and at the end of your life and, you know, maybe he has some other goals that he'd like to accomplish with the time that he has left and maybe going to inpatient rehab would rob him of the quality time that he could have with his family and that he wouldn't be having at home. That is an excellent point, goals, right? Goals is what we need to focus on and we need to know what the patient's goals are. And it seems like, again, in this case, goals may be trying to improve performance, starting to see if they can get more treatment. No doubt this is a risky patient. Our cancer patients are risky patients and that's why we love what we do, right? Because we want to take those patients that are the most risk and improve their quality of life and their function. So in this particular case, I think even though it's risky, it's worth trying. And like Dr. Ng said, like, we cannot just go and say, okay, yeah, we didn't try. And therefore, because you're risky and you're difficult, then we don't bring you to rehab. I think we have a physical responsibility to take into account too. This guy's prognosis is not good just based on his performance status and his diagnosis. Are we serving the greater good, the insurance good, the usage of money, and the best way sending this patient to rehab or transitioning to hospice? That's a big question in my mind too, is this goal of responsibility. But it sounds like we may be beneficial from a little follow-up, doctor. Do you want to take it, Brian, we can switch back to the screen for our follow-up on this patient? Yeah, so this was actually a patient of mine. He is a patient of mine. And you know, he stayed in rehab for 15 days and had a total FIM gain of 16. We were able to discharge him home with home health. And actually, our rehab facility is right next to the cancer center, so we're discharging from the cancer center, coordinate care with oncology, and got his first treatment as he was exiting the building prior to even making it home. Then after the treatment, he made it home and was working with home health. This is a picture of him when the first day he got home. Yes, he was in Lodi at the time that he got there, but he got all the DME, the family training, and all the exercise and the tools in order for him to continue his recovery at home. So the next slide, sorry. Next slide. And then most importantly, look at how good he is here in this picture, just made my heart warm. He's able to stand and walk, and he's now walking with a walker around the house and using wheelchair for long distance. So definitely pay off taking the risk on this patient, and it's challenging because we have to consider the motivation, the family support, and what the patient's goals are. And in this case, he's a young guy with two kids and an amazing wife that was looking to improve his function. So his goal aligned better with acute inpatient rehab rather than hospice, and his motivation and all the work of the team got him where he is at right now. So right now he is actually undergoing CAR T cell treatment, and he is still alive and fighting with cancer, and his performance has improved significantly, like I said, walking now with a walker. So it looks like we have some really good questions in the chat. For the sake of time, we'll be able to try to hopefully gauge a few of them. There was one in terms of, as we talk about, obviously you guys are having this debate, the question about insurers and getting this approved for some of these patients, just like some people are arguing not appropriate. I'm sure some insurers would also say not appropriate for similar reasons. And so in the grand scheme of things, are there certain things or criteria or arguments you guys tend to make or think are more helpful to justify bringing someone who's in a similar scenario to inpatient rehab? I love that question because I actually did a peer-to-peer for this patient. He was initially denied by insurance, and they wanted to send him to a skilled nursing facility. Patient denied hospice, so hospice wasn't an option. So the only thing that insurer approved initially was skilled nursing facility. And my argument, and something that I found very helpful when I discussed these cases with the insurance company, is a long stay versus a short stay. We don't want these patients to stay in acute inpatient rehab for a long period of time because we want them to continue their oncological treatment. So that's what I told the insurance, and you're going to have this guy in SNF for like three or four weeks sometimes. And sometimes when you bring it to acute inpatient rehab, you can get him out in the community or continue with the oncological treatment faster. If this is not an option, then a skilled nursing facility will be the next option. But I will still, for those working in skilled nursing facility, keep in mind to try to keep this stay in rehab as short as possible. So kind of building a little off that, there's another question regarding a prognosis. Obviously, this case worked out quite well in terms of the rehab process, but I'm sure we've all had an experience where it may not have ended up as well. And there's a question about having a few patients who are admitted but unfortunately passed away a few weeks after being admitted, whether or not depending on how their rehab course goes. I know personally, we have this issue with sometimes that being challenging on the staff from the nurses to the therapists, including ourselves, in terms of how we're making this decision. How do you kind of balance the idea of where rehab would go versus kind of potential acuity of prognosis and the terminality of their disease versus what you can benefit from them? Are there certain approaches you guys take with your staff and then as well as with the patients and families? I think Diana's point to the goals of care is the key in making sure the medical oncology team and also the patient and their family is on board with the same goals of care and not really knowing the outcome. None of us have a crystal ball. And then if you see them proceed to decline on the inpatient scenario, then I think you dig into your additional resources even more. And sometimes I think patients and their families need to prove to themselves that maybe this is the end. Maybe we all think maybe it is, but we're giving it our valiant effort and that's what they want. That's what their desire is. And I know I'm supposedly anti-inpatient rehab on this talk, but there's many patients, though. I think it is all about the goals of care. Yeah, I would add that I think this is an important topic. I think that's a great question. And part of it comes, particularly the part about with the staff and being part of the dying process, are you putting staff and faculty into the position of being part of the dying process? But part of that, I think, is just us sort of being uncomfortable with death and communicating with a dying patient is something that can be often very uncomfortable and very difficult. So actually, I enjoy talking about this particular topic. Full disclosure. So I would recommend there's an app for your phone. It's called Vital Talk. Vital Talk. It's made by a group of excellent communication specialists, many of whom are oncologists. And they talk about how to approach the topic of death, how to become uncomfortable with working with a patient who's dying, how to use empathy and how to treat the person who's in that particular situation. So just like we try to improve ourselves and all the other aspects of our physician lives, I think improving your communication skills with the dying patients is important too. Communication is a skill that you can practice and improve. I just want to say thank you to Dr. Nelson and Dr. Khanna because they had the hard job of saying no to these patients when we know that we want the best for these patients. So they had a hard argument. Definitely easier for Dr. Molinares and myself. And also, I do agree with bringing in having the goals of care talk. We find often that that's not the case. Patients sometimes have never had a talk about goals of care. About goals of care. And I think part of it is true. Like physicians, oncologists, we don't want to, they don't want to give up. You know, there's always something else to try. There's always, this is why they come, you know, to your hospital because your hospital has the best, whatever it might be, you know, immunotherapy or next chemotherapy or some, you know, trial. And Dr. Gupta actually did a study recently, I was just published about over prognostication of both, you know, rehab patients, rehab providers and oncologists. So interesting paper to read because we do all have good, we wanna give our patients hope and we want them to know that, you know, doing rehab will get them better in some shape or form, exactly. And what it, but nobody knows like what's the next step, right? All of our cancer patients are very sick. They all could die on us at any moment, but being physicians, you know, there are cases when you look back and say, I could have done this, I could have done that. But in the end, you know, I think that even the patients that only had a few short days or weeks to live after they left me, they all still think that process and think for going there. I haven't had any families admit to me any way that they wish that they didn't go to inpatient rehab during those last few, you know, weeks or months of their lives. So obviously this is a really emotional component for ourselves, our patients, our families, and clearly we can keep going, which was the sake of the debate, but we will unfortunately have to cut short for the sake of time. At this point, we were planning on taking a five minute break. If people start coming back and are okay, we'll probably cut that down for the sake of time for our second group. We'll probably talk about maybe three minutes. I'm seeing 150 on my clock. So maybe around like 153, everyone get a little water and maybe bathroom break. And hopefully our debaters will hang along if we have more questions at the end. But I think this will lead very well into our next set of debaters in terms of the topics that we'll be discussing. Okay, so we will plan on reconvening in about three minutes if people want to give a quick stretch and powder their face for the camera. Thank you all. Thank you everybody. We'll see you in person next time. Yes. So I see that our first question is posted and people are already responding. So what outcomes are the most meaningful for physical medicine and rehabilitation? Survival slash mortality, quality of life, functional status and other should have been all of the above. But go ahead and choose that as what you would prefer. And it looks like we have about half the people voted so we can wait maybe 10 more seconds. All right, so I think we're at about 56%. And it looks like about 35% of people voted for quality of life, 20% for functional status and the other 50% or so for all of the above. So we can go ahead and switch to presenter view. And we'll see if we have any more questions. So we'll go ahead and switch to presenter view. And we'll hand it off to our debaters. So we're not nearly as organized as the last group. So we're just gonna kind of frame for this and I'm gonna open it up because I started talking first. And I think you're all right. The truth is the answer is it depends. In terms of our patients, they're interested in very different things from our referrers or from the hospital system that we work with. So I think for the patients, yeah, function and quality of life, it's getting back to work, it's getting back to family, it's participation, it's all those sort of typical mantras we have. That being said, when we're talking about the oncologists referring to us, it's their quality of life that is probably more important, frankly, than the patient's quality of life. They'll talk a good game. And I think most of them really do care about the patient quality of life, but they're gonna refer more to the patient and they're gonna refer more to us if we are able to decrease the amount of time they spend taking care of their patients. And in so doing, keep the patients from calling them and doing all the other things. The hospital system, we're always struggling to kind of justify our existence of rehabilitation is not gonna wanna just throw endless money after us to make us improve patient function and quality of life. They're gonna start looking at us in terms of return on investment, meaning, are we saving money for the patients either direct or for the system, either directly or indirectly by making the oncologist more efficient or keeping patients out of the emergency room in the hospital, that sort of thing. I think that's exactly right. And so, these variables are so intertwined that it's hard to choose one as the most important. But when we talk about the business of medicine and what we're doing here, we have to come up with approaches to each one of our stakeholders that are gonna be meaningful to them. So understanding their priorities and what's interesting to them. And so, exactly like Michael said, so survival may be more important to oncologists and their quality of life and handling all the patient aspects that they're not so comfortable treating is important to them. Whereas quality of life is more important maybe to our patients and cost effectiveness. Dr. Chavelle's study just showed that cost effectiveness of tele-rehab for these advanced cancer patients is cost-effective and reduces downstream hospitalization costs. So I think that we just kind of need to adapt our approach to each one of these groups when we're marketing ourselves and our skillset. All right, Sonal, why don't you go and then I'll finish it off. Yeah, I think I would agree with all of the above in catering what is important to each stakeholder. But I think it is important for us as a community to come to an agreement as to how we measure our value, whether it is to the patient, whether it is to the stakeholder and having some unified agreement on outcome measures and benchmarking. So if we say that we can improve quality of life function, perhaps even resumption of intended oncologic therapy and fewer interruptions, how are we demonstrating that across cancer centers and having that benchmarking? Like, how do we advance in demonstrating our contribution to quality of care? So I think the discussion is not so much what can we improve, but how are we demonstrating it and is that uniform across our cancer rehab community? Yes, I might jump in, just shake it up a little bit. You know, I was surprised on the survey that even though I know we had an all of the above, nobody actually picked survival and mortality as an outcome. I mean, you know, that's kind of important too. So, I mean, I would argue that survival mortality may be a role that PM&R has a place in with increased performance status. Better performance status puts people in a role where they can get treatment. So, I mean, I think that's one metric that we definitely have to look at. But one other thing, you know, I'm gonna say something else. I know it's gonna maybe not make a lot of people happy, but cash is king. And, you know, when you look at outcomes, no matter what outcome you look at, you have to look at in context of cost, reimbursement or savings. So for example, like Michael alluded to it from a hospital system point of view, the hospital system, if you're taking their patients and you're doing cancer rehab, I mean, they need to know that whatever you're doing is gonna have a positive return on investment for them. Now that definition would be variable depending on what you wanna define cash as, but you have to consider, does it improve their bottom line? Does it decrease their costs? Does it decrease the expense to payers for the treatments that they're gonna get or decrease the expense to payers for any comorbidities that they may assume? And you have to start thinking a little bit like that, right? So it's not just purely about all patient reported outcomes, not all patient metrics, but there's always a context of those metrics in terms of cash and costs. So I'll leave you guys with that and I welcome anybody's feedback, positive or negative on that statement. Just chiming in again, I think you're exactly right. Timmel, I think was the first one in palliative care to really show a mortality benefit, albeit small, for palliative care interventions. And I think the holy grail for rehab will be able to show that. And clearly we're not gonna be able to show it across the board in breast cancer patients. We're gonna be able to show it in patients who have shorter ends of life, potentially at some point, but I agree with you. There are a couple of good questions on the cat asked, and then it got moved up. Keeping patients on longer, she talked about like aromatase inhibitor, you know, induced arthralgia. And I think, yeah, absolutely that is a huge place where we can potentially show value. And I'll point out that actually one of the metrics looked at by the oncology care model. So those of you who are not familiar with oncology care model wanna start looking at it. This is how Medicare, it's kind of a demonstration project is starting to define the value of oncologic care. And, you know, it's very much like an HMO on steroids where you're responsible for the outcomes as opposed to just the number of patients you can take care of. And then Andrea pointed out that Temple showed a two month increase. So I guess that is big. I'll defer to her, she's the expert there down in the chat. Yeah, and I would just make a point and value Julie and Sonal's input on this, but I would just make this point to all of us in the audience or all of us who are listening that it's okay to talk about the return on investment. It's actually okay to talk about dollars. I know we're always taught clinically, you know, do what's best for the patient, but in this world that we live in, you know, we just went through this crazy election situation, right? And, you know, you listen to all the pundits on the news talk about, you know, what the critical issues are and healthcare would come up and they would say, well, one guy, one healthcare would be this way and another guy wins healthcare is that way. In the end, rehab has to be able to prove its value to everybody so that if anyone tries to come after rehab, especially cancer rehab, they're gonna be able to prove their value to everybody. And I think that's a big part of what we're trying to do. If someone comes after rehab, especially cancer rehab and says, well, you know, we don't support this and we don't think we should provide more funds or we should cut funds to this. We have to be able to come back with some real tangible evidence to show that the interventions that we do make the most sense and are most effective for the patient. Well, I think you guys have done a great job on this topic as we move along. This may lead into in part to our next question. And Brian, if we can switch back over to the screen, which will bring up our next poll question. Hopefully we'll, wait a minute. If we can get over, here we go. And so as we talk about values and if we go to this next slide, Brian, please, for our poll. How we define ourselves as a cancer physiatrist somewhat leads into our outcomes. A little bit of how we view ourselves because that's sometimes how we get utilized, right? And how we present ourselves. And so here's the next poll question of how we would define ourselves as a cancer physiatrist. Are we impairment-focused specialists? Are we assisting with goals of care planning? Are we focused on exercise? Interventional specialists or pain specialists? I think this will help guide a little bit of some of our different thoughts of how we function as an individual and how we are utilized in the healthcare system. It's like we're getting some good participation. We'll give it another 10 seconds. And we have just a little over 50% on and we'll end that poll now. And it seems like the majority goes down from impairment-focused specialists to assisting with goals of care, moving down with less frequent of the exercise and interventional slash pain specialists. And so if we can go back to our presenter screen, I think I would like to hear what our presenters have to say about this because I think this goes right in terms of what we're viewing as outcomes is how we view what we're trying to do, correct? And so hopefully we can get your thoughts on this next topic. I mean, I think this is kind of the beauty of our field and also the challenge of our field that we can wear so many hats and we do everything that's on that poll, but how do we really tell oncologists and our colleagues who are gonna refer to us what we do? And so I typically focus on impairments because I find those to be more concrete, but those are gonna change based on who you're speaking to. And so if you're speaking with a breast medical oncologist or breast surgeon, that's gonna be diagnosing and treating various impairments related to surgery, radiation, chemotherapy, such as lymphedema, post-surgical chest wall pain, rotator cuff tendinopathy. But when you're speaking to your patients, it's gonna be something different. And so I think we have to kind of change our approach again to each group that we're talking to in order to be kind of effective. And so another group that I think that we also need to be able to speak about our skillset to is just general physiatrists and our physiatry colleagues, because I have run into the situation a lot of the time where it's assumed that what we're doing is palliative care. So I think it's important to really educate each one of those groups with specific examples. I would agree. I think if kind of we take the conversation a little bit back to value, right? There are different value frameworks within the oncology sphere. ASCO's value framework is different from NCCN, which is different from ESMO. And they look at, they all calculate costs differently. Some include just chemo costs, some include the cost of the entire care. But I think what's interesting is that they also vary in their common endpoints. And so, but if we look at just the American frameworks, they include overall survival, progression-free survival, but they also include quality of life and palliation of symptoms. And all of these are included as endpoints of defining value. So would echo what Julia would say is that depending on what the patient's rehab needs and goals are and kind of what is important for that patient to be able to continue with their oncologic treatment, that may involve us being the impairment specialist. We may want to be the ones prescribing exercise, especially in our breast, colorectal and prostate cancer patients, knowing that these are the populations where we know, where we have such a strong association with increased survival. And so I think that our advantage, perhaps to some of our other subspecialty supportive colleagues is that we can address all of the above. And we can tailor that as to what that patient needs in that time, but then also what the oncologist goals are too in order to demonstrate, their treatment interventions are efficacious. So I think it's helpful for us to better understand what the state of the current value frameworks are, how we align with them, but then also how can we contribute to them and showing that we can address all of those areas. Yeah, so I would jump in and it's so interesting, when we all graduate in training, we're always looking for an identity, right? We want to be able to define ourselves by something and to say that this is what we do, this is who I am, this is what I do in practice and this is where I'm going to go. And it's just so interesting because in this world of cancer rehab, you could have several different debates about what you think are the primary goals and what you think are the primary impairments or things that physiatry should be in charge of and then somehow define yourself that way. But whether it's a physiatrist or anyone else in cancer rehab, other subspecialties like therapy services and other folks who are doing cancer rehab, I think this is a huge challenge for any provider to be able to define what they are. My definition has always been that a cancer physiatrist is what the community and the referring sources need you to be. And that sounds very vague and that sounds very general, but it's done so for a reason because here in Charlotte, when I first came here, I came with all this fervor to be a cancer rehab doctor and all anyone ever wanted to send me was lymphedema and I would sit there and say, well, I can do so much more, but that wasn't really relevant in the beginning. You had to build your case, you had to show your value. And then after I did show that value, I had the opportunity to expand into other disciplines, other service lines, other impairments. And so, I'd like to keep that definition super broad. I think a cancer physiatrist or a cancer rehabilitation specialist is specifically anyone who can address the physical and cognitive and psychological impairments that a patient needs at that given time. And if you can do that, that's good enough for me. Of course, I agree with everybody, which is kind of negating the point of this being a debate, but I wanna make one important point is that we have to differentiate ourselves. There's no question what a neurosurgeon does for a living. There's no question what a cardiologist does for a living. Even a pediatrician, it's pretty clear. But when you ask people what a physiatrist does, they think we treat depressed people, right? So we really do have a kind of identity crisis that needs to be filled in. So I think the concept of being really all things to all people may not be the best way to go, right? What we do do, the things that we are particularly good at, need to be things that other people don't necessarily do or don't do as well. And whatever that is for you, I'd say double and triple down on it, but you don't want people thinking that you're a psychiatrist for the rest of your career. Yeah, I think Michael brings up a great point. Gosh, I've been waiting for somebody to say something that ticks me off so I can keep talking. But Michael makes a great point, right? Because even though I'm sitting here saying, be what you need to be to whoever you need to be it to, you still have to do that at a very high level, whatever that is. And so I think that's the challenge of the field is that we come out and we wanna say that we're doing this or we're a specialist in that. But the problem is that you may come out of, let's say fellowship training and have a certain amount of fervor for, I don't know, say cancer fatigue. And then you go to a market where nobody's asking you to work on cancer fatigue. You gotta adapt real quick to figure out what that market is asking of you. And that may be going into the next question of who your customer is. But I just advise, I think we do have specialization, right? In all physiatry, there are several things that we do very well that nobody else can do. The key is capitalize on what that is in your market and be really, really good at it. And before you know it, your identity will be clear to your referral sources. Sorry, go ahead. Now, I was going to say, Sonal or Julia may have some more thoughts. I think you can tie that back to with whatever you're developing, your expertise or defining it as making sure you have a way to capture how you're doing it and what value that's bringing back to the cancer center and the oncologist too. Because I think there are multiple, for example, where I am, there are multiple individuals that can manage neuropathic pain, that can manage musculoskeletal symptoms. But if I'm able to go back to the oncologist and communicate that this is specifically what I've improved for your patient, and that can be a way for us to distinguish ourselves too, as kind of being organized and having that data as well, recognizing that there may be other specialists that could probably do very similar interventions as us. I'm happy to keep talking but you know we have another question. I think our biggest thing you know and I'm sure everybody's run up against this is how are we not physical therapists and that's one that you know I think everybody who's done this has come up at some point or you exercise patients like no I just get them hurt I treat you know neuromuscular musculoskeletal complications I give injections I do pain management I coordinate care at a very high level and I prescribe a lot of therapy and let them exercise patients well I think that kind of will move a little bit towards our advertising piece and then Brian if we can switch back to the screen to go to that third question that comes up in the poll question we'll move forward the next slide here who is your customer because obviously who we're talking to makes a big difference of who we can help right the patient the oncologist are the rehab colleagues I mean I know some PTs will say well what do you do that I can't do for the patient or anyone else that we're interfacing whether it's a palliative care colleagues or anyone else that we encounter from PCPs to anybody else so well move along here and we have about 27% voted I know we got more people in here hopefully we get more time I think one of the interesting parts of this question is generally we're a referral-based specialty so we're not necessarily the gatekeeper as people come through and so that's always the interesting part and we'll give it another little bit we're just at 50% so we'll see go another five seconds and it looks like most of us are on the camp of the patient followed by the oncologist followed by others which may be an open book depending on what we're thinking about and so we can switch back over to the presenter view I think with this question kind of moving through all the other ones obviously interconnected this will be a good way to as we finish up this group and hopefully open this up as questions once we let everyone speak their piece or move along so who will yeah I'm happy to start on that you know of course the answer is it depends like almost everything we do for a living so and this isn't a completely coherent analogy but on the therapy side for you know the revital program which is largely therapy based we're pretty confident that if our initial tactic was just to market this program to patients the program would have failed we've actually been successful in making this a you know gigantic national program exactly because we have been working with oncologists oncology practices private practice oncology as well as the big academic centers and making the value propositions to them now we understand fully that once we work with them and we've gotten their buy-in and we're going our patients have to be singing our praises or the program will fail but it would not have worked in our situation if we'd simply gone after the patients first yeah I agree you know we all kind of chose this field to put the patient first but unfortunately we have to think about the business aspect of this too and so you know the advice that I kept getting as I started was to be available affable and able but you also have to be extremely flexible and understand that these patients are really sick they have a lot of appointments what are you going to offer to them in your appointment that they definitely to come see you for and so we need to make sure that we're providing effective care that's worth your patients time energy and resources so that the oncologist will continue to refer to you and you know I hear what you're saying about the oncology referrals really driving the business but I do think that there is also value in the patient word of mouth and in really taking care of those first couple of patients that you get from a referring provider right doing a really really good job with those first couple of patients I think is really important to make a good impression and to continue that referral stream yeah I think right the oncologist are that are the gatekeepers and are the ones that are referring their patients to us but there is like Julia said like at least at our institution patients talk to each other patients will come prepared they've done their googling they're seeking out rehab as well they're seeking out guidance on exercise and so I think advertising to both of those populations will will enable us to grow our our practices but I think when in talking about the oncologist as our customer or their being our customer I think it's also of having that free conversation one of my my mentors in surgical oncology shared is, find out what the oncologist's biggest pain points are. What are things that bring their patients back to their clinic? And if you can demonstrate how you can improve that for patients, then like everything else will come into place. So I think it's identifying the customers, but also having some guidance on how do we show that we can help them, but then also moving that from helping them to showing that we're partners on the cancer team too. All right, yeah. And I'll jump in here. My family just came home, so I'm just gonna warn you, it might be a little noisy here for a second. But I think, you know, I think it was very interesting seeing that survey and seeing that survey, and then looking at the patients being the number one person that you're serving. There's no question that patients are, of course, you know, our primary focus. But in my mind, I think in several other minds, just what everybody had said, to some extent, your most important referral source, your most important customer is your referral sources in terms of the medical oncology and surgical oncology, radiation oncology, and all other folks who might be sending you patients, because ultimately you have to show your value to that group. If you can't show your value to that group, you won't have any referrals. If you don't have any referrals, you don't have any patients to treat. And it's a different way, again, that we're taught to approach the problem compared to maybe what we're trained to do, because what we're trained to do is, you know, the patients in residency come to us and we just kind of do our thing. I think it's so important to understand that we have to cater to those folks who are sending us the patients and make sure we bend over backwards to address whatever needs they might have, whether it's taking the burden off care. Like, so for example, even with the lymphedema patients, if you can take patients away from them so that a provider doesn't have to worry about the edema, we take care of all of it, we take care of it start to finish and try to figure it out, then we go from there, much in the same way from the surgeons and the other point of view, if you can take away the patients so that they can focus much more on the surgical issues, then you're gonna have a much more steady referral base and you're gonna have a much more steady customer base and many referrals to come in the future. I would actually even kick this up the latter one when you start thinking about it. So not every big academic center has a cancer rehabilitation program, even a therapy-based one, much less one that involves actual physiatrists. And the reason for that is they haven't seen the value of it. Most of them would much rather put in a new surgical day hospital or a few more chemotherapy beds, which are much more profitable than that. So we're constantly trying to claw away that ground. And the same thing with health systems, right? As opposed to just academic offices or private oncology groups, they need to recognize the value of us. But the problem is we haven't really shown, proven the value in the dollar and cents way. Even if we're giving great value to our patients, they're not gonna see it. So our customer, I think, will need to be kicked up to the health system and the oncologist. And even more than that, ultimately our customer is gonna be Medicare, right? So if we're gonna start making the oncology care model next iteration, where cancer rehabilitation's a built-in component of it, they need to see a return on investment of that, or they're just going to ghost us, basically, in terms of how they approach us. Yeah, and I might just add to that. Michael brings up an unbelievable point, which is we're sitting here talking about referrals and we're talking about our primary physician referrals. The payers are probably the most critical people because ultimately, if they don't pay for anything, you can't really do it. It's pretty simple. And so until you can prove to Medicare, either via the oncology care model or other models that are gonna probably be forthcoming for cost savings, or you can provide evidence to payers, Medicare HMOs, private insurance companies, and others, so that you can say, well, these are the interventions I'm doing, and this is how it benefits you that I do this intervention. That's ultimately what you have to do to make sure people understand and can really buy into what you're selling. And I think a way as a, just personal experience as a young faculty member is how do you understand even how does your institution work? How does your healthcare system work? Ours, I'm sure many will have something with the equivalence of like a chief value officer. And it could be as simple as sitting down with that chief value officer and bluntly asking, you know, what is your mission? What are the goals for your, what's your strategic plan for the next three to five years? At our institution on the inpatient side, it was, of course, like many others, reducing length of stay post-operatively, and then how to manage the long length of stay among our BMT patients. Our therapists were able to demonstrate early mobility in fibular flap patients post head and neck, reduced ICU length of stay by one full day. Our BMT therapy teams are able to deliver comparable inpatient rehab for those with a certain AMPAC score, and we were able to discharge more to home rather than to a SNF. So I think it's, we know we need to understand the healthcare system, but how do we as a junior faculty member of physiatrists get there? And I think things like identifying who are the value officers of your institution, who's overseeing the operational flow, and asking them about their data. And then I think they'll see that you're trying to be aligned with what their, what their outcomes are as well. And then I think they'll start looping you into conversations. So I think those are really great points. Leading into a little bit more discussion, we have a few points from the audience that maybe you guys could also help us address. So Andrea mentions continuing treatment eligibility seems to be a powerful motivator for both patients as well as oncologists. Is there anything that you can do or support this with to really send that message across to our oncologists and institutions? I think the short answer is yes, but our data for it is largely anecdotal, right? Which is one of our issues, unless somebody knows something I don't, we have not shown that what we do for patients. And often we're using the therapists as a surrogate. For us, I see Jen Byma's on here talking about prehab, which is wonderful, but are we really a part of most of the prehab protocols that have actually been researched and given and added to our evidence base? It's really largely therapy-based. So the answer is yes, probably, but it really hasn't been shown. Okay, and it sounds like the prehab group is going to present some of that evidence on Tuesday that will help us see where we can be incorporated into that rehabilitation course for these patients. Vish, did you have a comment that you wanted to make? Yeah, I was just gonna say, I think the critical piece to all of this, when you're looking at our role and looking at where we fit in, we try so hard to identify ourselves in our own field and we all pat each other on the backs when we get together and talk about how great we're doing. And that's great, we should do that. But the more important thing is that we have to embed ourselves into the other folks, to the referral sources, to the medical oncologist, surgical oncologist, radiation oncologist, the administrators, all the folks who are running the hospital, who's running the processes, the procedures and the people who control the cash flow. Those ultimately are the people that we have to be aligned with, embedded with. And when we do, then we have more opportunity to present our outcomes, our evidence based on what they think is valuable and what we think is valuable in a way that's more universal than just rehab. And when you can do that, when you can actually prove your case and you can show that whatever it is you're doing has positive value for other folks, in addition to positive value for folks in our own field, then I think you've made it. And so I would just wanna leave people with that point, just to remember, we have to think bigger than rehab. We have to think, how does rehab impact the entire oncological continuum of care and where do we have an impact? And when we can do that, then I think we have a really great chance of being successful in presenting our evidence. So, in response to that, I think Lynn had actually posed this question earlier when we had been talking about the impact and who our customers are and the value of rehabilitation is how important is it to have patient input in determining the most important rehab outcomes? I'm curious to see what Sonal or Julia says. I mean, I think it's really important to have their input. And I think that some of the recommendations that I've had in starting up is to meet with the support groups and meet with the patients directly to really get an idea of what's most important to them. And so I think that can't be understated at least for early career physicians or people starting up in this, attending those meetings and really getting that face time with the patients so that you can advocate for them and really learn what's most important to them is critical. Yeah, I think it's absolutely critical. Michael Porter's right definition of value-based healthcare, of just quoting it says, the focus should be on increasing value for patients. In other words, increasing health outcomes that matter to patients. And if we look at the current ASCO and CCN value-based frameworks, what's missing is the focus on the patient. And if we look at the current ASCO and CCN value-based frameworks, what's missing are the stakeholders, the community, the public policy advocates and the patients. There've been commentaries that have come out from surgical radiation oncology specialties calling for a patient input. And I think that's something as we as rehabilitation physicians, all of our work should be centered around what the patient's goals are. And I think there is a shift in oncology to show our referring sources that we already do this. As part of my intake form, there's objective physical function outcome measures, but number one in our flow sheet is what are the patient's rehab goals? And so I think we can lead by example and demonstrate our worth by demonstrating how we can deliver that patient-centered care. And I agree with everybody. Of course, this has been a terrible debate because we all agree so much, but one of the things we've really doubled down on initiating is using patient-reported outcomes to try to drill down in a way we haven't been able to before to try to find out what really matters to them, what the real issues they're having are. And it's often surprising. Yes. So I'm actually very surprised that these questions were not more debated. We expected a lot of arguments going back and forth here, but you guys have done a great job agreeing with each other. So as we kind of are close on time, it's 2.30, if we can go back to the PowerPoint. And so thank you all for attending. I know there are still some chat questions that are coming up, so we can leave it open for a few minutes if our group wants us to try to respond on the chat. So just a reminder, the second part of the debate will be on Tuesday from 1 to 2.30 p.m. Central Time, once again on Zoom. The two topics that will be covered at that time period will be cancer prehabilitation as well as interventional options for our cancer patients. And I know those are pretty hot topics. The chat is going on about some of them already. And we'll do a quick conclusion on Tuesday and we'll set up a different networking session because I think we have a lot of really great comments, ideas, and thoughts that are being shot around. And I would love to hear more from everybody. So Sam and I are really appreciative of everybody joining in for this session. Thank you to our debaters. We know you put in a lot of time and effort and we really appreciate the discussion points that have gone on. And thank you again, Brian and Grace from AAP MNR who have really helped us with all the technology concerns that we had. Thank you, everyone. And we'll at least see you on Tuesday, hopefully. All right. And if anybody has any questions, I think I'm seeing a few more. Feel free to respond. Tuesday's session will be recorded like today's session. I think we're good. All right. Thank you all and enjoy the rest of your Sunday. Hi, everyone. Thanks. Great job. Thanks, everyone.

physiatrists

cancer rehabilitation

meaningful outcomes

stakeholders

patients

health systems

value demonstration

cost savings

differentiation

clear identity